The pulmonary root (which still contains the pulmonary valve at the base) is placed in the opening where the native aortic valve was removed at the outlet of the left ventricle. Because both the pulmonary and the aortic valve are attached to the wall in a coronal (crown-shaped) configuration, the pulmonary root must be oriented in such a way as to allow the coronary artery "buttons" to fit properly in the sinuses between commissures.

A strip of Teflon felt is incorporated into this crucial suture line to support the tissues, avoid bleeding, and provide fixation of the annulus diameter to avoid stretching in the future that might distort the base of the valve and cause it to leak. Between 35 and 50 "bites" are taken (1-1.5 mm apart) to attach the autograft securely. After all the stitches are placed, they are carefully tightened with little hooks and tied securely.

The new valve can be filled with saline solution to test gross competence and inspected to make sure all the sutures are tight.