Undersizing will result in valvular incompetence. After tying the proximal suture line, each commissural post of the bioprosthesis is held in place with a single horizontal mattress 4-0 polypropylene suture. This maneuver ensures proper positioning of the commissural posts to achieve excellent coaptation of the aortic cusps and avoids occlusion of the coronary ostia. The distal suture line is a running 4-0 polypropylene suture that extends from the nadir of each cusp outward to the tip of each commissural post. It is this distal suture line that bears the stress of the valve closure.
Care is taken to avoid obstruction of the coronary ostia.
A full thickness of aortic wall is sutured to the bioprosthetic valve to prevent paravalvular leak. The aortic wall is lifted and kept on tension and the valve is pushed down while placing this suture line. De-airing is performed followed by removal of the aortic crossclamp. The patient is gradually wean off cardiopulmonary bypass, then decannulation is effected. Atrial and ventricular wires are placed.