Composite Aortic Root Replacement Research Articles

Giant Morgagni Hernia and Aorto-Pulmonary Collaterals in a Loeys-Dietz Patient Undergoing Surgery for Aortic Root Aneurysm and Mitral Valve Prolapse.

The case of a Loeys-Dietz Syndrome patient undergoing mitral valve repair and composite aortic root and valve replacement is here described: pre-operative CT scan unraveled a previously misdiagnosed Morgagni hernia (anterior diaphragmatic), containing omentum only, compressing the right ventricle. Intra-operatively, an abnormal oxygenated blood backflow into the left ventricle was observed, post-operatively found to be caused by major aorto-pulmonary collateral arteries. This is the first case of Morgagni hernia and systemic-pulmonary shunt ever reported associated with Loeys-Dietz Syndrome. These congenital features may be important in both phenotyping and surgical management.

Contemporary outcomes of composite aortic root replacement in elderly patients.

We investigated the clinical and haemodynamic outcomes in elderly patients undergoing composite aortic root replacement. Between 2005 and 2017, 135 patients underwent aortic root surgery at our hospital. Of these 135 patients, 47 patients aged ≥65 years were included in this study. Pathologies included aneurysms in 31, chronic aortic dissection in 6, acute aortic dissection in 4 and other causes in 6 patients. A bioprosthesis was used in 27 and a mechanical valve in 20 patients. The mean age was 71.0 ± 4.3 years. The mean follow-up period was 61 ± 35 months. Follow-up echocardiographic data (average 48 months after surgery) were collected in 35 patients (74%). The in-hospital mortality rate was 2.1% (1 patient). Seven late deaths occurred during follow-up. The 1-, 5- and 8-year overall survival was 93.6%, 82.9% and 82.9%, respectively. Infective endocarditis, Marfan syndrome and diabetes were independent predictors of poorer survival. During the follow-up, thromboembolism occurred in 1 patient, major bleeding events in 5 patients, or proximal reoperation for prosthetic valve endocarditis in 1 patient. The type of valve, mechanical or biological valve, did not affect late mortality and morbidity. Follow-up echocardiography revealed significantly improved left ventricular ejection fraction compared with that at discharge. Composite aortic root replacement provided satisfactory midterm outcomes in patients aged ≥65 years. Further studies with a longer follow-up are warranted to evaluate late valve-related events.

A systematic review and meta-analysis of mechanical vs biological composite aortic root replacement, early and 1-year results.

Composite aortic root replacement is a standard procedure for various aortic root pathologies. This systematic review was set to identify the postoperative outcomes for composite mechanical root replacement (mCRR) compared to composite biological root replacement (bCRR). We systematically reviewed four major databases for all papers assessing outcomes in composite root replacement. Articles selected were chosen by two reviewers. Amongst our inclusion and exclusion criteria, all pediatric populations were excluded as were studies with a cohort less than 50 patients. We identified seven studies that conformed to our inclusion criteria and incorporated 2240 patients. In-hospital mortality was higher but non-significant in the mechanical group (6.1 vs 4.2% respectively). There was no significant difference demonstrated in the risk of in-hospital stroke, late stroke and re-operation in either groups. Additionally, there was no significant difference in: endocarditis, 1-year mortality, 5-year mortality, mean cardiopulmonary or aortic cross-clamp time. Composite mechanical root offers no superiority to composite biological root. There is a significant increase in the perioperative bleeding amongst composite mechanical root cohort. There is a need for further randomized control trail to assess the efficacy of either methods.

Transcatheter Closure of Aortic Anastomosis Leak Resulting in Patent Cabrol Shunt After Aortic Replacement

A 50-year-old woman with aortic valve stenosis and ascending aorta dilatation underwent composite aortic valve and root replacement (the Bentall’s & Cabrol’s procedure) 8 months before. During the follow-up, computed tomography angiography demonstrated a 4-mm × 7-mm oval leak at the distal

Aortic Root Replacement for Children With Loeys-Dietz Syndrome

Loeys-Dietz syndrome (LDS) is an aggressive aortopathy with a proclivity for aortic aneurysm rupture and dissection at smaller diameters than other connective tissue disorders. We reviewed our surgical experience of children with LDS to validate our guidelines for prophylactic aortic root replacement (ARR). We reviewed all children (younger than 18 years) with a diagnosis of LDS who underwent ARR at our institution. The primary endpoint was mortality, and secondary endpoints included complications and the need for further interventions. Thirty-four children with LDS underwent ARR. Mean age at operation was 10 years, and 15 (44%) were female. Mean preoperative root diameter was 4 cm. Three children (9%) had composite ARR with a mechanical prosthesis, and 31 (91%) underwent valve-sparing ARR. Concomitant procedures included arch replacement in 2 (6%), aortic valve repair in 1 (3%), and patent foramen ovale closure in 16 (47%). There was no operative mortality.Two children (6%) required late replacement of the ascending aorta, 5 (15%) required arch replacement, 1(3%) required mitral valve replacement, and 2 (6%) had coronary button aneurysms/pseudoaneurysms requiring repair. Three children required redo valve-sparing ARR after a Florida sleeve procedure, and 2 had progressive aortic insufficiency requiring aortic valve replacement after a valve-sparing procedure. There were 2 late deaths (6%). These data confirm the aggressive aortopathy of LDS. Valve-sparing ARR should be performed when feasible to avoid the risks of prostheses. Serial imaging of the arterial tree is critical, given the rate of subsequent intervention.

Comparison of Quality of Life Perceived by Patients with Bioprosthetic versus Mechanical Valves after Composite Aortic Root Replacement

Objective: To assess whether postoperative quality of life (QOL) for composite aortic root replacement patients differs according to whether it is based on the use of mechanical valves or bioprosthetic valves. Methods: The study included 146 consecutive patients who underwent composite aortic root replacement at our institution from January 2010 to April 2014 with bioprosthetic (34.9%, n = 51) and mechanical (65.1%, n = 95) valves. Patient-perceived QOL was measured by administering the Short Form (SF)-36v2 Health Survey and a series of supplemental questions to further evaluate valve-specific differences. Final survey participation (n = 121) included 82.9% of the qualifying patients, and involved 76.5% (39/51) of those with bioprosthetic valves and 86.3% (82/95) of those with mechanical valves. Reasons for not completing the survey included 5 expired patients (3.4%), 1 lost due to a language barrier (0.7%), 6 who refused to participate (4.1%) and 13 who were lost to follow-up (8.9%). The mean follow-up time was 32 months (range 4-56 months). Results: Patients in the bioprosthetic valve group were older (mean age 67.5 ± 13.6 years) and included more females (25.6% or 10/39) than those in the mechanical valve group (mean age 56.6 ± 12.0 years; 11.0% or 9/82 were female). No significant differences were found between the bioprosthetic and mechanical valve groups for any QOL aspects scored by the SF-36v2 survey. All 8 domains and 2 summary scales comprising the QOL evaluation were above national norms calculated using gender- and age-matched, norm-based scoring for a standard national average of 50. The supplemental questions indicated satisfaction with each valve type despite characteristics that were of concern to patients. In the mechanical valve group, 90.2% (74/82) reported that the audible valve click was not troublesome, 85.4% (70/82) that taking a blood thinner regularly did not affect daily life and 81.7% (67/82) that blood testing for anticoagulation therapy was not troublesome. Conclusions: Receiving a tissue or a mechanical valve does not directly affect postoperative QOL. Answers to supplemental questions suggest that prior concerns with mechanical valves do not affect patients in the commonly anticipated negative manner. The preconception of a heavy QOL burden for mechanical composite grafts is contradicted by this study.

Proximal Redo after Acute Type A Aortic Dissection: Early Results form a Multicenter Experience

Objectives: The aim of this European multicenter-experience was to report on surgical outcomes in terms of mortality and complications of proximal reoperation after intial repair of acute typ A dissection (AAD). Methods: Between May 1998 and January 2014, 71 isolated proximal aortic re-operation (mean time from the first procedure was 3.67 years, range 0.15–16.6) were performed in 66 patients (mean age 60.8 ± 12.4 years, males 50). Proximal causes for re-operation were aortic root aneurysm in 17, root re-dissection in 13, aortic valve insufficiency in 24 and proximal anastomic pseudoaneurysm in 19 patients. Result: The most frequent proximal procedure during redo was the composite aortic root replacement (Bentall procedure) (40 operations, 56.35%), followed by isolated aortic valve replacement (13 pts., 18,31%) and ascending aorta replacement (9 pts., 12,68%). David procedure was performed in 4 patients (5.63%). In-hospital mortality was 14% (10 pts.), of them 7 deaths were reported after emergency operations and 3 in elective or urgent setting. Causes of deaths were cardiac in 5, neurological in 2, MOF in 3. Major adverse event included low output syndrome in 7, neurological complications in 7, acute renal failure 7 and bleeding complications in 10 patients and lung failure in 5 patients. Conclusion: Proximal re-operations can be performed with acceptable in-hospital results. Thus conservative approach of the proximal aorta for AAD should not be considered a concern for late reoperations. Strict follow-up after AAD is mandatory to avoid emergency re-operations.

Postoperative Electrocardiogram in a Man with the Marfan Syndrome

A 53-year-old man with the Marfan syndrome had undergone aortic valve replacement with a Bjork-Shiley prosthesis for aortic regurgitation at another hospital 15 years earlier. At the same operation he had a Kay-type suture plication tricuspid annuloplasty of the posterior-septal commissure. He came to the cardiology clinic for preoperative clearance for inguinal hernia repair. An aortic regurgitation murmur was noted, and he admitted to exertional dyspnea. An electrocardiogram showed sinus rhythm, a normal P-R interval, and right bundle branch block. An echocardiogram revealed a dilated ascending aorta, severe aortic regurgitation due to a perivalvular leak, normal left ventricular systolic function, and pulmonary arterial hypertension with tricuspid regurgitation and a large right ventricle. Because of these findings he underwent a Cabrol procedure, i.e., a composite aortic valve and root replacement with reimplantation of the coronary arteries, and tricuspid valve replacement. Mechanical valves were used in both the aortic and tricuspid positions. A postoperative electrocardiogram showed sinus arrhythmia, at a rate of 88 beats/minute, that was completely dissociated from a regular, accelerated junctional rhythm, at a rate of 67 beats/minute, with right bundle branch block and left anterior fascicular block (Figure). Alternatively, the subsidiary pacemaker could have been in the left posterior fascicle. Many of the P waves were positioned where they would be expected to be conducted to the ventricles, but the perfectly regular ventricular rhythm indicated that none were. Thus, there was some degree of atrioventricular block. The relatively rapid subsidiary pacemaker may have contributed to the complete atrioventricular dissociation, and the atrioventricular block may have not been complete. Marriott has referred to this as “block-acceleration dissociation” (1). Figure Electrocardiogram recorded in the early postoperative period. See text for explication. Aortic valve replacement requires the surgeon to operate in close proximity to the atrioventricular conduction tissue (2). As a consequence, atrioventricular block and/or an accelerated junctional rhythm may develop, and the chances of this are greater if, as in this patient, the anatomy has been distorted by a prior operation. The rhythm disturbance in this patient is a combination of the two, i.e., a conduction disturbance in combination with increased automaticity. Other conditions, such as inferior myocardial infarction or digitalis toxicity, also may produce block-acceleration atrioventricular dissociation (1). Complete atrioventricular block is virtually never persistent in patients with inferior myocardial infarction or digitalis toxicity, and consequently these patients do not require permanent electronic pacing. In contrast, complete atrioventricular block developing after aortic valve surgery may be persistent, and those patients require permanent pacing (3, 4).

Failed Autograft After the Ross Procedure in Children: Management and Outcome

Autograft dilatation (AD) and aortic insufficiency (AI) after the Ross procedure are the most common causes of late autograft failure. The purpose of this study was to examine the results of valve-sparing root replacement (modified David) and composite root replacement. We performed a retrospective review of all children (n=78) undergoing a Ross procedure at our Center from 1993 to 2011. Median follow-up was 10 years (1to 18 years). Freedom from autograft reoperation was 94% at 5 years, and 65% at 15 years. Freedom from greater than 2+ autograft AI was 93% at 5 years and 76% at 15 years. Autograft reoperation was necessary in 22 patients, at a median interval of 8.7 years after the original procedure. Indications for reoperation were AI with autograft dilatation in 15 patients, AI without dilatation in 2 patients, and AD without AI in 5 patients. Surgical procedures used at reoperation included valve-sparing root replacement in 14 patients, root replacement either mechanical or biologic valved conduit in 6 patients, and valve replacement in 2 patients. At a mean follow-up of 5.8 years after reoperation, 4 patients from the valve-sparing group underwent second reoperation (valve replacement). Freedom from second autograft reoperation was 71% for patients after a valve sparing procedure and 100% for patients after an aortic valve or root replacement (Bentall procedure) at 5 years. Autograft valve-sparing root replacement and composite aortic root replacement are effective treatments for aortic root dilation and AI after the Ross procedure. The potential of late autograft insufficiency after valve-sparing root replacement warrants annual follow-up.

Longevity after mechanical aortic root replacement—do men live longer?

To investigate whether longevity after mechanical aortic root replacement is influenced by the patient's gender. From February 1998 to June 2011, 476 patients (376 men, 100 women, mean age, 53±12 years; range, 18-88) underwent composite aortic root replacement. Of these patients, 398 (312 men) were included in the present analysis. The indications for root replacement were aortic valve dysfunction (mostly stenosis) and concomitant aneurysmal disease in 334 (83.9%), acute type A aortic dissection in 51 (12.8%), and infective endocarditis in 10 (2.5%). Other indications were technical or anatomic considerations (0.8%). The women who presented for surgery were significantly older (men, 52±12 years vs women, 56±12 years; P=.01). However, no significant differences were found with regard to previous cardiac surgery (5.3%, 20 men [6.4%] vs 1 woman [1.2%]; P=.06), concomitant procedures (38%; 117 men [37.5%] vs 35 women [40.7%]; P=.62), or additive EuroSCORE (men, 5.1±2.2; women, 5.2±2.2; P=.55). The mean diameter of the ascending aorta was not significantly different between the 2 groups (men, 54±9 mm; women, 56±14 mm; P=.97). The median follow-up period was 7.4 years (range, 0-13; 2366 cumulative patient-years), with no significant difference in hospital mortality (men, 6.7% vs women, 10.5%; P=.25). Overall, men enjoyed significantly better longevity than did women. After 10 years, 73%±3% of the men and only 60%±6% of the women were alive (P=.03). Although no long-term survival benefit for either gender was found in an age-matched subgroup among young patients (P=.66), men experienced much more favorable longevity after 55 years of age (P=.04). Consequently, the longevity in men-but not in women-was equal to an age-matched normal population. Overall, long-term survival after mechanical aortic root replacement was significantly better among men. However, comparing age-matched subgroups≤55 years old, no significantly different life expectancy was found after mechanical root replacement.

Homografts for the management of graft infections in the ascending aortic position

We read with great interest the article by Khaladj et al. [1] describing their experience with cryopreserved homografts for the management of a severe complication following reconstructive surgery on the ascending aorta and aortic arch, namely prosthetic graft infection. However, we would like to add some comments on the topic. According to their institutional policy, all patients with infected grafts of their ascending aorta, where the aortic arch was also involved, were treated by removal and replacement of the prosthetic material with homografts. Historically, replacement of infected thoracic aortic graft has been reported by individual surgeons, however, with unsatisfactory results. Hospital mortality rates have been as great as 46% [2] typically resulting from the invasiveness and complexity of the procedure, emergency conditions, contaminated field and the difficulties of exposure in the redo aortic setting. Our group, as others [3] too, experienced exceptionally disappointing results following the principle of redo ascending/arch prosthetic graft replacement, due to uncontrollable infective process. We congratulate the outstanding work of Khaladj et al. [1] from Hannover, who reported in their explants series a hospital mortality rate of 24%. This is the largest single-centre experience published so far treating 17 patients with cryopreserved homografts in the ascending/arch and aortic root. However, surgical mortality and morbidity are still a major concern with this aggressive treatment strategy. Moreover, there are no surgical guidelines on proper surgical management for such cases. Other strategies that have been applied in the surgical treatment of ascending/arch prosthetic graft infection are based on the principle of a more conservative, non-resectional, and thus, graftsparing surgical approach [2–6]. It is well documented that many institutions have switched during the last decades to this so-called ‘in situ preservation’ concept performing debridement of perigraft-infected mediastinal tissue, open surgical disinfection and transposition of viable omentum, as suggested by Hargrove and Edmunds [4] and Coselli et al. [5], with excellent clinical results. We were, therefore, surprised to read that ‘the use of omentum has not been evaluated for ascending aortic graft infections’. The literature certainly provides sufficient information concerning the role of this method which is feasible, safe and highly effective in controlling thoracic aortic prosthetic graft infection with superior outcomes when compared with traditional redo ascending/arch prosthetic graft replacement [2–6]. Inspired by a case we treated successfully with open surgical disinfection followed by omentum flap coverage after the Bentall operation and total aortic arch replacement, we reviewed the literature and recognized 77 similar cases for the treatment of infected ascending/arch prosthetic grafts with a collective early survival rate of 95% and a 100% success rate in terms of non-recurrence of graft infection [2–6]. Many of these patients with ascending aortic grafts also received an arch graft, composite valve graft or separate aortic valve prosthesis. We think, as other authors [2–6] too, that the dogma of the need for removal and replacement of the prosthetic graft is unjustified, at least in certain patients with ascending/arch prosthetic graft infection, even after composite aortic root replacement, as long as the infection is not associated with native or prosthetic aortic valve endocarditis or valve dysfunction. The present evidence and knowledge on current preservation strategies has the potential to spare patients high-risk procedures and higher mortality.

Repair of Aortic Regurgitation due to Takayasu Arteritis

Prosthetic valve detachment after aortic valve replacement and pseudoaneurysm formation are the most important postoperative complications in patients with Takayasu arteritis with aortic regurgitation. We reviewed our experience of surgical treatment of aortic regurgitation in patients with Takayasu disease. Between November 1997 and September 2011, 11 patients (4 women and 7 men) with Takayasu arteritis with aortic regurgitation underwent surgical treatment. The age of the patients ranged from 26 to 56 years (mean, 40 ± 9 years). Primary isolated aortic valve replacement was performed in 1 patient, David procedure in 1 patient, Wheat procedure in 1 patient, Bentall procedure in 2 patients, and Cabrol procedure in 6 patients (including 2 patients who underwent primary aortic valve replacement in other hospitals before being admitted to our surgical team). There was no in-hospital death. All patients had an uneventful recovery during the postoperative course and were discharged. Prosthetic valve detachment, pseudoaneurysm formation at the suture line, and dilatation of the ascending aorta were not found in patients with composite aortic root replacement during a mean follow-up of 98 ± 45 months. One patient died during follow-up. Valve detachment after composite aortic root replacement was not observed in patients with Takayasu disease with aortic regurgitation. Satisfactory surgical outcomes were obtained using composite aortic root replacement. However, close follow-up was needed to assess the effectiveness of the Cabrol procedure in patients with Takayasu disease with aortic regurgitation.

Biological composite aortic root replacement: A single center experience of 310 consecutive patients

Biological composite aortic root replacement: A single center experience of 310 consecutive patients

Calculative prosthesis-patient mismatch after mechanical composite aortic root replacement: Does size really matter?

Objective: The impact of prosthesis-patient-mismatch (PPM) on outcome after mechanical composite aortic root replacement has not been previously investigated.

Myocardial infarction in non-dissecting aortic root aneurysm

We describe a case of a 49-year-old man who presented with an uncomplicted aortic root aneurysm, aortic insufficiency, and ST-elevation myocardial infarction (STEMI) without obstructive coronary artery disease on angiography. The computed tomo- graphy angiogram (CTA) of the thorax, performed without cardiac gating, was misinterpreted as normal. In retrospect, an overlooked extravasation of contrast material lateral to the aortic root was detected on non-gating magnetic resonance angiography (MRA). Exploration of the aortic root revealed an unsuspected horizontal intimal tear of the left sinus of Valsalva with limited extramural hematoma. The presence of an otherwise silent intimal tear on preoperative imaging studies makes the overall management more problematic. For example, initiating early broad empirical anticoagulants or fibrinolytics therapy to treat the accompanied myocardial infarction may extend the tear into a full life-threatening aortic dissection, tamponade or rupture. We highlight many of the difficulties associated with the diagnosis and treatment of limited sinus tear when aortic root aneurysm is presenting with cryptogenic STEMI. Accurate morphologic characterization of intimal tear would be best defined with either an electrocardiogram-gating CTA or MRA imagings. These non-invasive tests are needed to make appropriate management decisions. Depending on other pathologic components of aortic root, cusps and the commissural geometry, sinus tear is a critical component for the overall treatment plan and it shifts the surgical intervenetion from valve-sparing operation, commissural resuspension and leaflet repair to composite aortic root replacement (modified version of the Bentall procedure).

Composite Aortic Root Replacement for Complex Prosthetic Valve Endocarditis: Initial Clinical Results and Long-Term Follow-Up of High-Risk Patients

Little information is available regarding the clinical and long-term results of patients with complex prosthetic valve endocarditis (PVE) involving the aortic root who undergo root replacement based on the Cabrol or Bentall procedures. Between January 2007 and December 2011, 148 patients underwent cardiac operations for PVE. The analysis included 31 patients with complex PVE and concomitant destruction of the aortic root. Of these, 13 patients were treated by the Cabrol procedure and 18 patients by the Bentall procedure. The mean EuroSCORE for mortality was 50.7%±3.8%. Mean follow-up was 3.8±0.4 years (range, ≤8.0 years), with a total of 97 patient-years. The observed 30-day mortality was 12.9% and 5-year survival was 75.3%. The most common cause of death was septic multiple organ failure (42.9%). Independent predictors of mortality in multivariate analyses were terminal renal failure (odds ratio [OR], 4.8; p<0.01), type 2 diabetes mellitus (OR, 4.6; p<0.01), postoperative renal failure (OR, 4.0; p<0.01), and staphylococcal infection (OR, 2.1; p=0.01). The prevalence of freedom from reinfection was 100.0% and that from valve-related events was 93.5%. Complex PVE is associated with quite high mortality and morbidity. Composite aortic root replacement provided good clinical and long-term outcomes as well as a low prevalence of reinfection and valve-related events. These results seem not to be inferior to those reported for noncomplex PVE. If the Bentall "button" technique was not feasible, the Cabrol procedure also provided excellent results.

Are Thromboembolic and Bleeding Complications a Drawback for Composite Aortic Root Replacement?

Valve-preserving aortic root reconstruction is being performed with increasing frequency. Independent of durability concerns, enthusiasm for retaining the native valve is often championed on the presumption that composite graft replacement of the aorta will be complicated by thromboembolism and bleeding. Our goal in this late follow-up study is to determine if thromboembolism or bleeding, or both, are indeed problematic after composite aortic root replacement. Between 1995 and 2011, 306 patients (mean age, 56±14 years) underwent composite graft replacement of the aorta. St. Jude mechanical valve conduits (St. Jude Medical, St Paul, MN) were used in 242 patients, and 64 received a biologic conduit. Long-term postoperative follow-up (mean, 56 months; range, 1 to 97 months) was performed through our Aortic Database, supplemented by patient interviews and use of the Social Security Death Index. Hospital mortality was 2.9% overall and 1.4% in the last 8 years. Kaplan-Meier curves showed freedom (±standard deviation) from bleeding, stroke, and distal embolism as 94.3%±1.7% at 5 years and 91.3%±2.4% at 10 years. Survival was 93.5%±1.8% at 5 years and 80.9%±4.6% at 10 years, which was not statistically different from that for an age- and sex-matched population in Connecticut. Freedom from reoperation of the aortic root was 99% at 10 years. Patients had excellent survival and few thromboembolic and bleeding complications after composite aortic root replacement. These data supporting minimal morbidity in the setting of well-established durability should be used to put alternative procedures, such as valve-preserving aortic root reconstruction, into context.

Redo Autograft Operations After the Ross Procedure

Autograft dilatation after the Ross procedure is the most common cause of late autograft failure. We looked at results after reoperation for autograft dysfunction using autograft sparing and composite root replacement techniques. Data were abstracted from our prospectively collected Ross registry for 160 consecutive patients who underwent a Ross procedure by a single surgeon between 1994 and 2008. Follow-up records were obtained, and the last echocardiographic report after reoperation was analyzed. Autograft reoperation was necessary in 17 patients, at a median interval of 6.9 years after the original procedure. Indications for reoperation were insufficiency with autograft dilatation in 16 patients, and without dilatation in 1 patient. Surgical procedures used at reoperation included autograft reimplantation in 6 patients (35.3%), autograft remodeling procedure in 1 patient (5.9%), composite root replacement with mechanical valved conduit in 5 patients (29.4%), composite root replacement with biologic valved conduit in 3 patients (17.6%), and mechanical aortic valve replacement in 2 patients (11.8%). At a median follow-up of 5.0 years after reoperation, freedom from greater than 2+ aortic insufficiency was 100% (17 of 17 patients) in both reimplantation and replacement groups. There was 1 death after reoperation (at >14 years) related to complications from systemic lupus erythematosus. There have been no strokes after autograft reimplantation. Autograft valve reimplantation and composite aortic root replacement are effective treatments for aortic root dilatation and aortic insufficiency after the Ross procedure. Echocardiographic follow-up demonstrates reasonable short-term function after autograft preservation procedures.

Histological and genetic studies in patients with bicuspid aortic valve and ascending aorta complications

Aneurysm diameter and growing rate does not represent a definite parameter for operation in bicuspid aortic valve (BAV), ascending aortic aneurysm and normal root patients. Thus, we investigated histological and immunohistochemical aspects of different segments of ascending aorta (precisely, aortic root without dilatation, aneurysmatic tubular portion, dissected ascending aorta) and genetic features of patients with BAV and ascending aorta complication (aneurysm or dissection). Aorta tissue samples of 24 BAV patients were examined. The patients comprised of 18 men and 6 women; the mean age was 54.2 ± 14.3 years. All patients underwent composite aortic root replacement (button Bentall operation). Multiple histological sections were prepared from each aortic specimen. The evaluated features included elastic fibre fragmentation, cystic medial change, smooth muscle cell necrosis, medial fibrosis, and the markers of medial apoptosis and the metalloproteinases. Furthermore, genetic risk factors were also investigated. The same medial degenerative lesions in tissue samples of different aorta segments (precisely of aortic root without dilatation, and aneurysmatic ascending aorta portion) were observed. More significant associations between single nucleotide polymorphisms (-786T/C endothelial nitric oxide synthase enzyme, D/I angiotensin-converting enzyme, -1562C/T metalloproteinase-9 and -735C/T metalloproteinase-2) and aneurysm risk were detected in BAV patients than in controls. Based on our histological and genetic data, we underline that a surgical approach in patients with BAV, ascending aortic aneurysm and normal root, should consider not only the diameter of the aneurysmatic aortic portion but also the histological features of the whole ascending aorta and the genetic risk profile.

Aortic Pseudoaneurysm Complicated by Aortopulmonary Fistula

A 78-year-old woman presented with an abrupt onset of chest pain and dyspnea. Fourteen years before admission, she had undergone aortic root and valve replacement with the Bentall-de Bono continuous-suture wrap-inclusion technique because of an aneurysm of the ascending aorta and severe aortic valve regurgitation. Physical examination revealed signs of congestive heart failure and poor peripheral perfusion. The admission radiograph (Figure 1) showed lung congestion predominantly in the right lung, bilateral pleural effusion, elevation of the left hemidiaphragm, tracheal shift to the right side, and aortic arch calcification. The ECG (Figure 2) revealed sinus tachycardia at 111 bpm, frequent premature atrial beats, and repolarization …