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+Our patient was a 50-year old man with bicuspid aortic valve insufficiency and ascending aorta dilatation.
+He had undergone a free-hand aortic homograft implantation with replacement of the non-coronary sinus using a 24-mm homograft in 2006 (at the age of 41).
+Follow-up evaluations were performed every 6 months and showed mild aortic valve insufficiency.
+After 8 years of follow-up, the patient presented to hospital with fever and the echocardiography showed severe aortic insufficiency due to a rupture of one of the cusps of the homograft, worsening of cardiac contractility with left ventricular ejection fraction (LVEF) depression (40–45%) and dilatation of the left ventricle (telediastolic/telesystolic diameters 60/42 mm, respectively).
+The patient presented orthopnoea and hypotension, which needed infusion of dopamine and diuretics.
+Computed tomography scan showed calcifications on the homograft, pleural effusions and no signs of pericardial effusion (Fig.1).
+Since the Dukes criteria for endocarditis were not satisfied, the final diagnosis was an early structural deterioration of the homograft, due to a severe calcification process.
+The operation was performed through median resternotomy and with standard aorta-right atrium central cannulation for the extracorporeal circulation.
+The leaflets and the annulus of the homograft presented severe calcifications and no signs of endocarditis were found.
+An Edwards Intuity bioprosthesis (21 mm) was then implanted (Fig.2).
+The cross-clamping time was 41 min, and the cardiopulmonary bypass time was 64 min.
+The patient required dopamine and adrenaline at low doses for bypass weaning.
+No complications occurred during the postoperative period.
+Echocardiography before the discharge showed the absence of paravalvular leaks, a peak/mean aortic gradient of 34/20 mmHg and an LVEF of 33%.
+Follow-up echocardiography after 3 months from the operation showed neither leaks nor malfunctions of the Edwards Intuity prosthesis, a peak/mean gradient of 38/22 mmHg and initial recovery of the LVEF (valued 47%).
+Patient was asymptomatic again.