Late survival was excellent, with a low incidence of reoperations in both groups of patients. The era of repair has a big influence on total and operative mortality, but has only a small impact on late mortality. Ongoing analysis of follow-up will possibly reveal subsequent changes with time.

Nitroglycerin may have detrimental effects evidenced by the increase in lipid peroxidation, which implied peroxynitrite formation. However, the overall effect of nitroglycerin was cardioprotective. Although the exact mechanism is yet to be clarified, the superb cardioprotective effect of nitroglycerin overwhelms the exaggeration of lipid peroxidation.

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Total replacement of the aortic root in patients with anomalous origin of the coronary arteries has not been reported. We report a 63-year-old male with anomalous origin of the right coronary artery from the left sinus of Valsalva in whom aortic root replacement was performed to correct a 60mm aortic root aneurysm and a grade 4/4 aortic regurgitation. In this operation with a composite graft (a 24mm Gelseal graft with a 23mm St. Jude Medical prosthesis), modified reconstruction of the coronary arteries was necessary not only because both coronary ostia were in close proximity but also because the proximal portion of the right coronary artery was intramural. We used a modification of Piehler's technique in which both coronary ostia were simultaneously anastomosed to a beveled 10mm Gelseal graft. In this anastomosis, a small piece of the autologous pericardium was interposed between the graft and the aortic wall surrounding the ostium of the right coronary artery to protect the intramural artery from injury. This modification in reconstructing the coronary arteries was technically easy and effective in the special setting of the anomalous origin of the coronary arteries.