It is essential to continue dissection of the aorta well beyond the pericardial reflection, and to apply continuous traction on the tape, which is passed around the ascending aorta. This brings the innominate artery and the left carotid in view, so that a high cannulation of the aortic arch can be performed, leaving place for the aortic cross-clamp close to the origin of the innominate artery.

With continuous traction on the tape, which was previously passed around the ascending aorta, the arch is brought into view and one (or 2, when the aorta is friable) purse string suture(s) is passed through the adventitia, taking care not to penetrate full thickness of the aorta.

Good fixation of the cannula to the tourniquet is essential to prevent the migration of the cannula during manipulation on the arch. When a short arterial cannula is used, a second ligature, which fixes the cannula to skin, should be used.

A two-stage cannula is placed in the right atrium, and a LV vent is introduced through the right upper pulmonary vein.

The clamp is placed on the distal ascending aorta after traction has been applied to the tape, which was placed around the aorta. This brings the innominate artery into view; the clamp is placed just at the origin of this artery to assure that the diseased part of the ascending aorta is removed. The vent is placed on suction, and the aorta is opened after it collapses.

In cases with substantial aortic incompetence, an initial dose of antegrade cardioplegia is administered directly into the coronary arteries using hand-held cannulas.

The aneurysm has been opened longitudinally, and the incision is carried to the cross-clamp. The aortic remnant is dissected away from the pulmonary artery and the aorta is divided circumferentially.

Longitudinal aortic incision is carried into the non-coronary sinus, aortic leaflets are removed, and a circumferential incision is carried along the sino-tubular junction to the ostia of both coronary arteries.

Under continuous coronary retrograde perfusion with cold (16°C) oxygenated blood the wall of the aneurysm is dissected away from the pulmonary artery using cautery. The ostium of the left coronary artery is extensively mobilized, leaving a 3.5 mm button of aortic tissue to facilitate the anastomosis. Dissection is carried along the left main coronary artery for at least 1-1.5 cm.

Ostium of the right coronary artery is mobilized in a similar fashion, taking care to preserve the conal branch of the right coronary artery (RCA), which usually curves towards the right ventricular outflow tract and can be easily damaged during mobilization.

Traction sutures are placed in all three commissures and tension is applied: this lifts the aortic annulus upward and facilitates the implantation of the composite graft.

After sizing and selecting the graft to be used, seating of the prosthesis in the annulus is checked.

Pledgetted sutures are placed through the annulus of the aorta using supra-annular stitching. In a small aortic root these sutures would have been placed from below the annulus. After placing the stitch through the aortic annulus, the pledgetted sutures are immediately carried through the sewing ring of the prosthesis.

Keeping previously placed stitches under tension, further sutures are placed in the non-coronary sinus.

While the assistant pushes the composite graft into the annulus by applying pressure to the valve holder, sutures are being tied; two-color stitches facilitate quick orientation.

After tying the prosthesis in place, the graft is cut to appropriate length and the position of the left coronary orifice is assessed. A round hole is cut with a thermal cutter, reducing the fraying of the graft.

The left coronary is attached to the graft with a running 4-0 or 5-0 suture under continuous retrograde coronary perfusion. This can be interrupted to improve vision. Reinforcement with Teflon felt or pericardium is necessary only in Marfan and connective tissue disorders.

The exact positioning of the opening for right coronary artery is much more critical than the one for the left, because the right ventricle distends and rolls over the graft when the heart resumes action. A short clamping of the venous line helps to establish the position of the coronary opening in the graft.

The same technique is applied for the right coronary artery, keeping continuous retrograde coronary perfusion.

This suture is performed during rewarming, with retrograde warm blood reperfusion already initiated. A small 4-0 needle is used for a continuous stitch; wall reinforcement can be necessary in acute dissection or connective tissue disorders.