The Use of Branched Endografts for the Aortic Arch in the Endovascular Era.

The endovascular realm has steadily increased its footing in the treatment of the aorta and all of its territories since the foundational case in 1990 by Parodi. The aortic arch, however, continues to be one of the last bastions for treatment via open surgery, which remains the gold standard. Significant comorbidity and prior cardiac surgery prevent open surgery from being the only preferred option, allowing novel endovascular procedures to be considered. Since 1999, more advanced endovascular systems have been created by companies such as Cook Medical, Bolton Medical, Medtronic, Endospan, Gore Medical, and, recently, Kawasumi. The unique shape and angulation of the aortic arch often require the use of custom-made grafts, though arch reconstruction may also include in situ or back-table physician alterations to off-the-shelf devices. The goal of branched endografts is to exclude the aneurysm, while maintaining flow to supra-aortic trunk vessels. Technical success and device durability are limited by the physical constraints of the aortic arch, though greater experience may yield better patient outcomes. Typically, the initial stent-graft (SG) is introduced and deployed into the arch first. Bridging SG are then inserted via axillary or carotid access. Most often, the bridging SG extends from the innominate branch to the distal innominate, and from the left carotid branch to the left common carotid. The major concern is that manipulation of catheters and wires, both within the carotid arteries and aortic arch, create the potential for emboli leading to stroke and paraplegia. The development of endovascular-only techniques for aortic arch pathology will only increase with the aging population of the United States and associated accumulation of comorbidities, making open surgery too grave of a risk.

Hybrid Repair Techniques for Complex Aneurysms and Dissections Involving the Aortic Arch and Thoracic Aorta.

Aortic aneurysms involving the ascending aorta, aortic arch, and descending thoracic aorta have been a challenging entity to surgically treat for over 60 years. Despite the mortality of the disease, early open surgical procedures also had significant morbidity and mortality. The inherent risk in treating multiple anatomic segments simultaneously led to the innovation of the staged elephant trunk (ET) approach by Borst in 1983. To avoid the thoracotomy and associated complications related to the second stage of the procedure, an endovascular completion paradigm was begun by Volodos in 1991. This theoretical hybrid technique combinined shorter and less elaborate open supra-aortic trunk debranching with less invasive endovascular exclusion and has grown since then in terms of different approaches and case volume. The rise of thoracic endovascular aortic repair (TEVAR) combined with debranching bypass has allowed certain lesions to be treated without a large scale intrathoracic open surgical procedure. The complexity and extensiveness of certain lesions, however, has necessitated a hybrid approach such as the frozen elephant trunk (FET) and the standard ET with second stage TEVAR. The former has been used to treat multifocal degenerative aneurysms, chronic dissections with aneurysm, and acute extensive dissections. After conventional proximal aortic replacement, a stent-graft (SG) is delivered antegrade through the transected arch where it is sutured proximally and then "frozen" distally via endovascular means. The FET has the advantage of avoiding a second stage, but potentially introduces a greater rate of spinal cord ischemia compared to the standard elephant trunk. Improvements on the FET procedure have included the development of more advanced hybrid SG such as the Vascutek® Thoraflex™ Hybrid graft (Vascutek Ltd, Scotland, UK), which consists of a distal en,dograft sealed to a proximal four-branched Vascutek Gelweave™ Vascutek Ltd, Scotland, UK) and incorporated sewing collar. While open surgery continues to be a component of complex aortic arch aneurysms, the development of hybrid devices that can bridge the gap between open and endovascular surgery will continue to flourish.

Short-term outcomes in adult cardiac surgery in the use of del Nido cardioplegia solution.

OBJECTIVES: Del Nido cardioplegia in adult cardiac surgery has not been studied although it has been in common use as a "single" dose cardioplegia in pediatric heart surgery. We retrospectively assessed the short-term (in-hospital) clinical outcomes of patients undergoing aortic valve replacement (AVR) using del Nido cardioplegia solution, comparing it to conventional multi-dose whole blood cardioplegia. METHODS: We switched our cardioplegia protocol from conventional whole blood cardioplegia exclusively to del Nido solution in May 2011. In 2011, 240 consecutive patients underwent isolated AVR. One hundred and seventy-eight of them were operated on with the use of del Nido cardioplegia (del Nido group) and whole blood cardioplegia (conventional group) was used in the other 62 patients. Isolated AVR was chosen as a cohort because of its relative simplicity and the similarity of surgical techniques among surgeons. Propensity-score matching identified 54 matched pairs for analysis. RESULTS: The retrograde cardioplegia technique was used in 19 cases (35.2%) in the del Nido group and 52 cases (96.3%) in the conventional group (p<0.001). Mean cardiopulmonary bypass time and mean aortic cross-clamp time were significantly shorter in the del Nido group compared to the conventional group: 71 ± 16 min vs. 84 ± 28 min (p<0.01), 52 ± 14 min vs. 60 ± 16 min (p<0.01), respectively. Postoperative inotropic support was required in 11 patients (20.4 %) in the del Nido group and 13 patients (24.1 %) in the conventional group (p=0.82) with no statistical difference. No patient required a postoperative intra-aortic balloon pump and in-hospital mortality was 0% in both groups. There was no significant difference in postoperative complications between the two groups. CONCLUSIONS: Short-term outcomes in adult cardiac surgery using del Nido solution were acceptable and comparable to conventional multi-dose whole blood cardioplegia. The del Nido cardioplegia technique was associated with shortened cross-clamp times and less frequent utilization of the retrograde cardioplegia delivery technique.

Circulating activated and effector memory T cells are associated with calcification and clonal expansions in bicuspid and tricuspid valves of calcific aortic stenosis.

We sought to delineate further the immunological significance of T lymphocytes infiltrating the valve leaflets in calcific aortic stenosis (CAS) and determine whether there were associated alterations in circulating T cells. Using clonotypic TCR ß-chain length and sequence analysis we confirmed that the repertoire of tricuspid CAS valves contains numerous expanded T cell clones with varying degrees of additional polyclonality, which was greatest in cases with severe calcification. We now report a similar proportion of clonal expansions in the much younger bicuspid valve CAS cases. Peripheral blood flow cytometry revealed elevations in HLA-DR(+) activated CD8 cells and in the CD8(+)CD28(null)CD57(+) memory-effector subset that were significantly greater in both bicuspid and tricuspid CAS cases with more severe valve calcification. Lesser increases of CD4(+)CD28(null) T cells were identified, principally in cases with concurrent atherosclerotic disease. Upon immunostaining the CD8 T cells in all valves were mainly CD28(null), and CD8 T cell percentages were greatest in valves with oligoclonal repertoires. T cell clones identified by their clonotypic sequence as expanded in the valve were also found expanded in the circulating blood CD28(null)CD8(+) T cells and to a lesser degree in the CD8(+)CD28(+) subset, directly supporting the relationship between immunologic events in the blood and the valve. The results suggest that an ongoing systemic adaptive immune response is occurring in cases with bicuspid and tricuspid CAS, involving circulating CD8 T cell activation, clonal expansion, and differentiation to a memory-effector phenotype, with trafficking of T cells in expanded clones between blood and the valve.

Modified bentall procedure with composite biologic grafts.

OBJECTIVES: The search continues for the ideal composite biologic graft (CBG). We have performed aortic root replacements with CBGs, initially with a stented pericardial valve in a Valsalva graft (Gen1) and subsequently with the stentless 3f valve (Gen2). The valve is sewn at the base of the graft sinuses, leaving residual proximal graft to sew separately to the left ventricular outflow tract. This allows for CBG size standardization and permits fabrication prior to bypass. We share our institutional experience and aim to show noninferiority of this technique, as well as discuss potential advantages. METHODS: The first 75 patients to receive each generation of CBG were identified and assessed retrospectively. Overall survival was assessed as our primary outcome. Various secondary outcomes were also analyzed, including operative times and short-term outcomes. RESULTS: Operative times were shorter for Gen2, with cardiopulmonary bypass times that were significantly reduced (126.3 ± 5.2 minutes vs. 157.6 ± 5.8 minutes for Gen1, p = 0.001) and aortic cross-clamp times that trended lower (98.2 ± 4.2 minutes vs. 107.7 ± 3.8 minutes for Gen1, p = 0.095). There were no postoperative myocardial infarctions (MIs) or aortic insufficiency graded 2+ or greater in either group. There was only one stroke in a Gen1 patient who recovered fully. Kaplan-Meier survival analysis showed a strong trend toward improved survival among Gen2 patients (p = 0.0566). CONCLUSIONS: Our experience with Gen2 CBG showed decreased operative times and a trend toward improved survival, though further patient follow-up and larger sample sizes in prospective studies are necessary. Further research with this CBG and additional improvements are warranted.

Designing a stentless valve conduit for use in a biological Bentall procedure.

Various modifications of the Bentall procedure have been described using mechanical valve conduits. A further modification, using a bioprosthetic valve, has grown in popularity as this prevents the need for lifelong anticoagulation. Additional innovation using a stentless bioprosthetic valve has the theoretical advantages of allowing for a larger bioprosthesis and an improved durability. The technical aspects involved in designing a stentless valve conduit for use in a biological Bentall procedure are described.

Survival after heart transplantation is not diminished among recipients with uncomplicated diabetes mellitus: an analysis of the United Network of Organ Sharing database.

BACKGROUND: This study compares posttransplantation outcomes of survival and morbidity among recipients with and without diabetes mellitus (DM). METHODS AND RESULTS: The United Network of Organ Sharing (UNOS) provided deidentified patient-level data. Primary analysis focused on 20,412 first-time heart transplant recipients aged > or = 18 years who underwent transplantation between January 1, 1995, and December 31, 2005. To determine severity of DM, DM recipients were stratified by their aggregate number of diabetes-related complications (DRCs), including pretransplantation history of renal failure (serum creatinine = 2.5 mg/dL), peripheral vascular disease, cerebrovascular accident, and severe obesity (body mass index > or = 35 kg/m2). Kaplan-Meier analysis was performed to compare time to event. Although posttransplantation survival was significantly better (P<0.001) among patients without DM (median survival 10.1 years) than among those with DM (9.0 years), survival did not differ (P=0.08) between those without DM (10.1 years) and those with uncomplicated DM (0 DRCs; 9.3 years). Among those with DM, survival was worse with each additional DRC: 0 DRC, 9.3 years; 1 DRC, 6.7 years; and > or = 2 DRCs, 3.6 years. Although acute rejection and transplant coronary artery disease-free survival did not differ between groups, renal failure and severe infection-free survival were worse in those with DM and were inversely related to the number of DRCs. CONCLUSIONS: Posttransplantation survival among patients with uncomplicated DM was not significantly different than that among nondiabetics. However, when stratified by disease severity, recipients with more severe diabetes had significantly worse survival than nondiabetics. Therefore, although DM alone should not be a contraindication to heart transplantation, given the critical shortage of transplantable organs, maximal benefit may be achieved by exploring alternative treatment options in patients with severe DM. These include use of high-risk transplant lists and destination therapy.

Viral gene transfer of the antiapoptotic factor Bcl-2 protects against chronic postischemic heart failure.

BACKGROUND: Apoptosis secondary to acute ischemia and chronic remodeling is implicated as a mediator of heart failure. This study was designed to assess the effect of in vivo viral gene transfer of the anti-apoptotic factor Bcl-2 to block apoptosis and preserve ventricular geometry and function. METHODS AND RESULTS: In a rabbit model of regional ischemia followed by reperfusion, an experimental group treated with adeno-Bcl-2 was compared with a control group receiving empty vector adeno-null. Function was assessed by echocardiography, and sonomicrometry of the border zone was compared with the normal left ventricle (LV). Animals were killed at 6 weeks, and an additional group was killed after 3 days to see whether virus administration conferred an immediate effect. Animals that were administered Bcl-2 maintained higher ejection fractions at 2, 4, and 6 weeks compared with controls. Sonomicrocrystals demonstrated greater protection of border zone fractional shortening at 6 weeks. The Bcl-2 group had superior preservation of LV geometry with less ventricular dilatation and wall thinning. There was also reduced apoptosis compared with the controls. Finally, in the animals killed at 3 days, no functional difference was observed between the Bcl-2 and control groups. CONCLUSIONS: Gene transfer of Bcl-2 preserves LV function after ischemia despite the absence of an observed acute protective effect. The benefit at 6 weeks is postulated to result from a Bcl-2-mediated reduction in apoptosis and ventricular remodeling. Adeno-Bcl-2 administration offers a potential strategy to protect the heart from late postischemic heart failure.

Simplified placement of multiple artificial mitral valve chords.

BACKGROUND: The use of artificial chords for the replacement of diseased mitral valve chordae and the correction of anterior and posterior leaflet prolapse is well described, although it is infrequently applied because of technical challenges. METHODS: A simplified approach to attaching the new chords to a single papillary muscle base within the left ventricle has been reported, and we present a series of 13 patients with moderate-severe mitral regurgitation (MR) who underwent chordal replacement using this improved technique. RESULTS: The MR grade by echocardiogram improved from 3.7 +/- 0.4 preoperatively to 1.0 +/- 0.8 postoperatively. All patients were doing well at a mean follow-up interval of 285 +/- 62 days. CONCLUSION: Chordal replacement for both anterior and posterior leaflet prolapse is an effective treatment for MR when combined with standard mitral valve repair techniques. The authors' technique of determining proper chordal height and placing multiple chordae is also discussed.

Blocking the development of postischemic cardiomyopathy with viral gene transfer of the apoptosis repressor with caspase recruitment domain.

OBJECTIVES: Apoptosis caused by acute ischemia and subsequent ventricular remodeling is implicated as a mediator of heart failure. This study was designed to assess the efficacy of in vivo viral gene transfer of the antiapoptotic factor apoptosis repressor with caspase recruitment domain to block apoptosis and preserve ventricular geometry and function. METHODS: In a rabbit model of regional ischemia followed by reperfusion, an experimental group treated with adenovirus-apoptosis repressor with caspase recruitment domain was compared with empty vector adenovirus-null controls. Cardiac function was assessed by echocardiography and sonomicrometry of the border zone compared with the normal left ventricle. Animals were killed at 6 weeks with measurements of ventricular geometry and apoptosis. RESULTS: Animals with the apoptosis repressor with caspase recruitment domain (ARC group) maintained higher ejection fractions at 4 and 6 weeks, and sonomicrometry demonstrated greater protection of border zone fractional shortening at 6 weeks compared with the control group. The ARC group maintained superior preservation of left ventricular geometry with less ventricular dilation and wall thinning. Finally, there was reduced apoptosis in the rabbits treated with apoptosis repressor with caspase recruitment domain compared with the controls. CONCLUSIONS: Gene transfer of apoptosis repressor with caspase recruitment domain preserves left ventricular function after ischemia. The benefit at 6 weeks is postulated to result from an apoptosis repressor with caspase recruitment domain-mediated reduction in apoptosis and ventricular remodeling. Adenovirus-apoptosis repressor with caspase recruitment domain administration offers a potential strategy after myocardial ischemia to protect the heart from late postischemic cardiomyopathy.

Left ventricular assist device for right side assistance in patients with transposition.

Right (systemic) ventricular dysfunction is well described after Senning operations for transposition of the great arteries, and patients with congenitally corrected transposition of the great arteries. Transplantation remains the only definitive therapy for refractory heart failure, however patients may deteriorate clinically prior to the availability of a donor heart. This report details the implantation of a TCI Heartmate (Thoratec Corp., Pleaston, CA) as a morphologic right ventricular assist device to bridge these patients to transplantation.

Role of the Abiomed BVS 5000 device for short-term support and bridge to transplantation.

Over the last 10 years, we have gained experience implanting the Abiomed BVS 5000 (Abiomed, Inc., Danvers, MA) device for short-term mechanical support. We retrospectively reviewed our experience with this device. From April 1993 through January 2003, 71 patients underwent implantation of an Abiomed BVS 5000 device. This included 19 left ventricular assist devices (LVADs), 30 right ventricular assist devices (RVADs), and 22 biventricular assist devices (BIVADs). Demographics of device recipients, conditions for mechanical support, and outcome were evaluated for each device type. Devices were inserted for postcardiotomy cardiogenic shock in 53 (74.6%) patients and precardiotomy cardiogenic shock in 18 (25.4%) patients. Mean duration of support was 4.9+/-4.1 days, with 64 (90.1 %) patients supported for fewer than 10 days. Twenty-nine (40.8%) patients were successfully weaned from support after myocardial recovery: 7 (36.8%) LVADs, 13 (43.3%) RVADs, and 9 (40.9%) BIVADs. Eight (11.3%) patients received devices as a "bridge to bridge," undergoing implantation of a long-term HeartMate LVAD (Thoratec, Pleasanton, CA): six (31.6%) LVADs and two (9.1 %) BIVADs. Seven (9.9%) Abiomed patients were successfully bridged to transplantation: two (10.5%) LVADs, two (6.7%) RVADs, and three (13.6%) BIVADs. Overall, 44 (62.0%) patients survived support: weaned, "bridged to bridge," or transplanted. The Abiomed BVS 5000 can be used effectively for short-term stabilization and for bridging to transplant in select patients.

Thoracic aortic aneurysm and dissection.

Aortic dissection is the most devastating complication of thoracic aortic disease. In the more than 250 years since thoracic aortic dissection was first described, much has been learned about diseases of the thoracic aorta. In this review, we describe normal thoracic aortic size; risk factors for dissection, including genetic and inflammatory conditions; the underpinnings of genetic diseases associated with aneurysm and dissection, including Marfan syndrome and the role of transforming growth factor beta signaling; data on the role for medical therapies in aneurysmal disease, including beta-blockers, angiotensin receptor blockers, and angiotensin-converting enzyme inhibitors; prophylactic surgery for aneurysm; surgical techniques for the aortic root; and surgical and endovascular management of aneurysm and dissection for different aortic segments.

Feasibility of temporary biventricular pacing after off-pump coronary artery bypass grafting in patients with reduced left ventricular function.

In selected patients undergoing cardiac surgery, our research group previously showed that optimized temporary biventricular pacing can increase cardiac output one hour after weaning from cardiopulmonary bypass. Whether pacing is effective after beating-heart surgery is unknown. Accordingly, in this study we examined the feasibility of temporary biventricular pacing after off-pump coronary artery bypass grafting. The effects of optimized pacing on cardiac output were measured with an electromagnetic aortic flow probe at the conclusion of surgery in 5 patients with a preoperative mean left ventricular ejection fraction of 0.26 (range, 0.15-0.35). Atrioventricular (7) and interventricular (9) delay settings were optimized in randomized order. Cardiac output with optimized biventricular pacing was 4.2 ± 0.7 L/min; in sinus rhythm, it was 3.8 ± 0.5 L/min. Atrial pacing at a matched heart rate resulted in cardiac output intermediate to that of sinus rhythm and biventricular pacing (4 ± 0.6 L/min). Optimization of atrioventricular and interventricular delay, in comparison with nominal settings, trended toward increased flow. This study shows that temporary biventricular pacing is feasible in patients with preoperative left ventricular dysfunction who are undergoing off-pump coronary artery bypass grafting. Further study of the possible clinical benefits of this intervention is warranted.

Aortic root and right ventricular outflow tract reconstruction using composite biological valved conduits after failed Ross procedure.

The Ross procedure or pulmonary autograft has been frequently used for surgical treatment of aortic valve disease. One considerable disadvantage of the Ross procedure is the involvement of two valves (aortic and pulmonary) in treatment of single (aortic) valve disease. Both the aortic and pulmonary valves are at risk for future degeneration. Concurrent failure of both valves after a Ross procedure is rare but presents a significant technical challenge when reoperation is necessary. We describe a novel approach to this complication using composite biological valved conduits comprised of stentless bioprosthetic valves and polyester grafts.

On-pump versus off-pump surgical revascularization in patients with acute coronary syndromes: analysis from the Acute Catheterization and Urgent Intervention Triage Strategy trial.

OBJECTIVE: Early invasive strategy, defined as early coronary angiography and subsequent revascularization, when appropriate, is recommended by current guidelines for the management of patients with moderate- to high-risk acute coronary syndromes. We sought to compare the outcomes of patients with acute coronary syndromes undergoing surgical revascularization with an on-pump versus off-pump approach. METHODS: Among a total of 13,819 patients with moderate- to high-risk acute coronary syndromes enrolled in the Acute Catheterization and Urgent Intervention Triage Strategy trial, 1375 patients were triaged to isolated coronary artery bypass grafting. One thousand one hundred fifty-four patients underwent operations with cardiopulmonary bypass (the coronary artery bypass grafting group), and 221 patients underwent off-pump coronary artery bypass grafting (the off-pump coronary artery bypass grafting group). Propensity score matching (1:3) was applied to adjust for differences in baseline clinical and angiographic characteristics, yielding a total of 880 matched patients with acute coronary syndromes (220 managed with off-pump coronary artery bypass grafting and 660 managed with coronary artery bypass grafting). RESULTS: At 30 days, patients undergoing off-pump coronary artery bypass grafting had fewer events of bleeding (43.7% vs 56.3%, P = .0005) and myocardial infarction (7.3% vs 12.1%, P = .055) but higher rates of reintervention (3.7% vs 1.2%, P = .02). At 1 year, there was no difference between groups in death, total myocardial infarctions, reinterventions, strokes, or major adverse cardiac events, but there was a lower rate of non-Q-wave myocardial infarctions in the off-pump coronary artery bypass grafting group (4.6% vs 9.2%, P = .03). CONCLUSIONS: In this large-scale study evaluating the outcomes of patients with acute coronary syndromes, off-pump coronary artery bypass grafting was associated with lower rates of bleeding and non-Q-wave myocardial infarction but more reinterventions early after the procedure. At 1 year, there was no major outcome difference between the 2 surgical strategies.

Modified Bentall operation with a novel biologic valved conduit.

PURPOSE: The optimal conduit for a modified Bentall operation remains unknown. The current study tested hemodynamics and early clinical results of the newly developed valved conduit composed of the 3f Aortic Bioprosthesis (ATS Medical, Minneapolis, MN) and the Vascutek Gelweave Valsalva Aortic Root Graft (Terumo Cardiovascular Systems, Ann Arbor, MI). DESCRIPTION: Between December 1, 2008, and April 6, 2009, 20 patients underwent a modified Bentall operation with this valved conduit and their clinical records were retrospectively reviewed. EVALUATION: The indication for aortic root replacement in the 20 patients was aortic root aneurysm in 14, acute type A dissection in 5, and structural deterioration of an aortic root homograft in 1. Four patients had had previous cardiac operations, and 8 patients required concomitant procedures. Mean cardiopulmonary bypass and aortic cross-clamp times were 146 +/- 110 minutes and 110 +/- 32 minutes, respectively. There were no perioperative deaths. The average mean pressure gradient across the bioprosthesis assessed with intraoperative transesophageal echocardiogram was 4.0 +/- 1.7 mm Hg. CONCLUSIONS: Our initial experience with our new valved conduit showed favorable results. Further accumulation of cases and longer follow-up are warranted.

Open distal anastomosis in aortic root replacement using axillary cannulation and moderate hypothermia.

OBJECTIVE: Recent advance in surgical technique facilitates more aggressive approaches for thoracic aortic diseases. We sought to address the outcomes of our strategy of open distal anastomosis with aortic root replacement using axillary cannulation and moderate hypothermia. METHODS: A retrospective review of 228 patients who underwent aortic root replacement between July 2004 and December 2007 was performed. RESULTS: Axillary artery cannulation was successful in 98% of the attempted cases and resulted in no adverse events in 97%. The axillary artery was the site of arterial cannulation in 89% of the cases, among which 136 patients (60% of the cases) underwent an open distal anastomosis, consisting of the cohort of interest. Median age of the patients was 60 years (ranging from 16 to 89 years) with 79% being male. The principal diagnosis for the operation included aneurysmal disease without aortic dissection (78%), type A aortic dissection with or without aneurysm (12%), and endocarditis (5.9%). Performed operations were modified Bentall operation (53% of the cohort), valve-sparing aortic root replacement (26%), and replacement with a homograft (20%). Hemiarch replacement was added in 43%. Mean +/- standard deviation of the lowest temperature was 27 degrees C +/-2.6 degrees C. There were 5 deaths (mortality 3.7%). A total of 16 patients (12%) had major complications. CONCLUSIONS: Open distal anastomosis at the time of aortic root replacement can safely be performed with axillary artery cannulation and moderate hypothermia. Axillary cannulation provides a reliable route of antegrade cerebral perfusion and enables the complex procedure to be performed without deep hypothermic circulatory arrest.

Modified Bentall operation with bioprosthetic valved conduit: Columbia University experience.

A conduit was made by sewing a bovine pericardial valve into a graft conduit with the pseudo-sinuses of Valsalva. The graft collar below the valve cuff ring was sewn to the aortic annulus with interrupted pledgeted sutures. From August 2005 to February 2008, 68 patients underwent aortic root replacements with this technique. Operative mortality was 2.9% (2 acute aortic dissection patients died). During median follow-up of 11 months, 1 patient had reoperation for conduit failure due to infectious endocarditis. This technique is safe and feasible with favorable early outcomes. Because the valve is sewn above the outflow tract, superior hemodynamics are achieved. Reoperation may be accomplished by removal of the valve rather than full root re-replacement.