Surgical Treatment of Aortic Valve Regurgitation Secondary to Ascending Aorta Aneurysm: Is Adjunctive Subcommissural Annuloplasty Necessary?

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1 Surgical Treatment of Aortic Valve Regurgitation Secondary to Ascending Aorta Aneurysm: Is Adjunctive Subcoissural Annuloplasty Necessary? Charles Mve Mvondo, MD, Paolo Nardi, MD, PhD, Carlo Bassano, MD, PhD, Fabio Bertoldo, MD, PhD, Susanna Grego, MD, Francesca D Auria, MD, Antonio Scafuri, MD, and Luigi Chiariello, MD Division of Cardiac Surgery, Policlinico Tor Vergata, Tor Vergata University of Rome, Rome, Italy Background. Subcoissural aortic annuloplasty (SCA) has been recoended for treatment of functional aortic regurgitation (AR), but its association with sinotubular junction adjustment is still controversial. Methods. Sixty patients with moderate or severe functional AR secondary to proximal ascending aorta aneurysm operated on between May 2004 and December 2010 were reviewed. Forty patients underwent SCA and ascending aorta repair (SCA group; mean age, 65 9 years) and 20 underwent ascending aorta repair alone (non-sca group; mean age, 69 8 years). Preoperative AR grades were comparable between groups (p 0.9). Echocardiographic data at discharge and during follow-up (SCA group, months; non-sca group, months) were analyzed. Results. Improvement of mean AR grade was better in the SCA group than in the non-sca group at discharge ( vs /4, p ) and at follow-up ( vs /4, p ). Cox-regression analysis (odds ratio [95% confidence interval]) identified a higher residual AR at discharge (0.14 [ ], p 0.02) and the surgical technique, SCA or not (0.5 [ ], p 0.04), as predictors of more than grade 2/4 AR at follow-up. Five-year freedom from more than grade 2/4 AR was 94.4% 5.4% vs 58% 16% in SCA vs non-sca (p 0.02), respectively, and the survival rate was 95% 5% vs 89% 7.5% (p 0.7). No valve stenosis was observed in the SCA group. Conclusions. SCA is effective for treatment of functional AR, providing stable results even for significant AR. Our results suggest that it should be possibly associated to sinotubular junction adjustment. SCA seems to not impair normal aortic valve opening. (Ann Thorac Surg 2013;95:586 92) 2013 by The Society of Thoracic Surgeons The Permanent Patency of the Mouth of the Aorta, a publication by Corrigan [1] in 1832, first described the mechanism of aortic valve regurgitation (AR) caused by proximal ascending aorta aneurysm. This type of valve incompetence is coonly defined as functional AR (FAR) because of the absence of primitive aortic cusps lesions. Although sinotubular junction (STJ) dilatation seems its primary cause, the whole physiopathology of FAR remains complex and correlates with the integrity of all of the aortic root components. Frater [2] described in 1986 the reduction of dilated STJ diameter to restore normal cusps coaptation. To date, however, this seems an incomplete approach, because its poor effect on basal annulus stabilization may contribute to later recurrence of AR. To attempt aortic valve annuloplasty, several techniques have been proposed, along with ring prosthesis implantation or aortic annulus plication techniques such as subcoissural annuloplasty (SCA). The latter, described early by Cabrol and colleagues [3] in 1966, is still Accepted for publication Sept 20, Address correspondence to Dr Mve Mvondo, Policlinico Tor Vergata, Tor Vergata University of Rome, Viale Oxford 81, Rome, Italy; vondocarlo@yahoo.fr. the most coon procedure of aortic valve annuloplasty. More recently, Mangini and coworkers [4] reported great improvement by means of SCA in increasing cusp coaptation length and valve competence. Moreover, lesionspecific classifications by El Khoury and associates [5] and Lansac and associates [6] have recoended SCA as an adjunctive procedure to STJ adjustment for the treatment of FAR. Despite this evidence, isolated STJ adjustment is still considered sufficient to restore normal cusp coaptation in the surgical treatment of FAR [7 9]. The aim of our study was to assess the safety and possible benefits of SCA as an adjunctive procedure to STJ adjustment performed in patients affected by FAR secondary to ascending aorta aneurysm. Material and Methods This study was approved by the Tor Vergata University Hospital Institutional Review Board. The requirement for written informed consent was waived for this study. Patients From May 2004 to December 2010, 567 patients underwent thoracic aorta aneurysm operations at the Divi by The Society of Thoracic Surgeons /$36.00 Published by Elsevier Inc

2 Ann Thorac Surg MVE MVONDO ET AL 2013;95: SCA FOR FUNCTIONAL AR 587 sion of Cardiac Surgery of Tor Vergata University of Rome. The study excluded patients with aortic dissection, Marfan syndrome, or other genetic disorders, bicuspid aortic valve, or primitive aortic valve lesions. Also excluded were patients with dilation of the aortic root who underwent valve-sparing procedures. We identified 190 patients with ascending aorta aneurysm and STJ dilatation as the main cause of AR; among those, 60 patients with moderate or severe AR were included and subdivided in two groups according to the surgical treatment. The SCA group included 40 patients who underwent SCA and STJ adjustment with ascending aorta graft replacement. The non-sca group (n-sca) group included 20 patients treated with STJ adjustment alone. All preoperative and discharge 2-dimensional echocardiograms, and when available, computed tomography data were obtained from hospital records and contact with patients or their physicians. Clinical and echocardiography follow-up was 100% complete at a mean duration of months for SCA and months for n-sca (p 0.1). Patients in n-sca group had greater preoperative ascending aorta diameter (p 0.003) and New York Heart Association (NYHA) functional class (p 0.001) compared with the SCA group (Table 1). No differences were found preoperatively in STJ diameter (p 0.08) and AR grade between the two groups (p 0.2). Mean extracorporeal circulation time was almost similar (p 0.06), but aortic clamping time was significantly higher in the SCA group (p 0.001; Table 2). Long-term medical treatment at discharge included antihypertensive drugs with angiotensin-converting enzyme inhibitors and -blockers in all patients according to patient cardiologic status and comorbidities. An antiplatelet regimen with aspirin (100 mg/daily) was recoended in all patients. Echocardiography Assessment of FAR Preoperative transthoracic and intraoperative transesophageal echocardiograms were performed in all patients. The anatomy of the aortic valve was accurately inspected with regurgitant jet analysis to exclude primary cusp lesions, because an eccentric jet may be associated with cusp prolapse. Thus, only patients with central jet were selected for STJ adjustment, with or without SCA. Eccentric jet often requires an additional procedure, such as free margin plication or cusp resuspension, and could have led to misinterpretation of SCA effect in our cohort of patients. Diameters of ascending aorta, STJ, aortic root, and aortic annulus were routinely registered. These measurements allowed an accurate definition of the AR mechanism and oriented the surgical strategy. AR was defined as functional when STJ dilation was the only mechanism sustaining valve regurgitation. AR severity was defined according to the American Society of Echocardiography recoendations [10]. Table 1. Clinical Profile of Patients Variable a (n 40) (n 20) SCA n-sca p Value Age, years Sex Female Male 18 3 Hypertension 39 (97.5) 18 (90) 0.7 Smoking habit 12 (30) 9 (45) 0.5 Dyslipidemia 4 (10) 3 (15) 0.4 Chronic renal failure 1 (2.5) COPD 6 (15) 4 (20) 0.6 NYHA class Left ventricular variables Ejection fraction End-diastolic diameter, End-systolic diameter, Ascending aorta diameter, Aortic root diameter, STJ diameter, Aortic annulus (VAJ), Aortic regurgitation grade III 32 (80) 17 (85) IV 8 (20) 3 (15) a Continuous data are presented as mean standard deviation and categoric data as number (%). COPD chronic obstructive pulmonary disease; NYHA New York Heart Association; n-sca no subcoissural annuloplasty; SCA subcoissural annuloplasty; STJ sinotubular junction; VAJ ventriculoaortic junction. Indication for Ascending Aorta Graft Replacement and SCA Aortic aneurysm resection was done according to the American College of Cardiology Foundation/American Heart Association Guidelines for the diagnosis and management of patients with thoracic aortic disease [11]. Aortic root disease was treated according to data obtained from the regression formulas suggested by Roman and colleague [12]. An aortic root ratio of 1.5 or greater was the main indication for operation, and particular attention was paid to aortic root morphology, patient age, and comorbidities. Early at our institution, we performed SCA predominantly for moderate or severe FAR. As benefits from SCA became evident, we have successively extended the indication to patients with mild AR. Their follow-up period was short, however, and their clinical data were not investigated in the current study because our main concern was to evaluate the effect of this technique only in significant FAR.

3 588 MVE MVONDO ET AL Ann Thorac Surg SCA FOR FUNCTIONAL AR 2013;95: Table 2. Operative and Postoperative Data Variable a (n 40) (n 20) SCA n-sca p-value Cardiopulmonary bypass time, min Aortic clamping time, min Vascular graft diameter, Others cardiac procedures 0.2 Coronary artery bypass 9 (22) 3 (13) grafting Hemiarch replacement 3 (7) 1 (4) with DHA and ACP Modified Maze for AF 3 (7) 0 (0) ablation Mitral valve repair 4 (10) 1 (4) Tricuspid valve repair 2 (5) 0 (0) Postoperative 0.6 complications Reoperation for 0 (0) 0 (0) postoperative AR Bleeding 1 (2.5) 0 (0) Acute heart failure 0 (0) 2 (10) Atrial fibrillation/ 7 (17) 0 (0) nonfatal arrhythmias Stroke 0 (0) 0 (0) Mortality (30 days) 1 (2.5) 0 (0) 0.8 Aortic annulus (VAJ), Residual AR at discharge a Continuous data are presented as mean standard deviation and categoric data as number (%). ACP antegrade cerebral perfusion; AF atrial fibrillation; AR aortic regurgitation; DHA deep hypothermic arrest; n-sca no subcoissural annuloplasty; SCA subcoissural annuloplasty; VAJ ventriculoaortic junction. Surgical Technique A full median sternotomy was performed in all patients. Cardiopulmonary bypass was established through distal ascending aorta or proximal arch cannulation and right atrium or bicaval venous cannulation, according to the associated procedures (Table 2). Antegrade blood cardioplegia was administrated selectively through the coronaries ostia after a transverse supracoronary aortotomy performed at the STJ level. The decision of whether to perform an SCA was by surgeon s preference, because some believed that adjunctive SCA was not useful in FAR, whereas other surgeons were convinced of the contrary. Three stitches (2-0 silk) were passed at the tip of each coissure to permit a good aortic annulus and valve exposure. After accurate aortic root and valve inspection, a single 2-0 TI-CRON mattress suture (Sherwood Medical, St Louis, MO), reinforced with a double Teflon (DuPont, Wilmington, DE) pledget, was passed at the upper half of each intercoissural triangle (Fig 1). A correctly sized Dacron (DuPont) graft was chosen, as previously described by Morishita and colleagues [13], and sutured proximally at the STJ level. A warm blood cardioplegia catheter was inserted in the Dacron tube graft, which was clamped, leaving enough space to inject the solution under pressure. Valve competence was evaluated by inspection of a proper bulging of the graft and manual assessment of the filling pressure. After the patient was weaned from cardiopulmonary bypass, a transesophageal echocardiogram was performed intraoperatively to exclude significant residual AR. Postoperative and Follow-Up Evaluation The patients were admitted to the intensive care unit iediately after the operation and then successfully transferred to the cardiology wards. A control echocardiogram was obtained before discharge, and follow-up echocardiograms were performed every 6 months for the first 2 years, and once yearly thereafter. Closer follow-up was advised only in patients with less than optimal echo findings (AR 2/4). Clinical evaluation and echocardiograms data were analyzed or performed during the follow-up period by the same cardiologist (S.G.). Statistical Analysis Statistical analysis was performed with Stat View 4.5 software (SAS Institute Inc, Cary, NC). Univariate anal- Fig 1. Aortic valve subcoissural annuloplasty and intercoissural triangle placation.

4 Ann Thorac Surg MVE MVONDO ET AL 2013;95: SCA FOR FUNCTIONAL AR 589 Fig 2. Freedom from late death in patients with (black line) subcoissural annuloplasty (SCA) and without (n-sca; dotted line). (NS not significant.) ysis was performed using the Student t test for continuous data and the 2 with Fisher exact test for categoric data to compare preoperative and perioperative characteristics. Preoperative variables selected for analysis included age, sex, NYHA class, left ventricular ejection fraction, left ventricular end-systolic and end-diastolic diameters, aortic root and ascending aorta diameters, and AR grade. Operative variables were SCA, cardiopulmonary bypass and aortic cross-clamp times, associated surgical procedures, and postoperative variables, including residual AR at discharge and aortic root and ascending aorta dimensions (vascular prosthesis). The Cox proportional hazards method was used to evaluate the influence of variables on time to progression to AR grade greater than 2 /4. Survival and event-free (AR 2 /4 ) survival estimates 1 standard error were obtained with the Kaplan-Meier method. The log-rank test was used to compare survival estimates among subgroups. A p value of less than 0.05 was considered statistically significant. No reoperation for AR recurrence was performed in either group. Echocardiography Results At discharge, the AR grade was significantly lower in the SCA group than in n-sca patients ( vs , p ), despite an almost similar preoperative mean between the groups (Table 1 and Table 2). The 3-year and 5-year freedom from AR recurrence more than grade 2 /4 was, respectively, 100% and 94.4% 5.4% in the SCA group and 78% 9% and 58% 16% in the n-sca group (p 0.02; Fig 3). Although the preoperative diameter of the ascending aorta was greater in n-sca group, this poorly influenced the surgical result, because the STJ mean value and AR grade were comparable between the two groups. Enddiastolic diameter reduction at follow-up was better in the SCA group (from to ) than in the n-sca group (from to ; Table 3). Aortic root diameter reduced in both groups, but the SCA group presented better results at follow-up ( vs , p 0.003), despite almost similar preoperative values for both groups ( vs , p 0.4). Changes in ascending aorta (vascular prosthesis) diameter in SCA vs n-nca ( ; p 0.7) and mean aortic gradient (5 2vs4 2Hg,p 0.6) were comparable at follow-up. Functional Results At follow-up, the NYHA class decreased significantly compared with preoperative values in both groups, from to in SCA patients and from to in n-sca patients. Cox regression analysis identified the residual AR at discharge (odds ratio, 0.14; 95% confidence interval, ; p 0.02), and the type of surgical procedure Results Early and Late Survival One patient in the SCA group died of multiorgan failure on postoperative day 6, for overall hospital mortality rate of 2.5%. This patient had chronic renal failure and had required several hospital admissions for heart failure before the operation. No n-sca patients died during the same period. The survival at 5 years was 95% 5% in the SCA group and 89% 7.5% in the n-sca group (p 0.7; Fig 2). No deaths occurred at follow-up in SCA patients, and 2 deaths were registered among n-sca patients. Causes of death were cardiac (sudden death) in 1 patient and noncardiac (pulmonary cancer) in the other patient. Fig 3. Actual freedom from aortic regurgitation more than grade 2/4 in patients with (black line) subcoissural annuloplasty (SCA) and without (n-sca; dotted line). (AR aortic regurgitation.)

5 590 MVE MVONDO ET AL Ann Thorac Surg SCA FOR FUNCTIONAL AR 2013;95: Table 3. Follow-Up Data Variable a (n 39) (n 18) SCA n-sca (SCA vs n-sca: odds ratio, 0.5; 95% confidence interval, ; p 0.04) as significant risk factors for recurrence of AR. Coent p Value Follow-up duration, mon NYHA class Left ventricle variables Ejection fraction End-diastolic diameter, End-systolic diameter, Aortic regurgitation Grade Grade 2 /4 1 (2.5) 6 (33) Aortic annulus (VAJ), Aortic valve gradient, Hg Ascending aorta diameter, Aortic root diameter, a Continuous data are presented as mean standard deviation and categoric data as number (%). NYHA New York Heart Association; n-sca no subcoissural annuloplasty; SCA subcoissural annuloplasty; VAJ ventriculoaortic junction. Although controversies still exist on long-term durability of aortic valve repair, there is an increasing consent to promote nonthrombogenic surgery, with the aim to limit prosthetic valve related complications, especially in patients with a longer life expectancy. However, despite descriptions of various techniques of aortic valve repair, these conservative procedures are not yet standardized. This is partly due to the unpredictability of valve repair, which strongly correlates with the surgeon s ability; however, good results of prosthetic valve replacement have contributed to reduce the repair rate, even in patients suitable for valve repair. Various classifications of AR have recently been proposed, with lesion-specific surgical approaches, reporting similar principles of mitral valve repair operations promoted by Carpentier [14]. El Khoury and colleagues [5] and Lansac and colleagues [6] recoend the stabilization of the annulus in all types of aortic valve repair. They suggest that FAR after ascending aorta dilatation should be treated by STJ adjustment and annuloplasty (either SCA or ring prosthesis), especially in presence of aortic annulus dilation. FAR was described by Corrigan [1] in 1832 as the result of an STJ dilation, with normal cusps pulled away from each other, thus preventing central coaptation. The surgical reduction of a dilated STJ as specific treatment of FAR was first reported by Frater [2] in 5 patients. Other clinical studies have successively corroborated this approach with encouraging long-term freedom from significant AR [7 9]. However, the increasing interest for aortic valve repair supported by the long-term experience acquired from valve-sparing procedures and a better understanding of aortic root physiopathology have introduced the concept of functional aortic annulus, defined as one unit formed by the STJ, the ventriculoaortic junction (VAJ), and the anatomic crown-shaped annulus [15]. Therefore, an isolated STJ adjustment seems an incomplete strategy to treat FAR because it cannot address basal annulus abnormalities. In our study, we found that residual AR at discharge was strictly related to late recurrence of AR. Although AR grade significantly decreases in both groups at discharge compared with preoperative values, patients in the SCA group present better improvement, with more stable results at follow-up. The increment of cusp coaptation length by means of SCA technique reported in previous studies [4] may guarantee better valve competence and stability over time, because a suboptimal value ( 4 ) has been identified as a predictor of late repair failure [16, 17]. Thus, STJ adjustment may restore only partially the cusp coaptation area, with the inferior component of the functional annulus (VAJ) left untreated, increasing the risk of progressive dilation and subsequent AR recurrence over time. In fact, recent studies have pointed out that the VAJ dilation is a strong predictor of AR recurrence after aortic valve repair [18, 19]. This has emphasized the effectiveness of various anuloplasty techniques to reduce the VAJ diameter. De Kerchove and colleagues [20], in their recent in vitro study, observed that the SCA was less effective than prosthetic rings in narrowing the VAJ diameter. Similarly, Aicher and associates [19] identified the SCA procedure as a predictor for repair failure in patients with bicuspid aortic valve who underwent aortic valve repair. However, Mangini and coworkers [4] reported in their studies of bioengineering and anatomic models a significant reduction of aortic annulus with the SCA technique. This latter finding was consistent with our series, where the VAJ diameter reduced significantly at discharge in SCA patients, despite no difference being found at follow-up, compared with n-sca patients. Indeed, the SCA technique is a noncircular annuloplasty, performed slightly above the level of the VAJ [20]. This may partly explain the poor restrictive effect compared with prosthetic annular rings, which are closely fixed at the level of the VAJ. Nevertheless, De Kerchove and colleagues [20] report comparable improvement in cusp coaptation length between the two techniques (SCA vs rings). Thus, although the SCA procedure can modify or stabilize the VAJ diameter, its main effect seems to be the increment of the cusp coaptation by reducing the width of the intercoissural triangles. The actual experience with prosthetic rings remains poor, because many have been evaluated only in experimental studies, with variations in their modalities of use

6 Ann Thorac Surg MVE MVONDO ET AL 2013;95: SCA FOR FUNCTIONAL AR 591 among centers [20, 21]. Moreover, prosthetic ring implantation may be troublesome, and the ideal mode of implantation and the type of prosthetic material (rigid or flexible) are still to be defined. Therefore, the complexity of aortic ring implantation and its long-term unpredictable effects on cusps and aortic root components have to be balanced with its real benefits over SCA technique in the treatment of FAR. In their study, Mangini and coworkers [4] found that SCA stitches should be passed at 50% of the intercoissural triangle upper tract to permit optimal leaflet coaptation and avoid cusp stress or valve stenosis. These findings may help to resolve the limitation of the SCA technique in standardizing the ideal size of coissure plication. In our series, SCA was performed in the upper half of each intercoissural triangle according to the degree of aortic annulus diameter. No increase in aortic gradient was observed, demonstrating a conserved aortic root expansibility and normal cusp movement after SCA. However, care should be taken to avoid excessive annular plication, which may lead to valvular stenosis [22]. Patients who are candidates for aortic valve repair should undergo an accurate echocardiography assessment, especially with the transesophageal modality [23, 24]. Regurgitant jet characteristics, bicuspid morphology, cusp thickness, and coaptation length should be evaluated, because these features often influence the surgical strategy. Some degree of cusp prolapse should be suspected in the presence of eccentric regurgitant jet, requiring additional procedures such as free margin plication or cusp resuspension [7, 8]. Our preoperative data found the diameter of the STJ was greater in the n-sca group, even though the difference did not reach statistical significance (p 0.08). Although it appears reasonable that this difference might influence the surgical results, we believe that it was entirely reset by using similar Dacron graft size in both groups (p 0.9), thus cancelling the preoperative bias. We can therefore assume that all patients started their follow-up period with a similar STJ diameter, regardless of the preoperative value. Late recurrence of AR could be partly explained by the progressive dilatation of the Dacron vascular graft [25, 26]. Thus, although this vascular prosthesis has demonstrated long-term durability in vascular operations, its progressive expansion, reaching nearly 25% of its initial diameter, could theoretically contribute to later dilation of the neo-stj and cause recurrence of AR, especially after isolated STJ adjustment. A slight increase of ascending aorta diameter (vascular graft) was present in both groups at follow-up and could have contributed to AR recurrence in n-sca patients. Among the limitations of the study were that patients with a bicuspid aortic valve were excluded from our study groups; thus, we were not able to verify the safety of the SCA technique in this subgroup of patients. Moreover, data on cusp coaptation length were not reported. Because the aim of the study was to assess the effectiveness of SCA in FAR, rather than to define pathophysiologic mechanisms after the technique, this variable was not registered in a consistent number of patients. However, evidence of cusp coaptation length improvement by means of SCA has been reported in previous studies [4]. In suary, SCA is a simple and safe technique contributing to achieve stable results, even in patients with an advanced grade of functional AR. It does not seem to add risk to isolated thoracic ascending aorta repair and is definitively not detrimental compared with isolated STJ diameter reduction because it does not cause any significant valvular obstruction. We therefore recoend SCA to be possibly associated to ascending aorta repair, especially in patients with a moderate to severe grade of FAR. Prospective randomized studies and longer follow-up could further confirm the benefit of associating SCA to STJ adjustment. References 1. Corrigan DEJ. Permanent patency of the mouth of the aorta. Edinborough Med Surg 1832;37: Frater RWM. Aortic valve insufficiency due to aortic dilatation: correction by sinus rim adjustment. Circulation 1986; 74(Suppl II): Cabrol C, Cabrol A, Guiraudon G, et al. Le traitement de l insuffisance aortique par l annuloplastie aortique. Arch Mal Coeur Vaiss 1966;59: Mangini A, Lea MG, Soncini M, et al. The aortic interleaflet triangles annuloplasty: a multidisciplinary appraisal. Eur J Cardiothorac Surg 2011;40: El Khoury G, Glineur D, Rubay J, et al. Functional classification of aortic root/valve abnormalities and their correlation with etiologies and surgical procedures. Curr Opin Cardiol 2005;20: Lansac E, Di Centa I, Raoux F, et al. A lesional classification to standardize surgical management of aortic insufficiency towards valve repair. Eur J Cardiothorac Surg 2008;33: Morimoto N, Matsumori M, Tanaka A, et al: Adjustment of sinotubular junction for aortic insufficiency secondary to ascending aortic aneurysm. Ann Thorac Surg 2009;88: David TE, Feindel CM, Armstrong S. Replacement of the ascending aorta with reduction of the diameter of the sinotubular junction to treat aortic insufficiency in patients with ascending aortic aneurysm. J Thorac Cardiovasc Surg 2007; 133: Tataroglu C, Cenal AR, Tekumit H, Uzun K, Polat A, Akinci E. Reduction of the sinotubular junction in patients undergoing ascending aortic replacement with coexisting aortic insufficiency. J Card Surg 2011;26: Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recoendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003;16: Hiratzka LF, Bakris GL, Beckman JA, et al. ACCF/AHA/ AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM Guidelines for the Diagnosis and Management of Patients With Thoracic Aortic Disease. Circulation 2010;121:e266 e Roman MJ, Devereux RB, Kramer-Fox R, O Loughlin J, Spitzer M, Robins J. Two-dimensional echocardiographic aortic root dimensions in normal children and adults. Am J Cardiol 1989;64: Morishita K, Abe T, Fukada J, et al. A surgical method for selecting appropriate size of graft in aortic root remodeling. Ann Thorac Surg 1998;65: Carpentier A. Cardiac valve surgery- the French correction. J Thorac Cardiovasc Surg 1983;86:

7 592 MVE MVONDO ET AL Ann Thorac Surg SCA FOR FUNCTIONAL AR 2013;95: Anderson RH. Clinical anatomy of the aortic root. Heart 2000;84: Le Polain de Waroux JB, Pouleur AC, Robert A, et al. Mechanism of recurrent aortic regurgitation after aortic valve repair: predictive value of intraoperative transesophageal echocardiography. JACC Cardiovasc Imaging 2009;2: Van Dyck MJ, Watremez C, Boodhwani M, Vanoverschelde JL, El Khoury G. Transesophageal echocardiographic evaluation during aortic valve repair surgery. Anesth Analg 2010; 111: Kunihara T, Aicher D, Rodionycheva S, et al. Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valvepreserving aortic root repair. J Thorac Cardiovasc Surg 2012;143: Aicher D, Kunihara T, Abou Issa O, Brittner B, Gräber S, Schäfers HJ. Valve configuration determines long-term results after repair of the bicuspid aortic valve. Circulation 2011;123: de Kerchove L, Vismara R, Mangini A, et al. In vitro comparison of three techniques for ventriculo-aortic junction annuloplasty. Eur J Cardiothorac Surg 2012;41: Lansac E, Di Centa I, Raoux F, et al. An expansible aortic ring for a physiological approach to conservative aortic valve surgery. J Thorac Cardiovasc Surg 2009;138: Fraser CD, Cosgrove DM. Surgical techniques for aortic valvuloplasty. Texas Heart Inst J 1994;21: David TE. Preoperative selection of patients for aortic valve repair. Rev Esp Cardiol 2010;63: Boodhwani M, De Kerchove L, Glineur D, et al. Aortic valve repair with ascending aortic aneurysms: associated lesions and adjunctive techniques. Eur J Cardiothorac Surg 2011;40: Daniel B. Nunn, Marc H. Freeman, Paul C. Hudgins. Postoperative alterations in size of Dacron aortic grafts: an ultrasonic evaluation. Ann Surg 1979;189: Stollwerck PL, Kozlowski B, Sandmann W, Grabitz K, and Pfeiffer T. Long-term dilatation of polyester and expanded polytetrafluoroethylene tube grafts after open repair of infrarenal abdominal aortic aneurysms. J Vasc Surg 2011;53: Southern Thoracic Surgical Association: Sixtieth Annual Meeting Call for Abstracts You are invited to submit abstracts and surgical motion pictures for the Southern Thoracic Surgical Association (STSA) Sixtieth Annual Meeting to be held October 30 November 2, 2013 at the Hyatt Regency Scottsdale Resort & Spa at Gainey Ranch in Scottsdale, Arizona. To submit an abstract, access the online submission site through the STSA website at beginning in early February. Abstracts must be submitted by Monday, April 8, 2013 at 11:59 PM, Eastern Time. Accepted abstracts will be presented at the STSA Sixtieth Annual Meeting as oral presentations or surgical videos. Please direct any questions regarding abstract submission to STSA at stsa@stsa.org or (800) by The Society of Thoracic Surgeons Ann Thorac Surg 2013;95: /$36.00 Published by Elsevier Inc

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