Pseudoaneurysm Formation After Medtronic Freestyle Porcine Aortic Bioprosthesis Implantation: A Word of Caution Brian R. Englum, MD, Elizabeth N. Pavlisko,

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Pseudoaneurysm Formation After Medtronic Freestyle Porcine Aortic Bioprosthesis Implantation: A Word of Caution Brian R. Englum, MD, Elizabeth N. Pavlisko, MD, Molly C. Mack, BA, Asvin M. Ganapathi, MD, Matthew A. Schechter, MD, Jennifer M. Hanna, MD, MBA, G. Chad Hughes, MD The Annals of Thoracic Surgery Volume 98, Issue 6, Pages 2061-2067 (December 2014) DOI: 10.1016/j.athoracsur.2014.06.062 Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Computed tomography angiography three-dimensional reconstruction shows a pseudoaneurysm of the left coronary sinus after Medtronic Freestyle Bioprosthesis (Medtronic, Minneapolis, MN) full root replacement and hemiarch repair. The Annals of Thoracic Surgery 2014 98, 2061-2067DOI: (10.1016/j.athoracsur.2014.06.062) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Intraoperative photograph from same patient as Figure 1 demonstrates a large defect (black double arrow) in the left coronary sinus of the porcine root. The left coronary button (black solid arrow) has been displaced significantly away from the annulus toward the main pulmonary artery by the pseudoaneurysm. The Annals of Thoracic Surgery 2014 98, 2061-2067DOI: (10.1016/j.athoracsur.2014.06.062) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 (A) Photomicrograph of mononuclear inflammatory cell infiltrate within the media (arrow) of the porcine root shows positive staining for macrophage marker cluster of differentiation (CD) 68. The lumen is seen to the right and the adventitia to the left (immunoperoxidase stain; original magnification ×4). (B) Macrophages magnified (original magnification ×20). The Annals of Thoracic Surgery 2014 98, 2061-2067DOI: (10.1016/j.athoracsur.2014.06.062) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 The solid line represents the aneurysm/pseudoaneurysm-free survival curve for 36 patients who develop eventual aneurysmal deterioration and the dotted lines represent the 95% confidence intervals. The Annals of Thoracic Surgery 2014 98, 2061-2067DOI: (10.1016/j.athoracsur.2014.06.062) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Intraoperative photograph demonstrates lack of adhesions to stentless porcine root, which is easily separated from surrounding cardiac structures. The Annals of Thoracic Surgery 2014 98, 2061-2067DOI: (10.1016/j.athoracsur.2014.06.062) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 (A) Intraoperative photograph demonstrates another example of the left coronary button displaced away from the annulus by a left porcine sinus pseudoaneurysm and also clearly demonstrates the left coronary button anastomosis (arrow) is intact and that the pseudoaneurysm arises directly from the left porcine sinus wall lateral to the button. (B) Completion of redo root replacement from same patient demonstrating use of the “legs” technique, whereby a short interposition Dacron (DuPont, Wilmington, DE) graft (arrow) is used to anastomose the displaced left coronary button to the Dacron valved conduit. The Annals of Thoracic Surgery 2014 98, 2061-2067DOI: (10.1016/j.athoracsur.2014.06.062) Copyright © 2014 The Society of Thoracic Surgeons Terms and Conditions