a 74-year - old man was referred to our hospital for surgical management of aortic root aneurysm found by echocardiography during a preoperative work - up for spinal surgery .
his past medical history revealed hypertension requiring drug therapy and herniated nucleus pulposus at the lumbar area .
trans - thoracic echocardiography revealed an enlarged sinus of valsalva 58 mm in diameter with mild aortic regurgitation ( fig .
1 ) . the left ventricular ejection fraction was 60% without regional wall motion abnormality . a computed tomography ( ct ) scan identified severe aortic sinus dilatation and a coaptation defect in the aortic valve ( fig .
the maximal diameter of the aortic sinus and aortic tubular portion were 60 and 36 mm , respectively .
a coronary angiography showed 80% stenosis of the proximal left anterior descending artery ( lad ) , and total occlusion of the distal left circumflex artery .
thallium single - photon emission computed tomography showed fixed medium - sized moderately decreased perfusion in the basal anterolateral and basal inferolateral wall .
consequently , the patient was scheduled for concomitant aortic root surgery and coronary artery bypass grafting ( cabg ) . at the beginning ,
the patient underwent off - pump cabg ( from the in situ left internal mammary artery to the lad and the saphenous venous graft to the obtuse marginal branch ) . after establishing cardiopulmonary bypass ( cpb ) and aortic clamping (
cardioplegic solution was delivered via the coronary sinus in a retrograde manner and concomitant antegrade infusion via saphenous vein graft to the obtuse marginal graft ) , the ascending aorta was transected above the sinotubular junction and the aortic root was mobilized to the aortic annular level , and the origins of the coronary arteries were mobilized . after measuring the aortic annular size , a 30-mm vascular graft ( gelweave valsalva ; terumo inc . ,
then , six anchoring sutures were made on the lowest level of the annulus , at the commissure and midpoint of each leaflet .
after locating the graft to the patient 's aortic root , a running suture was done together with the transected sinotubular junction and the graft . after confirming adequate coaptation of the aortic leaflets , distal anastomosis between the graft and distal ascending aorta was made .
the patient was extubated on postoperative day 1 and transferred to the general ward on day 2 .
ct and echocardiographic evaluations were performed on postoperative day 4 , and they demonstrated a competent aortic valve with no regurgitation , and a stable aortic graft without any distortion or leakage .
the diameter of the sinus portion of the aorta was measured at 37 mm with excellent coaptation of the aortic valve ( fig .
there was no aortic insufficiency and the stability of the sinus portion of the aorta was maintained with its diameter at 38 mm .
surgical options in the management of aortic root dilatation combined with aortic valve insufficiency include root replacement and valve - sparing root remodeling ( yacoub ) or reimplantation ( david procedure ) [ 1 - 3 ] .
although the latter two techniques have been reported to show excellent results in selected patients , the valve - sparing aortic operations are not widely performed because of the technical challenge requiring a learning curve .
therefore , many centers still prefer the bentall operation rather than the valve - sparing procedures for the aortic insufficiency associated with aortic root aneurysm . in efforts to reduce the procedural complexity of the valve - sparing root surgery , hess et al .  
described a new technique for aortic root remodeling with preservation of the aortic valve , the " florida sleeve " technique . in their follow - up report of 18 patients , clinical and echocardiographic outcomes showed excellent results at mid - term follow - up .
the most important advantage of the florida sleeve technique is the technical simplicity , in that coronary reimplantation is not required and suture burden at the aortic root is greatly decreased without a concern for surgical bleeding .
consequently , the technique can shorten the aortic clamping , cpb , and procedural times .
for these reasons , this technique may be more easily reproducible than conventional valve - sparing aortic operations .
since the enlarged aortic sinus has to be inserted in a smaller graft , anatomical distortion of the aortic root can be created .
distortion between the residual aortic sinus and vascular graft can cause aortic insufficiency and coronary malperfusion , both of which can be fatal .
therefore , extreme caution should be taken while tailoring the artificial graft and anchoring it to the native aortic wall .
the coronary ostium should also be positioned as carefully as possible to prevent kinking or obstruction of the origins of the coronary artery . in the present case
, the surgical risks had been expected to be high because of old age and combined coronary artery disease . in order to shorten the cardiac ischemic and cpb times , we performed off - pump cabg combined with the florida sleeve technique .
fortunately , the surgery was completed successfully without leaving any postoperative complications . in conclusion , we report a case of aortic root aneurysm combined with coronary disease that was successfully treated with concomitant off - pump cabg and the florida sleeve technique . in order to further verify the feasibility and reproducibility of the florida sleeve technique , experiences in a larger number of patients with long - term follow - up
 a 74-year - old man was diagnosed with aortic root aneurysm and two - vessel coronary disease . 
 echocardiographic assessment revealed an enlarged sinus of valsalva 60 mm in diameter with mild aortic regurgitation . 
 florida sleeve repair was performed using a vascular graft combined with coronary artery bypass grafting . 
 the postoperative course was uncomplicated and follow - up echocardiographic evaluations showed an aortic root diameter of 38 mm without aortic insufficiency up to 1 year after surgery . 
CASE REPORT
DISCUSSION