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performed that showed a linear line restraining the filling up of the coronary ostia (Fig. 1, Video 1). Challenging imaging of coronaries unselectively could have been performed, and the patient was transferred to a cardiovascular surgery clinic for ascending aortic surgery. After completing the preoperative procedures, he was transferred to the operating room. Under general anesthesia, the mediastinum was opened by median sternotomy and the aorta was dissected properly. The aortic valve was located in its natural location with a bicuspid appearance, and the sinus valsalva was dilated and anatomically original. Any kind of intimal laceration or aortic rupture was not found, indicating successful aortic dissection. In the distal part of aortic root (3 cm), second and bigger triple annulus was observed (Fig. 2). The bicuspid aortic valve and ascending aorta were excised. A composite graft that was prepared in vitro by primary suture of 31 no metallic valve and 30 mm dacron graft to each other was implanted instead. After successful operation, sternum was closed anatomically. The patient was successfully discharged, and he was followed up uneventfully until the first month control. He was followed up for 1 month without any complication related to disease or surgery. During clinical and echocardiographic evaluation after 1 month, no abnormal findings was observed. His EF was 60%, and no aortic valveor ascending aorta-related complication was observed. This is the first case, to the best of our knowledge, with a second annulus-like structure in the aortic root preventing coronary cannulation significantly. Second and larger than normal aortic annulus triple aortic annulus in a patient with ascending aortic aneurysm and bicuspid aorta

Second and larger triple aortic annulus in a patient with ascending aortic aneurysm and bicuspid aorta