Re-operative hemi-commando operation without a homograft: an alternative approach for complex aortic root abscess

Re-operative management of a failing aortic homograft presents substantial technical challenges due to progressive calcification of the valve leaflets, annulus, coronary button attachments and surrounding aortic root structures. In this video tutorial, we demonstrate the explantation of a heavily calcified 21-mm aortic homograft and performance of a redo aortic root replacement using a handmade composite Bentall graft with a 25-mm bioprosthesis and 28-mm straight Dacron graft. A 73-year-old man, 23 years post-homograft root replacement, presented with torrential aortic regurgitation and a small, densely calcified aortic root. Following redo sternotomy and cardiopulmonary bypass initiation, the homograft was meticulously debrided with careful preparation of the coronary buttons, which required extensive decalcification. A composite graft was created with a tailored skirt to accommodate upsizing of the valve despite the small native annulus. Reimplantation of the left coronary button was performed, followed by distal aortic anastomosis. After removing the aortic cross-clamp, the anastomotic site of the right coronary button anastomosis was identified. The aorta was cross-clamped again, and the right coronary button was anastomosed.