Reinforcing the proximal anastomosis in Bentall’s procedure: before or after unclamping the aorta?

blood and blood products transfusion, which has its own implications and complications. Sometimes it leads to alarming postoperative drainage mandating re-exploration. Many modifications have been suggested to prevent this complication. Bentall and De Bono wrapped the graft with native aneurysm wall, but the idea was soon abandoned because of development of hematoma between the graft and the wrap w1x. Cabrol et al. suggested anastomosing covered native aneurysm to the right atrium, but the procedure was found to be complicated by the development of persistent aorta to right atrial fistula w2x. Copeland et al. used a annular and supra-annular aortic wall tandem suture-lines technique which consists of using interrupted mattress sutures to anchor the lower part of the valve sewing ring to the aortic annulus. The upper part of the sewing ring is then anchored with a running suture line to the cut-edge of the supra-annular aortic wall w3x. Khanna and Akhter claimed to achieve similar effects without cutting the aortic wall by applying a purse string using 3y0 polypropylene suture through the aortic wall just above the proximal suture line and taking it out of the aortic wall through a polytetrafluoroethylene pledget w4x. Reinforcement suturing of the proximal anastomosis as mentioned in different techniques, is essentially difficult and frustrating because of lack of space and poor visibility in that region. We propose the technique of encircling a sewing ring of valved conduit with a pericardial strip and passing anastomosis sutures through it. It is a simple and reproducible technique which confers strength to the repair. In a case of bleeding from the proximal anastomosis, the pericardial strip can be sutured to the left ventricular outflow tract. As one margin of the pericardial strip is already fixed to the sewing ring of the valved conduit, it becomes easy to suture only the peripheral margin to the left ventricular outflow tract in the region of bleeding. In addition, the authors avoided resecting the aortic valve leaflets before passing sutures through left ventricular outflow tract. The aortic valve leaflets encompassed into the left ventricular outflow tract sutures gives strength to the repair.