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Annular enlargement for failed aortic root homograft

Methods and results A 33-year-old man was admitted to our department for correction of severe aortic valve incompetence. At the age of 6 months, he had undergone repair of aortic coarctation and 9 years previously, because of endocarditis on a bicuspid aortic valve, full root replacement using a cryopreserved homograft was done using multiple single stitches. On admission, he was in sinus rhythm with an enlarged cardiac shadow on chest radiograph. Transthoracic two-dimensional echo showed a 4þ aortic regurgitation, a dilated left ventricular cavity with an end-diastolic volume of 206 ml and an ejection fraction of 36%, and a pulmonary artery pressure of 60 mmHg. Angiography confirmed the severe aortic incompetence and showed normal coronary ostia and arteries. At operation, the chest was re-entered through a repeat median sternotomy. Moderately hypothermic cardiopulmonary bypass was instituted by cannulation of the ascending aorta and right atrium, whereas myocardial protection was achieved with cold Custodiol cardioplegia into the coronary ostia and by topical cooling. The homograft aortic root, which appeared thickened but not calcified, was opened just below the previous suture line. The aortic cusps were retracted and fibrotic with mild annular calcification. Excision of the homograft valve and annular debridement left a rigid and diminutive aortic annulus (20 mm). Anticipating a potential prosthesis–patient mismatch, it was decided to enlarge the aortic annulus using a previously described technique. The aortotomy was