CHB and PPM implantation continue to be common complications of AVR. Preexisting atrioventricular with intrafascicular or intraventricular conduction disease along with cardiac arrest and dual valve surgery are the most important significant predictors of PPM implantation and PPM dependency during follow-up. The selection of valve types did not predict conduction disease requiring PPM implantation.

Aortic valve sparing operations were developed to preserve the native aortic valve during surgery for aortic root aneurysm as well as surgery for ascending aortic aneurysms with associated aortic insufficiency. There are basically two types of aortic valve sparing oprations: remodeling of the aortic root and reimplantation of the aortic valve. These operations have been performed for over two decades and the clinical outcomes have been excellent in experienced hands. Although remodeling of the aortic root is physiologically superior to reimplantation of the aortic valve, long-term follow-up suggests that the latter is associated with lower risk of developing aortic insufficiency. Failure of remodeling of the aortic root is often due to dilatation of the aortic annulus. Thus, this type of aortic valve sparing should be reserved for older patients with ascending aortic aneurysm and normal aortic annulus whereas reimplantation of the aortic valve is more appropriate for young patients with inherited disorders that cause aortic root aneurysms. This article summarizes the published experience with these two operations. They are no longer experimental procedures and should be part of the surgical armamentarium to treat patients with aortic root aneurysm and ascending aortic aneurysms with associated aortic insufficiency.

SummaryBackground:Subclavian Steal Syndrome (SSS) is a fascinating vascular phenomenon in which a steno-occlusive lesion of the proximal subclavian artery causes retrograde flow in the vertebral artery away from the brain stem subsequently causing vertebrobasilar insufficiency. SSS can present with a myriad of neurological and vascular signs and symptoms, but most commonly this phenomenon presents as an incidental finding in an asymptomatic patient.Case Report:Our patient is a 73-year-old female sent to the cardiology clinic for surgical clearance in preparation for an elective cholecystectomy. Shortness of breath was her only complaint. Review of systems was remarkable for left arm pain and blurry vision with repetitive movement. Physical examination noticeable for absence of left radial pulse. Percutaneous angiography demonstrated a totally occulted left subclavian artery with collateral circulation form the vertebrobasilar apparatus.Conclusions:Atypical presentation of this unique entity represents a challenge for physicians who require a high index of suspicion to make the diagnosis. We present an atypical case with radiographical evidence of the steal syndrome, followed by an extensive literature review of the most current diagnostic methods as well as latest recommendations for treatment options and secondary prevention.