Surgical Technique
Surgical aortic valve replacement was carried out in a typical fashion, with minor variation among surgeons. Briefly, cardiopulmonary bypass with right atrial and aortic cannulation, mild hypothermia, and a combination of retrograde and direct ostial cardioplegia was used. Transverse aortotomy with sharp excision of the valve, followed by valve sizing and implantation using interrupted, pledgeted sutures of 2-0 braided, permanent suture was employed. De-airing after closure of aortotomy was carried out with transesophageal echo (TEE) guidance, and TEE used to evaluate valve function after weaning from bypass.