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Sutureless bioprosthetic valves are typically used in patients with a normal sized aortic root and annulus due to concerns that the stent portion of the valve will not be properly anchored. We describe an initial series of sutureless valve implantation in the setting of a diseased aortic root and ascending aortic aneurysm showing that the use of the Perceval valve is feasible in these complex situations.

BACKGROUND: Repair of complete atrioventricular canal (CAVC) is often complicated by atrioventricular valve regurgitation, particularly of the left-sided valve. Understanding the three-dimensional (3D) structure of the atrioventricular canal annulus prior to repair may help to inform optimized repair. However, the 3D shape and movement of the CAVC annulus has yet to be quantified nor has it been rigorously compared to a normal mitral valve annulus. METHODS: The complete annuli of 43 patients with CAVC were modeled in 4 cardiac phases using transthoracic 3D echocardiograms and custom code. The annular structure was compared to the annuli of 20 normal pediatric mitral valves using 3D metrics and statistical shape analysis (Procrustes analysis). RESULTS: The unrepaired CAVC annulus varied in shape significantly throughout the cardiac cycle. Procrustes analysis visually demonstrated that the average normalized CAVC annular shape is more planar than the normal mitral annulus. Quantitatively, the annular height to valve width ratio of the native left CAVC atrioventricular valve was significantly lower than that of a normal mitral valve in all systolic phases(p

Rafflesia zollingeriana Koord. was one of Rafflesia that distributed in Java. Although it has been stated as a different species, R. zollingeriana is sometimes still regarded as a synonym of R. patma. In addition, there are several contradictions in description of R. zollingeriana. Therefore, further investigation is needed. This study attempts presents a full the description of the R. zollingeriana female flower. In this study, a full description of female flower of R. zollingeriana and pictures of important characters such as ramenta, annulus, perigone lobes, disc, processes, bractea are presented. This study is also compared the morphology of R. zollingeriana and R. patma, to confirm their differences in size, opening of diaphragm, blotches and warts pattern on perigone lobes and diaphragm, annulus, and ramenta.

OBJECTIVES Cases in which the left circumflex coronary artery (LCX) runs close to the mitral annulus are considered high risk for LCX injury during mitral surgery. We investigated the anatomical relationship between the LCX and the mitral annulus using 3-dimensional (3D) computed tomography (CT). METHODS We constructed 3D-CT images of the LCX and the mitral annulus before surgery in 122 patients with mitral regurgitation (MR). We classified coronary dominance by 3D-CT and MR aetiologies (degenerative, atrial functional MR, ventricular functional MR and Barlow’s disease) using echocardiography. We detected the point on the mitral annulus closest to the LCX (X point) and measured the minimum distance from the LCX to the mitral annulus (mCAD). We judged whether atrioventricular disjunction existed using CT. We also investigated the factors affecting mCAD and examined how coronary dominance and MR aetiologies relate to the location of the X point. RESULTS The median mCAD was 4.2 mm (range 0.9–11.4 mm). Considering coronary dominance and MR aetiologies, mCAD was shorter in patients with left coronary dominance and Barlow’s disease. The X point mostly existed on the lateral side of the posterior annulus, but it sometimes existed on the medial side. Multiple regression revealed left dominance and mitral annular disjunction as significant factors affecting mCAD (P = 0.01). CONCLUSIONS The anatomical relationship between the LCX and the mitral annulus can be recognized using superimposed 3D-CT images. This approach is useful to avoid LCX injury in mitral valve surgery since the X point varies between patients.

OBJECTIVES This study sought to report the calcification pattern of the mitral valve annulus and its implications for procedural and safety outcomes in transcatheter aortic valve implantation. METHODS Between November 2018 and September 2019, a total of 305 patients had transcatheter aortic valve implants at our institution. The extent of calcification of the mitral valve annulus was analysed, and the impact on safety outcomes was evaluated. RESULTS The prevalence of mitral annular calcification (MAC) was 43%. Calcification of the mitral valve annulus was either less than or at least one-third of the posterior annulus (34% and 32%), the whole posterior annulus (28%) or the extension to the attachment of the anterior leaflets (7%). Severe circumferential MAC revealed moderate paravalvular leaks in 5/8 (63%) patients and was associated with right branch bundle block [odds ratio (OR) 2.01 (0.39–3.06); P = 0.098] and low cardiac output [OR 3.12 (1.39–7.04); P = 0.033]. Subannular calcification at the anterolateral trigonum represented a risk factor for left ventricular outflow tract injury [OR 3.54 (1.38–8.27); P = 0.001] in balloon-expandable valves, associated with relevant rhythm disorders [OR 2.26 (1.17–5.65); P = 0.014] and female gender (7/8, 88%). The 30-day all-cause mortality in circumferential MAC reaching into the anterior annulus (grade IV) compared to patients with less MAC (grade I–III) was 13% vs 2% with a mean valve size of 24.6 vs 25.7 mm. CONCLUSIONS Extensive MAC was associated with moderate paravalvular leaks, with implications for the prosthesis size and survival in transcatheter aortic valve implants. In severe MAC, we recommend implanting oversized self-expandable prostheses, the goal being to reduce the risk of right branch bundle block and paravalvular leaks. Subj collection 122, 125, Mitral annular calcification (MAC) represents a chronic degenerative process in the fibrous base of the mitral valve (MV) that more commonly affects the posterior rather than the anterior annulus [1].

Accumulation of associated petroleum gas in the annulus is one of the negative factors that impede the intensification of mechanized oil production. An increase in annular gas pressure causes growth of bottomhole pressure, a decrease in back pressure to the formation and the inflow of formation fluid. In addition, accumulation of gas in the annulus leads to displacement and a decrease in the liquid level above the submersible pump. Insufficient level of the pump submersion (rod or electric submersible) causes a number of complications in the operation of mechanized production units associated with overheating of the elements in pumping units. Therefore, the development of technologies for optimizing the gas pressure in the annulus is relevant. Method for calculating the intensity of gas pressure increase in the annulus of production wells operated by submersible pumps has been developed. Analytical dependence for calculating the time interval of gas accumulation in the annulus, during which the dynamic level decreases to the pump intake, is obtained. This value can be used to estimate the frequency of gas withdrawal from the annulus using compressors. It has been found that the rate of increase in annular gas pressure in time increases non-linearly with a rise in the gas-oil ratio and a decrease in water cut, and also linearly increases with a rise in liquid flow rate. Influence of the operating (gas-oil ratio) and technological (value of the gas pressure maintained in the annulus) factors on the flow rate of the suspended reciprocating compressor driven by the beam engine, designed for forced withdrawal and redirection of the annular gas into the flow line of the well is analyzed.

Pankiv M. V., Paltov Ye. V., Masna Z. Z., Chelpanova I. V., Kovalska M. Ye. Dynamics of pathomorphological changes in the structural organization of the intervertebral disc at the end of the seventh and fourteenth day of experimental opioid exposure at the ultrastructural level. Journal of Education, Health and Sport. 2021;11(08):427-437. eISSN 2391-8306. DOI http://dx.doi.org/10.12775/JEHS.2021.11.08.048 https://apcz.umk.pl/czasopisma/index.php/JEHS/article/view/JEHS.2021.11.08.048 https://zenodo.org/record/5495940 The journal has had 5 points in Ministry of Science and Higher Education parametric evaluation. § 8. 2) and § 12. 1. 2) 22.02.2019. © The Authors 2021; This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 02.08.2021. Revised: 16.08.2021. Accepted: 31.08.2021. UDK:714.616.711-018.3⁄.4:615.212.7]-076.4 Dynamics of pathomorphological changes in the structural organization of the intervertebral disc at the end of the seventh and fourteenth day of experimental opioid exposure at the ultrastructural level M. V. Pankiv, Ye. V. Paltov, Z. Z. Masna, I. V. Chelpanova, M. Ye. Kovalska Danylo Halytsky Lviv National Medical University Pankiv M.V. Danylo Halytsky Lviv National Medical University, Department of Normal Anatomy, Lviv, Ukraine; https: //orcid.org/0000-0002-3714-2577 Paltov Ye.V. Danylo Halytsky Lviv National Medical University, Department of Normal Anatomy, Lviv, Ukraine; https://orcid.org/0000-0002-2622-4753 Masna Z.Z. Danylo Halytsky Lviv National Medical University, Department of Operative Surgery with Topographic Anatomy, Lviv, Ukraine; https://orcid.org/0000-0003-2057-7061 Chelpanova I.V. Danylo Halytsky Lviv National Medical University, Department of Histology, Cytology and Embryology, Lviv, Ukraine; https://orcid.org/ 0000-0001-5215-814X Kovalska M. Ye. Danylo Halytsky Lviv National Medical University, Department of pathological physiology, Lviv, Ukraine; https://orcid.org/0000-0002-6232-3951 Abstract In general, the modern literature pays attention to the issues of spine pathology and intervertebral discs. A significant percentage of vertebral disorders - scoliosis, osteochondrosis, spinal disc herniation, etc., occur as a result of exposure to various factors and manifest in changes of the intervertebral discs. The aim of our work was to study at the ultrastructural level the features of pathomorphological manifestations in the structural components of the intervertebral disc at the end of the seventh and fourteenth days of experimental opioid exposure. Materials and methods of research. The objects of the study were 32 sexually mature, white, male rats, weighing 92 - 103 g, aged 4.5 months. Animals were injected with nalbupine intramuscularly once daily (at 10-11 a.m.) for 14 days. The initial dose of nalbuphine was 8 mg/kg during the first week, 15 mg/kg during the second week. It created the conditions of chronic opioid exposure. Before sampling, the animals were withdrawn from the experiment using dibutyl ether. Intervertebral discs of rats were used as a material for ultrastructural study. Ultrastructural specimens were prepared according to the accepted methods. The results of the study. As a result of the sampling after 7 days of opioid exposure we found inhomogeneous osmiophilicity and compaction of the nucleus pulposus matrix in which intensively accumulated osmiophilic grains of glycogen proteoglycans, increased the number of collagen fibers, some of them were heterogeneous. It was also noted the development of moderate degenerative changes in some notochondral cells, which was accompanied by increased vacuolization of the cytoplasm by inhomogeneous compaction of the nucleus and an increase of heterochromatin there. After 14 days necrotic changes in the cells of the nucleus pulposus, as well as the destruction of collagen fibers of the annulus fibrosus were found. In particular, an increase in the amount of heterochromatin in the nucleui of notochondral cells, which was accompanied by a decrease in the volume of the nucleui and inhomogeneous swelling of the cytoplasm. Active fibroblasts were often visualized in the annulus fibrosus. Intense osmiophilicity and thickening of collagen fibers of the annulus fibrosus were observed in some areas of the fibrous ring. Focal destruction of collagen fibers was also noted. In the areas of destruction the fibrils of collagen fibers disintegrated into an inhomogeneous fine-grained stratified mass and were located loosely. Conclusions. At the end of the first week we found that the cytoplasmic processes of chondrocytes decreased in volume, shortened, underwent fragmentation and destruction, some of them detached from the surface of the plasmolemma. At the end of the second week signs of opioid exposure progressed and manifested by an increase in the destruction of cytoplasmic processes in chondrocytes. Also focal destruction of collagen fibers was noted. Keywords: opioid; intervertebral disc; rat; seventh and fourteenth day.

Objectives This study aimed to assess whether patients with MAD also have disjunction of the tricuspid annulus. Background Mitral annulus disjunction (MAD) is an abnormal atrial displacement of the mitral annulus. Whether the disjunction extends to the right side of the heart is not known. Methods In a cohort of patients with MAD, we assessed the presence of tricuspid annulus disjunction (TAD) with the use of cardiac magnetic resonance. We explored the associations between TAD and MAD characteristics and the relationship to ventricular arrhythmias (nonsustained/sustained ventricular tachycardias and aborted cardiac arrest). Results We included 84 patients (mean age: 48 ± 16 years; 63% female). We observed TAD in 42 (50%). Patients with TAD were older (age 52 ± 16 years vs. 43 ± 15 years; p = 0.02), had greater circumferential extent of MAD (164 ± 57° vs. 115 ± 58°; p = 0.002), greater maximum longitudinal MAD distance (9.4 ± 2.9 mm vs. 6.2 ± 2.8 mm; p Conclusions We report for the first time the existence of right-sided annulus disjunction as a common finding in patients with MAD. TAD was associated with more severe left-sided annulus disjunction and mitral valve prolapse, but not with ventricular arrhythmias.

Background A small aortic annulus is associated with increased risk of prosthesis–patient mismatch (PPM) after transcatheter aortic valve implantation (TAVI). Whether specific transcatheter heart valve (THV) designs yield superior hemodynamic performance in these small anatomies remains unclear. Methods Data from 8411 consecutive patients treated with TAVI from May 2012 to April 2019 at four German centers were retrospectively evaluated. A small aortic annulus was defined as multidetector computed tomography-derived annulus area 2. TAVI was performed with a balloon-expanding intra-annular (Sapien-3, n = 288), self-expanding intra-annular (Portico, n = 110), self-expanding supra-annular (Evolut, n = 179 and Acurate-Neo, n = 428) and mechanically expanding infra-annular (Lotus, n = 64) THV according to local practice. PPM was defined as indexed effective orifice area ≤ 0.85cm2/m2. Results A small annulus was found in 1069 (12.7%) patients. PPM was detected in 38.3% overall with a higher prevalence after implantation of a balloon-expanding intra-annular or mechanically expanding infra-annular THV compared to self-expanding intra- and supra-annular THV. Multivariable analysis linked self-expanding THV (Evolut: Odds ratio [OR] 0.341, Acurate-Neo: OR 0.436, Portico: OR 0.291), postdilatation (OR 0.648) and age (OR 0.968) to lower rates of PPM, while aortic valve calcification was associated with an increased risk (OR 1.001). Paravalvular regurgitation > mild was more frequent after TAVI with self-expanding THV (p = 0.04). Conclusion In this large contemporary multicenter patient population, a substantial number of patients with a small aortic anatomy were left with PPM after TAVI. Self-expanding supra- and intra-annular THV demonstrated superior hemodynamics in these patients at risk, however at the cost of higher rates of residual paravalvular regurgitation. Graphic abstract

Merkel cell carcinoma is an extremely rare neuroendocrine neoplasm of the external auditory canal (EAC) skin, which requires wide excision and adjuvant radiation due to a high recurrence rate. In this report, we describe a case of Merkel cell carcinoma arising from the EAC which was successfully treated with endoscopic excision. A 32-years-old female patient with a history of papillary thyroid cancer was diagnosed with an EAC tumor incidentally. There was a erythematous papular lesion on the posterior EAC without any evidence of locoregional metastasis. The patient underwent endoscopic tumor resection under general anesthesia, and the final pathologic report confirmed the diagnosis of Merkel cell carcinoma. There was no clinical or radiographic evidence of recurrence or metastasis of Merkel cell tumor for 41 months after surgical resection alone.

Mitral annular calcification (MAC) is a chronic degenerative process involving the fibrous part of the mitral complex, characterized by calcium deposition and loss of valve function. MAC prevalence is 8–10%, but despite this, the clinical significance of MAC is underestimated. Currently, there are reports that complete decalcification leads to improved long-term outcomes in patients with severe MAC. An analysis of the immediate outcomes of mitral valve surgery in patients with severely calcified mitral annulus with decalcification was performed. The calcified annulus fibrosus underwent complete decalcification in all cases. Calcium deposits were removed in a single block, in 6 cases it was reconstructed with a xeno-pericardial patch; in 2 cases the annulus fibrosus was sutured. There were 2 cases of in-hospital mortality, caused by acute heart failure on day 8 in 1 patient and pulmonary embolism on day 30 after operation in the second patient. There were no complications associated with coronary artery injury and left ventricular posterior wall rupture. Experience in the treatment of severe mitral valve calcification with extensive annulus fibrosus decalcification and subsequent reconstruction is possible and gives satisfactory results.

Embryonic muscle forces are necessary for normal vertebral development and spinal curvature, but their involvement in intervertebral disc (IVD) development remains unclear. The aim of the current study was to determine how muscle contractions affect (1) notochord involution and vertebral segmentation, and (2) IVD development including the mechanical properties and morphology, as well as collagen fibre alignment in the annulus fibrosus. Muscular dysgenesis (mdg) mice were harvested at three prenatal stages: at Theiler Stage (TS)22 when notochord involution starts, at TS24 when involution is complete, and at TS27 when the IVD is formed. Vertebral and IVD development were characterised using histology, immunofluorescence, and indentation testing. The results revealed that notochord involution and vertebral segmentation occurred independently of muscle contractions between TS22 and TS24. However, in the absence of muscle contractions, we found vertebral fusion in the cervical region at TS27, along with (i) a displacement of the nucleus pulposus towards the dorsal side, (ii) a disruption of the structural arrangement of collagen in the annulus fibrosus, and (iii) an increase in viscous behaviour of the annulus fibrosus. These findings emphasise the important role of mechanical forces during IVD development, and demonstrate a critical role of muscle loading during development to enable proper annulus fibrosus formation. They further suggest a need for mechanical loading in the creation of fibre-reinforced tissue engineering replacement IVDs as a therapy for IVD degeneration.

Background: Multidetector computed tomography (MDCT) is the gold standard in annulus sizing before transcatheter aortic valve replacement (TAVR). However, MDCT has limited applicability in specific subgroups of patients, such as those with atrial fibrillation and chronic kidney disease. Two-dimensional transesophageal echocardiography (2DTEE) has traditionally been limited to the long-axis measurement of the anteroposterior diameter of the aortic annulus. We describe a new 2DTEE approach for the measurement of the major diameter of the aortic annulus. Methods: Seventy-six patients with symptomatic severe aortic valve stenosis and high surgical risk underwent MDCT and 2DTEE before TAVR. A modified five-chamber view was used to measure the major aortic annulus diameter. This was obtained starting from a mid-esophageal four chamber and retracting the TEE probe up until the left ventricular outflow tract and the left and noncoronary aortic cusps were visualized: major aortic annulus diameter was measured as the distance between their insertion points in systole. Results: Major aortic annulus diameters measured at 2DTEE showed good correlation with MDCT diameter (r = 0.79; P < 0.001) and perimeter (r = 0.87; P < 0.0001). Using factsheet-derived sizing criteria, 2DTEE alone would have allowed accurate sizing in 75% of patients, with 21% of oversizing predominantly with smaller annuli. Conclusions: We describe a new method for 2DTEE measurement of the major aortic annulus diameter; this approach is simple, correlates with MDCT, and allows adequate TAVR sizing in most patients. These findings may help in the assessment of patients with contraindications to or inadequate MDCT images.

OBJECTIVE It is very important to accurately assess the transannular patch (TAP) in the surgical treatment of tetralogy of Fallot (TOF). The pulmonary annulus index (PAI; the actual pulmonary annulus diameter divided by the expected pulmonary annulus diameter), GA ratio (the ratio of pulmonary annulus and aortic annulus), PAAI (the ratio of pulmonary annulus cross-section and aortic annulus cross-section), and pulmonary annulus Z score (PA Z score) were compared. This study aimed to analyze and explore the application value of PAI in predicting the need for TAP in children undergoing TOF repair. METHODS In total, 130 patients who were diagnosed with TOF and underwent TOF repair in Beijing Anzhen Hospital affiliated to Capital Medical University from December 2018 to December 2019 were retrospectively studied. In total, 112 cases were included in this study and 18 cases were excluded, of which 16 cases were aged above 18 years and 2 cases suffered from Down syndrome. They were divided into TAP group and no TAP group; the values of the pulmonary annulus and aortic annulus were measured. GA ratio, PAI, PAAI, the pulmonary annulus Z score, and main pulmonary artery (MPA) Z score were calculated to perform statistical analysis. RESULTS A total of 112 patients were included in the study, aged 4-177 months, with an average of 22.87 ± 30.21 months; 66 males and 46 females; weighing 5.3-29 kg, with an average of 9.94 ± 4.08 kg; three cases died, one case died of sepsis caused by pulmonary infection, one case died of low cardiac output syndrome, and one case died of multiple organ failure. In total, 62 cases (55.8%) did not undergo TAP and 50 cases (44.2%) underwent TAP. The pulmonary annulus Z score, main pulmonary artery Z score, and PAI in the TAP group were smaller than those in the no TAP group (p

This report describes Thismia belumensis Siti-Munirah & Suhaimi-Miloko, a novel species of achlorophyllous herb discovered in the Royal Belum State Park, Peninsular Malaysia. This new species is unlike any previously described species of Thismia. In particular, T. belumensis possesses a unique annulus, which has been expanded and modified into a cucullate (hood-like) structure. This structure covers the apical floral tube and has an opening on one side facing a thickened part of the annulus, and the off-centre floral aperture confers a zygomorphic symmetry to the flower, indicating T. belumensis is more similar to Thismia labiata J.J.Sm. This morphological detail makes this new species distinct from all other described species of Thismia. In this report, we provide descriptions, illustrations, colour plates, and the provisional conservation status of Thismia belumensis.

Background : During repair of tetralogy of fallot (TOF) we modified surgical strategies to preserve the valve and annulus if the pulmonary valve leaflets are pliable and not significantly dysplastic. Methods : Initially, the repair was done from the main pulmonary artery (Group-1, 215 patients) and later through an additional incision in the infundibulum of the right ventricle (Group-2, 73 patients). Recently, we changed the approach to commissurotomy of the fused leaflets by releasing the supra valvar tethering and delamination of the cuspal apparatus till the base to improve the mobility of the cusps and do a controlled commissurotomy (Group-3, 14 patients). With delamination, we could extend the limit of the repair to a z-score of -3.5. Results : There was no hospital mortality; two patients died at home after discharge. A mean follow-up of 42.01 months ± 19.25 is available for 198 patients (92%) for group 1, 16.03 ± 7.45 for group 2, and 4.07 ± 2.09 for group 3. The re-intervention-free survival is 94.4% in group 1. The z value improved from -3 (-3–-2) to -1.2 (-3 – 0), P = 0.001 in Group 1, from -2.8 (-3–-2.4) to -1 (-1.1–-0.7), P = 0.001 in Group 2 and from –3 (-4–-3) to -1, P = 0.001 in Group 3. In all the groups, there was trivial or mild pulmonary regurgitation. Conclusions : During repair of TOF, adequate valve/annulus sparing is possible if the repair is done from both the main pulmonary artery and infundibular incisions using the delamination technique.

Background To assess the effects of proteoglycan-depleted regions of annular disruptions on nerve ingrowth in the injury site in vivo. Methods New Zealand white rabbits (n = 18) received annular injuries at L3/4, L4/5, and L5/6. The experimental discs were randomly assigned to four groups: (a) an annular defect was created; (b) an annular defect implanted with a poly lactic-co-glycolic acid (PLGA)/fibrin/PBS plug; (c) an annular defect implanted with a PLGA/fibrin/chondroitinase ABC (chABC) plug; and (d) an uninjured L2/3 disc (control). Disc degeneration was evaluated by radiography, MRI, histology, and analysis of the proteoglycan (PG) content. Immunohistochemical detection of nerve fibers and chondroitin sulfate (CS) was performed. Results The injured discs produced progressive and reliable disc degeneration. In the defective discs, the lamellated appearance of AF (Annulus fibrosus) was replaced by extensive fibrocartilaginous-like tissue formation outside the injured sites. In contrast, newly formed tissue was distributed along small fissures, and small blood vessels appeared in the outer part of the disrupted area in the PLGA/fibrin/PBS discs. More sprouting nerve fibers grew further into the depleted annulus regions in the PLGA/fibrin/chABC discs than in the control discs and those receiving PLGA/fibrin/PBS. In addition, the innervation scores of the PLGA/fibrin/chABC discs were significantly increased compared with those of the PLGA/fibrin/PBS discs and defected discs. Conclusion ChABC-based PLGA/fibrin gel showed promising results by achieving biointegration with native annulus tissue and providing a local source for the sustained release of active chABC. Disc-derived PG-mediated inhibition of nerve and blood vessel ingrowth was abrogated by chABC enzymatic deglycosylation in an annular-injured rabbit disc degeneration model.

OBJECTIVES Tissue reaction to transcatheter mitral valve replacement in the mitral annulus remains to be elucidated. METHODS Trileaflet porcine pericardial valves were sewn onto self-expanding d-shaped nitinol stents, which were delivered transapically and in an off-pump fashion into the mitral position of 10 pigs. After at least 4 weeks of follow-up, gross pathological assessment and histological examination were performed. The specimens were stained with Movat’s pentachrome, Elastica-van-Gieson and von Kossa staining. The leucocytes, B cells, T cells or macrophages were detected by specific immunohistochemical staining. RESULTS Proper stent positioning in the mitral annulus was achieved in 9/10 animals. Nine of 10 animals survived the desired observation period. In all but one, the mitral valve stent was well integrated into the left atrium and perpendicularly embedded into the annulus by 85 ± 24%. One animal had minor fractures in the nitinol struts and another animal showed tearing of 1 of 4 tethers. Histological examination demonstrated no major tissue reaction with the nitninol struts but well-preserved overall structures around the mitral annulus in 8/9 cases. CONCLUSIONS This is the first report demonstrating good in-growth of transcatheter-delivered anatomically shaped mitral valve stents after at least 4 weeks of follow-up. Histological examination demonstrated progressive healing and neointimalization.

Background: Mitral valve surgery can be challenging for patients with mitral annular calcification (MAC). The prevalence of MAC in patients who undergo mitral valve replacement is 19.9%. The treatment options for MAC include complete decalcification and annular reconstruction with valve repair/replacement or performing a surgical valve repair or replacement without decalcification, accepting the risk of paravalvular leak. We describe three cases of mitral valve prolapse with posterior annular calcification, which were repaired using a unique technique that does not require decalcification. Case reports: The mitral annular calcification was heavy and involved most of the posterior annulus just sparing the commissures in all the three cases. Leaflet prolapse was dealt with by using neochordae, closing any clefts, and leaflet plication. Since the MAC ring was not complete and there was chance of further dilatation of the annulus, a partial annuloplasty was done using a PTFE felt (cut as strip). There was trivial to no mitral regurgitation with this technique in the immediate postoperative and five-year follow-up period echocardiography in all the three cases. Conclusion: This technique can benefit the major subset of pure mitral valve regurgitant lesions associated with MAC, which is limited to the posterior annulus.

OBJECTIVE The aim was to identify the source of cells within the center of the abnormal fibrocartilage tissue of the degenerative intervertebral disc after injury. DESIGN Cross-breeding of mice with an inducible type II promoter collagen construct (Col2CreER) to Rosa26-TdTomato mice has been shown to result in Cre-recombinase activity and Tomato expression in inner annulus fibrosus cells after tamoxifen injection. To investigate the role of the inner annulus fibrosus in the intervertebral disc injury response, tail intervertebral discs of Col2CreER/tdTomato mice were punctured with a needle and examined 1-4 wks after injury. N-cadherin was examined by immunostaining. RESULTS After the injury, the fibrocartilage in the degenerative intervertebral disc consisted of residual diseased nucleus pulposus cells and encroaching inner annulus fibrosus cells. The residual nucleus pulposus cells had lost their epithelial cell-like morphology and instead became oval shaped, with reduced adhesion to neighboring nucleus pulposus cells. This change in cellular morphology coincided with a loss of N-cadherin, which contributes to maintenance of healthy nucleus pulposus cell morphology. As expected, injured tail intervertebral discs showed reduced compressive properties as determined by biomechanical assessments. CONCLUSIONS The cellular composition of the degenerative intervertebral disc has been defined here, which is an important step in developing future treatments.

Purpose Disc herniations are usually treated by decompression of the spinal nerves via a partial nucleotomy. As a consequence of reduced disc height (DH), reduced intradiscal pressure (IDP) and increased range of motion (ROM), accelerated degeneration may occur. Nucleus replacement implants are intended to restore those values, but are associated with the risk of extrusion. Methods In six fresh frozen lumbar spinal segments (L2-3/L3-4/L4-5/L5-S1, age median 64.5 years (57–72), Pfirrmann grade 2–3), a prolapse was provoked through a box defect (6 × 10 mm) in the annulus. The herniated nucleus material was removed and replaced by a novel collagen-based nucleus implant. An annulus closure device sealed the defect. ROM, neutral zone (NZ) and IDP were measured in the (1) intact and (2) defect state, (3) postoperatively and (4) after cyclic loading (n = 100,000 cycles) applying pure moments (± 7.5 Nm) in flexion–extension, lateral bending and axial rotation. Additionally, the change in DH was determined. Extrusion of implants or nucleus material was evaluated macroscopically. Results In all specimens, a prolapse could be provoked which decreased DH. Subsequent nucleotomy changed ROM/NZ and IDP considerably. Initial values could be restored by the implantation. Macroscopically, none of the implants nor nucleus material did migrate after cyclic loading. Conclusions In this study, a prolapse followed by a nucleotomy resulted in a biomechanical destabilisation. Implantation of the nucleus replacement combined with an annulus closure restored the intact condition without showing signs of extrusion nor migration after cyclic loading. Hence, nucleus replacements could have a new chance in combination with annulus closure devices.

This paper deals with the bioconvection of microploar fluid in an annulus containing microorganisms in which the outer cylinder is rotating. A mathematical model, with a fully coupled system of partial differential equations presenting the velocity, total mass, momentum, thermal energy, mass diffusion, and motile microorganisms is presented. A suitable transformations is adopted to reduce the governing non-linear governing to a set of non-linear ordinary differential equations and then linearized by means of successive linearization method. The resulign linearized equaions are solved using Chebyshev collocation method. The illustrating analysis of influences of the various flow governing physical parameters such as the micropolar coupling number, the bioconvection Schmidt-number, Prandtl number, Lewis number and bioconvection Peclet-number and Reynolds number on motile microorganism distribution are studied and is presented. Also, the density number of motile microorganism is examined for various governing parameters along with slip parameter of motile microorganism.

Current tissue engineering strategies through scaffold-based approaches fail to recapitulate the complex three-dimensional microarchitecture and biochemical composition of the native Annulus Fibrosus tissue. Considering limited access to healthy annulus fibrosus cells from patients, this study explored the potential of bone marrow stromal cells (BMSC) to fabricate a scaffold-free multilamellar annulus fibrosus-like tissue by integrating micropatterning technologies into multi-layered BMSC engineering. BMSC sheet with cells and collagen fibres aligned at ~30° with respect to their longitudinal dimension were developed on a microgroove-patterned PDMS substrate. Two sheets were then stacked together in alternating directions to form an angle-ply bilayer tissue, which was rolled up, sliced to form a multi-lamellar angle-ply tissue and cultured in a customized medium. The development of the annulus fibrosus-like tissue was further characterized by histological, gene expression and microscopic and mechanical analysis. We demonstrated that the engineered annulus fibrosus-like tissue with aligned BMSC sheet showed parallel collagen fibrils, biochemical composition and microstructures that resemble the native disk. Furthermore, aligned cell sheet showed enhanced expression of annulus fibrosus associated extracellular matrix markers and higher mechanical strength than that of the non-aligned cell sheet. The present study provides a new strategy in annulus fibrosus tissue engineering methodology to develop a scaffold-free annulus fibrosus-like tissue that resembles the microarchitecture and biochemical attributes of a native tissue. This can potentially lead to a promising avenue for advancing BMSC-mediated annulus fibrosus regeneration towards future clinical applications.

Golden Shiner Notemigonus crysoleucas is found in many lakes and ponds across the southeastern United States. Though it is a common species, otolith age validation methods have not been published. The objective of this study was to confirm annulus formation in lapillar otoliths of Golden Shiners collected monthly from September 2015 through August 2016 in Lake Jackson, Florida (Leon County). We collected at least 12 individuals each month of similar length (168–249 mm; presumably of the same cohort) to document annulus formation throughout the year. We sacrificed a total of 177 individuals from the 2013 year class, and we used their lapillar otoliths for marginal incremental analysis to calculate an index of completion and validate annulus formation. The monthly index of completion was highest from January through March and lowest in May and June, indicating that annuli were deposited once per year and confirming that lapillar otoliths are a valid age estimation structure for Golden Shiners.

Background: This disease of heart is named after Fallot who correlated the pathologic and clinical manifestations of this cardiac malformation in his description of L'anatomie pathologique de la maladie bleu by 1888. He was the first to appreciate the complex of this cardiac malformation which he coined a “Tetralogy” consisting of pulmonary stenosis, Ventricular Septal Defect (VSD), dextroposition of the aorta, and RV hypertrophy. Aim of Study: To collect, review and analyze the data of Fallot patient undergoing total repair and to compare the early outcome of Fallot repair with preservation of the annulus versus transannular patch. Patients and Methods: This is a retrospective analysis which conducted at the Cardiothoracic Surgery at Ain Shams University Hospital from the first of January 2014 till the end of December 2016. Results: The majority of patients with TOF have a bicuspid or tricuspid PV, which is the most favorable surgical anatomy for preserving the PV, independent of the presence or degree of leaflet dysplasia. We believe that the preservation of the PV annulus and PV function during early repair of TOF, by combining intraoperative PV dilation and additional surgical procedures, can be extended to the majority of patients with classic TOF. The recent introduction of more-complex PV plasty techniques allowed us to further extend the applicability of PV-preservation techniques. Conclusion: The optimal repair technique would be there-fore, dictated to the anatomical substrate of the lesion, the patient's age, prevailing surgical practice and other patient preoperative characteristics which all should be taken into relevance in an effort to improve patient outcomes.

For next generation tissue-engineered constructs and regenerative medicine to succeed clinically, the basic biology and extracellular matrix composition of tissues that these repair techniques seek to restore have to be fully determined. Using the latest reagents coupled with tried and tested methodologies, we continue to uncover previously undetected structural proteins in mature intervertebral disc. In this study we show that the “embryonic” type IIA procollagen isoform (containing a cysteine-rich amino propeptide) was biochemically detectable in the annulus fibrosus of both calf and mature steer intervertebral discs, but not in the nucleus pulposus where the type IIB isoform was predominantly localized. Specifically, the triple-helical type IIA procollagen isoform immunolocalized in the outer margins of the inner annulus fibrosus. Triple helical processed type II collagen exclusively localized within the interlamellae regions and with type IIA procollagen in the intra-lamellae regions. Mass spectrometry of the α1 (II) collagen chains from the region where type IIA procollagen localized showed high 3-hydroxylation of Proline-944, a post-translational modification that is correlated with thin collagen fibrils as in the nucleus pulposus. The findings implicate small diameter fibrils of type IIA procollagen in select regions of the annulus fibrosus where it likely contributes to the organization of collagen bundles and structural properties within the type I-type II collagen transition zone.

Even though the tricuspid valve is no longer “forgotten”, it still remains poorly understood. In this review, we focus on some controversial and still unclear aspects of tricuspid anatomy as illustrated by noninvasive imaging techniques. In particular, we discuss the anatomical architecture of the so-called tricuspid annulus with its two components (i.e., the mural and the septal annulus), emphasizing the absence of any fibrous “ring” around the right atrioventricular junction. Then we discussed the extreme variability in number and size of leaflets (from two to six), highlighting the peculiarities of the septal leaflet as part of the septal atrioventricular junction (crux cordis). Finally, we describe the similarities and differences between the tricuspid and mitral valve, suggesting a novel terminology for tricuspid leaflets.

We present a case of pneumomediastinum associated with an endplate fracture adjacent to a vacuum disc. Pneumomediastinum from trauma can be due to damage to the lungs, airway, or esophagus. In this case, we present a unique complication of the vacuum disc phenomenon in which vertebral injury at the site of a vacuum disc releases gas bubbles into the mediastinum. We believe that compressive forces from the trauma produced a disruption of the annulus fibrosis and forced gas previously sequestered in the intervertebral disc space to escape into the mediastinum.

We describe a new species of Rhinella from montane forests between 1788 and 2305 m a.s.l. in the Departamentos Amazonas and San Martín, Peru. We tentatively assign the new species to the Rhinella festae species Group based on morphological similarities with its other 19 members. It is characterised by large size (maximum SVL 91.6 mm in females), a pointed and protruding snout that is posteroventrally inclined, absence of a visible tympanic annulus and tympanic membrane, long parotoid glands in contact with upper eyelid, presence of a dorsolateral row of enlarged tubercles, outer dorsolateral tarsus surface with a subconical ridge of fused tubercles, and absence of subgular vocal sac and vocal slits in males. One specimen from Departamento Amazonas tested positive for Batrachochytrium dendrobatidis.

International audience; The interface between the intervertebral disc and the vertebral body is important to the discs’ biomechanics and physiology, and is widely implicated in its pathology. This study aimed to explore biochemically and structurally the bony endplate, cartilage endplate and intervertebral disc, below the nucleus and below the annulus in healthy bovine tails. Multiphoton imaging and spontaneous Raman spectroscopy were employed. Raman spectroscopy provided relative quantification of mineral and matrix components across the vertebral endplate and its adjacent areas with microscopic spatial resolution. Microscopy utilising second-harmonic generation (SHG) and two-photon fluorescence (TPF) allowed for the structural identification of distinct endplate regions. The cartilage endplate was revealed as structurally distinct from both the bone and disc, supporting its biomechanical function as a transition zone between the soft and hard tissue components. The collagen fibres were continuous across the tidemark which defines the interface between the mineralised and non-mineralised regions of the endplate. Raman spectroscopy revealed gradients in phosphate and carbonate content through the depth of the endplate and also differences beneath the nucleus and annulus consistent with a higher rate of remodelling under the annulus.

Right‐sided infected endocarditis (IE) is very rare, especially PVIE accounts for 1.6%‐2.7% % of all IE cases. We successfully treated a IE of pulmonary valve patient with bioprosthetic valve and annulus enlargement with pericardial patch.

A calcified amorphous tumor (CAT) is a rare, non-neoplastic cardiac mass frequently located in cardiac chambers, especially the mitral valve or annulus. Here, we report an exceedingly rare case of CAT as an atypical mobile mass in the ascending aorta in a 62-year-old man who was on hemodialysis for 11 years. The CAT grew rapidly within 3 months. We resected the mass, and he was discharged with no complications. This report shows that the CAT can grow rapidly, even in the aorta, and provides important information on the progression of this rare disease and its clinical features.

Objective: Intervertebral disc herniations with wide annulus defects have been stabilised with the posterior dynamic stabilisation method following microlumbar discectomy. Materials and Methods: The injured anulus is divided into two groups; a) the anulus weakens without losing its integrity and b) tearing all layers of the annulus. Results: In a one year control, it was found that the annulus was adequately repaired in both groups. The repair process in the full-layer tear occurred with connective tissue. There was no recurrence. Conclusion: Posterior transpedicular stabilisation is an effective treatment method for annulus repair.

Transcatheter repair systems are becoming increasingly popular as a potential solution for high-risk and inoperable patients with mitral regurgitation. The cardioband (Edwards Lifesciences, Irvine, California) is a transcatheter direct annuloplasty device, based on the concept of an undersized ring annuloplasty. We report a case of minimally invasive surgical explantation of a failed cardioband device 21 months after its implantation. Intraoperatively, it was found that three anchors of the cardioband device were detached from the posterior annulus at P2. In this report, a "cut and unscrew" technique with some tips and tricks is presented for the removal of the device.

Tympanic membrane perforation is a common pathology encountered by an ear surgeon. The surgical repair and reconstruction of these defects of the drumhead has been addressed by two popular techniques - viz., the common and popular underlay technique and the lesser known interlay technique. In underlay technique of tympanoplasty, mucosalization of the graft many a times leads to continuous or intermittent discharging ear despite an intact tympanic membrane - and this has been called the “Red Drum Conundrum”. Total annulus excision (TAE) implies that the entire annulus is removed along with remnant of tympanic membrane during the procedure to surgically reconstruct a diseased membrane. TAE is an essential step of a broader technique of interlay technique. This novel Interlay technique’s basic premise is that - Once the graft is placed, there must not be any mucous membrane lateral to the graft and no epithelium medial to the graft. One very important benefit of TAE is neovascularization around the graft. Total annular excision is a new emerging technique of tympanoplasty as it gives patient a three layered physiologically and anatomically near natural membrane with good vibratory function without possibility of weeping membrane or granular myringitis. Key Words: Annulus, tympanoplasty, interlay, middle ear, tympanic membrane, Myringoplasty

In fibrous tissues, prestressed boundary constraints at bone interfaces instil residual strain throughout the tissue, even when unloaded. For example, internal swelling pressures in the central nucleus pulposus of the intervertebral disc generate prestrain in the outer annulus fibrosus. With injury and depressurization, these residual strains are lost. Here we show that the loss of residual strains in the intervertebral disc alters the microenvironment and instigates aberrant tissue remodelling and the adoption of atypical cellular phenotypes. By using puncture surgery of the annulus fibrosus in rabbits, ex vivo puncture experiments and electrospun nanofibrous scaffolds recapitulating these evolving boundary constraints, we show that the loss of residual strain promotes short-term apoptosis and the emergence of a fibrotic phenotype. We also show that local fibre organization and cellular contractility mediate this process and that the aberrant cellular changes could be abrogated by targeting the cell-mechanosensing machinery with small molecules. Our findings indicate that injury to dense connective tissues under prestrain alters boundary constraints and residual strain; this leads to aberrant mechanosensing, which in turn promotes disease progression.

The genus Macrolepiota (Agaricales, Basidiomycota) is easy to recognize at the genus level because of big, fleshy basidiocarps with squamules covering the pileus; a single or double annulus; and big, thick-walled basidiospores with a germ pore. However, morphological identification is often unreliable in Macrolepiota due to similar morphological features among species. Due to the uncertainty of previous morphological identification in the genus Macrolepiota, it is necessary to re-examine Korean Macrolepiota using molecular data. We re-examined 34 Macrolepiota specimens collected from 2012 to 2018 in Korea using a reverse taxonomic approach, whereby species identification was first done based on the internal transcribed spacer (ITS) region analysis, followed by morphological confirmation. We identified the presence of four species: M. detersa, M. mastoidea, M. procera, and M. umbonata sp. nov. Two species (M. detersa and M. mastoidea) were previously unrecorded from Korea and M. umbonata is a new species. Detailed descriptions of all four species and taxonomic key are provided in this study. Macrolepiota procera and M. umbonata are distributed through the country, but M. detersa and M. mastoidea are distributed only in limited areas. According to our results, the combination of ITS locus and morphology proved to be a robust approach to evaluate the taxonomic status of Macrolepiota species in Korea. Additional surveys are needed to verify the species diversity and clarify their geographic distribution.

Severe mitral annular calcification is not an uncommon occurrence in the elderly and up to now, this has often precluded surgical replacement of the mitral valve. Initial attempts at percutaneous placement of transcatheter aortic valves in the calcified mitral annulus, has not been very successful due to obstruction of the left ventricular outflow tract. We describe a surgical approach where the anterior mitral valve leaflet was resected and a balloon expandable transcatheter aortic valve then deployed within the calcified annulus. The benefits of this technique over a fully percutaneous approach is discussed.

The microdiscectomy used for the treatment of intervertebral disc disorders leaves an open incision in the annulus fibrosus that must be sealed to avoid re-herniation and other subsequent degenerations. In this study, we developed an injectable and in situ polymerizable polyurethane adhesive as a long-term post-surgical annulus fibrosus repair strategy. It was investigated the chemical structure of the urethane-based adhesive and its physico-chemical, viscoelastic, kinetic, and in vitro cytotoxic properties. The adhesive formulated from the polycarbonate diol with the highest molar mass was the one that exhibited a compressive behavior closest to the intervertebral disc outer region, and therefore, the most suitable for restoration. This adhesive showed 18-day stability under moisture and required a preparation time of 10 h at 60°C before use. The material also adhered covalently to gelatin (without catalyst or initiator) and positively impacted cell proliferation after its polymerization, which are essential requirements for clinical translation. These findings confirmed the ability of the polyurethane adhesive to act as an annulus fibrosus sealant, although further improvements in its formulation are necessary.

Focal defects in the annulus fibrosus (AF) of the intervertebral disc (IVD) arising from herniation have detrimental impacts on the IVD's mechanical function. Thus, biomimetic-based repair strategies must restore the mechanical integrity of the AF to help support and restore native spinal loading and motion. Accordingly, an annulus fibrosus repair patch (AFRP); a collagen-based multi-laminate scaffold with an angle-ply architecture has been previously developed, which demonstrates similar mechanical properties to native outer AF (oAF). To further enhance the mimetic nature of the AFRP, interlamellar (ILM) glycosaminoglycan (GAG) was incorporated into the scaffolds. The ability of the scaffolds to withstand simulated impact loading and resist herniation of native IVD tissue while contributing to the restoration of spinal kinematics were assessed separately. The results demonstrate that incorporation of a GAG-based ILM significantly increased (p 0.001) the impact strength of the AFRP (2.57 ± 0.04 MPa) compared to scaffolds without (1.51 ± 0.13 MPa). Additionally, repair of injured functional spinal units (FSUs) with an AFRP in combination with sequestering native NP tissue and a full-thickness AF tissue plug enabled the restoration of creep displacement (p = 0.134), short-term viscous damping coefficient (p = 0.538), the long-term viscous (p = 0.058) and elastic (p = 0.751) damping coefficients, axial neutral zone (p = 0.908), and axial range of motion (p = 0.476) to an intact state. Lastly, the AFRP scaffolds were able to prevent native IVD tissue herniation upon application of supraphysiologic loads (5.28 ± 1.24 MPa). Together, these results suggest that the AFRP has the strength to sequester native NP and AF tissue and/or implants, and thus, can be used in a composite repair strategy for IVDs with focal annular defects thereby assisting in the restoration of spinal kinematics.

Field experiment was conducted in the non-heated plastic house at Al-Mussaib Technical College in the autumn season 2016 to study the Response of sweet pepper Capsicum annuum L. (Qurtuba cultivar) to foliar spraying with two types of foliar commercial Potassium fertilizers in loamy sand soil. To study the effect of four levels of potassium fertilizer and micronutrients (0, 4, 6, 8 ml.L-1), four levels of potassium fertilizer and Sulfur KTS (0, 2, 4, 6 ml.L-1) and their interaction on some vegetative and flowering growth indicators, yield and its components. The experiment was designed according to the Randomized Complete Block Design (RCBD) and the averages were compared with the least significant difference (LSD), with a significant level of 5%. The result indicated to the excelling of the spraying treatment with potassium and micronutrient (8 ml.L-1) by giving it a significant level in increasing the averages of plant height, number of branches, leaf area, dry weight for total vegetative, number of flowers in plant, percentage of fruit set, the leaves content of (chlorophyll, nitrogen, Phosphorus and potassium), early and total yield, the content of vitamin C, and percentage of Total Soluble Solids, with an increasing percentage of (19.47, 29.54, 16.68, 30.01, 11.26, 24.09, 38.16, 24.36, 16.67, 34.00, 21.87, 20.27, 50.46, 45.96, 39.33, 70.85%), respectively, compared to control treatment. Which is the same behavior as spraying treatment with potassium fertilizer and sulfur, where treatment (4 ml.L-1) was excelled in all the above traits, where the percentages of increasing were (31.72, 53.53, 49.88, 15.82, 14.84, 24.54, 19.79, 36.73, 21.05, 47.55, 24.53, 19.07, 49.43, 48.01, 30.29, 36.56%), respectively, compared to the control treatment. As for interaction treatments, it has showed excelling the spraying treatment with a mixture of (8 ml. L-1 + 4 ml. L-1) by giving it the highest values for all the above traits amounted of (109.5 cm, 6.4 branches, 25.3 dm2, 132.7 g, 62.7 flower, 43.9% 2.22%, 0.75%, 2.55%, 34.6 fruits, 108.3 g, 0.790 kg. plant-1, 3.747 kg. plant-1, 69.2 mg.100 ml-1, 10.4%), respectively.

Background: Catheter-tissue contact force is an important factor influencing lesion size and efficacy and thereby potential for arrhythmia recurrence following accessory pathway (AP) radiofrequency ablation. We aim to evaluate adequacy and perception of catheter contact on the tricuspid and mitral annuli. Methods: Data were collected from 42 patients undergoing catheter ablation. Operators were blinded to contact force information and reported perceived contact (poor, moderate, or good) while positioning the catheter at four tricuspid annular sites (12, 9, 6 and 4 o'clock positions; abbreviated as TA12, TA9, TA6 and TA4) and three mitral annular sites (3, 5 and 7 o'clock positions; abbreviated as MA3, MA5 and MA7) through long vascular sheaths. Results: The highest and lowest mean contact forces were obtained at MA7 (13.3 ± 1.7 g) and TA12 (3.6 g ± 1.3 g) respectively. Mean contact force on tricuspid annulus (6.1 g ± 0.9 g) was lower than mitral annulus (9.8 ± 0.9 g) locations (p = 0.0036), with greater proportion of sites with

Background Sinus of Valsalva aneurysm (SVA) is relatively rare and commonly reported as a congenital anomaly. It is usually found in a single Valsalva sinus protruding into another cardiac chamber and is termed as intracardiac SVA. The aneurysm usually originates from the Valsalva sinus itself, and an orifice of the aneurysm is observed surrounded by the aortic wall. Thus, extracardiac multiple SVAs originating from the orifices with partial aortic wall defects are extremely rare. We report a very rare case of unruptured extracardiac SVAs in both left and right coronary sinuses originating from the aortic annulus. Case presentation A 76-year-old Japanese male was diagnosed with enlarged Valsalva sinuses by transthoracic echocardiography during follow-up for peripheral artery disease. Five years after careful observation, gradual SVA enlargement and moderate aortic insufficiency were observed. He underwent modified Bentall’s procedure, with an uneventful postoperative course. Intraoperatively, SVAs were found in the left lateral half of the left and right coronary sinuses of Valsalva on both sides of the commissure between the left and right coronary cusps. Aortic walls were missing at the SVA floor adjacent to the aortic annulus. Pathological examination revealed only mild atherosclerotic changes of the aortic wall near the SVAs. The cause was estimated as either focal degeneration of the sinuses of Valsalva just above the aortic annulus or congenital anomaly, or combination of both of them. Conclusions We report on the case of unruptured extracardiac multiple SVAs missing aortic orifice just above the annulus. No similar case presentation was found in the literature. In this paper, we present details of operative findings and procedures, which will aid in procedure selection.

Transcatheter aortic valve replacement (TAVR) has become a treatment alternative for patients with severe aortic stenosis. As broadened indications and increasing clinical demand, the population referred for TAVR will become much more heterogeneous and anatomically challenging. Herein, we report an 88-year-old man with severe aortic stenosis and huge aortic annulus (annular area 831.8 mm2) successfully treated with overexpansion of a 29 mm Edwards SAPIEN 3 transcatheter heart valve.

BACKGROUND The details and consequences of a small aortic annulus among transcatheter aortic valve replacement (TAVR) patients remain uncertain. This study investigated the short-term outcomes in patients with small annular size and compared the 30-day outcome between intra- and supra-annular devices, with similar outer casing diameter in this subgroup.Methods and Results:Cases registered in the Japanese national TAVR registry between August 2013 and December 2017 were analyzed. Among a total of 5,870 registered patients, 647 (11.0%) had small annulus (area ≤314 mm2) measured by multi-detector computed tomography. Patients with a small annulus had a significantly smaller indexed effective orifice area (iEOA, 1.10 cm2/m2[0.92-1.35] vs. 1.16 cm2/m2[0.96-1.39], P

In patients with a small aortic annulus, the clinical benefits of aortic valve replacement depend on avoidance of patient-prosthesis mismatch as it is associated with reduced overall survival. Aortic root widening or enlargement is a useful technique to implant larger valve prosthesis to prevent patient-prosthesis mismatch. Posterior annular enlargement is the commonest technique used for aortic root enlargement. Consistent enlargement of the aortic root requires more extensive procedures like Manouguian or Konno-Rastan techniques. The patients commonly selected are younger patients with good life expectancy. However, caution is advised in applying this procedure in elderly patients, patients with heavily calcified annulus and when performing concomitant procedures. There is no definitive conclusion on the best material to use for the reconstruction of aortic annulus and aorta in aortic root enlargement procedures.