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Cardiac computed tomography (CCT) has rapidly evolved, becoming a powerful integrated tool for the evaluation of coronary artery disease (CAD), and being superior to other noninvasive methods due to its high accuracy and ability to simultaneously assess both lumen stenosis and atherosclerotic plaque burden. Furthermore, CCT is regarded as an effective gatekeeper for coronary angiography, and carries independent important prognostic information. In the last decade, the introduction of new functional CCT applications, namely CCT perfusion (CCTP) imaging and CT-derived fractional flow reserve (FFR(CTA)), has opened the door for accurate assessment of the haemodynamic significance of stenoses. These new CCT technologies, thus, share the unique advantage of assessing both myocardial ischemia and patient-specific coronary artery anatomy, providing an integrated anatomical/functional analysis. In the present review, starting from the pathophysiology of myocardial ischemia, we evaluate the existing evidence for functional CCT imaging and its value in relation to alternative, well-established, non-invasive imaging modalities and invasive indices of ischemia (currently the gold-standard). The knowledge of clinical applications, benefits, and limitations of these new CCT technologies will allow efficient and optimal use in clinical practice in the near future.

Aims Cardiac magnetic resonance (CMR) is part of the diagnostic work-up for cardiac amyloidosis (CA). Deep learning (DL) is an application of artificial intelligence that may allow to automatically analyze CMR findings and establish the likelihood of CA. Methods and results 1.5 T CMR was performed in 187 subjects with suspected CA (n = 92, 49% with unexplained left ventricular—LV—hypertrophy; n = 95, 51% with blood dyscrasia and suspected light-chain amyloidosis). Patients were randomly assigned to the training (n = 121, 65%), validation (n = 28, 15%), and testing subgroups (n = 38, 20%). Short axis (SA), 2-chamber (2 C), 4-chamber (4 C) late gadolinium enhancement (LGE) images were evaluated by 3 networks (DL algorithms). The tags “amyloidosis present” or “absent” were attributed when the average probability of CA from the 3 networks was ≥50% or Conclusion A DL approach evaluating LGE acquisitions displayed a similar diagnostic performance for CA to a ML-based approach, which simulates CMR reading by experienced operators.

Background Cardiovascular magnetic resonance (CMR) is part of the diagnostic work-up for cardiac amyloidosis (CA). Deep learning (DL) is an application of artificial intelligence that may allow to automatically analyze CMR findings and establish the likelihood of CA. Methods 1.5 T CMR was performed in 206 subjects with suspected CA (n = 100, 49% with unexplained left ventricular (LV) hypertrophy; n = 106, 51% with blood dyscrasia and suspected light-chain amyloidosis). Patients were randomly assigned to the training (n = 134, 65%), validation (n = 30, 15%), and testing subgroups (n = 42, 20%). Short axis, 2-chamber, 4-chamber late gadolinium enhancement (LGE) images were evaluated by 3 networks (DL algorithms). The tags “amyloidosis present” or “absent” were attributed when the average probability of CA from the 3 networks was ≥ 50% or Results The DL strategy displayed good diagnostic accuracy (88%), with an area under the curve (AUC) of 0.982. The precision (positive predictive value), recall score (sensitivity), and F1 score (a measure of test accuracy) were 83%, 95%, and 89% respectively. A ML algorithm considering all CMR features had a similar diagnostic yield to DL strategy (AUC 0.952 vs. 0.982; p = 0.39). Conclusions A DL approach evaluating LGE acquisitions displayed a similar diagnostic performance for CA to a ML-based approach, which simulates CMR reading by experienced operators.

Introduction In patients (pts) undergoing cardiac surgery for primary mitral regurgitation (PMR), coronary angiography (CA) is always scheduled shortly before surgery to rule out significant coronary artery disease (CAD), despite this population is often young and with relatively low risk for CAD. Computed Tomography Coronary Angiography (CTCA) could be an alternative approach to evaluate coronary arteries, at least ruling out significant CAD in selected pts, due to its high negative predictive value. Purpose A safer, more appropriate and efficient clinical and diagnostic pathway for patients undergoing cardiac surgery for PMR by stratifying patients prior cardiac surgery according to pretest probability score (PTP) and therefore shifting imaging of epicardial coronary arteries from invasive to noninvasive in specific patients subsets. Methods A retrospective analysis (Jan 2014–Dec 2020) was carried out through the extraction of 7343 electronic medical records of pts who underwent cardiac valve surgery. In 1556 pts with PMR (1195 with no-CAD and 361 with CAD) a PTP was retrospectively calculated according to Genders, 2012, to stratify their risk of CAD. A Decision oriented Health Technology Assessment (DoHTA) and a cost analysis were also performed to support the analysis results. A survey was distributed to a team of experts with a multidisciplinary background to analyze the most significant evaluation areas (Economic Aspects, Clinical Effectiveness, Safety, Innovation) and the sub-criteria related to them. Following the Core Model Eunethta as a guideline, a Rapid Report HTA has been drawn up to identify the best solution. Results Patients characteristics are listed in Picture 1. Pts with normal coronary arteries showed a PTP low-to intermediate while pts with high PTP had CAD and therefore had a real pretest need for a CA (average 11 percent ± 9 in noCAD group vs 20 percent ± 14 in the CAD group). In two thirds of PMR population coronary angiography could have been avoided according to a PTP score The cost analysis results were significantly lower in CTCA (1,315.00 EUR vs 180.00 EUR, CA vs CTCA respectively), The Decision Oriented HTA conducted by a multidisciplinary team showed a relevant preference for the new pathway (Picture 2) with a score of 70.23 percent of preference among the Team. Conclusions This new pathway, already proposed for selected pts in ESC guidelines on valve diseases (class IIA, LOE C) could be always adopted in PMR pts with low-to intermediate PTP score undergoing cardiac surgery. It could improve workflow efficiency and reduce LOS, and last but not least, avoid an invasive test, reduce radiation exposure and AKI risk in in a relatively young population The DoHTA provided a more effective and efficient support to the decision-making process. Funding Acknowledgement Type of funding sources: None. Picture 1. Patients characteristics (noCAD-CAD)Picture 2. HTA Score CTCA vs CA

This report describes a case of a young lady who, following extracardiac bypass between ascending and descending aorta for severe aortic coarctation,…, This report describes a case of a young lady who, following extracardiac bypass between ascending and descending aorta for severe aortic coarctation, underwent 4-dimensional flow cardiac magnetic resonance, a technique that, by 3-dimensional flow assessment over time (4-dimensional), allows not only quantification of flows but also wall shear stress. In this case, increased wall shear stress was observed in the conduit's acute angle (kinking) as well as at the distal anastomosis level. The authors postulate that increased wall shear stress could help identify and risk stratify adult congenital heart disease who could develop vascular complications in the future. (Level of Difficulty: Intermediate.), Graphical abstract

OBJECTIVES Arterial stiffness as pulse wave velocity (PWV) predicts cardiovascular events independently of blood pressure (BP). PWV does not distinguish between stiffness in systole and diastole. This cross-sectional study aimed to test the hypothesis that viscous and elastic carotid wall properties differ between systole and diastole, distinguishing effects of ageing, hypertension and T2 diabetes (T2DM). METHODS We examined carotid visco-elasticity in 307 people (180 men), with hypertension alone (n = 69), combined hypertension/T2DM (H-T2DM, n = 99), normotensive (N-T2DM, n = 25) and healthy controls (n = 114). Diameter (D)/pressure (P) waveforms were measured at right /left common carotid arteries, respectively. Local carotid PWV and distensibility in systole and diastole were evaluated by the D2P-loop method, and wall viscosity from hysteresis, the area (HA) within the P--D loop, as a dynamic measure of systolic loading and diastolic unloading. RESULTS Controls' hysteresis fell quadratically with age (R2 = 0.23, P

Background Cardiac magnetic resonance (CMR) is an important diagnostic technique for cardiac amyloidosis (CA). A deep learning (DL) approach to define the likelihood of CA based on automated interpretation of CMR images has never been attempted so far. Methods 187 subjects underwent standard 1.5 T CMR examination (GE-Healthcare, Milwaukee, USA) as part of a diagnostic workup for either unexplained left ventricular hypertrophy or blood dyscrasia with suspected light-chain (AL) amyloidosis. Patients were randomly assigned to 3 subgroups, which were used for training (n=121, 65%), internal validation (n=28, 15%), and model testing (n=38, 20%). LGE images in different orientations (short-axis, 2- and 4-chambers) were selected as the most informative CMR features. A deep convolutional neural network was trained to classify CMR examinations as “amyloidosis” (probability ≥50%) or “no amyloidosis” (probability Results CA was diagnosed in 101 subjects (54%; 45 AL, 56 transthyretin amyloidosis). A model including 2C, 4C and SA LGE images was created. In the test cohort, it allowed to diagnose CA with good diagnostic accuracy (84.2%), and an area under the curve (AUC) of 0.96 (Figure). The precision (positive predictive value), recall score (sensitivity), and F1 score (a measure of test accuracy) were 0.78, 0.94, and 0.86, respectively. An ML algorithm considering all available parameters (LV volumes and function, LGE presence and pattern, early darkening, pericardial and pleural effusion, etc.) displayed a similar diagnostic performance than the DL method (AUC 0.93 vs. 0.96; p=0.45). Conclusions The deep learning technique allowed to create an accurate diagnostic tool for CA based on LGE patterns, which could be easily converted into an online platform for automated image analysis. Funding Acknowledgement Type of funding source: None

Background Non-contrast-enhanced cardiac computed tomography (CT) may provide two measures that are emerging as independent predictors of cardiovascular events: coronary calcium score (CCS) and the volume of epicardial fat, a metabolically and immunologically active tissue surrounding the coronary arteries. The quantification of epicardial fat volume (EFV) is not routinely performed in clinical practice for the long time required for image reconstruction and the intra- and inter-observer variability. Purpose We evaluated if artificial intelligence (AI) might prove a valuable tool to interpret the CT data-set, and to better understand the relative prognostic value of CCS and EFV compared to “traditional” cardiovascular risk factors. Methods The Montignoso HEart and Lung Project is a community-based study carried out in a small town of Northern Tuscany (Italy). Starting from 2009, asymptomatic individuals from the general population underwent a baseline screening including a non-contrast cardiac CT, and were followed-up. For the present study, CCS and EFV were automatically measured from CT scans through a deep learning (DL) strategy based on convolutional neural networks. Because of the low incidence of the primary endpoint (myocardial infarction [MI]), the observed cardiac events were predicted with a random forest model built using a subsampling approach. Results Study participants (n=1528; 48% males, age 40 to 77 years) experienced 47 MI events (3%) over 5.5±1.5 years. CCS and EFV independently predicted this endpoint (p values Conclusions The tools of AI allow to perform an automated analysis of non-contrast-enhanced CT scans, with rapid and accurate measurement of CCS and EFV through a DL approach. In asymptomatic individuals from the general population, these features are more predictive of non-fatal MI than other variables related to the cardiovascular risk, as we can be demonstrated through an application of AI. Figure 1 Funding Acknowledgement Type of funding source: None

Vascular biomarkers are associated with risk burden and are capable to predict the development of future cardiovascular (CV) events; yet, their additive predictive value over and above established risk algorithms seems to be only modest. The present study evaluated the cross-sectional associations between vascular biomarkers, 10-year Framingham risk (FR) and prevalent CV events in a population with a high prevalence of hypertension and diabetes.As many as 681 subjects (419 men, age = 60 ± 10 years, 282 diabetics, 335 hypertensives, mean FR score = 22.5 ± 16.5%) underwent an integrated vascular examination including: radiofrequency-based ultrasound of common carotid artery (cca) to measure intima-media thickness (IMT), inter-adventitial diameter (IAD) and local pulse wave velocity (PWV); applanation tonometry to assess carotid pulse pressure (PP) and augmentation index (AIx); carotid-femoral PWV (cfPWV) measurement. One hundred and thirty-five subjects (19.8%) had history of CV events, and CV events were independently associated with male sex, age, antihypertensive treatment, current smoking, HDL-cholesterol and ccaIAD. In logistic regression model, only ccaIAD was associated with prevalence of CV events after adjustment for FR score, with the OR of 1.71 [1.34-2.19] (P 0.0001) that remained unchanged when ccaIMT was included into the model (OR = 1.76 [1.36-2.27]; P 0.0001). The association between prevalent CV events and ccaIAD was significant (OR of 1.65 [1.24-2.20]; P = 0.0005) also in a subgroup of subjects being at a high 10-year risk of CV disease (N = 330).In a population with a high prevalence of diabetes and hypertension, ccaIAD was the only vascular measure associated with prevalent CV events, independently of FR score.

ObjectivesThe pericardial fat represents a powerful (promising) index which has been seen to correlate with several cardiovascular events. We propose a novel approach to automatically measure it from CT scans and we seek to explore how it is distributed in a study population.MethodsWe studied a population of 1528 patients where 47 (3%) showed a cardiac event. The fat segmentation model was based on a deep neural network to identify the heart and from it, the pericardial fat was extract by threshold. Statistical analysis was finally computed to stratify the population according the quantity of pericardial fat.ResultsThe high segmentation quality was reported with a Dice index (92.5%) and a Pearson coefficient (0.990, p3/m2, p=0.005) with a AUC of 63,44% for discrimination of cardiac event.ConclusionsThe proposed approach reached accurate and fast performance for the evaluation of the pericardial fat making it reliable for a population analysis.

Background and Aims. Atherosclerosis is an inflammatory disease with long-lasting activation of innate immunity and monocytes are the main blood cellular effectors. We aimed to investigate monocyte phenotype (subset fraction and marker expression) at different stages of coronary atherosclerosis in stable coronary artery disease (CAD) patients. Methods. 73 patients with chronic coronary syndrome were evaluated by CT coronary angiography (CTCA) and classified by maximal diameter stenosis of major vessels into three groups of CAD severity: CAD1 (no CAD/minimal CAD, n°=30), CAD2 (non-obstructive CAD, n°=21), and CAD3 (obstructive CAD, n°=22). Flow cytometry for CD14, CD16, and CCR2 was used to quantify Mon1, Mon2, and Mon3 subsets. Expression of CD14, CD16, CD18, CD11b, HLA-DR, CD163, CCR2, CCR5, CX3CR1, and CXCR4 was also measured. Adhesion molecules and cytokines were quantified by ELISA. Results. Total cell count and fraction of Mon2 were higher in CAD2 and CAD3 compared to CAD1. By multivariate regression analysis, Mon2 cell fraction and Mon2 expression of CX3CR1, CD18, and CD16 showed a statistically significant and independent increase, parallel to stenosis severity, from CAD1 to CAD2 and CAD3 groups. A similar trend was also present for CX3CR1 and HLA-DR expressions on total monocyte population. A less calcified plaque composition was associated to a higher Mon2 expression of CD16 and higher TNF-α levels. IL-10 levels were lower at greater stenosis severity, while the IFN-γ/IL-10 ratio, a marker of a systemic pro-inflammatory imbalance, was directly correlated to stenosis degree and number of noncalcified plaques. Conclusions. The results of this study suggest that a specific pattern of inflammation-correlated monocyte marker expression is associated to higher stenosis severity and less calcified lesions in stable CAD. The clinical trial Identifier is NCT04448691.

OBJECTIVES Central pulse pressure (PP) has been suggested a better predictor of cardiovascular risk than brachial PP, and its routine noninvasive assessment can be useful for risk stratification. The present study evaluated the capability of a radiofrequency-based carotid wall tracking to estimate central PP from distension curves, comparing the values of carotid PP as obtained by wall tracking with those provided by applanation tonometry. Furthermore, the associations of carotid PP with intermediate markers of cardiovascular risk, like carotid intima-media thickness (IMT) and left ventricular mass (LVM), were assessed. METHODS Carotid PP was measured by wall tracking and applanation tonometry during the same session in 346 individuals (healthy controls, patients with hypertension and diabetes). IMT was measured in all individuals and LVM was measured in 253. RESULTS Carotid PP values as measured by wall tracking and applanation tonometry were highly correlated [r = 0.87; slope 0.90 (0.85-0.95); P

Significant underexpansion or distortion of valved stents may be associated with altered leaflet function, leading to increased transprosthetic gradients and, possibly, early structural degeneration. We investigated the relationship between a computed tomography measure of the degree of oversizing and the early hemodynamic and clinical outcomes in patients undergoing aortic valve replacement with the Perceval sutureless aortic valve (LivaNova, Saluggia, Italy).The degree of oversizing of the implanted prosthesis was calculated as the ratio between the patients' aortic annulus cross-sectional area and the ex vivo cross-sectional area of the implanted prosthesis in 151 Perceval patients who underwent preoperative cardiac computed tomography. This value was then entered in a multivariate analysis to ascertain its role as a predictor of increased postoperative gradient.The operative mortality was 1.3%. Procedural success, defined as having a normally functioning valve in the proper anatomical location, was achieved in 150 patients (99.3%). The mean transprosthetic gradient was 13.4 ± 5.0 mm Hg, and 23 patients (15.2%) showed a gradient of 20 mm Hg or more at discharge or at the 1-month follow-up. The degree of oversizing of the implanted prosthesis was the most important predictor of increased postoperative gradient (odds ratio, 1.264; 95% confidence interval, 1.147 to 1.394; p0.0001). Interestingly, other relevant factors (patients' body surface area, prosthesis size) were not associated with increased gradients.Our study demonstrates that excessive oversizing should be avoided in Perceval patients and suggests that a different sizing algorithm, possibly based on cardiac computed tomography, should be developed. Further studies are needed to optimize the sizing strategy for the Perceval sutureless valve.

We read with interest the manuscript by Lee et al. [(1)][1], which reports statin use impact on coronary plaque features. Statins increase coronary artery calcification, reducing local inflammation, changing phenotypic plaque composition, and lowering the high-risk plaques, as also observed in

Objectives: It was the aim of this study to assess the pathophysiological, prognostic role of aortic regurgitation (AR) in the ‘mixed pictures' of degenerative aortic valve stenoinsufficiency (ASI) by a multimarker clinical approach. Methods: We enrolled 112 consecutive surgical patients: 19 with pure valve stenosis (PAS), 39 with mild regurgitation, 29 with severe regurgitation, and 25 controls with annulo-ectatic AR. All underwent complete echocardiography, carotid ultrasound and aortic/coronary multislice computed tomography calcium score evaluation. We determined tissue semiquantitative osteopontin, metalloproteinases (MMPs), tissue inhibitors of MMPs (TIMPs) and circulating brain natriuretic peptide. We evaluated major adverse cardiac events and cardiovascular early, long-term mortality after bioprosthetic valve implantation. Results: Tissue calcification, carotid and coronary atherosclerotic disease were prevalent in PAS versus ASI and AR patients. The multislice computed tomography calcium score (Agatston) was comparable between PAS and ASI (PAS 3,507.3 + 2,442.6; mild AR 4,270.7 + 2,213.5; severe AR 3,568.5 + 1,823.4), but much lower in AR (1,247.8 + 2,708.6). In ASI, a plasma/tissue ‘profibrotic' MMP/TIMP balance prevailed, with circulating and echocardiographic indices of myocardial dysfunction. Percentages of major adverse cardiac events and early, long-term mortality were higher in ASI. Conclusions: In ASI, different, still unknown, genetic and dysplastic factors could work synergically with cardiovascular risk factors, determining a much more adverse myocardial and valve remodeling, resulting in worse clinical outcome.

Aims Hybrid imaging provides a non-invasive assessment of coronary anatomy and myocardial perfusion. We sought to evaluate the added clinical value of hybrid imaging in a multi-centre multi-vendor setting. Methods and results Fourteen centres enrolled 252 patients with stable angina and intermediate (20-90%) pre-test likelihood of coronary artery disease (CAD) who underwent myocardial perfusion scintigraphy (MPS), CT coronary angiography (CTCA), and quantitative coronary angiography (QCA) with fractional flow reserve (FFR). Hybrid MPS/CTCA images were obtained by 3D image fusion. Blinded core-lab analyses were performed for CTCA, MPS, QCA and hybrid datasets. Hemodynamically significant CAD was ruled-in non-invasively in the presence of a matched finding (myocardial perfusion defect colocalized with stenosed coronary artery) and ruled-out with normal findings (both CTCA and MPS normal). Overall prevalence of significant CAD on QCA (.70% stenosis or 30-70% with FFR≤0.80) was 37%. Of 1004 pathological myocardial segments on MPS, 246 (25%) were reclassified from their standard coronary distribution to another territory by hybrid imaging. In this respect, in 45/252 (18%) patients, hybrid imaging reassigned an entire perfusion defect to another coronary territory, changing the final diagnosis in 42% of the cases. Hybrid imaging allowed non-invasive CAD rule-out in 41%, and rule-in in 24% of patients, with a negative and positive predictive value of 88% and 87%, respectively. Conclusion In patients at intermediate risk of CAD, hybrid imaging allows non-invasive co-localization of myocardial perfusion defects and subtending coronary arteries, impacting clinical decision-making in almost one every five subjects. -------------------------------------------------------------------------------------------------------------------------------

The aim of our study was to evaluate the role of multidetector-row computed tomography (MDCT) in patients referred for heart valve surgery. We studied the diagnostic performance of CT coronary angiography (CTCA) compared with conventional coronary angiography (CCA) before valve surgery.During a 13-month period, 55 consecutive patients under evaluation for aortic (40/55) or mitral valve (15/55) disease before potential valve replacement underwent CTCA using a 64-detector-row scanner within 2 months of CCA for comparative purposes. All 17 major coronary artery segments were evaluated by one observer and compared with the reference standard. Patient-based, vessel-based and segment-based analyses of the data were performed.Prevalence of significant coronary artery disease, defined as having at least one stenosis/=50% per patient, was 36%. On a patient-based analysis, sensitivity, specificity and positive and negative predictive values were 100%, 91%, 83% and 100%, respectively.The diagnostic accuracy of 64-row CTCA for ruling out the presence of significant coronary stenoses in patients undergoing valve surgery is excellent and allows CTCA to be used as a gatekeeper for invasive CCA in these patients. MDCT is a necessary preoperative examination that provides useful information for identifying potential operative complications of surgical procedures.

Coronary-to-bronchial artery fistulae are the most common found in adulthood and have often been associated with bronchiectasis and other abnormalities of pulmonary parenchyma. In this study we describe an unusual case in which circumflex coronary artery-to-left bronchial artery fistula was associated with the presence of extensive aneurysmatic dilatation of thoracic arteries.

A 66-year-old man, who had a 20-year-old history of mechanical mitral valve replacement for rheumatic valve disease and concomitant epicardial monopolar lead implantation for symptomatic bradycardic atrial fibrillation, was diagnosed with significant increase in pacing threshold. Therefore, a novel endocardial ventricular lead …

Objective: It has been suggested that atherosclerotic mechanisms are involved in the pathogenesis of aortic valve stenosis (AVS). We hypothesised that low levels of the soluble receptor for advanced glycation end-products (sRAGE) might be associated with AVS due to its clinical and pathological associations with atherosclerosis. Methods: We enrolled 75 consecutive patients with severe AVS scheduled for surgical aortic valve replacement and 39 controls without AVS matched for age and gender. Besides the traditional risk factors, we evaluated plasma levels of sRAGE, C-reactive protein (CRP) and IL-6. All patients underwent transthoracic echocardiography, carotid arteries ultrasound scan and coronary angiography. The aortic and coronary calcium by multislice computed tomography was assessed in AVS patients. Results: The values of sRAGE were significantly lower (pConclusion: Since sRAGE could exert antiatherogenic effects by preventing inflammatory responses mediated by cell surface RAGE activation, low levels in AVS patients indicate that ligand-RAGE axis could contribute to pathogenesis of AVS., This article may be used for non-commercial purposes in accordance with CC BY-NC-ND license terms and conditions.

NT-proBNP is associated with several indexes of cardiac and vascular subclinical disease, but its role in screening for asymptomatic cardiovascular involvement is still debated. 810 asymptomatic people without previous cardiovascular disease underwent laboratory assessment with NT-proBNP, echocardiography and CCS and CIMT evaluation by CT and neck echography, respectively. Asymptomatic cardiovascular involvement was defined by one among LVEF 15 and/or LV mass index >115 in men or >95 g/m2 in women, LV end diastolic diameter >55 mm, CCS >400AU or CIMT >0.9 mm. 31%, 10%, 6%, 5%, 25% and 8% of subjects presented LV hypertrophy, E/E' 55 mm, CIMT >0.9 mm and CCS >400 A.U., respectively. Subjects with at least one index of cardiovascular involvement (331, 40%) showed lower hemoglobin, BMI and eCrCl with higher 10 yrs. Framingham risk score and NT-proBNP (61; 34-103 vs. 37; 22-79 ng/L, p

Fig. 2. (A) With anulo-aortic ectasia and severe aortic insufficiency, pulmonary artery valve displasia and severe insufficiency, pulmonary artery ectasia, the patient underwent a surgical intervention. Ascending aorta (Ao) and pulmonary artery trunk (PA) were exposed by median sternotomy. (B) Ascending aorta aneurysm and aortic valve were replaced with bioprosthesis and Dacron conduit. Pulmonary artery trunk was open; another bioprosthesis and Dacron tube were used to replace the native valve and pulmonary trunk. Subsequently, the Dacron graft was sheltered by native pulmonary artery wall.