Aortic Root Repair Research Articles

PROSTHETIC VALVE INFECTIVE ENDOCARDITIS CAUSED BY SERRATIA MARCESCENS IN A PATIENT WITH SURGICAL WOUND INFECTION

PROSTHETIC VALVE INFECTIVE ENDOCARDITIS CAUSED BY SERRATIA MARCESCENS IN A PATIENT WITH SURGICAL WOUND INFECTION

BioBentall procedure and autological materials in aortic root surgery

The BioBentall procedure has many options, but the optimal approach is still not determined. Alternative options for aortic root surgery include Ross procedure and modification of the Bentall – De Bono procedure using autologous pericardium leaflets. This literature review showed topical issues of surgical technique and the results of various modifications of the BioBentall operation, as well as methods of the aortic root repair using autologous materials. The search strategy included the analysis of international (PubMed, Scopus, Embase) and Russian’s databases (Russian Science Citation Index). The BioBentall procedure demonstrates satisfactory early and long-term results comparable to both the classic Bentall – De Bono procedure and valve-sparing techniques. Composite grafts containing frameless bioprostheses seem to be more promising and durable in comparison with stent-grafts, however, given the minimal amount of publications directly comparing these techniques, further study of this hypothesis is necessary. Total xenopericardial conduits have demonstrated higher rates of degradation and are currently not recommended for use, as demonstrated in most foreign studies. Modified Ross procedure shows excellent hemodynamic outcomes in the long-term follow-up, however, the literature data regarding its applicability in a cohort of patients with proximal aortic aneurysms are limited. The combination of the Bentall – De Bono procedure and autopericardial neocuspidization seems to be a promising and cost-effective method, however, this approach requires a clinical assessment, which results have not been yet published. Received 26 February 2022. Revised 20 April 2022. Accepted 21 April 2022. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Contribution of the authorsConception and study design: R.N. Komarov, A.M. IsmailbaevDrafting the article: A.N. Dzyundzya, A.O. Danachev, O.O. Ognev, M.V. LencovetsCritical revision of the article: S.V. CherniavskiiFinal approval of the version to be published: R.N. Komarov, A.M. Ismailbaev, S.V. Cherniavskii, A.N. Dzyundzya, A.O. Danachev, O.O. Ognev, M.V. Lencovets

Ministernotomy approach to aortic arch inclusion and frozen elephant trunk in the treatment of acute Stanford A aortic dissection.

This study aimed to report our results of ministernotomy approach to Liu’s aortic root repair technique, Liu’s aortic arch inclusion technique with frozen elephant trunk (FET) in the treatment in type A aortic dissection (TAAD). We retrospectively analyzed data on 68 Stanford A aortic dissection patients from October 2017 to March 2020. All patients underwent Liu’s aortic root repair technique, Liu’s aortic arch inclusion technique with FET and mild-moderate hypothermic circulatory arrest combined with ministernotomy approach. 154 TAAD patients between January 2014 and December 2016 underwent complete sternotomy were selected as control group. Clinical characteristics, data during operation, in-hospital and postoperative outcomes of these patients were observed. The mean hypothermic circulatory arrest time in ministernotomy Patients was 39.3 ± 7.9 min, aortic cross-clamp time was 105.9 ± 12.8 min, cardiopulmonary bypass time was 152.8 ± 24.3 min. Three patients died of multiple organ dysfunction syndrome in ministernotomy Patients. Perioperative temporary neurological dysfunction occurred in three (4.41%) patients, and 53 (77.9%) patients did not require any blood product transfusion during and after operation in ministernotomy Patients. Postoperative CT angiography (CTA) examination at 6-32 months showed excellent outcomes except in three (4.41%) cases where arch false lumen patency persisted. The Liu’s aortic root repair technique, Liu’s aortic arch inclusion technique with FET and mild-moderate hypothermia circulatory arrest simplify the surgical procedure and reduce bleeding, which can be accomplished through minimally invasive approach.

454 Sinus of Valsalva Rupture

Abstract Background Sinus of Valsalva (SVA) rupture is a rare cardiac pathology which is important to recognise and diagnose early. Case Summary This case report details a 30-year-old gentleman who presented with a 3-day history of dyspnoea and palpitations on a background of previous congenital heart disease. The patient's examination highlighted a continuous harsh pan-systolic murmur as well as an ECG finding of sinus tachycardia. Transthoracic echocardiography identified a ruptured Sinus of Valsalva. The patient was transferred to a cardiothoracic surgery centre and definitively treated with an aortic root and ventricular septal defect repair. Discussion This case highlights the clinical findings of a patient with an acute left to right shunt and the importance of early diagnosis and urgent surgery. This case emphasises the factors required to decide which surgical approach is appropriate such as the presence of aortic valvular pathology size, size of Sinus of Valsalva aneurysm, any simultaneous cardiac anomaly and the cardiac chamber involved. Learning Points

Traboulsi syndrome caused by mutations in ASPH: An autosomal recessive disorder with overlapping features of Marfan syndrome

Traboulsi syndrome, otherwise known as facial dysmorphism, lens dislocation, anterior-segment abnormalities and spontaneous filtering blebs, is an autosomal recessive condition associated with characteristic ocular features including dislocated crystalline lenses, anterior segment abnormalities and in some individuals, non-traumatic conjunctival cysts. There is a distinctive facial appearance which includes flattened malar region with convex nasal ridge. Alterations in the aspartate beta-hydroxylase (ASPH) gene are known to be the cause of the condition.We report seven further individuals from six unrelated families with characteristic ocular and facial features. Five individuals had aortic root dilatation, with childhood onset in some, and one undergoing aortic root repair aged 47 years for severe aortic regurgitation and aortic root dilatation. Interestingly, inguinal hernias were commonly reported. Although some skeletal features were seen, these were not consistent. One of the patients had mild deficiency of factor VII on clotting studies. The ASPH protein hydroxylates specific asparagine- and aspartate-residues in epidermal growth factor (EGF)-domain containing proteins including coagulation factors and associated genes including FBN1. We propose this as an explanation for the overlap in clinical features with Marfan syndrome and conclude that Traboulsi syndrome is an important differential diagnosis. We strongly recommend echocardiography surveillance for patients with Traboulsi syndrome.

Predictors of early adverse events after ascending aortic replacement

Objective. The aim of this study was to identify predictors of adverse events after ascending aortic replacement for the aortic aneurysms in the early postoperative period.Material and Methods. The analysis included 151 patients with ascending aortic aneurysm who underwent non-hemiarch or hemiarch repair. The following adverse outcomes were selected: postoperative delirium, respiratory failure, bleeding, multiple organ dysfunction syndrome, and in-hospital mortality. Predictors of adverse clinical events were identified by constructing uni- and multivariate logistic regression.Results. Significant predictors of early outcomes and mortality after ascending aortic replacement were as follows: female gender, atrial fibrillation, low glomerular filtration rate, chronic obstructive pulmonary disease, aortic root repair, multiple organ dysfunction, duration of cardiac arrest, operation time, and reoperation for bleeding.Conclusions. The risk factors of adverse outcomes after ascending aortic replacement were decreased kidney function, atrial fibrillation, female gender, aortic root repair, and increased duration of cardiac arrest and operation time.

Surgical explantation of failed transcatheter heart valves: indications and results

Given the recent surge in transcatheter heart valve replacement (THVR), cardiac surgeons will surely face the challenge of eventual explantation. The aim of this study was to determine indications for reoperation, while exploring pertinent technical aspects and survival after THV explantation in a cohort originally deemed high risk or even inoperable. Between February 2008 and March 2019, 31 patients with failed transcatheter aortic valve replacement (TAVR) underwent surgical explantations at our facility. Data were prospectively collected for retrospective analysis of procedural indications, technical issues, and postoperative survival. The major reason for TAVR removal was bioprosthetic valve failure (BVF) due to infective endocarditis (IE: 16/31 [51.6%]), non-structural (NSVD: 14/31 [45.2%]) and structural (SVD: 1/31 [3.2%]) valve deterioration accounting for the rest. Mean age at THV explantation was 76.3 ± 8.3 years, and median time from TAVR to explantation was 153 days (0 days–56.6 months). Median ICU and hospital stay were 6 days (1–44 days) and 23 days (8–62 days), respectively. Thirty-day and 1-year survival rates were 74.2% and 67.2%, respectively. Median follow-up interval after explantation was 364 days (3 days–80 months). Mean cardiopulmonary bypass time was 124.6 ± 46.8 min, and mean aortic cross-clamp time was 84.3 ± 32.9 min. There was no need for unplanned aortic root repair owing to tissue damage during dissection of the TAVR from surrounding tissue. The most common reason for THV explantation was (a) BVF for IE and (b) BVF secondary to NSVD. Although 30-day and 1-year mortality rates in this multimorbid cohort were predictably high, no procedural mortalities occurred.

Percutaneous Transvenous Balloon Mitral Commissurotomy: A Single-Center Experience.

Rheumatic heart disease and its impact on cardiac health is still a concern in developing countries. Percutaneous trans-mitral commissurotomy (PTMC) is the standard of care in managing severe rheumatic mitral stenosis (MS). This article reports a single-center, 10-year real-world experience in Qatar. In this retrospective study, we reviewed all the patients who underwent PTMC in Qatar between January 1, 2012, and January 1, 2022. Periprocedural data were collected at baseline, postprocedural, 1 year, and during the last follow-up. The primary outcome was procedural success (improvement in valve area by 50%, final valve area >1.5 cm2, and freedom from > moderate mitral regurgitation, stroke, or pericardial effusion). Safety endpoints were freedom from death, periprocedural cardiogenic shock and cardiac arrest, stroke urgent mitral valve replacement (MVR), or pericardiocentesis. Long-term outcomes included the requirement of redo PTMC or MVR, in addition to rehospitalization due to arrhythmias, heart failure, or stroke. Sixty-five patients were included in the review (age 42 ± 10, female 38 [58.5%]). Sixty-two patients (95.4%) had a successful procedure. One patient developed a hemorrhagic pericardial tamponade and cardiogenic shock, for which he underwent pericardiocentesis and emergency aortic root repair. One patient developed acute stroke 8 h after the procedure, and one patient had tamponade resolved with emergency pericardiocentesis. Two patients required MVR after 1 and 4 years, respectively. PTMC is the mainstay of rheumatic MS management in patients with suitable anatomy as most patients have excellent outcomes with long-term freedom from surgery, which has been the case in our single-center experience.

Long-Term Outcomes after Aortic Valve and Root Replacement in a Very High-Risk Population.

Background: Aortic valve and root replacement (AVRR) is a standardised procedure to treat patients with aortic valve and root disease. In centres with a well-established aortic valve and root repair program (valve repairs and Ross operations), only patients with very complex conditions receive AVRR; this procedure uses a mechanical or biological composite valve graft (modified Bentall–de Bono procedure). The aim of the study was to evaluate the short- and long-term results after AVRR in a high-risk population with complex pathologies. Methods: Between 2005 and 2018, a total of 273 consecutive patients (mean age 64 ± 12.8 years; 23% female) received AVRR. The indication for surgery was an acute type A aortic dissection in 18%, infective endocarditis in 36% and other pathologies in 46% patients; 39% were redo procedures. The median EuroSCORE II was 11.65% (range 1.48–95.63%). Concomitant surgery was required in 157 patients (58%). Results: The follow-up extended to 5.2 years (range 0.1–15 years) and it was complete in 96% of the patients. The 30-day mortality was 17%. The overall estimated survival at 5 and 10 years was 65% ± 3% and 49% ± 4%, respectively. Univariate and multivariate logistic regression analyses revealed the following risk factors for survival: perioperative neurological dysfunction (OR 5.45), peripheral artery disease (OR 4.4) and re-exploration for bleeding (OR 3.37). Conclusions: AVRR can be performed with acceptable short- and long-term results in a sick patient population. The Bentall–De Bono procedure may be determined to be suitable for only elderly or high-risk patients. Any other patients should receive an AV repair or the Ross procedure in well-established centres.

Valve-Sparing Aortic Root Replacement in a Patient With an FLNA Variant

We report a case of a 38-year-old female with an FLNA variant who underwent valve-sparing aortic root replacement. FLNA encodes Filamin A, an actin-binding protein. Our patient had aortic root dilation due to this variant. Aortic root repair was conducted using the David procedure, with modifications to account for tissue fragility associated with this genetic condition. This case demonstrates the value of patient-specific genetic information for the timing of surgery and operative course planning.

Early outcomes of transcatheter versus surgical aortic valve implantation in patients with bicuspid aortic valve stenosis.

Limited information is available on outcomes in patients with bicuspid aortic valve (BAV) stenosis undergoing transcatheter aortic valve implantation (TAVI) compared with surgical aortic valve replacement (SAVR), as pivotal randomised trials excluded patients with BAV pathology due to anatomic complexity. The aim of the study was to compare early outcomes between TAVI and SAVR in patients with BAV stenosis. We queried the Nationwide Readmission Database (NRD) between 2016 and 2018 to identify adults who underwent TAVI or SAVR for BAV stenosis. The study's primary outcome was in-hospital mortality. Secondary outcomes were 30-day and six-month major adverse cardiovascular events (MACE). We matched both cohorts using propensity score matching, and applied logistic and Cox-proportional hazard regression to compute the odds ratio (OR), the hazard ratio (HR), and the 95% confidence interval (CI). Out of 17,068 patients with BAV stenosis, 1,629 (9.5%) patients underwent TAVI and 15,439 (90.5%) underwent SAVR. After propensity score matching (PSM), we found 1,393 matched pairs. Of the matched pairs, 848 had complete six-month follow-ups. In the PSM cohort, TAVI was associated with reduced in-hospital mortality (0.7% vs 1.8%, OR: 0.35, 95% CI: 0.13-0.93; p=0.035), and a similar rate of MACE at 30 days (1% vs 1.5%, OR: 0.65, 95% CI: 0.27-1.58; p=0.343) and at six months (4.2% vs 4.9%, HR 0.86, 95% CI: 0.44-1.69; p=0.674), compared with SAVR. In the propensity score-matched cohort, TAVI was associated with reduced odds of in-hospital mortality and a similar risk of 30-day and six-month MACE, supporting the feasibility of TAVI in BAV patients without a need for concurrent aortic root repair.

Predictors of early adverse events after ascending aortic replacement

Objective. The aim of this study was to identify predictors of adverse events after ascending aortic replacement for the aortic aneurysms in the early postoperative period.Material and Methods. The analysis included 151 patients with ascending aortic aneurysm who underwent non-hemiarch or hemiarch repair. The following adverse outcomes were selected: postoperative delirium, respiratory failure, bleeding, multiple organ dysfunction syndrome, and in-hospital mortality. Predictors of adverse clinical events were identified by constructing uni- and multivariate logistic regression.Results. Significant predictors of early outcomes and mortality after ascending aortic replacement were as follows: female gender, atrial fibrillation, low glomerular filtration rate, chronic obstructive pulmonary disease, aortic root repair, multiple organ dysfunction, duration of cardiac arrest, operation time, and reoperation for bleeding.Conclusions. The risk factors of adverse outcomes after ascending aortic replacement were decreased kidney function, atrial fibrillation, female gender, aortic root repair, and increased duration of cardiac arrest and operation time.

Selective sinus replacement for aortic root repair in bicuspid aortopathy

ObjectivesTo evaluate the results after selective sinus replacement (SSR) for aortic root remodeling in bicuspid aortopathy. MethodsAmong 662 patients who underwent root repair using SSR between 2005 and 2020, there were 114 with bicuspid aortopathy. SSR was performed either as an isolated procedure (31) or as an adjunct to aortic valve repair (83) and was adjusted to the existing aortic annulus diameter rather than a downsized diameter. In valves with asymmetrical commissural orientation, the repair aimed for the achievement of a 180°-commissural orientation. ResultsAbolishment of aortic insufficiency (AI) ≥2+ using root repair alone was only possible in 2 patients with acute-dissection-related AI, yet isolated root repair was also performed in 29 further patients with no/mild AI. All remaining patients with AI ≥2+ presented cusp-related regurgitation and necessitated an additional valve repair. During the mean follow-up of 91 months (range, 13-196), a relevant valve defect (AI ≥3+ in 8, stenosis in 2) occurred in 10 patients (all after combined repair) resulting in an estimated freedom from a relevant aortic valve defect and/or reoperation of 96 ± 2%, 89 ± 4%, and 82 ± 6% at 5, 10, and 12 years, respectively. Echocardiographically, no patient revealed a considerable change of form or size of the repaired root nor was any root reintervention necessary. ConclusionsPatient-tailored root repair using SSR is a very effective and durable valve-sparing approach for bicuspid aortopathy. Aortic cusp repair is decisive for both abolishment of AI in bicuspid aortopathy and for the functional durability of the repaired aortic valve.

Progression of aortic root based on long-term imaging studies after acute type A dissection repair.

To determine the progression of aortic root in acute type A aortic dissection (ATAAD) patients after aortic root repair (ARr) or replacement (ARR) based on long-term follow-up imaging studies. From 1996 to 2019, 732 patients had ATAAD repair at our institution. Six hundred and seven of these patients had either ARr, (n = 383) or ARR (n = 224). Eighty-one patients were excluded due to a lack of postoperative imaging. Three hundred and thirty-two patients were included in the repair group and 194 patients in the replacement group for long-term follow-up imaging study. Compared to the ARR group, the ARr group was significantly older (60 years vs. 55 years) and had more patients with hypertension (79% vs. 63%) but less male patients (63% vs. 79%) and connective tissue disorder (1.8% vs 8%). The ARr group had more zone two arch replacement (22% vs. 11%), similar HCA time (35 min vs. 31 min), shorter cardiopulmonary bypass time (203 min vs. 266 min), aortic cross-clamp time (128 min vs. 214 min), and fewer concomitant coronary artery bypass (3.9% vs. 8.9%). The root growth rate over 12 years was similar between the repair and replacement group (0.20 mm/year vs. 0.18 mm/year, p = .75). Both the repair and replacement group had similar 15-year cumulative incidence of reoperation (6.9% vs. 5.9%; p = .67), operative mortality (7.8% vs. 8.5%; p = .78), and 15-year survival (51% vs. 52%; p = .40). There was minimal growth of the aortic root after root repair or replacement for ATAAD patients. Both aortic root repair and replacement were acceptable techniques for ATAAD surgery in select patients.

Impact of aortic root repair or replacement in severe destructive aortic valve endocarditis with paravalvular abscesses on long-term survival.

OBJECTIVESSurgical treatment of destructive infective endocarditis consists of extensive debridement followed by root repair or replacement. However, it remains unknown whether 1 is superior to the other. We aimed to analyse whether long-term results were better after root repair or replacement in patients with root endocarditis.METHODSA total of 148 consecutive patients with root endocarditis treated with surgery from 1997 to 2020 at our department were included. Patients were divided into 2 groups: aortic root repair (n = 85) or root replacement using xenografts or homografts (n = 63).RESULTSPatients receiving aortic root repair showed significantly better long-term survival compared to patients receiving aortic root replacement (log-rank: P = 0.037). There was no difference in terms of freedom from valvular reoperations among both treatment groups (log-rank: P = 0.58). Patients with aortic root repair showed higher freedom from recurrent endocarditis compared to patients with aortic root replacement (log-rank: P = 0.022). Patients with aortic root repair exhibited higher event-free survival (defined as a combination end point of freedom from death, valvular reoperation or recurrent endocarditis) compared to patients receiving aortic root replacement (log-rank: P = 0.022). Age increased the risk of mortality with 1.7% per year. Multi-variable adjusted statistical analysis revealed improved long-term event-free survival after aortic root repair (hazards ratio: 0.57, 95% confidence interval: 0.39–0.95; P = 0.031).CONCLUSIONSAortic root repair and replacement are feasible options for the surgical treatment of root endocarditis and are complementary methods, depending on the extent of infection. Patients with less advanced infection have a more favourable prognosis.Clinical trial registrationUN4232 382/3.1 (retrospective study).

Early and mid-term outcomes of modified aortic root repair for acute stanford type A aortic dissection

Abstract Background Acute Stanford type A aortic dissection (ATAAD) is the most common catastrophic aortic event. Most ATAAD involves the aortic root which has many important anatomical structures such as aortic valve, so the proper treatment of dissected root can ensure a good prognosis for patients. However, there is still no consensus on root management strategies for ATAAD patients with aortic root involvement. Purpose This clinical study aimed to evaluate the therapeutic effect of modified aortic root repair in ATAAD. Methods From September 2017 to September 2020, Participants with root involvement of ATAAD were recruited who underwent modified aortic root repair as well as some additional procedure such as aortic valve junction suspension plasty based on the aortic sinus tear extent. During this novel procedure, the proximal anastomosis plane was at the level of the sinu-tubular junction and the false lumen below it was retained. We collected and analyzed the perioperative clinical data and follow-up imaging data of patients, and further evaluated the early and mid-term efficacy of this surgical approach. Results A total of 79 patients were enrolled, including 59 males and 20 females, the age was (52.4±11.3) years old (28–73 years), the diameter of aortic sinus was (38.6±4.1) mm, and the diameter of sinu-tubular junction was (41.8±4.8) mm. In this group, 75 patients (94.9%) received ascending aorta replacement, total arch replacement and frozen elephant trunk, 2 patients (2.5%) received ascending aorta replacement and hybrid total arch replacement, 2 patients (2.5%) received ascending aorta replacement and partial arch replacement. Cardiopulmonary bypass time was (197.2±58.6) min (118–455 min), blocking time was (132.6±38.9) min (73–323 min), circulatory arrest time was (10.3±7.0) min (0–27 min). There was no perioperative death, no paraplegia, one secondary thoracotomy, five renal failures needing hemodialysis treatment and two cerebral infarctions. Before patients discharged, aortic CTA showed that the residual false lumen in the sinus disappeared. And the diameter of the aortic sinus was (35.5±3.1) mm, the diameter of the junction of the aortic sinus was (30.0±3.0) mm. The patients were followed up for (18±12) months (3–35 months). There was one patient died during follow-up and no further surgical intervention at the root of the aorta. Follow-up aortic CTA showed no residual or new dissection in the aortic sinus and no significant difference in the diameters of aortic sinu-tubular junction (P=0.122) or aortic sinus (P=0.37) between postoperative period and follow-up period. Echocardiography showed that the structure and function of the aortic valve were normal. Conclusions The modified aortic root repair for ATAAD is relatively simple, easy to learn and safe in perioperative period. Early and mid-term follow-up image examination showed that the structure of aortic sinus returned to normal. The long-term clinical effect requires close attention. Funding Acknowledgement Type of funding sources: None. Modified aortic root repair procedureAortic root diameter change under CTA

Florida Sleeve for type A dissection

: In properly selected patients, an aortic root repair with valve salvage is a viable alternative to root replacement. Acute type A aortic dissections are often emergency operations with a high complexity. These cases are particularly difficult when the aortic root is enlarged, but the aortic valve leaflets and morphology are normal. In the setting of an acute ascending aortic dissection and enlarged aortic root, preservation of the valve via the use of the Florida Sleeve root repair technique is an alternative to root replacement. We present a case of our standard Florida Sleeve root repair in a patient with an ascending aortic aneurysm of 6.0 cm and an aortic root of 5.3 cm with moderate aortic insufficiency. The patient is a healthy 57-year-old male that had normal trileaflet anatomy but central aortic insufficiency appearing to be related to his root dilation on pre-operative echocardiogram. The Florida Sleeve technique for root remodeling with preservation of the aortic valve and sinuses is a technique for saving the aortic valve while narrowing the annulus and sinotubular junction. Familiarity with root replacement and valve preserving techniques during non-emergency setting is crucial in order to complete the procedure in an efficient manor during an aortic dissection operation.

Long-term outcomes after aortic root repair using selective sinus replacement

ObjectivesThe study aim was to evaluate long-term results after anatomic restoration of the aortic root. MethodsDuring an 18-year period, a total of 669 patients underwent valve-sparing root repair (aneurysm 554, dissection 115) using selective sinus replacement. None/trivial, mild, moderate, and severe (grades 3+ and 4+) insufficiency were present in 57, 146, 204, and 262 patients, respectively. ResultsThe anatomic repair was adjusted to the existing aortic annulus diameter, which was 27.0 ± 3.0 mm on average. Replacement of 1, 2, or 3 sinuses of Valsalva was performed in 209, 234, and 226 patients, respectively. Altogether, 454 additional procedures on the cusps were performed, mostly as cusp patch plasty with pericardium (210). Thirty-day mortality was 0.6%. The mean follow-up duration was 7.1 ± 4.1 years (range, 0.01-19.1 years). The estimated freedom from relevant aortic insufficiency grade 3+ or greater (15 events) was 98% ± 1%, 97% ± 1%, and 94% ± 3% at 5, 10, and 15 years, respectively. On echocardiogram, no patient revealed a considerable change of the form or size of the repaired root, which was confirmed radiologically in 160 patients who received computed tomography angiography for any reason. Multivariate logistic regression analysis identified cusp prolapse/pseudo-prolapse as the only independent risk factor for the development of recurrent insufficiency grade 2+ or greater (41 occurrences), with a hazard ratio of 3.258 (95% confidence interval, 1.658-6.403; P = .001). An association between aortic annulus size and functional results could not be demonstrated. ConclusionsPatient-tailored root repair using isolated sinus replacement offers excellent functional long-term results regardless of underlying root pathology or annulus size. Aortic cusp pathology was decisive for long-term valve function.

Aortic root repair in a patient with acquired hemophilia A: case report

BackgroundPatients with acquired hemophilia A (AHA) who require open heart surgery have a life-threatening risk of hemorrhage. Limited data exist to guide perioperative management of these patients.Case presentationA 53-year-old female with rheumatoid arthritis, concomitant aortic valve endocarditis, and severe aortic regurgitation presented to our hospital. Bleeding and abnormal coagulation tests were noted during the initial workup, and she was diagnosed with AHA. The perioperative management plan included the use of pharmaceuticals, porcine recombinant factor VIII, and blood products. Extensive preoperative coagulation data were obtained, and factor VIII levels were continuously monitored to mitigate bleeding complications. The aortic valve replacement and root repair were uneventful.ConclusionCardiac surgery in patients with AHA is possible as long as complex perioperative hemostatic and hematology management is used.

David procedure for aortic root aneurysm in the background of Marfan syndrome patient with severe kyphoscoliosis and previous mitral valve replacement

Cardiac complication is one of the diseases that usually develop in Marfan syndrome patient such as mitral valve regurgitation and aortic root aneurysm. Apart from that, other congenital anomalies also tend to occur in this group of patients such as pectus excavatum and scoliosis. We report a case of successful high-risk surgery involving a Marfan syndrome patient who had underlying severe kyphoscoliosis and previous mitral valve replacement that underwent redo sternotomy and valve sparing aortic root repair (David procedure). The surgery was challenging due to the need to perform redo-sternotomy on severe pectus patient, performing valve sparing aortic root repair, and complicated with injury to right coronary artery require modified Cabrol modification for implantation of the coronary artery. The available literature about redo sternotomy on severe pectus excavatum for aortic root repair is limited, hence this paper aims to highlight the successful of performing the procedure, and the complication that might occur during the procedure.