The ascending aorta is cross-clamped using a trans-thoracic aortic cross clamp inserted previously through the axillary chest wall. An aortic root infusion of cold crystalloid cardioplegia is given to affect cardiac asystole and myocardial protection. Thereafter, the aorta is retracted toward the incision with sutures. Throughout the arrest period, the pericardial well is irrigated with saline. To maintain a clear operative field, a left ventricular vent is positioned through the right superior pulmonary vein.

After a transverse aortotomy has been made, we place three commissural sutures to retract and expose the aortic valve annulus. Robotic scissors and forceps are inserted through the pre-placed trocars. Then, the surgical cart of daVinci™ Surgical System (Intuitive Surgical Inc., Sunnyvale, CA) is docked to these instruments, and the aortic valve is excised (Fig. 26.2). Any calcific debris is removed by irrigation and suction. Using a robotic needle holder, we place 12 subannular pledgeted 2/0 Ethibond sutures (Ethicon, Somerville, NJ) around the annulus (Fig. 26.3). Care is taken to arrange sutures in an organized fashion around the incision. Suture guides are helpful for this purpose (Fig. 26.4). Thereafter, sutures are passed through the sewing ring of the prosthesis, which then is seated at the annulus (Fig. 26.5). All knots are tied by the tableside assistant and secured in place with a knot pusher. De-airing is done through a vent placed in the ascending aorta and is facilitated by filling the ventricle and ventilating.