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Bilateral internal thoracic artery harvesting carries a higher risk of sternal infection than harvesting a single internal thoracic artery. Skeletonization of both internal thoracic arteries significantly decreases this risk. A strategy of bilateral thoracic artery grafting can also be offered to patients at high risk for wound infection.

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The majority of patients who had their valve reimplanted in a graft with sinuses continue to perform well after 10 years.

The reimplantation type of valve-sparing procedure can be facilitated by the use of the Valsalva graft and can be performed with satisfactory perioperative and midterm results. How an optimal root reconstruction will affect the second decade of follow-up has yet to be determined.

Objective: The present in vitro study was designed to ascertain whether the presence of sinuses of Valsalva in the aortic root were able to regulate the valve effective orifice area and modulate the gradient across the valve independently from root compliance. Methods: Four different root configurations were prepared. Of the 4, 2 were silicon configurations with the same compliance, 1 with and 1 without sinuses of Valsalva, in which a 25-mm Solo stentless aortic valve was sutured inside. The other 2 configurations were obtained by substituting the upper part of the root with a straight Dacron graft or with a Valsalva graft in a remodeling fashion to reproduce the surgical situation. All roots were mounted in a pulse duplicator to measure the pressure decrease across the valve and effective orifice area at different cardiac outputs. Results: With increasing cardiac output up to 7 L/min, an increase in the pressure decrease across the valve was evident in both configurations without sinuses of Valsalva (7.90 AE 1.7 and 11 mm Hg AE 0.1 mm Hg, respectively) but not in those with sinuses (2.87 AE 0.5 and 2.42 mm Hg AE 0.5 mm Hg). Similarly, with increasing cardiac output, the effective orifice area increased significantly only in the roots with sinuses (5.13 AE 0.5 and 5.47 AE 0.5 vs 3.06 AE 0.3 and 2.50 cm 2 AE 0.02 cm 2 , respectively). Conclusions: When the cardiac output is increased to greater than the resting physiologic values, the presence of sinuses of Valsalva, independently of root compliance, prevents an increase in the pressure decrease across the valve by way of an increase of the effective orifice area.

The new aortic root prosthesis allowed the reconstruction of the aortic root anatomy in all types of surgical techniques with low postoperative morbidity.