Arch Surgery Research Articles

An Alternative Technique for Ascending and Arcus Aorta Repair in Case of Vascular Diameter Mismatch

Complicated Type A intramural hematoma involving the arcus aorta requires emergency correction of the aortic arch. Surgical options include reimplantation of the brachiocephalic vessels as an island to a vascular graft, debranching aortic arch surgery, and Kazui technique. This report describes a modified technique for aortic arch repair in a patient with vascular diameter mismatch between the ascending and descending aorta, as well as an intimal tear between the brachiocephalic vessels.

Endovascular management of chronic post-dissection aneurysms of the aortic arch.

This article reviews endovascular management of chronic post-dissection aneurysms of the aortic arch. Therapeutic strategies intended for this complex aortic condition are evolving rapidly to allow the treatment of various hostile aortic anatomy and frail patients. Principles, technical considerations, devices and outcomes of each technique are reviewed and summarized. Hybrid repair offer similar early mortality and stroke rates compared to open conventional surgery. Arch chimney and other parallel graft techniques present poor long term outcome, and should be limited to emergency situations where no other option is available. Fenestrated stent-grafting is subjected to many technical challenges in aortic arch due to difficulties in stent-graft orientation and fenestration positioning. In situ fenestration is an off-label technique that should only be used as an emergency bailout maneuver, considering that temporary coverage of supra aortic trunk vessel and its long-term durability raise concern. Finally, in experienced hands and appropriate anatomic conditions, arch branched graft technology has shown itself to be a safe and effective alternative to open conventional surgery. No randomized controlled trials have yet compared total endovascular aortic arch repair with hybrid techniques and open arch repair. The management of chronic post-dissection aneurysms of the aortic arch is challenging, decision-making and interventions should continue to be performed in high-volume centers with a dedicated aortic team with an expertise in both open and endovascular repairs.

Intrathoracic right subclavian artery cannulation in aortic arch surgery.

Intrathoracic right subclavian artery cannulation in aortic arch surgery.

Arch Surgery for Type Ia Endoleak: How to Remain Normothermic and Avoid Circulatory Arrest

Type Ia endoleak after thoracic endovascular aortic repair is an ominous complication that requires an aggressive treatment. Total arch replacement with a distal suture taking the native distal aorta, the stent graft, and the arch graft, by allowing a perfect closure of the proximal endoleak, represents the most common treatment in this setting. Nevertheless, such intervention continues to carry significant mortality and morbidity that are mostly related to prolonged extracorporeal circulation time and hypothermic circulatory arrest. Here, we present a technique for total arch replacement that, with the use of stent graft balloon endoclamping, avoids both hypothermia and circulatory arrest.

Surgery of ascending aorta with complex procedures for aortic dissection through upper mini-sternotomy versus conventional sternotomy

BackgroundUse of minimally invasive approaches for isolated aortic valve or ascending aorta surgery is increasing. However, total arch replacement or aortic root repair through a minimally invasive incision is rare. This study was performed to report our initial experience with surgery of the ascending aorta with complex procedures through an upper mini-sternotomy approach.MethodsWe retrospectively analyzed 80 patients who underwent ascending aorta replacement combined with complex procedures including hemi-arch, total arch, and aortic root surgeries from September 2010 to May 2018. Using standard propensity score-matching analysis, 36 patients were matched and divided into 2 groups: the upper mini-sternotomy group (n = 18) and the median sternotomy group (n = 18). The preoperative assessment revealed no statistically significant differences between the two groups.ResultsHospital mortality occurred in one patient (2.8%). The mini-sternotomy group showed a longer cross-clamping time (160 ± 38 vs. 135 ± 36 min, p = 0.048) due to higher rate of valve-sparing aortic root replacement and total arch repair. The cardiopulmonary bypass time in mini-sternotomy group was shorter than that of full sternotomy group (209 ± 47 min vs 218 ± 62 min, p = 0.595) but fell short of significance. There was no significant difference in lower body hypothermia circulatory arrest time between the two groups (40 ± 10 min vs 48 ± 20 min, p = 0.139). The upper mini-sternotomy group displayed a shorter ventilation time (22 vs. 45 h, p = 0.014), intensive care unit stay (4.6 ± 2.7 vs. 7.9 ± 3.7 days, p = 0.005), and hospital stay (8.2 ± 3.8 vs. 21.4 ± 11.9 days, p = 0.001). The upper mini-sternotomy group showed a lower postoperative red blood cell transfusion volume (4.6 ± 3.3 vs. 6.7 ± 5.7 units, p = 0.042) and postoperative drainage volume (764 ± 549 vs. 1255 ± 745 ml, p = 0.034). The rates of dialysis for newly occurring renal failure, neurological complications, and re-exploration were similar between the two groups (p = 1.000).ConclusionThe upper mini-sternotomy approach is safe and beneficial in ascending aorta surgery with complex procedures for aortic dissection, including total arch replacement and aortic root repair.

TİP-A AORT DİSSEKSİYONU CERRAHİ TEDAVİSİNDE ANTEGRAD VE RETROGRAD SEREBRAL PERFÜZYONUN KARŞILAŞTIRMASI

OBJECTIVES:
 Substantial improvement has been observed in the surgical treatment of Type-A aortic dissections in parallel with the developments in cerebral perfusion techniques. Introduction of antegrade (ACP) and retrograde (RCP) cerebral perfusion techniques with deep hypothermic total circulatory arrest (HTCA) significantly decreased neurological complications which are the most important cause of morbidity and early mortality. The incidence of temporary (TND) or permanent neurological dysfunction (PND) is still between 5.5 – 33.3%. The cerebral perfusion method is effective on this ratio, as well as factors such as age, presence of co-morbidities, emergency, diameter of the aortic arch and the ascending aorta segment that is replaced. 
 METHODS:
 In this study we have compared the operative and clinical outcomes of patients with Stanford Type-A dissection whom we operated by using antegrade and retrograde cerebral perfusion. We have also investigated which perfusion method is superior to the other, the determinants of mortality and complication rates according to the groups in order to find the determinants of mortality, and to evaluate the complication rates. The data of 115 patients who were operated for acute, subacute or chronic Stanford Type A dissection and intramural hematoma (IMH) between January 2001 – March 2013 were retrospectively evaluated.
 RESULTS: 
 No significant differences in CPB, XC, TCA, ACP, total amount of post-operative drainage, requirement of blood products, ventilation time, duration of ICU stay, hospital stay, and early mortality rates were found in our evaluation of findings and outcomes of patients in whom we either used the ACP or the RCP technique. In the multivariate analysis determinants of mortality were preoperative presence of hypertension, diabetes mellitus, extremity malperfusion, duration of CPB, and postoperative renal complications.
 CONCLUSIONS: 
 The results of our study and results of others in the medical literature regarding techniques for brain protection in open ascending and aortic arch surgery have suggested that the most effective approach to decrease the neurological complications and to obtain better outcomes may be to decrease the duration of perfusion to the possible extent.

Skeletal congenital abnormalities induced by nickel chloride hexahydrate on Balb/C albino mice embryos during organogenetic period

Nickel is an essential metal, and its compounds are widely used in industry and commerce. The development of industrialization has led to increased emission of nickel into environment causing teratogenesis in the developing embryos. This study aimed to investigate the toxic and teratogenic effects of nickel on Balb/C albino mice embryos during organogenetic period. This study was carried out on forty pregnant female albino mice; they were randomly divided into four equal groups: group I (control group) received distilled water; groups II, III, and IV (experimental groups): each group contains ten mice received 46.125 mg, 92.25 mg, and 184 mg Ni/kg body weight, per day, respectively, by orogastric tube for successive 8 days started from the 6th gestational day. The extracted lived fetuses were examined externally then double-stained and prepared for skeletal examination by dissecting microscope. The numbers of live-birth pups decreased significantly (p value for comparing between control and each other group, statistically significant at p ≤ 0.05). But there was significant increase in resorption sites in all nickel-treated groups compared to control group. Total number of resorption sites in all nickel-treated groups is 28: 15 resorption sites are present at left horn and 13 in the right horn. At the same time, there was significant increase in stillbirth fetuses in group IV. Double-stained fetal skeleton showed incomplete ossification of skull bones, unossified interparietal bone, open arch of atlas, incomplete ossification of vertebrae, supernumerary lumbar rib, incomplete ossification of ribs and sternebrae, incomplete ossification of bones of forelimb, incomplete ossification of bones of hindlimb, unossified carpals, metacarpals, tarsals, metatarsals, and phalanges in nickel-treated groups, compared to control group. Nickel results in number of skeletal congenital abnormalities indicating its teratogenic effect.

MHCA with SACP versus DHCA in Pediatric Aortic Arch Surgery: A Comparative Study

The safety and efficacy of selective antegrade cerebral perfusion (SACP) in children undergoing aortic arch surgery are unclear. In this retrospective analysis, we compared moderate hypothermic circulatory arrest (MHCA; n = 61) plus SACP vs deep hypothermic circulatory arrest (DHCA; n = 53) in children undergoing aortic arch surgery during a period from January 2008 to December 2017. Demographic characteristics and the underlying anomalies were comparable between the two groups. The MHCA + SACP group had shorter cardiopulmonary bypass (CPB) time (146.9 ± 40.6 vs 189.6 ± 41.2 min for DHCA; p < 0.05) and higher nasopharyngeal temperature (26.0 ± 2.1 vs 18.9 ± 1.6 °C; p < 0.01). The MHCA + SACP group had lower rate of neurologic complications (3/61 vs 10/53 for DHCA; p < 0.05) but not complications in other organ systems. The MHCA + SACP group also had less 24-hour chest drainage (median, interquartile rage: 28.9, 12.6–150.0 vs 47.4, 15.2–145.0 ml/kg for DHCA; p < 0.05), shorter duration of postoperative mechanical ventilation (35.0, 15.4–80.3 vs 94.0, 42.0–144.0 h; p < 0.01), and shorter stay in intensive care unit (3.9, 3.0–7.0 vs 7.7, 5.0–15.0 d; p < 0.05). In regression analysis, in-hospital mortality was associated with longer CPB time. In conclusion, MHCA + SACP is associated with better short-term outcomes in children receiving aortic arch surgery under CPB.

Incidence of permanent pacemaker implantation after valve replacement surgery

Our study aimed to explore the incidence and risk factors of permanent pacemaker implantation (PPI) after valve replacement surgery (VR). The influence of long-term pacemaker dependency on cardiac structure and function at the 1‑year follow-up was also assessed. The demographic and surgical data of all consecutive patients who underwent VR between 2013 and 2016 were collected. Univariate and multivariate analyses were performed to identify variables independently associated with PPI after VR. A 1‑year follow-up was undertaken of patients who underwent dual-chambers pacemaker after VR because of complete atrioventricular block (AVB). Long-term pacemaker dependency and recovery of cardiac structure and function were evaluated. There were 5320 consecutive patients with VR. The incidence of postoperative PPI was 2.42%. Multivariate analysis indicated that among the 62patients who underwent PPI due to AVB and sick sinus syndrome, isolated aortic valve replacement (AVR; OR: 2.24, p < 0.05), VR combined with ventricular septal defect (VSD) repair (OR: 6.78, p < 0.05), and VR with aortic root and arch surgery (OR: 4.14, p < 0.05) were independent predictors of PPI after surgery. In total, 89.6% (43/48) of the survivors showed pacemaker dependency. Of these 43patients, 24 had enlarged left heart before VR. Compared with preoperative values, the left atrial and left ventricular end-diastolic diameter post-PPI decreased significantly, while left ventricular ejection fraction was not significantly different. Isolated AVR, VR concomitant with VSD repair, and VR with aortic root and arch surgery are independent predictors of PPI after VR. The majority of patients do not recover from AVB disorders and there is no significant negative effect on recovery of cardiac structure and function.

Utility of neuromonitoring in hypothermic circulatory arrest cases for early detection of stroke: Listening through the noise

ObjectiveStroke remains a potentially devastating complication of aortic arch intervention. The value of neurophysiologic intraoperative monitoring (NIOM) in the early identification of stroke is unclear. We evaluated the utility of NIOM for early stroke detection in aortic arch surgery. MethodsAcross 8 years at our institution, 365 patients underwent aortic arch surgery with hypothermic circulatory arrest, and 224 cases utilized NIOM. One patient was excluded for intraoperative death. In the remaining cohort, we reviewed the incidence, timing, and location of strokes, and the incidence and nature of NIOM alerts. ResultsHemiarch was performed in 154 patients and total arch replacement in 69 patients. Stroke occurred in 6.3% of all cases (14 out of 223), 15.9% of total arches (11 out of 69), and 2.0% of hemiarches (3 out of 154). There were 33 NIOM alerts (14.8%), and 9 patients had both alerts and stroke. Of these, NIOM deficits plausibly correlated with imaging findings in 7 cases (78%). Of the 5 stroke patients without NIOM alerts, 2 developed neurologic symptoms 3 days or more postoperatively, and infarcts in 3 patients did not result in sensory or motor deficits. Excluding 2 patients with late stroke, the sensitivity of NIOM for stroke detection was 75%, specificity was 88.5%, positive predictive value was 27.3%, and negative predictive value was 97.4%. ConclusionsDespite a low positive predictive value requiring a high level of discrimination when interpreting abnormal findings, NIOM has high sensitivity and specificity for the early stroke detection. Furthermore, its high negative predictive valve is reassuring for low risk of stroke in the absence of alerts.

The impact of age on patients undergoing aortic arch surgery: Evidence from a multicenter national registry

ObjectiveElderly patients are typically offered aortic surgery at similar diameter thresholds as younger patients, despite limited data quantifying their operative risk. We aim to report the incremental risk experienced by elderly patients undergoing aortic arch surgery. MethodsIn total, 2520 patients underwent aortic arch surgery between 2002 and 2018 in 10 centers. Patients were divided into 3 groups: <65 years (n = 1325), 65 to 74 years (n = 737), and ≥75 years (n = 458). Outcomes of interest were in-hospital mortality, stroke, and the modified Society of Thoracic Surgeons composite for mortality or major morbidity (STS-COMP). Multivariable modeling was performed to determine the association of age with these outcomes. ResultsAs age increased, there was an increasing rate of comorbidities, including diabetes (P < .001), renal failure (P < .001), and previous stroke (P = .01). Rates of acute aortic syndrome (P = .50) and total arch repair were similar (P = .59) between groups. Older patients had greater mortality (<65: 6.1% vs 65-74: 9.0% vs ≥75: 14%, P < .001), stroke (6.3% vs 7.7% vs 11%, P = .01) and STS-COMP (25% vs 32% vs 38%, P < .001). After multivariable risk-adjustment, a step-wise increase in complications was observed in the older age groups relative to the youngest in terms of in-hospital mortality (65-74: odds ratio [OR] 1.57, P = .04; ≥75: OR, 2.94, P = .001) and STS-COMP (65-74: OR, 1.57, P < .001; ≥75: OR, 1.96, P < .001). ConclusionsOlder patients experienced elevated rates of mortality and morbidity following aortic arch surgery. These results support a more measured approach when evaluating elderly patients. Further research is needed on age-dependent natural history of thoracic aneurysms and size thresholds for intervention.

Outcomes of Concomitant Frozen Elephant Trunk (FET) in Aortic Arch Surgery in a Specialised Aortic Centre

Objective: FET is a relatively new technique which allows combined pathologies of the thoracic aorta to be treated in a 1 stage procedure using a hybrid surgical prosthesis. The purpose of this stu...

Maintaining the permanence principle for death during in situ normothermic regional perfusion for donation after circulatory death organ recovery: A United Kingdom and Canadian proposal.

There is international variability in the determination of death. Death in donation after circulatory death (DCD) can be defined by the permanent cessation of brain circulation. Post‐mortem interventions that restore brain perfusion should be prohibited as they invalidate the diagnosis of death. Retrieval teams should develop protocols that ensure the continued absence of brain perfusion during DCD organ recovery. In situ normothermic regional perfusion (NRP) or restarting the heart in the donor's body may interrupt the permanent cessation of brain perfusion because, theoretically, collateral circulations may restore it. We propose refinements to current protocols to monitor and exclude brain reperfusion during in situ NRP. In abdominal NRP, complete occlusion of the descending aorta prevents brain perfusion in most cases. Inserting a cannula in the ascending aorta identifies inadequate occlusion of the descending aorta or any collateral flow and diverts flow away from the brain. In thoracoabdominal NRP opening the aortic arch vessels to atmosphere allows collateral flow to be diverted away from the brain, maintaining the permanence standard for death and respecting the dead donor rule. We propose that these hypotheses are correct when using techniques that simultaneously occlude the descending aorta and open the aortic arch vessels to atmosphere.

Resuscitating the Chimney Graft to Innominate Artery for Straightforward Cannulation During Infancy

Arterial cannulation with a chimney polytetrafluoroethylene graft to the innominate artery is commonly used for antegrade cerebral perfusion during neonatal aortic arch surgery. When properly retained and prepared before sternal closure, resuscitation of the polytetrafluoroethylene graft to innominate artery can be performed months later during sternal reentry. It is a safe and reproducible technique for expeditious arterial cannulation at stage II palliation in single-ventricle patients or complete intracardiac repair of biventricular lesions. We report our experience utilizing this technique successfully during reoperation in 90 of 92 patients, with no adverse thromboembolic events identified.

Association Between D-dimer and Early Adverse Events in Patients With Acute Type A Aortic Dissection Undergoing Arch Replacement and the Frozen Elephant Trunk Implantation: A Retrospective Cohort Study.

ObjectiveIn the present study, we investigated the associations between D-dimer levels at admission and early adverse events in patients with acute type A aortic dissection undergoing arch replacement and the frozen elephant trunk (FET).MethodsWe retrospectively analyzed data of patients with acute type A aortic dissection undergoing aortic arch surgery and FET from July 2017 to December 2018 at Beijing Anzhen Hospital. D-dimer levels were evaluated within 24 h of admission. Multivariate Cox regression analysis was used to determine independent predictors of early postoperative adverse events.ResultsA total of 347 patients were included in the study. The average age of the patients was 48.07 ± 10.56 years, with male predominance (79.25%). The incidence of 90-day postoperative adverse events was 18.7%, consisting of 14.7% mortality and 4.0% permanent neurological dysfunction (PND). The median D-dimer level was 1.95 ug/ml (interquartile range, 0.77–3.16 ug/ml). Multivariable Cox regression analysis revealed that D-dimer level was independently associated with 90-day postoperative adverse events after adjustment for confounding factors (hazard ratio = 1.19 per 10 ug/ml increase in D-dimer, 95% confidence interval: 1.01–1.41; P = 0.039). Kaplan–Meier analysis revealed that the highest tertile (median 6.27 ug/ml) had more 90-day postoperative adverse events compared with the median and lowest tertiles (P = 0.0014). Sub-analysis found that the association remained unchanged.ConclusionIncreased D-dimer levels at admission were associated with 90-day postoperative adverse events in patients with acute type A aortic dissection undergoing arch replacement and FET. These results may help clinicians optimize the risk evaluation and perioperative clinical management to reduce early adverse events.Key QuestionExplore the relationship between D-dimer and early outcomes in patients with aortic dissection with arch replacement.Key FindingsIncreased D-dimer at admission was associated with adverse events in patients with aortic dissection with arch surgery.Take-Home MessageThe high-risk patients deserve close medical monitoring.

Selective lower body perfusion during aortic arch surgery in neonates and small children.

Introduction:Aortic arch reconstruction surgery represents a challenge for the medical personnel involved in treatment. Along the years, the perfusion strategies for aortic arch reconstruction have evolved from deep hypothermic cardiac arrest to antegrade cerebral perfusion with moderate hypothermia, and recently to a combined cerebral and lower body perfusion with moderate hypothermia. To achieve a lower body perfusion, several cannulation strategies have been described. In this study, we investigated the feasibility of utilizing an arterial sheath introduced in the femoral artery to achieve an effective lower body perfusion.Methods:We included patients who underwent an aortic arch reconstruction surgery with a lower body perfusion, from January 2017 to June 2019. To achieve a lower body perfusion, a three-way stopcock was connected to the arterial line, where one end was connected to the central cannulation for cerebral perfusion and the other to an arterial sheath that was introduced through the femoral artery. A total of 25 patients were included. Peri- and postoperative lactate and creatinine levels and signs of malperfusion were recorded.Results:During the reperfusion phase, after selective perfusion ended none of the patients showed a significant increase in lactate, creatinine, and liver enzyme levels. After 24 hours, there were no signs of an acute kidney injury, femoral vessel injury, or limb malperfusion.Conclusion:These findings show that a sufficient lower body perfusion through an arterial sheath placed in the femoral artery for aortic arch reconstruction can be achieved. This approach caused no complications related to the arterial sheath during the early postoperative period and is an easy way to maintain perfusion of systemic organs.

OPEN ARCH: integrated care at the primary-secondary interface for the community-dwelling older person with complex needs.

Optimal care of community-dwelling older Australians with complex needs is a national imperative. Suboptimal care that is reactive, episodic and fragmented, is costly to the health system, can be life threatening to the older person and produces unsustainable carer demands. Health outcomes would be improved if services (health and social) are aligned towards community-based, comprehensive and preventative care. Integrated care is person-focussed in outlook and defies a condition-centric approach to healthcare delivery. Integration is a means to support primary care, with the volume and complexity of patient needs arising from an ageing population. Older Persons Enablement and Rehabilitation for Complex Health Conditions (OPEN ARCH) is a targeted model of care that improves access to specialist assessment and comprehensive care for older persons at risk of functional decline, hospitalisation or institutionalised care. OPEN ARCH was developed with primary care as the central integrating function and is built on four values of quality care: preventative health care provided closer to home; alignment of specialist and generalist care; care coordination and enablement; and primary care capacity building. Through vertical integration at the primary-secondary interface, OPEN ARCH cannot only improve the quality of care for clients, but improves the capacity of primary care to meet the needs of this population.

1638 A case of capturing changes in interatrial blood flow and anatomical structure during percutaneous PFO closure with platypnea orthodeoxia syndrome using intra-cardiac echocardiography

Abstract Background Platypnea–orthodeoxia syndrome (POS) is an uncommon condition characterized by positional dyspnea and hypoxemia due to intracardiac right-to-left shunting through a patent foramen ovale (PFO). The most commonly associated conditions included pneumonectomy, ascending aortic dilation, and arch surgery, as previously reported. Percutaneous closure of PFO is useful treatment for POS. Case A 76 year old man used home oxygen therapy because of unexplained hypoxemia. A decrease in blood oxygen saturation was observed in sitting and standing positions. The patient was diagnosed as "POS" because a shunt blood flow with PFO and atrial septal aneurysm (ASA) and eustachian valve was observed at transesophageal echocardiography. He was admitted for the purpose of percutaneous PFO closure. He was treated with intra-cardiac echocardiography (ICE) guidance under local anesthesia because of poor lung function. PFO closure was performed successfully with 30mm AMPLATZER Cribriform. The ICE findings prior to PFO closure showed a right-to-left shunt blood flow through the PFO in the sitting position but almost disappeared after closure. Furthermore, it was observed that the aortic artery compression was stronger in the sitting position than in the supine position with right-to-left shunt blood flow. After PFO closure, hypoxia associated with postural change improved and patient’s symptom as shortness of breath also significantly improved. Discussion POS is a position-dependent condition of dyspnea and hypoxemia due to right-to-left shunting. It often remains unrecognized in clinical practice, possibly because of its complex underlying pathophysiology. It is considered that the cause of POS in this patient was multiple factors such as ASA, aortic displacement, and venous valve remnant. In addition, being able to observe the change of the atrium due to compression from the aortic artery using ICE during the operation was very significant to explain the mechanism of POS. Abstract 1638 Figure. Intra-cardiac echocardiography

Aortic Arch Surgery Under Warm Conditions (Moderate to Mild Hypothermia)

Aortic Arch Surgery Under Warm Conditions (Moderate to Mild Hypothermia)

Does the Aortic Annulus Dilate After Aortic Root Remodeling?

The 2 main techniques of valve-sparing aortic root replacement (VSRR) are remodeling and reimplantation. There is concern that the aortic annulus, which is not stabilized in remodeling technique, may dilate over time and cause aortic regurgitation. Our aim was to assess whether the aortic annulus dilates after VSRR with remodeling technique without aortic annuloplasty. Data on patients undergoing elective or urgent VSRR remodeling technique between 2005 and 2018 were collected. Patients undergoing arch and emergency surgery for acute type A aortic dissection were excluded. Preoperative aortic annulus diameter was measured by transthoracic echocardiography, and this was compared with the annulus diameter measured from the most recently available transthoracic echocardiography. The requirement for reintervention during follow-up was recorded. Between 2005 and 2018, 98 patients underwent VSRR. Sixty-six (67.3%) had Marfan syndrome or Loeys-Dietz syndrome. Median age was 60 (interquartile range, 18-68) years and 71 (72.4%) were men. Median cross-clamp and cardiopulmonary bypass times were 122 (interquartile range, 104-164) minutes and 138 (interquartile range, 121-198) minutes, respectively. Median intensive care unit and hospital stay were 1 day and 6 days, respectively. No patients suffered perioperative stroke. There was no in-hospital mortality. At median follow-up of 7.1 years (interquartile range, 5-129 months), mean postoperative annular diameter was 25.7 mm, from 24.2 mm preoperatively (P= .403). One patient required aortic valve replacement during follow-up. Freedom from moderate or severe aortic regurgitation was 97%. There was no significant aortic annular dilatation in selected patients undergoing remodeling VSRR. Our data do not support routine use of annuloplasty in patients with annular diameter less than or equal to 25 mm.