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Letter by Giardini et al regarding article, "Maladaptive aortic properties in children after palliation of hypoplastic left heart syndrome assessed by cardiovascular magnetic resonance imaging".

that the reconstructed ascendingaorta in patients with hypoplastic left heart syndrome has reduceddistensibility. Using magnetic resonance imaging, Voges demon-strated that abnormal elastic properties in the ascending aorta areassociated with reduced right ventricular ejection fraction. However,in our opinion, several additional issues should be considered wheninterpreting the results.Distensibility of the aortic wall at any given location is determinedby the change in cross-sectional area and the pulse pressure at thatspecific location of interest. Thus, accurate calculation of thedescending aortic distensibility requires precise knowledge of geo-metric and pressure conditions within the descending aorta. Inhealthy individuals, without aortic coarctation, the pulse pressure isidentical throughout the arterial tree. However, in patients after theNorwood operation, the aortic reconstruction typically leaves geo-metric size mismatch between the reconstructed aortic arch anddescending aorta, leading to pressure drop. Moreover, up to 23% ofpatients after the Norwood operation can have varying degrees ofclinically significant aortic isthmus narrowing that require reinter-vention.