Impact of Non-Diameter Aortic Indices on Surgical Eligibility: Results from the TITAN: SvS Randomized Controlled Trial.

OBJECTIVES: Traditional criteria for intervention on an asymptomatic ascending aortic aneurysm has been a maximal aortic diameter of ⩾5.5cm. The 2022 ACC/AHA aortic guidelines adopted cross-sectional aortic area/height ratio, aortic size index (ASI) and aortic height index (AHI) as alternate parameters for surgical intervention. The objective of this study was to evaluate the impact of using these newer indices on patient eligibility for surgical intervention in a prospective, multicenter cohort with moderate sized ascending aortic aneurysms between 5.0-5.4 cm. METHODS: Patients enrolled from 2018 to 2023 in the randomization or registry arms of the multicenter trial, TITAN: SvS, were included in the study. Clinical data was captured prospectively in an online database. Imaging data were derived from a core CT lab. RESULTS: Among the 329 included patients, 20% were female. Mean age was 65.0 ± 11.6 years and mean maximal aortic diameter was 50.8 ±3.9 mm. In the one third of all patients (n=109) who met any one of the three criteria (i.e., ASI ⩾ 3.08 cm/m2, AHI ⩾ 3.21 cm/m or cross-sectional aortic area/height ⩾ 10 cm2/m), their mean maximal aortic diameter was 52.5 ±0.52 mm. Alternate criteria were most commonly met in females compared to males: 20% versus 2% for ASI (p<0.001), 39% versus 5% for AHI (p<0.001) and 39% versus 21% for cross-sectional aortic area/height (p=0.002), respectively. CONCLUSIONS: One third of patients in Titan:SvS would meet criteria for surgical intervention based on novel parameters vs. the classic definition of diameter⩾5.5cm. Surgical thresholds for ASI, AHI or cross-sectional aortic area/height ratio are more likely to be met in female patients compared to male patients.

Topical Versus Intravenous Tranexamic Acid in Patients Undergoing Cardiac Surgery: The DEPOSITION Randomized Controlled Trial.

BACKGROUND: Although intravenous tranexamic acid is used in cardiac surgery to reduce bleeding and transfusion, topical tranexamic acid results in lower plasma concentrations compared to intravenous tranexamic acid, which may lower the risk of seizures. We aimed to determine whether topical tranexamic acid reduces the risk of in-hospital seizure without increasing the risk of transfusion among cardiac surgery patients. METHODS: We conducted a multicenter, double dummy, blinded, randomized controlled trial of patients recruited by convenience sampling in academic hospitals undergoing cardiac surgery with cardiopulmonary bypass. Between September 17, 2019, and November 28, 2023, a total of 3242 patients from 16 hospitals in 6 countries were randomly assigned (1:1 ratio) to receive either intravenous tranexamic acid (control) through surgery or topical tranexamic acid (treatment) at the end of surgery. The primary outcome was seizure, and the secondary outcome was red blood cell transfusion. After the last planned interim analysis-when 75% of anticipated participants had completed follow up-the Data and Safety Monitoring Board recommended to terminate the trial, and upon unblinding, the Operations Committee stopped the trial for safety. RESULTS: Among 3242 randomized patients (mean age, 66.0 years; 77.7% male), in-hospital seizure occurred in 4 of 1624 patients (0.2%) in the topical group and in 11 of 1628 patients (0.7%) in the intravenous group (absolute risk difference, -0.5%; 95% CI, -0.9 to 0.03; P = .07). Red blood cell transfusion occurred in 570 patients (35.1%) in the topical group and in 433 (26.8%) in the intravenous group (absolute risk difference, 8.3%; 95% CI, 5.2 to 11.5; P = .007). The absolute risk difference in transfusion of ≥4 units of red blood cells in the topical group compared to the intravenous group was 8.2% (95% CI, 3.4 to 12.9). CONCLUSIONS: Among patients having cardiac surgery, topical administration of tranexamic acid resulted in an 8.3% absolute increase in transfusion without reducing the incidence of seizure, compared to intravenous tranexamic acid.

Durability of bioprosthetic aortic valve replacement in patients under the age of 60 years - 1-year follow-up from the prospective INDURE registry.

OBJECTIVES: We report 1-year safety and clinical outcomes in patients <60 years undergoing bioprosthetic surgical aortic valve intervention. METHODS: The INSPIRIS RESILIA Durability Registry is a prospective, multicentre registry to assess clinical outcomes of patients <60 years. Patients with planned SAVR with or without concomitant replacement of the ascending aorta and/or coronary bypass surgery were included. Time-related valve safety, haemodynamic performance and quality of life (QoL) at 1 year were assessed. RESULTS: A total of 421 patients were documented with a mean age of 53.5 years, 76.5% being male and 27.2% in NYHA class III/IV. Outcomes within 30 days included cardiovascular-related mortality (0.7%), time-related valve safety (VARC-2; 5.8%), thromboembolic events (1.7%), valve-related life-threatening bleeding (VARC-2; 4.3%) and permanent pacemaker implantation (3.8%). QoL was significantly increased at 6 months and sustained at 1 year. Freedom from all-cause mortality at 1 year was 98.3% (95% confidence interval 97.1; 99.6) and 81.8% were NYHA I versus 21.9% at baseline. No patient developed structural valve deterioration stage 3 (VARC-3). The mean aortic pressure gradient was 12.6 mmHg at 1 year and the effective orifice area was 1.9 cm2. CONCLUSIONS: The 1-year data from the INSPIRIS RESILIA valve demonstrate good safety and excellent haemodynamic performance as well as an early QoL improvement. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov: NCT03666741.

Extracorporeal membrane oxygenation and microaxial left ventricular assist device in cardiogenic shock: Choosing the right mechanical circulatory support to improve outcomes.

Objective: To evaluate the outcomes of patients supported with Impella (CP/5.0) or venoarterial extracorporeal membrane oxygenation (VA-ECMO) for cardiogenic shock according to shock phenotype. The primary end point was 30-day survival. Methods: A retrospective study of patients supported with Impella (CP/5.0) or VA-ECMO between 2010 and 2020 was performed. Patients were grouped according to 1 of 2 shock phenotypes: isolated left ventricular (LV) dysfunction versus biventricular dysfunction or multiple organ failure (MOF). The local practice favors Impella for isolated LV dysfunction and VA-ECMO for biventricular dysfunction or MOF. Results: Among the 75 patients included, 17 (23%) had isolated LV dysfunction. Patients with biventricular dysfunction or MOF had a greater median lactate level compared with those with isolated LV dysfunction (7.9 [2.9-11.8] vs 3.8 [1.1-5.8] mmol/L, respectively). Among patients with isolated LV dysfunction, 30-day survival was 46% for the Impella group (n = 13) and 75% for VA-ECMO (n = 4). Among patients with biventricular dysfunction or MOF, 30-day survival was 9% for the Impella group (n = 11) and 28% for VA-ECMO (n = 47). Patients supported with Impella 5.0 had better 30-day survival compared with those supported with Impella CP, for both shock phenotypes (83% vs 14% and 14% vs 0%, respectively). Conclusions: In this small cohort, patients supported with Impella for isolated LV dysfunction and VA-ECMO for biventricular dysfunction or MOF had acceptable survival at 30 days. Patients with biventricular dysfunction or MOF who were supported by Impella had the lowest survival rates. Patients with isolated LV dysfunction who were supported with VA-ECMO had good 30-day survival.

Structural dysregulation of the pulmonary autograft was associated with a greater density of p16INK4A-vascular smooth muscle cells.

The present study tested the hypothesis that a senescent phenotype of vascular smooth muscle cells (VSMCs) may represent the seminal event linked to maladaptive pulmonary autograft remodeling of a small number of patients that underwent the Ross procedure. The diameter of the pulmonary autograft (47±4 mm) of three male patients was significantly greater compared to the pulmonary artery (26±1 mm) excised from bicuspid aortic valve (BAV) patients. The pulmonary autograft was associated with a neointimal region and the adjacent medial region was significantly thinner compared to the pulmonary artery of BAV patients. Structural dysregulation was evident as elastin content of the medial region was significantly reduced in the pulmonary autograft compared to the pulmonary artery of BAV patients. By contrast, collagen content of the medial region of the pulmonary autograft and the pulmonary artery of BAV patients was not significantly different. Reduced medial elastin content of the pulmonary autograft was associated with increased protein levels of matrix metalloproteinase-9. The latter phenotype was not attributed to a robust inflammatory response as the percentage of Mac-2(+)-infiltrating monocytes/macrophages was similar between groups. A senescent phenotype was identified as protein levels of the cell cycle inhibitor p27kip1 were upregulated and the density of p16INK4A/non-muscle myosin IIB(+)-VSMCs was significantly greater in the pulmonary autograft compared to the pulmonary artery of BAV patients. Thus, senescent VSMCs may represent the predominant cellular source of increased matrix metalloproteinase-9 protein expression translating to maladaptive pulmonary autograft remodeling characterized by elastin degradation, medial thinning and neointimal formation.

Hybrid off-pump debranching and thoracic endovascular arch repair in a high-risk surgical patient.

Management of aortic arch pathologies remains challenging. Open total arch replacements have been associated with significant morbidity and mortality owing to the need for cardiopulmonary bypass and circulatory arrest. On the other hand, aortic arch-branched stent grafts are not widely available. In this context, hybrid techniques combining open arch debranching with endovascular graft placement have been identified as an attractive option in select patients. However, there still is a paucity of literature on their application and outcomes. A case is presented of an elderly frail patient diagnosed with a pseudoaneurysm of the aortic arch and who was successfully treated by an off-pump arch debranching followed by endovascular arch repair. This case highlights (i) the feasibility of hybrid debranching techniques, (ii) their technical challenges, and (iii) the need for long-term follow-up data.

Percutaneous Management of Septic Left Anterior Descending Coronary Occlusion Following Minimally Invasive Surgery for Mitral Valve Infective Endocarditis.

Coronary artery embolization is an unusual complication following infective endocarditis (IE) surgery. A 43-year-old woman developed an anterior ST-elevation myocardial infarction (STEMI) with acute left anterior descending artery occlusion due to septic emboli during the immediate postoperative period following minimally invasive mitral valve repair for IE. It was successfully treated with thromboaspiration and balloon angioplasty. Coronary septic emboli should be part of the differential diagnosis in patients presenting with STEMI during the early postoperative period for IE.

Frozen Elephant Trunk Repair for Acute Type A Dissection in Right Aortic Arch.

A 68-year-old woman with a right aortic arch and an aberrant left subclavian artery underwent urgent operation for type A aortic dissection. Surgical management included total arch repair with the frozen elephant trunk technique and left subclavian artery reimplantation. Her postoperative course was complicated by severe renal failure, delirium, and pneumonia. She underwent reoperation 3 weeks later for an expanding proximal aortic anastomosis pseudoaneurysm. Right aortic arch is a rare vascular anomaly requiring thoughtful preoperative planning for adequate myocardial, cerebral, and spinal protection. The frozen elephant trunk technique facilitates management of extensive dissection, relieves malperfusion, and may alleviate the need for subsequent operations.

Use of Mobile-Based Application for Collection of Patient-Reported Outcomes in Cardiac Surgery.

OBJECTIVE: Application-based (app) technology has been studied for patient engagement and collecting patient-reported outcomes (PROs) in several surgical specialties with limited research in cardiac surgery. The aim of study was to determine the effectiveness of app-based technology for collecting PROs, improving the patient experience, and reducing health services utilization in a cardiac surgery center. METHODS: Patients accessed an interactive app via smartphones. Patients were guided from 4 weeks preoperative to 4 weeks postoperative via reminders, tasks, PRO surveys, and evidence-based education. In the postoperative period, patients were engaged with daily health surveys to track warning signs and recovery milestones. Based on the patient's signs and symptoms, the app escalated lower risk issues to self-care education or higher risk issues to the care team (e.g., phone call to a nurse). RESULTS: Sixty-six percent of patients (730 of 1,108) activated their app account. Two hundred seventy-seven patients completed an end-of-program feedback survey, with 94% of patients recommending the app and 98% of patients finding the app was helpful in recovery. Patients also reported using the app to avoid unnecessary health services utilization, with 45% of patients using the app to avoid at least 1 phone call and 28% of patients using the app to avoid at least 1 hospital visit. CONCLUSIONS: App-based technology for patient engagement is an effective modality to enhance the patient experience, better understand the trajectory of recovery, and reduce unnecessary health services utilization in cardiac surgery.

Palpitations Revealing a Primary Pulmonary Artery Sarcoma.

Primary pulmonary artery sarcoma is an exceedingly rare and aggressive malignancy that carries poor prognosis. Clinical manifestations are nonspecific and include chest pain, dyspnea, syncope, palpitations, and asthenia, among others. Delay to diagnosis is common and compromises the prognosis. Here, we report an interesting case of primary pulmonary artery sarcoma presenting with frequent monomorphic premature ventricular contractions arising from the right/left ventricle outflow tract. Cardiac imaging is key in the evaluation of patients with frequent premature ventricular contractions to rule out rare pathologies such as tumour compression.

Le sarcome primaire de l'artère pulmonaire est une tumeur maligne extrêmement rare et agressive de mauvais pronostic. Les manifestations cliniques sont non spécifiques et peuvent inclure de la douleur thoracique, de la dyspnée, des syncopes, des palpitations et de l'asthénie. Le retard diagnostic est fréquent et compromet le pronostic. Nous rapportons ici un cas intéressant de sarcome primaire de l'artère pulmonaire pour lequel le patient présentait des extrasystoles ventriculaires prématurées monomorphes qui provenaient des chambres de chasse des ventricules gauche et droit. L'imagerie est essentielle à l'évaluation des patients présentant de fréquentes extrasystoles ventriculaires afin d'écarter des pathologies rares comme la compression tumorale d'une chambre cardiaque.

Active clearance vs conventional management of chest tubes after cardiac surgery: a randomized controlled study.

BACKGROUND: Chest tubes are routinely used after cardiac surgery to evacuate shed mediastinal blood. Incomplete chest drainage due to chest tube clogging can lead to retained blood after cardiac surgery. This can include cardiac tamponade, hemothorax, bloody effusions and postoperative atrial fibrillation (POAF). Prior published non randomized studies have demonstrated that active tube clearance (ATC) of chest tubes can reduce retained blood complications prompting the ERAS Cardiac Society guidelines to recommend this modality. OBJECTIVE: A randomized prospective trial to evaluate whether an ATC protocol aimed at improving chest tube patency without breaking the sterile field could efficiently reduce complications related to retained blood after cardiac surgery. METHODS: This was a pragmatic, single-blinded, parallel randomized control trial held from November 2015 to June 2017 including a 30-day post index surgery follow-up. The setting was two academic centers affiliated with the Université de Montréal School of Medicine; the Montreal Heart Institute and the Hôpital du Sacré-Coeur de Montréal. Adult patients admitted for non-emergent coronary bypass grafting and/or valvular heart surgery through median sternotomy, in sinus rhythm for a minimum of 30 days prior to the surgical intervention were eligible for inclusion. In the active tube clearance group (ATC), a 28F PleuraFlow device was positioned within the mediastinum. In the standard drainage group, a conventional chest tube (Teleflex Inc.) was used. Other chest tubes were left at the discretion of the operating surgeon. RESULTS: A total of 520 adult patients undergoing cardiac surgery were randomized to receive either ATC (n = 257) or standard drainage (n = 263). ATC was associated with a 72% reduction in re-exploration for bleeding (5.7% vs 1.6%, p = .01) and an 89% reduction in complete chest tube occlusion (2% vs 19%, p = .01). There was an 18% reduction in POAF between the ATC and control group that was not statistically significant (31% vs 38%, p = .08). CONCLUSIONS AND RELEVANCE: In this RCT, the implementation of active clearance of chest tubes reduced re-exploration and chest tube clogging in patients after cardiac surgery further supporting recommendations to consider this modality postoperatively. TRIAL REGISTRATION: Clinical Trials NCT02808897 . Retrospectively registered 22 June 2016.

Bicuspid Aortic Valve Stenosis: From Pathophysiological Mechanism, Imaging Diagnosis, to Clinical Treatment Methods.

Bicuspid aortic valve (BAV) is the most frequent congenital anomaly and has a natural evolution toward aortic regurgitation or stenosis due to the asymmetrical valve function associated with an evolutive ascending aortopathy. Several BAV classifications exist describing the presence and number of raphe, amount and location of calcium, and the symmetry of the functional cusps. The impact of BAV morphology on transcatheter aortic valve implantation (TAVI) outcomes still remains little investigated. Pivotal randomized trials comparing TAVI with surgery have excluded BAV until yet. However, data from registries and observational studies including highly selected patients have shown promising results of TAVI in BAV. With this review, we aimed at describing anatomical and pathophysiological characteristics of BAV, discussing the main aspects to assess diagnostic imaging modalities, and giving an overview of TAVI outcomes and technical considerations specific to BAV morphology.

Del Nido cardioplegia versus blood cardioplegia in adult aortic root surgery.

OBJECTIVE: Del Nido cardioplegia solution offers prolonged cardiac protection with single-dose administration; this is particularly interesting for aortic root surgery. However, there is a scarcity of data supporting its safety in adults undergoing complex cardiac surgery, such as aortic root repair. We hypothesized that del Nido cardioplegia solution and blood cardioplegia solution provide equivalent safety during aortic root surgery. METHODS: Between January 2015 and June 2018, 283 consecutive patients undergoing the Ross procedure (204) and valve-sparing operation (79) with del Nido cardioplegia solution or blood cardioplegia solution were 1:1 propensity matched (110 aortic root surgery), and outcomes were compared. Clinical patient characteristics and data were extracted from our local database for valve-sparing operations and for Ross procedures. RESULTS: Preoperative characteristics were similar between del Nido cardioplegia solution and blood cardioplegia solution after propensity matching (mean age, 48.6 ± 1.5 years). Median postoperative creatine kinase MB isotype did not differ between del Nido cardioplegia solution and blood cardioplegia solution (48.9 [14.9-300] µg/L vs 51.2 [12.4-116] µg/L for blood cardioplegia solution [P = .1]), but there was a trend toward higher troponin T levels with del Nido cardioplegia solution (748 [221-5834] ng/L vs 710 [212-3332] ng/L for blood cardioplegia solution [P = .07]). In patients with myocardial ischemia longer than 180 minutes, median creatine kinase MB isotype was higher in del Nido cardioplegia solution (75.1 [59.3-300] µg/L than in blood cardioplegia solution 60.5 [16.5-116] µg/L [P = .01]). Aortic crossclamp and cardiopulmonary bypass times were shorter with del Nido cardioplegia solution (163 ± 5 vs 181 ± 5 minutes, P = .01 and 145 ± 4 vs 161 ± 4 minutes, respectively, P = .006). Return to spontaneous rhythm was more frequent in the del Nido cardioplegia solution group (52% [29/55] vs 27% [15/55], P = .006). There was no difference in inotropic or vasoactive agent use (P = .8). Postoperative left ventricle ejection fraction was similar (0.54 ± 0.09 vs 0.55 ± 0.08 for del Nido cardioplegia solution and blood cardioplegia solution, respectively; P = .4). There was no difference between groups for perioperative mortality and postoperative complications. CONCLUSIONS: Del Nido cardioplegia solution can be used as an alternative to blood cardioplegia solution in adults undergoing complex aortic root surgery, providing comparable clinical outcomes and improved surgical workflow. However, del Nido cardioplegia solution seems to be associated with increased myocardial injury, especially with extended myocardial ischemic times, but this finding did not translate into adverse clinical events. Caution is warranted in adopting this cardioplegic solution in aortic interventions requiring long ischemic times, and further study is required to establish its exact role in complex cardiac surgery.

First-in-Human Use of the Cook Hybrid Frozen Elephant Trunk Graft: The Canadian Experience.

BACKGROUND: Advancements in technology have changed the treatment of aortic arch pathologies. Specifically, the introduction of the frozen elephant trunk technique has allowed one-stage treatment of pathologies that would have otherwise required a two-stage procedure. We present the early outcomes of a novel frozen elephant hybrid stent graft. METHODS: Between August 2015 and July 2019, 39 patients (56% male; mean age 67 ± 11years) underwent an arch reconstruction with a novel hybrid stent graft in four different Canadian centers. The most common indication for surgery was arch aneurysm (31%) followed by acute dissection (28%). All patients were prospectively followed with clinical and imaging assessments. RESULTS: The device was successfully implanted in all patients. There were 3 perioperative deaths (8%). Transient spinal cord injury occurred in 5 patients (13%); all had complete neurologic recovery before discharge. Seven patients had a perioperative stroke/transient ischemic attack; 3 of them initially presented with cerebral malperfusion caused by acute dissection. One patient died during the study follow-up. Survival at 30 days and at 1 and 3 years was 92% ± 5%, 89% ± 5%, and 89% ± 5%, respectively. At a median follow-up of 16 months, 3 patients required a reintervention to address a type I distal endoleak and 1 patient was treated for a type II endoleak. There was no arch anastomosis complications. CONCLUSIONS: The Cook hybrid stent graft device provides encouraging midterm results in a high-risk cohort. This novel graft is simple to deploy, may be customized to patients' anatomy in elective cases, eases arch reconstruction, and allows versatility in the choice of arch grafts.

Surgical management of a primary pulmonary artery sarcoma: A case report.

Pulmonary artery (PA) sarcoma is a rare tumor with an overall poor prognosis. It can often be misdiagnosed due to its nonspecific presentation and its similitude to pulmonary embolism on imaging. We, herein, describe the case of a 60-year-old male with a primary PA sarcoma for which a surgical approach was undertaken. Due to the low incidence of PA and therefore the absence of clear guidelines on the management of this disease, we also present a succinct literature review on the subject.

Durability of bioprosthetic aortic valves in patients under the age of 60 years - rationale and design of the international INDURE registry.

BACKGROUND: There is an ever-growing number of patients requiring aortic valve replacement (AVR). Limited data is available on the long-term outcomes and structural integrity of bioprosthetic valves in younger patients undergoing surgical AVR. METHODS: The INSPIRIS RESILIA Durability Registry (INDURE) is a prospective, open-label, multicentre, international registry with a follow-up of 5 years to assess clinical outcomes of patients younger than 60 years who undergo surgical AVR using the INSPIRIS RESILIA aortic valve. INDURE will be conducted across 20-22 sites in Europe and Canada and intends to enrol minimum of 400 patients. Patients will be included if they are scheduled to undergo AVR with or without concomitant root replacement and/or coronary bypass surgery. The primary objectives are to 1) determine VARC-2 defined time-related valve safety at one-year (depicted as freedom from events) and 2) determine freedom from stage 3 structural valve degeneration (SVD) presenting as morphological abnormalities and severe haemodynamic valve degeneration at 5 years. Secondary objectives include the assessment of the haemodynamic performance of the valve, all stages of SVD, potential valve-in-valve procedures, clinical outcomes (in terms of New York Heart Association [NYHA] function class and freedom from valve-related rehospitalisation) and change in patient quality-of-life. DISCUSSION: INDURE is a prospective, multicentre registry in Europe and Canada, which will provide much needed data on the long-term performance of bioprosthetic valves in general and the INSPIRIS RESILIA valve in particular. The data may help to gather a deeper understanding of the longevity of bioprosthetic valves and may expand the use of bioprosthetic valves in patients under the age of 60 years. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03666741 (registration received September, 12th, 2018).

The Ross procedure is a safe and durable option in adults with infective endocarditis: a multicentre study.

OBJECTIVES: Surgical treatment of infective endocarditis (IE) remains a challenge. The Ross procedure offers the benefit of a living substitute in the aortic position but it is a more complex operation which may lead to increased operative risk. The aim of this study was to assess the safety and late outcomes of the Ross procedure for the treatment of active IE. METHODS: From 2000 to 2019, a total of 31 consecutive patients underwent a Ross procedure to treat active IE (mean age 43 ± 12 years, 84% male). All patients were followed up prospectively. Four patients (13%) were intravenous (IV) drug users and 6 patients (19%) had prosthetic IE. The most common infective organism was Streptococcus (58%). Median follow-up was 3.5 (0.9-4.5) years and 100% complete. RESULTS: There were no in-hospital deaths. One patient suffered a postoperative stroke (3%) and 1 patient (3%) required reintervention for bleeding. Three patients had a new occurrence endocarditis: 2 patients were limited to the pulmonary homograft and successfully managed with IV antibiotics, whereas 1 IV drug user patient developed concomitant autograft and homograft endocarditis. Overall, cumulative incidence of IE recurrence was 13 ± 8% at 8 years. The cumulative incidence for autograft endocarditis was 5 ± 4% at 8 years. Two patients (6%) died during follow-up, both from drug overdoses. At 8 years, actuarial survival was 88 ± 8%. CONCLUSIONS: In selected patients with IE, the Ross procedure is a safe and reasonable alternative with good mid-term outcomes. Freedom from recurrent infection on the pulmonary autograft is excellent, labelporting the notion that a living valve in the aortic position provides good resistance to infection. Nevertheless, in IV drug user patients, pulmonary homograft endocarditis remains a challenge. Continued follow-up is needed to ascertain the long-term benefits of this approach.