Kathryn L. O'Keefe, MD, Stephen D. Cohle, MD, Jeremiah E

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Early Catastrophic Stentless Valve Failure Secondary to Possible Immune Reaction Kathryn L. O'Keefe, MD, Stephen D. Cohle, MD, Jeremiah E. McNamara, BS, Robert L. Hooker, MD The Annals of Thoracic Surgery Volume 91, Issue 4, Pages 1269-1272 (April 2011) DOI: 10.1016/j.athoracsur.2010.09.042 Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Low-power view taken near the xenograft anastamosis. The area between the arrows exhibits extensive granulation tissue with chronic inflammation. (*Denotes xenograft tissue.) The Annals of Thoracic Surgery 2011 91, 1269-1272DOI: (10.1016/j.athoracsur.2010.09.042) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 High-power view of Figure 1, showing granulation tissue and multi-nucleated giant cell (arrow). The Annals of Thoracic Surgery 2011 91, 1269-1272DOI: (10.1016/j.athoracsur.2010.09.042) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Coronary angiography with ostial left main lesion. The Annals of Thoracic Surgery 2011 91, 1269-1272DOI: (10.1016/j.athoracsur.2010.09.042) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Injection of the aortic root demonstrating no coronary flow. The Annals of Thoracic Surgery 2011 91, 1269-1272DOI: (10.1016/j.athoracsur.2010.09.042) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Right sinus of Valsalva and stenosed ostium of the right coronary button (arrow). There is dense neointimal hyperplasia covering much of the xenograft intimal surface (*), extending down into the coronary ostium. The Annals of Thoracic Surgery 2011 91, 1269-1272DOI: (10.1016/j.athoracsur.2010.09.042) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Medium-power view of xenograft (*) and native aorta (**) anastamosis. Arrows denote giant cells surrounded by a dense inflammatory reaction and area of neointimal hyperplasia. The Annals of Thoracic Surgery 2011 91, 1269-1272DOI: (10.1016/j.athoracsur.2010.09.042) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Anastamosis of xenograft and right coronary button. Severe neointimal hyperplasia as a result of inflammation (*). The Annals of Thoracic Surgery 2011 91, 1269-1272DOI: (10.1016/j.athoracsur.2010.09.042) Copyright © 2011 The Society of Thoracic Surgeons Terms and Conditions