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1/13. Aortic root replacement and coronary interposition using a cryopreserved allograft and its branch.

    This communication describes a modified aortic root replacement technique using a cryopreserved allograft consisting of the aortic conduit and its branch. This method was applied in a patient suffering from infective pseudoaneurysm which had developed after aortic root replacement using an artificial graft with a mechanical aortic valve. A piece of the innominate artery obtained from the aortic allograft was used for interposition between the fragile left coronary artery root and the main conduit of the allograft.
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2/13. Aortico-left ventricular tunnel: two new cases with a long-term follow-up.

    Aortico-left ventricular tunnel is a rare congenital communication between the ascending aorta and the left ventricle. Its hemodynamic effect is severe aortic incompetence. Surgery is the only treatment and should be performed before aortic incompetence or ventricular dilation develops. Two neonates with aortico-left ventricular tunnel were operated on at our institution, with closure of the aortic end of the tunnel with a Gore-Tex patch. The 2 patients were discharged in good conditions, and at 112 and 42-month follow-up respectively they are in good health, without medication and with a normal echocardiographic pattern. Aortico-left ventricular tunnel should be treated surgically as soon as possible in order to prevent any damage to the aortic valve and the left ventricle. The operative risk is not low, but results are very encouraging.
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3/13. Successful surgical repair of aortico-left ventricular tunnel in an infant.

    Aortico-left ventricular tunnel is a rare congenital malformation in which a perivalvular tunnel produces free communication between the aortic root and left ventricle. The hemodynamic consequences of this lesion are similar to those of aortic valve incompetence. Infants with this condition have clinical findings that should suggest it as a diagnostic possibility, and aortic root angiocardiography can establish the diagnosis. Early severe congestive heart failure is common in infants with this malformation, and in such patients prompt surgical correction of the deformity is recommended. This paper reports surgical correction of aortico-left ventricular tunnel in a 9-month-old child, the first reported patient to be successfully operated on before age 2 years.
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4/13. Gerbode's defect resulting from infective endocarditis.

    We present a report of a Gerbode's defect (left ventricular-right atrial communication) resulting from bacterial endocarditis in a 63-year-old man. Also presented is a brief overview of the literature and a possible preoperative echocardiographic diagnostic criterion relating to this unusual condition.
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5/13. Transoesophageal echocardiographic diagnosis of aortico-left atrial fistula in aortic valve endocarditis.

    Intra-cardiac fistulas are rarely seen and they are estimated to account for <1% of all cases of infective endocarditis. Fistulization of paravalvular abscesses has been found in 6% to 9% of cases. This is a report of an unusual communication between the abscess region in the aortic root and the left atrium. A 44-year-old patient diagnosed with infective endocarditis had continuous fevers despite antibiotic therapy. Transoesophageal echocardiography revealed multiple vegetations on aortic valve, fistulization of an aortic root abscess to the left atrium and mitral regurgitation and moderate aortic regurgitation. At surgery, multiple vegetations on the aortic valve and a large abscess cavity establishing direct communication between aortic root and the left atrial cavity through a fistulous tract were discovered. This experience demonstrates the improved sensitivity and specificity of transoesophageal echocardiography in defining periannular extension of infective endocarditis.
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6/13. aneurysm of sinus of valsalva dissecting into interventricular septum: a late complication of aortic valve replacement.

    A 43-year-old man who had a Carbomedics prosthetic aortic valve replacement in 1997 was admitted to our hospital with complaints of shortness of breath and dyspnea on exertion in 2000. The patient was hospitalized due to atrioventricular (AV) complete block and a permanent pacemaker was implanted. At that time echocardiography indicated an aneurysm at the left sinus of valsalva. In 2003, the patient was re-admitted to our clinic with complaints of shortness of breath and fatigue. echocardiography showed a sinus of valsalva aneurysm dissecting into interventricular septum. Operation confirmed dissection of the interventricular septum and communication between this cavity and the aneurysm of the left sinus of valsalva. The postoperative course was uneventful and the patient was discharged in a satisfactory condition. This is the first reported case of aneurysm of the sinus of valsalva dissecting into interventricular septum late and complicating aortic valve replacement.
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7/13. Surgical considerations in the correction of valve dysfunction following heart transplantation.

    Valve dysfunction is not an uncommon occurrence following heart transplantation but when present can be managed medically with diuretics and vasodilator therapy. If medical therapy fails, these patients are considered for retransplantation. Due to the scarcity of donor hearts, efforts aimed at limiting the pool of cardiac retransplantation candidates are being focused lately on preservation of cardiac allograft function by conventional operations in lieu of a retransplant. A review of the literature for patients who underwent valve operations following their heart transplants yielded 26 cases. Four of these had isolated mitral valve procedures, 18 had tricuspid procedures, two had combined mitral and tricuspid operations and two had aortic valve replacements. In this communication, we present a case of severe aortic insufficiency developing 7 yr after heart transplantation and leading to progressive clinical deterioration and NYHA class IV heart failure symptoms. The aortic valve was replaced with a 21-mm Carbo Medics supra-annular mechanical prosthesis (CarboMedics Inc.). She had a favorable postoperative course and remains well 7 months after her operation. Surgical correction of valvular lesions is warranted if the function of the previously transplanted heart is reasonably preserved.
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8/13. Left ventricle-to-ascending aorta communication complicating composite graft repair undetected by aortography: diagnosis by transesophageal echocardiography.

    A 57-year-old man underwent composite ascending aortic conduit and prosthetic aortic valve repair of a sinus of valsalva aneurysm. The patient's course was complicated by recurrent aneurysm formation caused by a communication between the left ventricular outflow tract and the ascending aorta outside the conduit. Transesophageal echocardiography documented the anatomic and functional characteristics of this complication, whereas aortography failed to demonstrate them. Findings at surgery confirmed the transesophageal echocardiogram results of a left ventricular outflow tract to aorta communication, a normal prosthetic aortic valve, and an intact distal anastomosis of the conduit with the aorta. Transesophageal echocardiography is a useful modality for the evaluation of composite graft repairs of the aortic valve and ascending aorta.
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9/13. Aortico--left ventricular communication: report of a case.

    An 11-month-old male infant whose condition had been followed since birth was referred to the National taiwan University Hospital for management of a congenital heart disease. On admission, this infant was noted to have a systolic and diastolic precordial thrill and a grade 4/6 systolic and diastolic murmur. echocardiography, cardiac catheterization and cineangiogram revealed aortic stenosis, aortic regurgitation and dilatation of the aortic root. Surgical repair was performed to correct this congenital anomaly due to the progressive congestive heart failure. Intraoperatively, a breach between the aortic valve and the edge of the sinus of valsalva along the aortic annulus was found. This congenital defect was repaired with a Teflon patch successfully. Postoperatively, this patient convalesced steadily and was discharged. We report this unique case with aortico-left ventricular communication which we believe to be the ninth case in the English-language literature and the first in the Republic of china.
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10/13. Right coronary-left ventricular fistula mimicking aortic valve insufficiency in infancy.

    Two infants had large communications between the right coronary artery just distal to its origin and the cavity of the left ventricle. The findings were essentially those of aortic insufficiency. In the first patient operation was delayed until there was secondary aortic insufficiency resulting from dilatation of the aortic root. The second patient was operated upon in infancy, and abolition of the fistula has relieved the clinical situation. Surgeons should recognize that isolated congenital aortic valve insufficiency has not been reported to our knowledge. Therefore, infants who appear to have this condition should undergo thorough angiographic studies which likely will reveal a remediable situation. A surgical approach for the type of fistula described herein is presented.
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