3|DISCUSSION
Aortic dilation is a common sequela among patients with an unrepaired TOF. Studies have suggested that aortic dilation may be attributed to longstanding volume overload of the ascending aorta as a result of right ventricular outflow tract obstruction and right-to-left shunting across the ventricular septal defect.[4],[5] VSARR is a well-established procedure that corrects AR as a result of aortic dilation, with recent studies suggesting that the modified David V technique that preserves sinus-like geometry may improve annular stabilization and hemostasis in the long term compared with those of remodeling techniques (Yacoub/David II).[2] Also, VSARR has also been successfully performed on patients with congenital heart defects.[2, 3] Adachi and colleagues have reported a case of TOF repair with VSARR on a patient who has previously undergone a left original Blalock-Taussig shunt during infancy.[6] Our report represents the first to describe a successfully performed VSARR procedure on a previously unoperated adult TOF patient. In our patient, the long-standing VSD fortunately has not caused a significant impairment to the aortic cusps or annulus. With our previous experience, extreme care was taken to avoid disrupting the balanced aortic root or distorting the aortic annulus during VSD repair. To better preserve the sinuses and considering the hemodynamics of this patient, we chose the Yacoub technique to reconstruct the aorta.