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Background We aimed to evaluate the impact of membranous interventricular septum (MIS) length and calcifications of the native aortic valve (AV), via preoperative multidetector computed tomography (MDCT) scan, on postoperative atrioventricular block III (AVB/AVB III) and permanent pacemaker implantation in surgical aortic valve replacement (SAVR). Methods We retrospectively analyzed preoperative contrast-enhanced MDCT scans and procedural outcomes of patients affected by AV stenosis who underwent SAVR at our center (June 2016–December 2019). The study population was divided into two groups (AVB and non-AVB), and variables were compared with a Mann–Whitney's U-test or chi-square test. Data were further analyzed using point biserial correlation and logistic regression. Results A total of 155 (38% female) patients (mean age of 71.2 ± 6 years) were enrolled in our study: conventional stented bioprosthesis (N = 99) and sutureless prosthesis (N = 56) were implanted. A postoperative AVB III was observed in 11 patients (7.1%). AVB patients had significant greater calcifications in left coronary cusp (LCC) -AV (non-AVB = 181.0 mm3 [82.7–316.9] vs. AVB = 424.8 mm3 [115.9–563.2], p = 0.044), LCC left ventricular outflow tract (LVOT) (non-AVB = 2.1 mm3 [0–20.1] vs. AVB = 26.0 mm3 [0.1–138.0], p = 0.048), right coronary cusp (RCC) -LVOT (non-AVB = 0 mm3 [0–3.5] vs. AVB = 2.8 mm3 [0–29.0], p = 0.039), and consequently in total LVOT (non-AVB = 2.1 mm3 [0–20.1] vs. AVB = 26.0 mm3 [0.1–138.0], p = 0.02), while their MIS was significantly shorter than in non-AVB patients (non-AVB = 11.3 mm [9.9–13.4] vs. AVB = 9.44 mm [6.98–10.5]; p=0.014)). Partially, these group differences correlated positively (LCC -AV, r = 0.201, p = 0.012; RCC -LVOT, r = 0.283, p ≤ 0.001) or negatively (MIS length, r = −0.202, p = 0.008) with new-onset AVB III. Conclusion We recommend including an MDCT in preoperative diagnostic testing for all patients undergoing surgical AVR for further risk stratification.

Introduction Sutureless biological valves for surgical aortic valve replacement (SAVR), characterized by the absence of anchoring sutures at the aortic annulus, are gaining popularity because of ease and reproducibility of implant, shorter operating times, and enhancement of minimally invasive approaches. The stentless configuration of the sutureless valve was designed to achieve optimal hemodynamic performance. Materials and Methods PERSIST-AVR (PERceval Sutureless Implant versus STandard Aortic Valve Replacement) is a prospective, randomized, adaptive, open-label, international, postmarket trial (NCT02673697). The primary objective of the trial is to assess the safety and efficacy of the Perceval (LivaNova, London, UK) sutureless bioprosthesis among patients undergoing SAVR in the presence of severe aortic stenosis to demonstrate the noninferiority of Perceval as compared with standard sutured stented bioprosthetic aortic valve as an isolated procedure or combined with coronary artery bypass grafting. Sample size will be determined adaptively through interim analyses performed by an Independent Statistical Unit till a maximum of 1,234 patients, enrolled at ∼60 sites in countries where the device is commercially available. Patients will be followed up for 5 years after implant. The primary end point is the number of patients free from major adverse cardiac and cerebrovascular-related events at 1 year. Additional secondary outcomes will be assessed up to 5 years. Discussion PERSIST-AVR is the first prospective, randomized study comparing in-hospital and postdischarge outcomes in a robust population of patients undergoing SAVR with either the Perceval sutureless bioprosthesis or a conventional sutured stented bioprosthesis up to 5 years.

Objectives: The aim of this European multicenter-experience was to report on surgical outcomes in terms of mortality and complications of proximal reoperation after intial repair of acute typ A dissection (AAD). Methods: Between May 1998 and January 2014, 71 isolated proximal aortic re-operation (mean time from the first procedure was 3.67 years, range 0.15–16.6) were performed in 66 patients (mean age 60.8 ± 12.4 years, males 50). Proximal causes for re-operation were aortic root aneurysm in 17, root re-dissection in 13, aortic valve insufficiency in 24 and proximal anastomic pseudoaneurysm in 19 patients. Result: The most frequent proximal procedure during redo was the composite aortic root replacement (Bentall procedure) (40 operations, 56.35%), followed by isolated aortic valve replacement (13 pts., 18,31%) and ascending aorta replacement (9 pts., 12,68%). David procedure was performed in 4 patients (5.63%). In-hospital mortality was 14% (10 pts.), of them 7 deaths were reported after emergency operations and 3 in elective or urgent setting. Causes of deaths were cardiac in 5, neurological in 2, MOF in 3. Major adverse event included low output syndrome in 7, neurological complications in 7, acute renal failure 7 and bleeding complications in 10 patients and lung failure in 5 patients. Conclusion: Proximal re-operations can be performed with acceptable in-hospital results. Thus conservative approach of the proximal aorta for AAD should not be considered a concern for late reoperations. Strict follow-up after AAD is mandatory to avoid emergency re-operations.

Objectives: Sutureless aortic valve replacement (AVR) has been associated with excellent hemodynamic and clinical outcomes, but less is known on the outcomes of the patients operated on for complex surgery. We aimed to evaluate the early outcomes and 1-year follow-up of patients undergoing AVR with a self expandable sutureless valve and concomitant procedures. Methods: Two European centers participated in the study, with a total number of self expandable aortic valve prosthesis implants equal to 682 (time frame May 2010 - May 2014). Of them, 168 (mean age 76.7 ± 6.4 years, female gender 93 (55.4%)) have been operated on for concomitant procedures.. Minimally invasive approach was chosen for 30 (17.9%) patients (14 ministernotomies and 16 right anterior minithoracotomies). 12 (7.1%), 45 (26.8%), 96 (57.1%) and 15 (8.9%) patients received 21 mm, 23 mm, 25 mm and 27 mm size prostheses, respectively. Common implantation technique was implemented in all the patients; coronary artery bypass grafting (if any) and mitral valve repair/replacement (if any) were performed prior to aortotomy and aortic valve replacement. Results: Overall surgical mortality was 7 (4.2%). Cardiopulmonary bypass time and aortic cross-clamp time were 136.3 ± 48 (median and interquartile range: 92 (71–114 minute)) and 94.3 ± 33 (74 (52–98)) min, respectively. Median assisted ventilation time was 10 (range 3–380) h. Revision for bleeding was necessary in 11 (6.5%) patients. 2 (1.2%) patients developed permanent neurological deficit following stroke. In 3 (1.8%) patients transient ischemic attack was observed. In 5 (3.0%) patients acute renal failure developed postoperatively. Permanent pacemaker implant due to advanced atrioventricular block was required in 16 (9.5%). 6/161 (3.7%) patients died during follow-up (mean duration 14 ± 11 months). Mean transprosthetic gradient averaged 13.6 ± 5.4 mm Hg. Conclusion: Good early outcomes, comparable to those of tissue valve prostheses, can be achieved in patients, undergoing sutureless AVR and associated procedures. Shortening the operative times, the self expandable sutureless prosthesis amplifies the armamentarium of aortic valve prostheses and represents a useful tool for associated and complex procedures.

BACKGROUND The aim of this study was to investigate necessity and outcome of late pulmonary valve replacement (PVR) after repair of tetralogy of Fallot (TOF). METHODS Hospital records from patients operated on for TOF at our institution between 1960 and 2002 were reviewed and patients were interviewed by questionnaires. RESULTS Out of 411 long-term survivors after TOF-repair, 47 (11.4 %) patients required reoperation after 13.2 +/- 7.4 years. Preoperative right ventricular (RV) dilatation was present in 36 (76.6 %) patients including 16 (34 %) with impaired RV function. Isolated PVR was performed in 12 patients (25.5 %). Additional procedures were necessary in 35 patients (74.5 %), including closure of residual defects (VSD, n = 11), tricuspid valve replacement (n = 1) and repair (n = 3). Obstructive right ventricular or pulmonary artery lesions (34 patients, 72.3 %) were all surgically addressed. RV pressure decreased from 61.1 +/- 27.7 to 42.9 +/- 13.3 mm Hg (p < 0.01) after PVR. RV size was reduced and RV function improved compared to preoperative values. Early mortality after reoperation was 2.1 % (n = 1) with one patient dying from biventricular failure. There was no late mortality. CONCLUSIONS PVR after Fallot repair is frequently required because of progressive RV enlargement with dysfunction. It can be performed with relatively low risk, even in the setting of multiple reoperation. Obstructive lesions (RVOTO, PA stenosis) and residual defects are frequently observed in patients needing late PVR and may play a crucial role in the development of RV failure. Timely valve replacement with repair of all obstructive lesions proximal and distal to the implanted valve is the key to preserving RV function.

Thirty years ago the Smeloff-Cutter double-caged ball prosthesis was developed for aortic valve replacement. Between 1967 and 1977 a total of 46 patients admitted to the University Hospital Munich underwent an isolated aortic valve replacement with the Smeloff-Cutter prosthesis. Postoperatively all patients received anticoagulation treatment with phenprocoumon (Marcumar). A retrospective follow-up of 95.6% of patients, representing 842 patient years, was completed. The corresponding actuarial survival rates after 10, 20, and 25 years were 69.1%, 47.4%, and 31.4%. The actuarial freedom rates from either valve-related complications, reoperations, or death were 72.9%, 47.4%, and 20.3%. Thromboembolism occurred in 1.41% per patient year, bleeding in 1.90%. The rates of valvular dysfunction, reoperation, and endocarditis were 1.16%, 1.16%, and 0.2% per patient-year. Today, of the surviving patients 81% are in NYHA Class I or II, 19% in NYHA Class III. No surviving patient deteriorated over the reported time in his or her functional NYHA classification. After 25 years the Smeloff-Cutter valve has proved to be a reliable prosthesis for aortic valve replacement and-together with the Starr-Edwards prosthesis-it has set a standard in longterm durability by which all other valve designs will have to be measured.

Results: During this time period, we operated upon 7470 patients through a median sternotomy. 268 patients (3.6%) received tracheostomy due to prolonged or expected prolonged assisted ventilation within 14 days (mean 8.1±2.64) after median sternotomy. In 240 patients (91.4%), tracheostomy was performed percutaneously with no major complication (bleeding, tracheal injury). 23 patients (8.6%) who were not suited for the percutaneous approach (anatomical reasons) underwent surgical tracheostomy in the OR. Deep sternal wound infection developed in 3 patient (1.1%), but the identified microbes (staph. aureus) were different to those cultured from the trachea, excluding cross-contamination. Survivors (219/268, 81.7%) were successfully weaned after 19.2±11.5 days (3–81).