Improvement of Coracoid Process Union Rates: A Comparative Study of Conventional Open and Arthroscopic-assisted Bristow Procedures for Treating Anterior Shoulder Instability in Rugby Players.

BACKGROUND: The Bristow coracoid transfer procedure is a reliable technique for treating anterior shoulder instability in patients with large glenoid bone loss or those involved in collision sports. However, its success is marred by its inferior bone union rate of the coracoid process as compared to the Latarjet procedure. This study aimed to evaluate whether arthroscopic confirmation of the secured coracoid fixation during the Bristow procedure improves the bone union rate and clinical outcomes as compared to the open procedure. METHODS: We retrospectively reviewed 104 rugby players (n = 111 shoulders) who underwent an open (n = 66 shoulders) or arthroscopy-assisted (AS-assisted; n = 45 shoulders) Bristow procedure at our center from 2007 to April 2019. In the AS-assisted group, the screw fixation and coracoid stability and contact were confirmed under arthroscopic visualization. Graft union was evaluated through computed tomography at 3 months, 6 months, and 1 year postoperatively. Patient-reported outcome measures were assessed based on the American Shoulder and Elbow Surgeons (ASES) score, Rowe score, and satisfaction rate. Recurrence, the rate of return to play (RTP), and the frequency of pain after RTP were also assessed. RESULTS: The mean follow-up period was 73.5 (range: 45-160) months for the open group and 32.3 (range: 24-56) months for the AS-assisted group. In the former, the rates of bone union were 50%, 72.7%, and 88.9% at 3 months, 6 months, and 1 year, respectively. In contrast, the AS-assisted group had significantly greater bone union rates-88.9%, 93.3%, and 95.6% at 3 months, 6 months, and 1 year, respectively. Both groups showed significant improvement in the ASES and Rowe scores compared to preoperative values as well as high satisfaction rates (open: 92%; AS-assisted: 95.7%). There were no statistically significant differences in the recurrence and RTP rates as well as the frequency of pain after RTP between the two groups. CONCLUSION: The AS-assisted procedure allows early and high bone healing without compromising the clinical outcomes.

Open-chest epicardial ablation of ventricular tachycardia during a left ventricular assist device implantation: a case report.

Background: Ventricular arrhythmias (VAs) are common after a left ventricular assist device (LVAD) implantation. Further, the majority of post-LVAD ventricular tachycardias (VTs) are secondary to a preexisting cardiomyopathy substrate. Intraoperative ablation of patients with recurrent preoperative VTs may reduce post-LVAD VTs. Case summary: A 59-year-old female with advanced heart failure due to non-ischaemic cardiomyopathy (LV ejection fraction = 24%) and recurrent VTs was referred for an LVAD implantation as a bridge to a heart transplant (INTERMACS Profile-5A). The previous endocardial ablation failed due to an epicardial arrhythmogenic substrate. Therefore, open-chest epicardial mapping during the LVAD implantation was indicated and three target areas of the arrhythmogenic substrate were found, which were ablated by radiofrequency applications. To minimize the cardiopulmonary bypass time, cardiopulmonary bypass was initiated after ablation, and then, an LVAD was implanted. An additional 68 min was required for mapping and ablation. All procedures were performed without any complications, and the post-operative course was uneventful. Thereafter, no VT episodes were observed without any anti-arrhythmic drugs during a 15-month follow-up with LVAD support. Discussion: Intraoperative epicardial mapping and ablation during an LVAD implantation can play an important role in the management of LVAD recipients with recurrent VAs.

Association Between Preoperative Glenoid Bone Loss and Postoperative Outcomes After Coracoid Transfer Combined With Open Bankart Repair: Comparison of the Bristow and Latarjet Techniques.

Background: Whether the extent of glenoid bone loss (GBL) affects clinical outcome after coracoid process transfer (CPT) is still unclear. Purpose: To evaluate postoperative outcomes after CPT combined with open Bankart repair in young rugby players in terms of the extent of GBL and between the Bristow and Latarjet techniques. Study Design: Cohort study; Level of evidence, 3. Methods: The authors investigated 101 shoulders in 91 competitive rugby players who underwent CPT combined with open Bankart repair by the Bristow (group B; 66 shoulders) or Latarjet (group L; 35 shoulders) procedure between 2007 and 2017. The extent of GBL was calculated from the en face view of the glenoid on preoperative 3-dimensional computed tomography scans and was used to categorize shoulders into 4 grades (grade 0, 0%; grade 1, >0% and ≤10%; grade 2, >10% and ≤20%; grade 3, >20%). At the minimum 2-year follow-up, the authors analyzed the relationship between GBL or GBL grade and postoperative outcome scores (American Shoulder and Elbow Surgeons score, Rowe score, Western Ontario Shoulder Instability Index, and patient satisfaction), return-to-play (RTP) times, graft failure (insufficient union or translocation), and recurrence. Results: The mean GBL in all shoulders was 10.9% ± 9.2% and was not significantly different between the 2 groups. There were no significant correlations between GBL and any outcome measure in either group. The mean RTP time was significantly shorter in group L versus group B (4.8 ± 1.1 vs 5.8 ± 1.8 months, respectively; P = .002), but it was not associated with GBL. In group B, the rate of graft failure was not significantly higher in shoulders with grade 0 or 1 GBL versus grade 2 or 3 GBL (8 [25.0%] vs 4 [11.8%], respectively; P = .21). In group B, graft failure was confirmed in 12 shoulders (18.2%), compared with 1 shoulder (2.9%) in group L. Postoperative recurrence occurred in significantly fewer shoulders in group B than in group L (2 [3.0%] vs 5 [14.3%], respectively; P = .047). Conclusion: The extent of GBL did not affect outcome scores after CPT, regardless of operative procedure.

Japanese single-center experience of abdominal aortic aneurysm repair over 20 years: should open or endovascular aneurysm repair be performed first?

PURPOSE: The present study analyzed the outcomes of our experience with abdominal aortic aneurysm (AAA) repair over 20 years using endovascular aortic repair (EVAR) with commercially available devices or open aortic repair (OAR) and reviewed our surgical strategy for AAA. METHODS: From 1999 to 2019, 1077 patients (659 OAR, 418 EVAR) underwent AAA repair. The OAR and EVAR groups were compared retrospectively, and a propensity matching analysis was performed. RESULTS: EVAR was first introduced in 2008. Our strategy was changed to an EVAR-first strategy in 2010. Beginning in 2018, this EVAR-first strategy was changed to an OAR-first strategy. After propensity matching, the overall survival in the OAR group was significantly better than that in the EVAR group at 10 years (p = 0.006). Two late deaths due to AAA rupture were identified in the EVAR group, although there were no significant differences between the OAR and EVAR groups with regard to the freedom from AAA-related death at 10 years. The rate of freedom from aortic events at 10 years was significantly higher in the OAR group than in the EVAR group (p < 0.0001). CONCLUSION: The rates of freedom from AAA-related death in both the OAR and EVAR groups were favorable, and the rate of freedom from aortic events was significantly lower in the EVAR group than in the OAR group. Close long-term follow-up after EVAR is mandatory.

Early and late outcomes of type A acute aortic dissection with common carotid artery involvement.

Objective: The relationship between common carotid artery (CCA) involvement in acute type A aortic dissection (ATAAD) and postoperative outcomes remains unclear. We investigated outcomes and described our current advanced strategy. Methods: Of 492 patients who underwent surgical repair for ATAAD between September 1999 and February 2021, CCA involvement was identified in 114. Eighty of these 114 patients (70.2%) were classified as having a thrombosed CCA and 34 (29.8%) were classified as nonthrombosed. To prevent postoperative cerebral malperfusion, we initiated a strategy of early reperfusion and direct reconstruction of dissected and thrombosed CCAs regardless of neurologic symptoms. Results: Fifty-five patients (48.2%) showed preoperative neurologic symptoms. No significant differences between the thrombosed and nonthrombosed groups were seen in postoperative mortality (20.0% vs 11.8%; P = .421) or frequency of postoperative modified Rankin scale (mRS) score ≥5 (30.0% vs 17.6%; P = .245). The rate of postoperative neurologic deficit was significantly higher (48.8% vs 23.5%; P = .013) and long-term survival rate was significantly lower (5 years; 59.1 ± 6.3% vs 77.9 ± 7.4%; 10 years: 50.0 ± 7.9% vs 72.3 ± 8.7%; P = .041) in the thrombosed group. Risk factors for mRS ≥5 from multivariable analysis included occluded thrombosed CCA, preoperative coma, preoperative shock, and prolonged operation time. Fifteen patients were treated with the early reperfusion and direct reconstruction strategy; postoperative mortality 13.3% (2 patients). No patients showed cerebral reperfusion syndrome. Conclusions: In patients with CCA involvement, a thrombosed false lumen, especially an occluded CCA, resulted in worse outcomes regardless of preoperative neurologic symptoms. Further study is needed to evaluate the efficacy of the current strategy.

Open Bristow Versus Open Latarjet for Anterior Shoulder Instability in Rugby Players: Radiological and Clinical Outcomes.

Background: Coracoid transfer is a reliable method for managing anterior shoulder instability in athletes who play contact sports; however, differences between the Bristow and Latarjet procedures are unclear. Purpose: To compare clinical outcomes and rates of bone union and bone resorption of the coracoid process between the open Bristow and open Latarjet procedures in rugby players. Study Design: Cohort study; Level of evidence, 3. Methods: Rugby players who underwent an open Bristow or an open Latarjet procedure were retrospectively reviewed for anterior shoulder instability, and 66 shoulders in the Bristow group and 35 in the Latarjet group were included. Graft union and resorption were evaluated using computed tomography at 3 months to 1 year postoperatively. Patient-reported outcome measures (American Shoulder and Elbow Surgeons score, Rowe score, and satisfaction rate) were obtained at a mean follow-up of 74 months (range, 45-160 months) for Bristow and 64 months (range, 50-76 months) for Latarjet procedures. Recurrence and the rate of return to play (RTP), frequency of pain after RTP, and retirement rate after RTP were also assessed. Results: In 97.1% of the Latarjet procedure cases, bone union of the coracoid was achieved at 3 months postoperatively; however, bone union was achieved in only 72.7% of the Bristow procedure cases at 6 months postoperatively. Bone resorption of the coracoid process occurred in 6.1% of shoulders after the Bristow procedure, whereas 100% of shoulders showed bone resorption after the Latarjet procedure. No statistical differences were found in outcome scores between the 2 procedures. Subluxation and persistent pain after returning to sports were identified at a significantly higher rate in the Latarjet group (5 shoulders [14%] and 9 shoulders [26%], respectively) than in the Bristow group (2 shoulders [3%] and 2 shoulders [3%]) (P = .0471 and P = .001, respectively). Conclusion: The Latarjet procedure had an advantage in the early and high rate of bone union but was at a disadvantage in bone resorption compared with the Bristow procedure. Subluxation and pain after returning to sports were more frequent in patients who underwent the open Latarjet procedure than in those who underwent the open Bristow procedure.

RC time (resistance × compliance) is related to residual symptom after pulmonary endarterectomy in chronic thromboembolic pulmonary hypertension.

Background: Right ventricular (RV) afterload is widely assessed by pulmonary vascular resistance (PVR). However, RV afterload is underestimated because PVR does not account for the pulsatile load. The pulsatile load is often evaluated by pulmonary arterial compliance (PAC). The RC (resistance-compliance) time, which is calculated from the product of PVR and PAC, is considered to remain constant under medical therapy. However, little is known on how RC time is affected by invasive therapy in chronic thromboembolic pulmonary hypertension (CTEPH). This study aimed to evaluate change of RC time in patients underwent pulmonary endarterectomy (PEA). Furthermore, we investigated the clinical relevance of RC time. Methods: We reviewed consecutive 50 patients except for death case underwent PEA. Baseline clinical parameters including RC time before performing PEA and follow-up were evaluated. Patients was classified as decrease or non-decrease according to change of RC time. Furthermore, we classified patients into a NYHA I group who had no symptom after treatment and a residual symptom group in order to investigate the relationship of RC time to residual symptoms. Results: RC time was significantly decreased after PEA (0.54 ± 0.16 to 0.45 ± 0.12 sec, p < 0.001). Residual symptom after PEA of Decrease group were significantly better than that of Non-decrease group in RC time (12 patients, 40% vs. 11 patients, 78.6%, p < 0.02). Furthermore, multivariate analysis revealed that only RC time after PEA was independently associated with residual symptom (OR 1.026, 95% CI 1.005-1.048; p = 0.017). Conclusions: RC time was decreased after PEA, and might be a possible indicator for predicting PEA success.

Impending paradoxical embolism.

An impending paradoxical embolism (IPDE) is seldom observed in clinical practice. We report a case of IPDE in a 67-year-old female with severe dyspnea and hypotension, which was detected and successfully treated with emergent cardiac surgery. The optimal treatment is still controversial. We believe that emergent surgery always should be considered in patients with IPDE. .

Intravenous injection of adult human bone marrow mesenchymal stromal cells attenuates spinal cord ischemia/reperfusion injury in a murine aortic arch crossclamping model.

Objective: We sought to investigate the efficacy of human bone marrow mesenchymal stem/stromal cell (hBM-MSC) in a murine spinal cord ischemia/reperfusion (SCIR) model. Methods: C57BL/6J mice were subjected to SCIR by crossclamping the aortic arch and left subclavian artery for 5.5 minutes. Two hours after reperfusion, hBM-MSCs (hBM-MSC group) or phosphate-buffered saline (control group) were intravenously injected without immunosuppressant. Hindlimb motor function was assessed until day 28 after reperfusion using the Basso Mouse Scale (BMS). The lumbar spinal cord was harvested at hour 24 and day 28, and the histologic number of NeuN-positive motor neurons in 3 cross-sections of each lumbar spinal cord and the gene expression were evaluated. Results: BMS score was 0 throughout the study period in all control mice. BMS score was significantly greater in the hBM-MSC group than the control group from hour 8 (P < .05) to day 28 (P < .01). The numbers of motor neurons at hour 24 (P < .01) and day 28 (P < .05) were significantly preserved in the hBM-MSC group than the control group. mRNA expression levels of proinflammatory cytokines were significantly lower (P < .05), and those of insulin-like growth factor-1 (P < .01) and proangiogenic factors (P < .05) were significantly greater in the hBM-MSC group than the control group at hour 24. Conclusions: hBM-MSC therapy may attenuate SCIR injury by preserving motor neurons, at least in part, through inhibition of proinflammatory cytokines and upregulation of proangiogenic factors in the reperfusion-injured spinal cord.

Symptomatic Intracranial Artery Stenosis Due to an Unknown Embolus Following Cardiac Surgery: A Case Report.

Intracranial artery occlusion due to a foreign body is a complication associated with cardiac surgery that is treated by various techniques. However, little is known about appropriate strategies for symptomatic intracranial artery stenosis due to an unknown embolic source. We reported a case of middle cerebral artery (MCA) stenosis after mitral valve repair (MVR) for infective endocarditis (IE). An 80-year-old man presented with right hemiplegia. MR angiography findings were normal, and diffusion-weighted imaging revealed subtle ischemic change in the left MCA territory. The patient was diagnosed with cardioembolic stroke owing to IE and performed MVR. Four days later, he suddenly presented with consciousness disorder and left hemiplegia. Computed tomography (CT) confirmed a very low-density area within the right MCA. MR angiography revealed right MCA stenosis, which corresponded to the low-density area on CT images. Diffusion-weighted imaging revealed new ischemic change in the right MCA territory. Angiography confirmed an irregular stenosis at the right M2 with antegrade blood flow, and the hemiplegia resolved during angiography. Conservative therapy was performed; however, the resting 123 I-IMP-single photon emission CT revealed moderate perfusion defect in the right MCA territory, and transient left hemiplegia appeared every few days. Therefore, 19 days after the initial transient ischemic attack, the patient was performed superficial temporal artery-MCA anastomosis, and the patient responded with a good clinical course without recurrence of the ischemic symptoms. This strategy may be a safe and effective treatment for symptomatic intracranial artery stenosis due to an unknown embolic source.

Anterolateral Partial Sternotomy for Treatment of Graft Infection with Fungal Vegetation on the Frozen Elephant Trunk: A Case Report.

A 49-year-old man, who had undergone total arch replacement (TAR) with frozen elephant trunk (FET) technique for type A acute aortic dissection, was subsequently transferred to our hospital for uncontrollable infection. Since multiple blood cultures were positive for Candida parapsilosis and transesophageal echocardiography revealed vegetation attached to the FET, he was diagnosed with a graft infection. In addition, on the 18-fluorodeoxyglucose positron emission tomography scans, high uptake lesions were found around the quadrifurcated graft as well as the FET. Therefore, an extensive TAR through anterolateral thoracotomy with partial sternotomy was performed to remove all infected prothesis. Consequently, the patient completely recovered.

Mitral Ebstein's Anomaly Modified with a Scarred Rhabdomyoma in Tuberous Sclerosis: An Extremely Rare Cause of Mitral Insufficiency.

We present an extremely rare case of mitral Ebstein's anomaly that resulted in severe mitral regurgitation (MR). A 41-year-old woman with a history of tuberous sclerosis underwent surgery. Preoperatively, it was assumed that MR had occurred due to leaflet tethering related to left ventricular posterior wall motion asynergy due to a scarred rhabdomyoma. However, surgical inspection revealed a dysplastic posterior leaflet adhering to the ventricular wall, which was completely covered by the endocardium. Both congenital mitral Ebstein's anomaly and acquired wall motion abnormality due to a scarred rhabdomyoma may have contributed to the development of severe MR in this case.

The role of balloon pulmonary angioplasty and pulmonary endarterectomy: Is chronic thromboembolic pulmonary hypertension still a life-threatening disease?

BACKGROUND: The management of non-operable chronic thromboembolic pulmonary hypertension (CTEPH) has evolved with the availability of balloon pulmonary angioplasty (BPA) and pulmonary vasodilators. We launched the BPA program in 2011. The aim was to analyze the survival and treatment efficacy of our CTEPH treatment program in the modern management era. METHODS AND RESULTS: We retrospectively reviewed data from 143 consecutive CTEPH patients diagnosed from January 2011 (i.e. after the availability of BPA) to December 2019. Of forty-one patients who underwent pulmonary endarterectomy (PEA), 25 underwent additional BPA (Combination group) and the others were treated with only PEA (PEA group). Ninety patients underwent BPA (BPA group). The remaining 12 patients did not undergo any interventional treatments. The 1- and 5-year survival rates of operated patients (n = 41) were 97.4% and 90.0%, compared to 96.9% and 86.9% in not-operated patients (n = 102), respectively (p = 0.579). There was no mortality in the Combination group. Mean pulmonary artery pressure after treatments in the PEA only, Combination, and BPA only groups was 20.5 ± 6.7, 17.9 ± 4.9, and 20.7 ± 4.6 mmHg, respectively (p = 0.067, one-way ANOVA). Percent decrease of pulmonary vascular resistance in each treatment groups was -73.7 ± 11.3%, -74.3 ± 11.8%, and - 54.9 ± 22.5%, respectively (p < 0.01, one-way ANOVA). CONCLUSION: There was no significant difference in long-term survival between operated and not-operated CTEPH. Moreover, the Combination approach might have the potential to introduce notable improvements in the prognosis of CTEPH. BPA and PEA appear to be mutually complementary therapies in the modern management era.

Mid-term outcomes of valve-sparing root reimplantation with leaflet repair.

OBJECTIVES: Valve repair for aortic insufficiency (AI) requires a tailored surgical approach determined by the leaflet and aortic disease. In this study, we used a repair-oriented system for the classification of AI, and we elucidated long-term outcomes of aortic root reimplantation with this classification system. METHODS: From 1999 to 2018, a total of 197 patients underwent elective reimplantation (mean age: 52.7 ± 17.7 years; 80% male). The aortic valve was tricuspid in 143 patients, bicuspid in 51 patients and quadricuspid in 3 patients. A total of 93 patients had type I AI (aortic dilatation), 57 patients had type II AI (cusp prolapse) and 47 patients had type III AI (restrictive). In total, 104 of the 264 patients (39%) had more than 1 identified mechanism. RESULTS: In-hospital mortality was 0.5% (1/197). Mid-term follow-up (mean follow-up duration: 5.5 years) revealed a late mortality rate of 4.2% (9/197). Aortic valve reoperation was performed on 16 patients (8.0%). Rates of freedom from aortic valve replacement and freedom from aortic valve-related events at 10 years of follow-up were 87.0 ± 4.0% and 60.6 ± 6.0%, respectively; patients with type Ib AI (98.3 ± 1.7%; 80.7 ± 7.5%) had better outcomes than patients with type III AI (59.6 ± 15.6%; 42.2 ± 13.1%, P = 0.01). In patients with types II and III AI who had bicuspid aortic valves, rates of freedom from aortic valve-related events at 5 years of follow-up were 95.2 ± 4.7% and 71.7 ± 9.1%, respectively (P = 0.03). CONCLUSIONS: This repair-oriented system for classifying AI could help to predict the durable aortic valve repair techniques. Patient selection according to the classification is particularly important for long-term durability. CLINICAL TRIAL REGISTRATION NUMBER: B190050.

Thoracic Endovascular Aortic Repair for Ruptured Intercostal Patch Aneurysm Following Thoracoabdominal Aortic Aneurysm Repair.

Aneurysmal change of reconstructed intercostal arteries is believed to be a rare complication after thoracoabdominal aortic repair. To our knowledge, there is no guideline or randomized controlled trials regarding intercostal patch aneurysm management. Therefore, the optimal treatment is still controversial. We describe a successful case of emergent thoracic endovascular aortic repair for ruptured intercostal patch aneurysm in an 83-year-old man following thoracoabdominal aortic aneurysm repair. Our experience illustrated that gradual expansion of large blocks of aortic wall reconstruction should be closely monitored after primary thoracoabdominal aortic replacement.

A successful report of mitral valve repair for parachute-like mitral valve in adult.

A 65 year-old man was diagnosed with congestive heart failure secondary to severe mitral regurgitation resulting from a parachute-like asymmetrical mitral valve. We performed mitral annuloplasty and triangular resection of the thick tissue. The postoperative course was uneventful with no recurrence of mitral regurgitation.

Results of staged repair of aortic disease in patients with Marfan syndrome.

OBJECTIVE: We present our open surgical strategies for staged replacement of the thoracic and thoracoabdominal aorta in patients with Marfan syndrome. METHODS: Between October 1999 and December 2017, 82 patients with Marfan syndrome underwent 118 aortic repairs. We divided the aorta into 4 segments for categorization: (1) the aortic root, (2) aortic arch, (3) descending thoracic, and (4) abdominal aorta. Procedures were categorized according to the types of surgery. Staged repair was defined as a subsequent operation on a different segment of the aorta after initial repair (n = 111, 94.1%), and reoperation was defined as an operation on the same segment (n = 7, 5.9%). RESULTS: The mean age at initial operation was 41.7 ± 14.9 years. Staged repairs included aortic root replacement (n = 42, 36%), total arch replacement (n = 11, 9.3%), combined aortic root and total arch replacement (n = 13, 11%), descending aorta replacement (n = 4, 3.4%), thoracoabdominal aortic repair (n = 36, 31%), and extensive arch-descending or thoracoabdominal repair (n = 5, 4.2%). Four patients received 3 staged repairs. Operative mortality was 0.8% (1/118). Stroke occurred in 1.7% (2/118), and spinal cord injury occurred in 1.7% (2/117). Overall survival was 95.8 ± 2.4% at 10-years. Twenty-four patients underwent replacement of the whole aorta after 2.5 ± 3.8 years following initial repair. CONCLUSIONS: Our strategies for staged replacement of the thoracic and thoracoabdominal aorta in patients with Marfan syndrome resulted in excellent early- and long-term outcomes.

Mid-term outcomes of simultaneous mitral valve repair in patients with miral regurgitation and concomitant annulo-aortic ectasia.

OBJECTIVE: This study investigated the mid-term outcomes of simultaneous mitral valve repair in patients with mitral regurgitation (MR) and concomitant annulo-aortic ectasia. METHODS: The study included 26 patients with MR and annulo-aortic ectasia [mean age 46.0 ± 19.9 (10-86) years] who underwent simultaneous mitral valve repair between January 2007 and March 2018. Of these 26 patients, 11 (42.3%) were diagnosed with Marfan syndrome and 10 (38.5%) with Barlow's disease. All patients underwent complete ring annuloplasty; a semi-rigid ring was used in 14 (53.8%) and a semi-flexible ring (anterior-flexible) in 12 patients (46.2%). All patients underwent valve-sparing root replacement using the reimplantation technique. RESULTS: The overall 3-year survival rate was 95.7 ± 4.3%. The 3-year freedom from > moderate MR rate was 94.7 ± 5.1%, and the 3-year freedom from > moderate aortic regurgitation (AR) rate was 86.7 ± 7.3%. The 3-year freedom from reoperation rate was 100%. The 3-year freedom from > moderate MR rate was 100% in the semi-rigid ring group and 85.7 ± 13.2% in the semi-flexible ring group (log-rank test, p = 0.5371). The 3-year freedom from > moderate AR rate was 100% in the semi-rigid ring group and 72.9 ± 16.5% in the semi-flexible ring group (log-rank test, p = 0.0815). CONCLUSIONS: Simultaneous mitral valve repair in patients with MR and concomitant annulo-aortic ectasia showed favorable mid-term outcomes.