The Role of Cardiovascular Surgeons in Oncovascular Surgery for Resection of Retroperitoneal Tumors: A Case Report.

A 43-year-old man diagnosed with a giant retroperitoneal tumor with suspected invasion of the abdominal aorta and inferior vena cava underwent surgery. Complete en bloc tumor resection could be achieved by transection and reconstruction of the abdominal aorta and inferior vena cava. This case highlights the need for aggressive, complete tumor resection when major vessels are invaded. To ensure comprehensive tumor removal, especially in cases requiring manipulation of major vessels, it is imperative to increase the involvement of cardiovascular surgeons in such surgeries. Therefore, widespread promotion of the concept of oncovascular surgery is essential.

Additive Effects of Esaxerenone, a Nonsteroidal Mineralocorticoid Receptor Blocker, on Cardioplegic Arrest in Rat Hearts.

PURPOSE: Esaxerenone, a mineralocorticoid receptor blocker, attenuates global ischemia-induced myocardial damage and coronary endothelial dysfunction. This study aimed to determine whether esaxerenone exerted cardioprotective effects against cardioplegic arrest in Wistar rat hearts. METHODS: Isolated male Wistar rat hearts aerobically perfused via the Langendorff method for 20 min were randomly allocated to the Control (n = 6; perfused for an additional 10 min and subjected to no treatment) or Esax (n = 6; perfused with 0.1 µmol/L esaxerenone in perfusate for 10 min before ischemia) groups. Hearts in both groups were perfused with St. Thomas' Hospital No. 2 solution (STH2) for 2 min and subjected to 28 min of global ischemia. The recovery of left ventricular developed pressure (LVDP) and total troponin T leakage were measured after reperfusion. RESULTS: The final recovery of LVDP (expressed as a percentage of pre-ischemic value) in the Control and Esax groups was 50.8 ± 3.5% and 62.1 ± 5.6%, respectively (p <0.05, Esax vs. Control). The total troponin T leakage in the Control and Esax groups was 138.8 ± 18.5 ng/g heart wt and 74.3 ± 18.6 ng/g heart wt, respectively (p <0.05, Esax vs. Control). CONCLUSION: The administration of esaxerenone before cardioplegic arrest enhanced the cardioprotective effect exerted by STH2.

Effect of esaxerenone on ischaemia and reperfusion injury in rat hearts.

OBJECTIVES: In myocardial infarction, the addition of mineralocorticoid receptor blockers to standard therapies, such as angiotensin-converting enzyme inhibitors or beta-blockers, reportedly reduces mortality and cardiac events. We investigated whether the non-steroidal mineralocorticoid receptor blocker esaxerenone has cardioprotective effects and its protective mechanisms. METHODS: Isolated rat hearts were Langendorff-perfused (constant pressure, 80 mmHg) with oxygenated Krebs-Henseleit bicarbonate buffer and reperfused for 60 min; afterwards, recovery of function (left ventricular pressure, measured with an intraventricular balloon) and myocardial injury were measured. In a preliminary study, we determined the optimal concentration of esaxerenone required for myocardial protection. Next, esaxerenone was administered in the pre- and post-ischaemic phases to determine the optimal timing of administration. In addition, we assessed coronary flow response to acetylcholine with and without esaxerenone. We examined whether esaxerenone-induced cardioprotection was prevented by targeting putative components in the preconditioning manner (the mitochondrial ATP-sensitive potassium [KATP] channel). RESULTS: Myocardial protection by esaxerenone was observed when esaxerenone was administered before ischaemia but not after ischaemia. The coronary flow response to acetylcholine was significantly better in the esaxerenone group than in the control group. The cardioprotective effect of esaxerenone was eliminated by the mitochondrial KATP channel blocker, 5-hydroxy decanoate. CONCLUSIONS: This study confirmed the myocardial protective effect of the pre-ischaemic administration of esaxerenone. Esaxerenone may contribute to coronary endothelial protection and exert pharmacological preconditioning via the mitochondrial KATP channel.

Successful surgical experience for acute severe aortic valve regurgitation with acquired Gerbode defect: A case report.

INTRODUCTION AND IMPORTANCE: The incidence of acquired Gerbode defect has been increasing due to advances in cardiac imaging technology, and some closure methods have been introduced. PRESENTATION OF CASE: A 58-year-old man developed cardiogenic shock due to acute severe aortic valve regurgitation with an acquired Gerbode defect caused by infective endocarditis. Emergency surgery was performed. A large patch with a 0.4 mm extended-polytetrafluoroethylene (e-PTFE) sheet covered with autologous pericardium was used to close the Gerbode defect, and a bioprosthetic valve was used for aortic valve replacement. CLINICAL DISCUSSION: Large patch closure with 0.4 mm e-PTFE sheet and autologous pericardium for fragile Gerbode defect caused by infective endocarditis might be effective with regard to sturdiness, good fitting to the tissue, and excellent resistance to bacteria. CONCLUSION: We encountered a rare case of cardiogenic shock due to acute severe aortic valve regurgitation and acquired Gerbode defect caused by infective endocarditis. In our case, large-patch closure for perforation in a fragile membranous septum was effective.

Predicting Inchinkoto efficacy, in patients with obstructive jaundice associated with malignant tumors, through pharmacomicrobiomics.

Inchinkoto (ICKT) is a popular choleretic and hepatoprotective herbal medicine that is widely used in Japan. Geniposide, a major ingredient of ICKT, is metabolized to genipin by gut microbiota, which exerts a choleretic effect. This study investigates the relationship between stool genipin-producing activity and diversity of the clinical effect of ICKT in patients with malignant obstructive jaundice. Fifty-two patients with malignant obstructive jaundice who underwent external biliary drainage were included. ICKT was administered as three packets per day (7.5 g/day) for three days and 2.5 g on the morning of the fourth day. Stool samples were collected before ICKT administration and bile flow was monitored on a daily basis. The microbiome, genipin-producing activity, and organic acids in stools were analyzed. The Shannon-Wiener (SW) index was calculated to evaluate gut microbiome diversity. The stool genipin-producing activity showed a significant positive correlation with the SW index. Stool genipin-producing activity positively correlated with the order Clostridia (obligate anaerobes), but negatively correlated with the order Lactobacillales (facultative anaerobes). Moreover, stool genipin-producing activity was positively correlated to the concentration valeric acid, but negatively correlated to the concentration of lactic acid and succinic acid. The change of bile flow at 2 and 3 days after ICKT administration showed significant positive correlation with genipin-producing activity (correlation coefficient, 0.40 and 0.29, respectively, P < 0.05). An analysis of stool profile, including stool genipin-producing activity, may predict the efficacy of ICKT. Modification of the microbiome may be a target to enhance the therapeutic effect of ICKT.

Comprehensive metabolome analysis for the pharmacological action of inchinkoto, a hepatoprotective herbal medicine.

INTRODUCTION: The precise pharmacological action of inchinkoto (ICKT, Yin-Chen-Hao-Tang in Chinese), a hepatoprotective herbal medicine, on total metabolic pathways has not been well investigated. OBJECTIVES: The aim of this study was to explore the serum metabolites reflecting the pharmacological activity of ICKT, and mechanism of action of ICKT using serum metabolome analysis. METHODS: 54 patients with obstructive jaundice due to malignancies were included in this study. ICKT was administered for 3 days. Serum and bile samples were collected before and 1 h after ICKT administration on days 1 and 4. Serum metabolome analysis including ICKT components were performed. RESULTS: The levels of total/direct bilirubin, C-reactive protein, γ-glutamyl transpeptidase, and albumin in the serum were significantly improved after ICKT administration. In the serum metabolome analysis, inosine was the only elevated metabolite on days 1 and 4. Most of the metabolites which were significantly changed after ICKT administration were lipid mediators, and all decreased on day 1. Notably, the levels of many lipid mediators were increased on day 4. The difference in serum aspartic acid 1 h after ICKT administration was significantly correlated with a decrease in the levels of total bilirubin in the serum on day 4. CONCLUSIONS: Using metabolome analysis, we demonstrated several metabolic changes that may be associated with the pharmacological mechanisms of ICKT. The biological implications of these metabolites should be further investigated in basic research studies.

Pleural dissemination of cholangiocarcinoma caused by percutaneous transhepatic biliary drainage during the management of resectable cholangiocarcinoma.

BACKGROUND: Only 3 case reports have addressed pleural dissemination in association with percutaneous transhepatic biliary drainage. The aim of this study was to investigate recurrence after resection of cholangiocarcinoma after percutaneous transhepatic biliary drainage and to clarify the incidence of and the factors responsible for pleural dissemination. METHODS: Between 2001 and 2015, we reviewed retrospectively all consecutive patients who underwent resection for perihilar or distal cholangiocarcinoma after percutaneous transhepatic biliary drainage for recurrence, including pleural dissemination. RESULTS: During the study period, all consecutive patients underwent resection of cholangiocarcinoma after management with percutaneous transhepatic biliary drainage. Of these, 100 patients (32.1%) underwent left-sided percutaneous transhepatic biliary drainage alone, and 212 (67.9%) underwent right-sided percutaneous transhepatic biliary drainage with or without left-sided percutaneous transhepatic biliary drainage. Pleural dissemination, which developed exclusively on the right side of the thoracic cavity after resection, was found in 12 patients (3.8%); these patients underwent right-sided percutaneous transhepatic biliary drainage; computed tomography demonstrated that the percutaneous transhepatic biliary drainage catheter passed through the thoracic cavity in all 12 patients. The diagnosis of pleural dissemination was made at a median of 381 days (range, 44 to 2,944 days) after operation. Survival was poor, with a median survival time of 516 days. Statistically, right-sided percutaneous transhepatic biliary drainage was identified as a risk factor for pleural dissemination. CONCLUSION: Pleural dissemination after right-sided percutaneous transhepatic biliary drainage is likely a procedure-related iatrogenic complication because of the "special route" by which the percutaneous transhepatic biliary drainage catheter must be passed through the right thoracic cavity.

8K ultra-high-definition microscopic camera for ophthalmic surgery.

BACKGROUND: We have developed a new compact lightweight 8K ultra-high-definition (UHD; 7,680×4,320 pixels) camera and started medical application with an ophthalmic surgical microscope which is interchangeable with the conventional high-definition (1,920×1,080 pixels)/4K UHD (3,840×2,160 pixels) microscopic camera. METHODS: We did a feasibility study to apply our 8K UHD microscope in cataract surgery, glaucoma surgery and vitreous surgery using pig cadaver eyes. The 8K UHD microscope comprises a surgical microscope, a camera adaptor with relay lenses, an 8K UHD camera and an 8K UHD LCD to share the 8K UHD images with all surgical staff in real time. RESULTS: In ophthalmic surgeries, higher resolution images than conventional microscopic cameras were obtained with 8K UHD LCD equivalent to the observation through the microscopic eye pieces. CONCLUSION: Based on the results of this feasibility study, clinical trials on human ophthalmic surgery using the new 8K UHD microscopic camera should be conducted in the near future.

Midterm outcomes after aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium.

OBJECTIVE: We had previously reported the short-term results of the aortic valve neocuspidization (AVNeo) procedure. We have now evaluated the midterm results with the longest follow-up of 118 months. METHODS: From April 2007 through December 2015, 850 patients were treated with AVNeo using autologous pericardium. Medical records of these patients were retrospectively reviewed. The procedure was on the basis of independent tricuspid replacement using autologous pericardium. The distances between the commissures were measured with an original sizing device, the pericardial cusp was trimmed using an original template, and then sutured to the annulus. RESULTS: There were 534 patients with aortic stenosis, 254 with aortic regurgitation, 61 with aortic stenoregurgitation, 19 with infective endocarditis, and 5 with a previous aortic valve procedure. Besides 596 patients with tricuspid aortic valve, 224 patients had bicuspid valve, 28 had unicuspid valve, and 2 had quadricuspid valve. There were 444 male and 406 female patients. The median age was 71 (range, 13-90) years old. Preoperative echocardiography revealed a peak pressure gradient average of 68.9 ± 36.3 mm Hg with aortic stenosis. Surgical annular diameter was 20.9 ± 3.3 mm. There was no conversion to a prosthetic valve replacement. There were 16 in-hospital mortalities. Postoperative echocardiography revealed a peak pressure gradient average of 19.5 ± 10.3 mm Hg 1 week after surgery and 15.2 ± 6.3 mm Hg 8 years after surgery. Fifteen patients needed reoperation (13 infective endocarditis, 1 break of thread, and 1 tear of cusp case). The mean follow-up period was 53.7 ± 28.2 months. Actuarial freedom from death, cumulative incidence of reoperation, and that of recurrent moderate aortic regurgitation or greater was 85.9%, 4.2%, and 7.3%, respectively, with the longest follow-up of 118 months. CONCLUSIONS: The midterm outcomes of AVNeo using autologous pericardium were satisfactory in 850 patients with various aortic valve diseases. However, further randomized, multicenter prospective studies are needed to confirm the results of the current study.

Effect of an 8K ultra-high-definition television system in a case of laparoscopic gynecologic surgery.

Various endoscopic devices have been developed for advanced minimally invasive surgery. We recently applied a new 8K ultra-high-definition television system during laparoscopic treatment of endometriosis. The procedure, which is described in detail, stands as the first reported application of an 8K ultra-high-definition system for laparoscopic gynecologic surgery. Comparison is made between depiction of the lesion by the new system and depiction by a full high-definition system. Improved diagnostic accuracy resulted from the increased image resolution, and we believe that this and other advantages will lead to widespread acceptance and further application of 8K ultra-high-definition systems in the field of gynecologic surgery.

Ultra-high definition (8K UHD) endoscope: our first clinical success.

BACKGROUND: We have started clinical application of 8K ultra-high definition (UHD; 7680 × 4320 pixels) imaging technology, which is a 16-fold higher resolution than the current 2K high-definition (HD; 1920 × 1080 pixels) technology, to an endoscope for advanced laparoscopic surgery. RESULTS: Based on preliminary testing experience and with subsequent technical and system improvements, we then proceeded to perform two cases of cholecystectomy and were able to achieve clinical success with an 8K UHD endoscopic system, which consisted of an 8K camera, a 30-degrees angled rigid endoscope with a lens adapter, a pair of 300-W xenon light sources, an 85-inch 8K LCD and an 8K video recorder. These experimental and clinical studies revealed the engineering and clinical feasibility of the 8K UHD endoscope, enabling us to have a positive outlook on its prospective use in clinical practice. CONCLUSIONS: The 8K UHD endoscopy promises to open up new possibilities for intricate procedures including anastomoses of thin nerves and blood vessels as well as more confident surgical resections of a diversity of cancer tissues. 8K endoscopic imaging, compared to imaging by the current 2K imaging technology, is very likely to lead to major changes in the future of medical practice.

Diagnostic value of procalcitonin for acute complicated appendicitis.

A rapid and reliable test for detection of complicated appendicitis would be useful when deciding whether emergency surgery is required. We investigated the clinical usefulness of procalcitonin for identifying acute complicated appendicitis. We retrospectively analyzed 63 patients aged ≥15 years who underwent appendectomy without receiving antibiotics before admission and had preoperative data on the plasma procalcitonin level (PCT), body temperature (BT), white blood cell count (WBC), neutrophil / lymphocyte ratio (N/L ratio), and C-reactive protein level (CRP). Patients were classified into 3 groups: group A (inflammatory cell infiltration of the appendix with intact mural architecture), group B (inflammatory cell infiltration with destruction of mural architecture, but without abscess or perforation), and group C (macroscopic abscess and/or perforation). For identifying destruction of mural architecture, the diagnostic accuracy of PCT was similar to that of BT or CRP. However, the diagnostic accuracy of PCT was highest among the five inflammatory indices for identifying abscess and/or perforation, with the positive predictive value of PCT for abscess and/or perforation being higher than that of CRP (73% vs. 48%). Univariate analysis of the predictors of abscess and/or perforation revealed that a plasma PCT level ≥0.46 ng/mL had the highest odds ratio (30.3 [95% confidence interval: 6.5-140.5] versus PCT <0.46 ng/mL). These findings indicate that procalcitonin is a useful marker of acute appendicitis with abscess and/or perforation.

Towards scene adaptive image correspondence for placental vasculature mosaic in computer assisted fetoscopic procedures.

BACKGROUND: Visualization of the vast placental vasculature is crucial in fetoscopic laser photocoagulation for twin-to-twin transfusion syndrome treatment. However, vasculature mosaic is challenging due to the fluctuating imaging conditions during fetoscopic surgery. METHOD: A scene adaptive feature-based approach for image correspondence in free-hand endoscopic placental video is proposed. It contributes towards existing techniques by introducing a failure detection method based on statistical attributes of the feature distribution, and an updating mechanism that self-tunes parameters to recover from registration failures. RESULTS: Validations on endoscopic image sequences of a phantom and a monkey placenta are carried out to demonstrate mismatch recovery. In two 100-frame sequences, automatic self-tuned results improved by 8% compared with manual experience-based tuning and a slight 2.5% deterioration against exhaustive tuning (gold standard). CONCLUSION: This scene-adaptive image correspondence approach, which is not restricted to a set of generalized parameters, is suitable for applications associated with dynamically changing imaging conditions. Copyright © 2015 John Wiley & Sons, Ltd.

Self-contained image mapping of placental vasculature in 3D ultrasound-guided fetoscopy.

BACKGROUND: Surgical navigation technology directed at fetoscopic procedures is relatively underdeveloped compared with other forms of endoscopy. The narrow fetoscopic field of views and the vast vascular network on the placenta make examination and photocoagulation treatment of twin-to-twin transfusion syndrome challenging. Though ultrasonography is used for intraoperative guidance, its navigational ability is not fully exploited. This work aims to integrate 3D ultrasound imaging and endoscopic vision seamlessly for placental vasculature mapping through a self-contained framework without external navigational devices. METHODS: This is achieved through development, integration, and experimentation of novel navigational modules. Firstly, a framework design that addresses the current limitations based on identified gaps is conceptualized. Secondly, integration of navigational modules including (1) ultrasound-based localization, (2) image alignment, and (3) vision-based tracking to update the scene texture map is implemented. This updated texture map is projected to an ultrasound-constructed 3D model for photorealistic texturing of the 3D scene creating a panoramic view of the moving fetoscope. In addition, a collaborative scheme for the integration of the modular workflow system is proposed to schedule updates in a systematic fashion. Finally, experiments are carried out to evaluate each modular variation and an integrated collaborative scheme of the framework. RESULTS: The modules and the collaborative scheme are evaluated through a series of phantom experiments with controlled trajectories for repeatability. The collaborative framework demonstrated the best accuracy (5.2 % RMS error) compared with all the three single-module variations during the experiment. Validation on an ex vivo monkey placenta shows visual continuity of the freehand fetoscopic panorama. CONCLUSIONS: The proposed developed collaborative framework and the evaluation study of the framework variations provide analytical insights for effective integration of ultrasonography and endoscopy. This contributes to the development of navigation techniques in fetoscopic procedures and can potentially be extended to other applications in intraoperative imaging.

A Case of Severe Unicuspid Aortic Valve Stenosis: Valve Repair With Tricuspidization in an Adult.

A 33-year-old male was referred to our institute with acute heart failure. The patient was found to have a unicuspid aortic valve (UAV) and severe aortic stenosis. He had been followed at a local university hospital during childhood. However, he stopped visiting the outpatient clinic after becoming an adult. His condition subsequently worsened, and he ultimately presented to our hospital with cardiogenic shock. In Japan, some adult congenital heart disease (ACHD) patients continue to be followed by pediatric cardiologists, though the patterns of practice are variable. This report describes the case of a patient who became lost to follow-up in early adulthood. We thus focus on this ACHD case as an example of the effects of inadequate communication among doctors and the need to establish better ACHD management protocols for treating this patient population.

Aortic Valve Reconstruction Using Autologous Pericardium for Aortic Stenosis.

BACKGROUND: To determine the feasibility of original aortic valve reconstruction (AVRec) for patients with aortic stenosis (AS), 416 consecutive cases were reviewed. METHODS AND RESULTS: AVRecs for AS were performed for 416 patients from April 2007 through April 2013. All 416 patients were retrospectively reviewed. One hundred and fourteen patients had bicuspid valves and 16 had unicuspid valves. There were 182 men and 234 women. Mean age was 71.2±12.0 years old. On preoperative echocardiography, peak pressure gradient averaged 79.0±33.6 mmHg. Surgical annular diameter was 20.1±2.8 mm. The procedure is based on independent tricuspid replacement by autologous pericardium using original sizing apparatus and template. There was no conversion to prosthetic valve replacement. There were 8 in-hospital mortalities due to non-cardiac cause. On postoperative echocardiography, peak pressure gradient averaged 21.2±10.7 mmHg 1 week after surgery and 14.3±5.0 mmHg 5.5 years after surgery. Four reoperations were done for infective endocarditis. The other 412 patients had less than mild regurgitation. No thrombo-embolic events were recorded. The mean follow-up period was 25.2±17.5 months. Freedom from reoperation was 96.7% with 73-month follow-up. CONCLUSIONS: Medium-term results were excellent. Original AVRec was feasible for the patients with AS. Long-term data will be presented in the future.

Novel, high-definition 3-D endoscopy system with real-time compression communication system to aid diagnoses and treatment between hospitals in Thailand.

INTRODUCTION: Traditionally, laparoscopy has been based on 2-D imaging, which represents a considerable challenge. As a result, 3-D visualization technology has been proposed as a way to better facilitate laparoscopy. We compared the latest 3-D systems with high-end 2-D monitors to validate the usefulness of new systems for endoscopic diagnoses and treatment in Thailand. METHODS: We compared the abilities of our high-definition 3-D endoscopy system with real-time compression communication system with a conventional high-definition (2-D) endoscopy system by asking health-care staff to complete tasks. Participants answered questionnaires and whether procedures were easier using our system or the 2-D endoscopy system. RESULTS: Participants were significantly faster at suture insertion with our system (34.44 ± 15.91 s) than with the 2-D system (52.56 ± 37.51 s) (P < 0.01). Most surgeons thought that the 3-D system was good in terms of contrast, brightness, perception of the anteroposterior position of the needle, needle grasping, inserting the needle as planned, and needle adjustment during laparoscopic surgery. Several surgeons highlighted the usefulness of exposing and clipping the bile duct and gallbladder artery, as well as dissection from the liver bed during laparoscopic surgery. In an image-transfer experiment with RePure-L®, participants at Rajavithi Hospital could obtain reconstructed 3-D images that were non-inferior to conventional images from Chulalongkorn University Hospital (10 km away). CONCLUSION: These data suggest that our newly developed system could be of considerable benefit to the health-care system in Thailand. Transmission of moving endoscopic images from a center of excellence to a rural hospital could help in the diagnosis and treatment of various diseases.

Image mapping of untracked free-hand endoscopic views to an ultrasound image-constructed 3D placenta model.

BACKGROUND: This study presents a tracker-less image-mapping framework for surgical navigation motivated by the clinical need for intuitive visual guidance during minimally invasive fetoscopic surgery. METHODS: A navigation framework mapping 2D endoscopic vision to a 3D ultrasound image model is proposed. This maps an endoscopic image onto a 3D placenta model through a one-time ultrasound image-based localization method followed by a series of concurrent image alignments and texture mapping of the untracked endoscopic video stream. RESULTS: The mean absolute error of our ultrasound image-based localization method was (1.63 mm, 0.93°). The simulation analysis reveals an upper bound mapping performance with a mean error of 1.53 mm. In a phantom experiment, the overall mapping performance is close to this accuracy and achieves a mean absolute error of 2 mm, thereby supporting the feasibility of this method. CONCLUSION: This novel integration of intraoperative visual guidance has potential contributions to innovative fusions of image guidance techniques for effective navigation in minimally invasive fetoscopic surgery.

Aortic valve reconstruction using autologous pericardium for patients aged less than 60 years.

OBJECTIVE: We have performed an original aortic valve reconstruction using autologous pericardium. The feasibility for patients aged less than 60 years is reviewed. METHODS: From April 2007 to April 2013, aortic valve reconstruction was performed in 108 patients aged less than 60 years. A total of 51 patients had aortic stenosis, 7 patients had annuloaortic ectasia, 7 patients had infective endocarditis, and 43 patients had aortic regurgitation. Fifty-seven patients had bicuspid valves, and 11 patients had unicuspid valves. There were 75 male and 33 female patients, with a mean age of 47.8 ± 11.2 years. Preoperative echocardiography showed an average peak pressure gradient of 86.1 ± 35.1 mm Hg with aortic stenosis. The surgical procedure is based on the independent tricuspid replacement using autologous pericardium. First, the distance between the commissures is measured using an original sizing apparatus, and then the pericardial cusp is trimmed using an original template and sutured to the annulus. RESULTS: There was no conversion to prosthetic valve replacement. There were no in-hospital mortalities. Postoperative echocardiography showed an average peak pressure gradient of 14.8 ± 7.8 mm Hg 1 week after surgery and 12.8 ± 3.1 mm Hg 4 years after surgery. One patient required reoperation because of infective endocarditis. The other 107 patients showed less than mild aortic regurgitation. No thromboembolic events were recorded. The mean follow-up period was 34.2 ± 15.7 months. Freedom from reoperation was 98.9% with 76 months of follow-up. CONCLUSIONS: Original aortic valve reconstruction was feasible for patients aged less than 60 years. Long-term data will be disclosed in the future.