Partially transect the aorta in a horizontal fashion 1.5 to 2 cm above the right coronary. Looking inside the aorta, extend the incision to the left ending 1.5 to 2 cm above the left coronary ostia, and to the right, ending 1.5 to 2 cm above the left non-coronary commissure post. Tack back the ascending aorta for visualization. Visualize the root and pathology, determine the number of commissures and their symmetry.
Place stay sutures through the commissures if desired for visualization.
If the aortotomy is too low, close the first incision, and make a second transverse incision at a more distal site. Locate the patient's left-right commissure and use this as the point of origin for implantation. If calcification of the aortic wall is extensive in the area underneath the coronary ostia, it may be necessary to implant the Freestyle bioprosthesis using a full root technique. If the calcium is limited to the annulus and other areas of the aortic wall, sutures can be taken completely through the Freestyle bioprosthesis and native aortic wall. The sizer need not pass through the annulus into the ventricle.