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We report a rare case of anomalous aortic origin of the right coronary artery from the posterior/non-coronary sinus of Valsalva in a 9-year-old male diagnosed during the workup of premature ventricular contractions. The finding was initially noted on transthoracic echocardiogram and further confirmed with computed tomography. The anomalous coronary artery shows a wide ostium with no intramural or interarterial course.

Several studies have shown the variation of aortic sinus structures’ hemodynamics with different flow and geometric characteristics. They have also correlated aortic sinus hemodynamics with the progression and evolution of calcific aortic valve disease (CAVD). This study aims at visualizing aortic sinus fluid structure variations as functions of different leaflet calcification degrees and assessing their potential relationship with CAVD. A degenerated 23 mm Carpentier-Edwards Perimount Magna valve extracted from a redo-surgery patient was implanted in an aortic root model and tested in a pulse duplicator left heart simulator. The valve has 3 leaflets with 3 different levels of calcium distribution: mild, moderate and severe. High-speed imaging and particle image velocimetry were performed to assess sinus vortices, leaflet tip position and velocity along with shear stress. Results have shown that (a) aortic sinus vortices initiation, entrapment and evolution varied with different calcified leaflet exposure; (b) higher velocities in the sinus were calculated with the mildly calcified leaflet compared to the moderately and severely calcified ones; (c) during systole, the mildly calcified leaflet sinus case shows the most spread-out and higher ranges of shear stress probabilities and highest magnitudes going from (− 1.5 to + 1.8 Pa) compared with (− 1.0 to + 1.0 Pa) for moderately and severely calcified leaflets. The higher the calcification degree the lower the shear stress range and likelihoods of having higher shear stress. This holds in diastole as well. This study shows the impact of calcification on the aortic sinus flow structures.

Catheter ablation of accessory pathways can be challenging depending on the location of these pathways, and accessory pathways are rare through the aortic cusps. We report a patient who underwent radiofrequency catheter ablation for manifestation of a left anterior accessory pathway from the left coronary sinus of Valsalva near the aortic–mitral continuity. Anterior accessory pathways can be safely and effectively ablated from the aortic cusps with favorable long-term outcomes.

Background Anatomically pre-shaped sinus prostheses (SP) were developed to mimic the aortic sinus with the goal to preserve near physiological hemodynamic conditions after valve-sparing aortic root replacement. Although SP have shown more physiological flow patterns, a comparison to straight tube prosthesis and the analysis of derived quantitative parameters is lacking. Hence, this study sought to analyze differences in aortic wall shear stress (WSS) between anatomically pre-shaped SP, conventional straight tube prostheses (TP), and age-matched healthy subjects) using time-resolved 3-dimensional flow cardiovascular magnetic resonance (4D Flow CMR). Moreover, the WSS gradient was introduced and analyzed regarding its sensitivity to detect changes in hemodynamics and its dependency on the expression of secondary flow patterns. Methods Twelve patients with SP (12 male, 62 ± 9yr), eight patients with TP (6 male, 59 ± 9yr), and twelve healthy subjects (2 male, 55 ± 6yr) were examined at 3 T with a 4D Flow CMR sequence in this case control study. Six analysis planes were placed in the thoracic aorta at reproducible landmarks. The following WSS parameters were recorded: WSS avg (spatially averaged over the contour at peak systole), max. WSS seg (maximum segmental WSS), min. WSS seg (minimum segmental WSS) and the WSS Gradient, calculated as max. WSS seg – min. WSS seg . Kruskal-Wallis- and Mann-Whitney-U-Test were used for statistical comparison of groups. Occurrence and expression of secondary flow patterns were evaluated and correlated to WSS values using Spearman’s correlation coefficient. Results In the planes bordering the prosthesis all WSS values were significantly lower in the SP compared to the TP, approaching the physiological optimum of the healthy subjects. The WSS gradient showed significantly different values in the four proximally localized contours when comparing both prostheses with healthy subjects. Strong correlations between an elevated WSS gradient and secondary flow patterns were found in the ascending aorta and the aortic arch. Conclusion Overall, the SP has a positive impact on WSS, most pronounced at the site and adjacent to the prosthesis. The WSS gradient differed most obviously and the correlation of the WSS gradient with the occurrence of secondary flow patterns provides further evidence for linking disturbed flow, which was markedly increased in patients compared to healthy sub jects, to degenerative remodeling of the vascular wall.

Background For acute type A aortic dissection involving the aortic root with root diameter no more than 45 mm, there are various aortic root repair techniques. In this study, a novel surgical technique using a pericardial autograft for aortic root repair was introduced. We described its surgical steps in detail and compare its clinical outcomes with direct suture technique. Methods Between July 2017 and August 2022, 95 patients with acute type A aortic dissection who underwent aortic root repair were enrolled, including aortic root repair using pericardial autograft (group A, n  = 49) or direct suture (group B, n  = 46). The patient’s clinical data were retrospectively analyzed, and a 5-year follow-up was conducted. Results The 30-day mortality, re-exploration for bleeding, postoperative new-onset renal failure requiring continuous renal replacement therapy, stroke, and paraplegia occurred in 3%, 4%, 11%, 5%, and 2% of the overall patients, respectively. There was no significant difference in the 30-day mortality and complication rate between the two groups. The 30-day mortality and re-exploration for bleeding marked the primary endpoint events. Logistic regression analysis indicated that there was a significant correlation between the primary endpoint events and surgical technique (odds ratio, 0.002; 95% confidence interval, 0-0.159; P  = 0.026). The aortic valve insufficiency of the two groups were significantly improved after operation (group A, P  < 0.001; group B, P  < 0.001). During follow-up, there was no significant difference in short-term survival between the two groups after surgery (log-rank P  = 0.75), and all patients were free from reoperation for aortic disease. Conclusions Patients who underwent aortic root repair using pericardial autograft tended to have reduced 30-day mortality and a lower risk of re-exploration for bleeding. Using pericardial autograft for aortic root repair is a safe and useful approach for patients with acute type A aortic dissection involving the aortic root.

Aortic chordae tendineae (ACT) are rare fibrous strands originating from early aortic valve cusp formation as embryonic remnants. Most aortic chordae tendineae are asymptomatic, but they may cause aortic regurgitation via chordal rupture or cusp restriction. This case presents transcatheter aortic valve replacement (TAVR) for aortic regurgitation secondary to aortic sinus dilation with incidentally detected ACT that did not directly contribute to valvular dysfunction. An 81-year-old female with hypertension presented with progressive dyspnea. Cardiac auscultation revealed a diastolic murmur over the left sternal border. Transthoracic echocardiography demonstrated severe aortic regurgitation due to significant aortic root dilatation. Transapical TAVR was planned. Prosthetic size was determined via computed tomography. Pre-procedure transesophageal echocardiography (TEE) identified two ACTs connecting the free margin of the non-coronary cusp to the aortic sinus wall. TAVR with a self-expanding valve was performed, with intraoperative TEE confirming stable deployment despite rupture of two ACTs. The patient recovered uneventfully without perioperative complications, and follow-up transthoracic echocardiography confirmed optimal valve position with no paravalvular leakage. ACT presence does not preclude TAVR but requires meticulous intraoperative surveillance, TEE is critical for detecting these structures and guiding TAVR planning. Precise intraoperative positioning of valve graspers ensures avoidance of ACT-related complications, and rupture of ACT confirmed that it would not compromise prosthetic valve stability in the future. This case supports the feasibility of TAVR in complex aortic root anatomies with incidentally detected ACT.

Few case reports have mentioned the aortic sinus aneurysm invading ventricular septum and dissection caused by Behcet’s disease. Here, we reported a 36-year-old male patient with an aortic sinus aneurysm invading the ventricular septum and dissection caused by Behcet’s disease, who manifested as recurrent chest tightness and shortness of breath. Cardiac ultrasound showed the rupture of the right aortic sinus and the formation of ventricular septal dissection. Ascending aortic valve prosthesis replacement, mitral valvuloplasty with ring implantation and tricuspid valvuloplasty were performed. Postoperatively, he was treated with hormones, hydroxychloroquine sulfate, mycophenolate mofetil tablets, thalidomide and warfarin, and his symptoms were relieved. This is a rare case easily being misdiagnosed and missed, early diagnosis and in-time treatment are crucial to avoid surgical complications. The diagnostic and therapeutic approaches of this patient were reported and related literature was reviewed in this case report.

Purpose Left ventricular outflow tract (LVOT) arrhythmias are commonly targeted from the aortic sinuses of Valsalva (SOV). Both presystolic potentials during ventricular arrhythmia (VA) and late diastolic potentials during sinus rhythm have been recognized as markers of successful ablation sites. The study aimed to evaluate the utility of high resolution mapping (HRM) with small and closely spaced electrodes for guiding ablation of VA from the SOV. Methods Seventeen patients with LVOT VA underwent HRM in the SOV with either PentaRay (13) or Orion (4) catheters. Ablation was guided by low amplitude high frequency potentials that were identified with HRM and tagged on the electroanatomic map. Results High frequency low amplitude potentials during sinus rhythm (late) or VA (early) were demonstrated with HRM in all 17 consecutive patients; while these potentials were either absent or usually had a far-field appearance in the recordings obtained at the same sites with a 3.5-mm standard ablation catheter. On intracardiac echocardiogram, sites with these potentials corresponded to the bases of the sinuses adjacent to the LV ostium. Ablation was acutely successful in 16 out of 17 patients. Significant reduction in VA burden (≥ 90%) was noted in 15 patients. Conclusions High frequency low amplitude potentials during sinus rhythm (late) and VA (early) are consistently recorded using HRM in the SOV in patients with VA arising from the aortic sinuses of Valsalva. Standard ablation catheters have limited resolution for detecting these potentials. HRM may potentially improve outcomes of ablation of VA originating from the aortic SOV.

Information on the biomechanical properties of aortic root aneurysms that would facilitate our understanding of their rupture modes is currently unavailable. In this study, whole-thickness wall specimens from aortic root aneurysms were studied in vitro so as to compare the biomechanical properties with gross histomorphology and composition, in relation to age, region, and direction. The stress–strain relationship was determined under uniaxial loading conditions and characterized by the Fung-type material model in terms of optimized material constants; failure properties were recorded. The connective tissue contents of the basic scleroproteins were also determined through computerized histology. Aging had a deleterious influence on the tensile strength of the aneurysmal sinus tissue, causing also stiffening and reduced extensibility that was consistent with the deficient elastin and collagen contents. Direction-dependent differences were demonstrated in the noncoronary sinus, with the circumferential being stiffer and stronger than the longitudinal direction, justified by the preferred collagen reinforcement along that direction there. In the left and right coronary sinus, the material constants and failure properties were essentially the same in the two directions, justified by the arbitrary orientation of medial (collagen and elastin fibers, and cellular) components relative to the circumferential–longitudinal directions. The material characterization results afforded, and the regional and age-related differences in the strength of the sinus wall, i.e. in its capacity to withstand hemodynamic stresses, are hoped to provide novel insight into the pathophysiological mechanisms responsible for the highest incidence of ruptured aortic root aneurysms in the right coronary and noncoronary sinus.

Left ventricular assist device (LVAD) implantation is a highly effective procedure for the management of selected advanced heart failure patients, prolonging patient life and improving quality. Additional cardiac pathologies, especially valvular regurgitation or coronary heart disease, are common in LVAD recipients, whereas reports on the surgical management of heart failure combined with aortic disease are rare. We present a case of a 60-year-old patient with an aortic sinus aneurysm, aortic regurgitation, and end-stage heart failure. LVAD implantation was performed concomitantly with the Bentall procedure and Cabrol shunt technique. The patient was discharged uneventfully on postoperative day 26. This suggests that combining LVAD implantation with additional cardiovascular procedures could be an alternative strategy for patients with complex heart failure conditions. LVAD implantation combined with additional aortic surgery can be a feasible alternative with acceptable risk, especially for patients who have elected to pursue LVAD as destination therapy. Successful outcomes require adequate preoperative evaluation, experienced cardiac surgeons, and close postoperative care.