1. Aortic Valve Reconstruction in the Young Infants and Children
Christopher W. Baird, Patrick O. Myers, Pedro J. del Nido 
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual 
Volume 15, Issue 1, Pages 9-19 (January 2012)
DOI: /j.pcsu
Copyright © 2012 Elsevier Inc. Terms and Conditions

2. Figure 1
Aortic valve reconstruction at Children's Hospital Boston
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
Copyright © 2012 Elsevier Inc. Terms and Conditions

3. Figure 2
Classification of aortic insufficiency (AI) encompasses all the mechanisms of aortic insufficiency, provides a common language for discussion among clinicians, and guides the repair techniques. In this classification (as in the mitral valve), AI associated with normal leaflet motion is designated as Type I and further divided into subtypes based on the specific pathologic condition. Type 2 AI is caused by excessive cusp motion (ie, cusp prolapse), and Type 3 AI is due to restrictive cusp motion as seen in rheumatic disease and in BAVs. a, artery; AI, aortic insufficiency; FAA, functional aortic annulus; SCA, sub-commissural annuloplasty; STJ, sinotubular junction.
(Reprinted with permission.14)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
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4. Figure 3
This represents a patient with a deficient left coronary leaflet (LCL): 3D intra-operative quantification of leaflets areas and deficiencies. NCL, noncoronary leaflet; RCL, right coronary leaflet.
(Reprinted with permission.15)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
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5. Figure 4
Matrix array 3D-echo images of aortic valve in a patient with severe congenital AR before (Pre) and after (Post) surgical aortic valvuloplasty. The image before surgical aortic valvuloplasty (top) demonstrates partial left-right leaflet fusion, large central deficiency in fused left-right leaflet, and thickening of all leaflets. The image after surgical aortic valvuloplasty (bottom) demonstrates three well-formed leaflets that have excellent coaptation. There was no AR after surgical aortic valvuloplasty. R, right leaflet; L, left leaflet; N, noncoronary leaflet.
(Reprinted with permission.4)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
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6. Figure 5
A, The unicusp aortic valve has the classic “toilet seat” appearance, with two primitive unsupported thickened raphe. B, The BAV has two developed commissures and a single primitive unsupported thickened raphe. LCA, left coronary artery; RCA, right coronary artery.
(Reprinted with permission.19)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
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7. Figure 6
Superior view of the aortic valve. A, This schematic shows an aortic commissuroplasty that is commonly used in situations with mild central regurgitation and a mildly dilated annulus. B, This schematic illustrates the classic “Trussler” repair of aortic valve insufficiency that originates from a prolapsing redundant leaflet that has had elongation of its free edge from chronic prolapse, as is often seen in outlet-type VSDs.
(Reprinted with permission.17)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
Copyright © 2012 Elsevier Inc. Terms and Conditions

8. Figure 7
Superior view of a BAV. Prêtre's technique involves sharply incising the aortic valve leaflet at the annulus. The fused leaflet is then trimmed and reconstructed into an acceptable non-coronary leaflet. The right coronary leaflet is created with a patch of pericardium. R, right coronary sinus; L, left coronary sinus; NC, non-coronary sinus.
(Reprinted with permission.21)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
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9. Figure 8
A, Schematic of a BAV where the right leaflet has been previously torn at a prior aortic balloon valvuloplasty. Portions of the right leaflet are used to support the raphe and to extend the height of the non- and left coronary leaflets. B, The right leaflet is then replaced with lightly tanned autologous pericardium. L, left coronary leaflet; R, right coronary leaflet; MV, ant leaflet of mitral valve; R1 and R2, divided raphe; N, non-coronary leaflet.
(Reprinted with permission.19)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
Copyright © 2012 Elsevier Inc. Terms and Conditions

10. Figure 9
A, Schematic showing measurements being taken using a silk tie. It is particularly important to take the measurements on a “stretched” leaflet so not to foreshorten the leaflet extension, which can lead to stenosis and/or regurgitation. B, The height of the leaflet extension(s) should be equal to optimize co-aptation. L, left coronary leaflet; R, right coronary leaflet; N, non-coronary leaflet.
(Reprinted with permission.19)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
Copyright © 2012 Elsevier Inc. Terms and Conditions

11. Figure 10
Schematic showing completed repairs after (A) 3-leaflet and (B) 2-leaflet extensions.
(Reprinted with permission.19)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
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12. Figure 11
Children's Hospital Boston data Kaplan–Meier graph demonstrating freedom from aortic valve replacement (AVR) among patients with moderate or greater aortic stenosis (AS) before surgical aortic valvuloplasty and those with less than moderate AS. Numbers of patients at risk at 0, 1, 3, 5, 7, 9, and 11 years are listed.
(Reprinted with permission.4)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
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13. Figure 12
Schematic illustrations showing external fibrous annulus reduction. The annulus was reduced with specially designed strips along the luminal and adventitial aspect of the fibrous portion of the left ventricular outflow tract. R, right coronary leaflet; L, left coronary leaflet; N, non-coronary leaflet.
(Reprinted with permission.36)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
Copyright © 2012 Elsevier Inc. Terms and Conditions

14. Figure 13
Schematic illustrations showing internal fibrous annulus reduction.
(Reprinted with permission.35)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
Copyright © 2012 Elsevier Inc. Terms and Conditions

15. Figure 14
Schematic illustrations showing an absorbable suture in an infant to reduce the internal fibrous annulus.
(Reprinted with permission.18)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
Copyright © 2012 Elsevier Inc. Terms and Conditions

16. Figure 15
Schematic illustration of sinotubular and subannular reduction.
(Reprinted with permission.36)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
Copyright © 2012 Elsevier Inc. Terms and Conditions

17. Figure 16
A, Schematic of an enlarged aortic sinus can cause stretching of the leaflet, resulting in poor leaflet mobility. B, A triangular resection of the aortic wall from the non-coronary sinus with primary closure will decrease the aortic diameter, allowing more leaflet mobility and improved co-aptation. C, A small aortic sinus can have the opposite effect whereby the leaflet “folds or buckles.” D, Enlarging the sinus and sinotubular junction allows improved co-aptation by stretching the leaflet.
(Reprinted with permission.19)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
Copyright © 2012 Elsevier Inc. Terms and Conditions

18. Figure 17 Ascending aortoplasty. (Reprinted with permission.19)
Seminars in Thoracic & Cardiovascular Surgery: Pediatric Cardiac Surgery Annual  , 9-19DOI: ( /j.pcsu )
Copyright © 2012 Elsevier Inc. Terms and Conditions