a 65-year - old man without any symptoms was referred for an operation on the aortic root and ascending aortic aneurysm .
he had undergone a total correction of tetralogy of fallot ( tof ) and aortic valve replacement with mechanical valvular prosthesis 22 years earlier ( in 1987 , at the age of forty - three ) . in august 2009 ,
a huge aneurysmal dilatation ( 9 cm ) of aortic root and proximal ascending aorta , severe tricuspid regurgitation , and good left ventricular ejection fraction were found on echocardiography .
computed tomography showed a huge saccular aneurysm of the aortic root and proximal ascending thoracic aorta ( fig .
1 ) . the patient underwent a bentall procedure involving a composite conduit with a mechanical valvular prosthesis .
the operation also included pulmonary valve replacement using a bioprosthesis , tricuspid annuloplasty , subaortic pannus resection , maze procedure , and coronary artery bypass surgery ( saphenous vein to proximal right coronary artery ) .
because the right coronary artery orifice was deviated to the left side and was close to the aortic annulus , coronary artery bypass surgery was chosen despite availability of the button technique .
after the operation , there was the microscopic finding of cystic medial degeneration in the ascending aortic wall ( fig .
he was discharged on his 37th postoperative day . at follow - up , he remains well 17 months after this latest procedure .
in 1997 , dodds and colleagues described the first series report about progressive aortic regurgitation and aortic root dilatation after complete , uncomplicated repair of tof .
a long - standing volume overload of the aortic root may cause aortic root dilatation in adults with a repaired tof .
the right to left shunt through the ventricular septal defect in unrepaired tof increases the volume overload effect on the aortic root . another causative mechanism for progressive aortic root dilatation
intrinsic histological changes were found in tof patients ; including medionecrosis , fibrosis , cystic medial necrosis , elastic fragmentation and elastic lamellae disruption .
our patient had initial reparative surgery at the age of forty - three in 1987 .
the phrase of the enlarged aorta was described in the record of the first operation .
, we did not know why correction was not performed in the initial operation . in 2002 ,
an operation for ascending aortic aneurysm was recommended , but he refused any surgery at that time .
the pathologic conditions of aortic root and ascending aorta in repaired tof are no longer a benign problem . in recent reports ,
these are the first reports of aortic dissection in tetralogy of fallot . after an initial curative operation for tof , meticulous monitoring of aortic root and ascending
 surgical repair of the tetralogy of fallot is one of the most successful operations in the treatment of congenital heart diseases . 
 we report the case of a 65-year - old man who had an aortic valve replacement at the time of complete repair of the tetralogy of fallot at the age of forty - three . 
 he subsequently had progressive aortic root and ascending aorta dilation to 9 cm . 
 the aortic root and ascending aorta replacement was done using a composite valve - graft and was performed along with other procedures . 
 thus , meticulous follow - up of aortic root and ascending aorta after corrective surgery for tetralogy of fallot is recommended following initial curative surgery . 