In this case, the right sinus segmental circumference was almost twice the corresponding leaflet free-edge length, and the non-coronary sinus also was much larger. However, the left sinus was of normal size (again relative to leaflet free-edge length); thus, the left sinus was not replaced. The non-coronary and right sinuses were excised, and the right coronary button was developed. A 30 mm Valsalva graft (7 mm larger than the annuloplasty ring) was chosen, and the bottom skirt was removed. Three 120º tongues were developed by cutting the 120º lines on the graft doughnut vertically (about 2/3rds up the Valsalva doughnut), and corners of the tongues were removed. The right and non-coronary tongues were sutured to their respective sinuses, starting the suture lines at the nadir of the tongue and sinus with horizontal mattress sutures that everted the graft edge. The running suture line then was carried up the sinus toward the top of the commissure, incorporating the ring pledgets into the closure to lock the graft into the ring.
A strip of autologous pericardium or Teflon felt can be incorporated into the sinus suture line as an added precaution for hemostasis. The vertical 120º incision in the graft doughnut can be extended, as needed, to accommodate the height of each commissural post. The tongue for the normal left sinus was removed, and the proximal root anastomosis was carried across the top of the left sinus. The single right coronary ostium was implanted into the graft, and the distal aortic anastomosis was completed. Post-bypass, the leaflets exhibited excellent effective height, and moved well with no residual leak. After valve repair, the mean valve gradient was 7 mmHg.