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Background: Current guidelines recommend valve-sparing aortic root replacement (VSRR) procedures over valve replacement for the treatment of root aneurysm. The reimplantation technique seems to be the most widely used valve-sparing technique, with excellent outcomes in mostly single-center studies. The aim of this systematic review and meta-analysis is to present a comprehensive overview of clinical outcomes after VSRR with the reimplantation technique, and potential differences for bicuspid aortic valve (BAV) phenotype. Methods: We conducted a systematic literature search of papers reporting outcomes after VSRR that were published since 2010. Studies solely reporting on acute aortic syndromes or congenital patients were excluded. Baseline characteristics were summarized using sample size weighting. Late outcomes were pooled using inverse variance weighting. Pooled Kaplan-Meier (KM) curves for time-to-event outcomes were generated. Further, a microsimulation model was developed to estimate life expectancy and risks of valve-related morbidity after surgery. Results: Forty-four studies, with 7,878 patients, matched the inclusion criteria and were included for analysis. Mean age at operation was 50 years and almost 80% of patients were male. Pooled early mortality was 1.6% and the most common perioperative complication was chest re-exploration for bleeding (5.4%). Mean follow-up was 4.8±2.8 years. Linearized occurrence rates for aortic valve (AV) related complications such as endocarditis and stroke were below 0.3% patient-year. Overall survival was 99% and 89% at 1 and 10-year respectively. Freedom from reoperation was 99% and 91% after 1 and 10 years, respectively, with no difference between tricuspid and BAVs. Conclusions: This systematic review and meta-analysis shows excellent short and long-term results of valve-sparing root replacement with the reimplantation technique in terms of survival, freedom from reoperation, and valve related complications with no difference between tricuspid and BAVs.

ObjectivesDifferences in indication and technique make a randomised comparison between valve-sparing root replacement (VSRR) and personalised external aortic root support (PEARS) challenging. We performed a propensity score (PS)-matched comparison of PEARS and VSRR for syndromic root aneurysm.MethodsPatients in the PEARS 200 Database and Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (undergoing VSRR) with connective tissue disease operated electively for root aneurysm ResultsMedian follow-up was 25 and 55 months for 159 PEARS and 142 VSRR patients. Seven (4.4%) patients undergoing PEARS required an intervention for coronary injury or impingement, resulting in one death (0.6%). After VSRR, there were no early deaths, 10 (7%) reinterventions for bleeding and 1 coronary intervention. Survival for matched cohorts at 5 years was similar (PEARS 98% vs VSRR 99%, p=0.99). There was no difference in freedom from valve or ascending aortic/arch reintervention between matched groups. Freedom from AR ≥2/4 at 5 years in the matched cohorts was 97% for PEARS vs 92% for VSRR (p=0.55). There were no type A dissections.ConclusionsVSRR and PEARS offer favourable mid-term survival, freedom from reintervention and preservation of valve function. Both treatments deserve their place in the surgical repertoire, depending on a patient’s disease stage. This study is limited by its retrospective nature and different follow-ups in both cohorts.

Although the use of the surgical robot facilitates less invasive mitral valve surgery, both real and perceived limitations have slowed the application of this technology. Aim of the present investigation was to report the early and long-term results of robotic mitral valve repair in a single institution over a 10-year period.Between March 2012 and May 2022, a total of 278 consecutive patients underwent robotically assisted mitral valve repair at the Cliniques Universitaires Saint-Luc (Brussels, Belgium). Indications have evolved over time allowing the treatment of complex mitral valve lesions. Clinical and echocardiographic follow-up were 97.8% and 86.1% complete, respectively.Mean age of the study population was 57.8±11.9 years and 221/278 (79.5%) patients were male. Despite being asymptomatic or mildly symptomatic [New York Heart Association (NYHA) class I-II], most of the patients presented with severe mitral regurgitation (MR). Degenerative mitral valve disease was the most common cause of MR. All patients underwent successful mitral valve repair using different techniques, and 25/278 (9.0%) had one or more concomitant procedures associated. The mean cardio-pulmonary bypass and aortic cross clamp times were 153±37 and 106±25 minutes, respectively. There was no operative or in-hospital mortality. Overall survival rate was 97.8%±3.2%, 95.8%±3.2% and 93.7%±3.0% at 3, 7 and 10 years. One early (0.4%) reoperation with re-repair was recorded for ring disruption, while late mitral valve re-repair was necessary in 4/279 (1.4%) patients for recurrent severe MR in three of them and mitral endocarditis in one. The overall freedom from mitral valve reoperation was 98.1%±1.0% at 3, 7 and 10 years. Overall freedom from MR (grade 2+ or more) was 91.7%±3.2%, 77.8%±4.8% and 67.1%±9.2% at 3, 7 and 10 years, respectively.Robotic mitral valve repair is safe and is associated with excellent clinical and echocardiographic results. The use of robotic technologies allows, after an appropriate learning curve, to reproduce all conventional techniques to treat MR, regardless of the complexity of the valve lesion.

Bicuspid aortic valves (BAVs) represent a wide spectrum of aortic valve phenotypes. We have therefore previously proposed a new repair-oriented surgical classification for BAVs in order to facilitate our understanding of any given phenotype and to guide surgical repair. BAVs can range from symmetric to very asymmetric, and classification is determined by commissural orientation. This can therefore range from 180° to 120° respectively, and as such has further implications for the presence or absence of a raphe; the height of the non-functional commissure (raphe); the length of the line of cusp fusion; and the architecture of the aortic valve sinuses. Over the last three decades, we have attempted different repair strategies for BAVs, with its respective learning curves and have achieved the best long-term repair results with our signature approach: the 180°-Reimplantation technique (El Khoury technique). Although very asymmetric and tricuspid aortic valve-like phenotypes are sometimes best repaired through tricuspidization, we have found that the majority of BAVs are amenable to our 180°-Reimplantation technique. This technique creates a symmetric valve, through a selective annuloplasty, and stabilization of the entire functional aortic annulus (FAA) with reimplantation of the commissure at 180° at the level of the virtual basal ring (VBR) and sinotubular junction (STJ). Depending on the valve phenotype, additional cusp modifications are often required to address one or two prolapsing cusps and/or a fibrous raphe. With this, we have previously reported a 12-year survival rate of 94%, which is alike the general population, and also an overall freedom from aortic valve reoperation of 91%.

A general misconception that unicuspid aortic valves (UAV) are just a subtype of bicuspid aortic valves (BAV) has now been perpetuated in the medical and surgical community for nearly two decades[1](#ref-0001), and there is no end in sight.

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Early aortomitral bioprosthetic degeneration with acute endocarditis represents a surgical challenge because it requires thoughtful preoperative evaluation and anticipation of a complex and difficult reoperation. The aortomitral continuity and fibrous skeleton is often completely destroyed, and hence mandates a double valve replacement with recreation of a new aortomitral continuity, with a pericardial patch for instance. This technique was originally described by Tirone David, and was named Commando procedure by the Cleveland Clinic group.1 Approaching the aortic root in the setting of redo surgeries is a challenge in and of itself, and herein we describe our technique for en bloc aortic root resection, followed by a Commando procedure.

OBJECTIVES To compare long-term outcomes after bicuspid aortic valve (BAV) repair utilizing the Cabrol annuloplasty versus valve sparing Reimplantation technique. METHODS From 1996 to 2018, 340 consecutive patients underwent BAV repair. Eighty underwent Cabrol annuloplasty and 189 underwent Reimplantation. Exclusion criteria were re-repairs (n = 6), active endocarditis (n = 4), no annuloplasty (n = 41) and ring or suture annuloplasty (n = 20). We compared both groups for survival, reoperations, valve related events and recurrent severe aortic regurgitation (AR > 2+). Inverse probability weighting (IPW) was used to balance the 2 groups. Cox regression analysis was used to identify outcome predictors. RESULTS After weighting, pre- and intraoperative characteristics were similar between groups, except for aorta replacement techniques and operative time, which was longer in the Reimplantation group (P 2+ were significantly lower in the Cabrol group (reoperation IPW: 69 ± 9% vs 91 ± 4%, P = 0.004 and AR > 2+ IPW: 71 ± 8% vs 97 ± 2%, P CONCLUSIONS In this study, comparing 2 annuloplasty strategies for BAV repair, we found statistically significant differences in long-term durability favouring the Reimplantation technique, and no differences in overall survival. The results support our current strategy of Reimplantation technique and repair of AR in patients with BAV. Cabrol annuloplasty is obsolete and should be generally abandoned in patients undergoing BAV repair for AR.

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Caseous liquefaction necrosis of mitral annular calcifications are rare. Rupture of its capsule may lead to systemic embolization. Surgical management entails Incision and Drainage with either mitral valve repair or replacement.

Unicuspid aortic valves are rare congenital malformations. Surgical repair is feasible in aortic regurgitation, and in some cases of aortic stenosis. The standard surgical approach is a bicuspidization and symmetrization with pericardial patch augmentation of valve cusps. Herein, we are describing our original technique for bicuspidization of a unicuspid aortic valve without cusp patch augmentation. We also address the surgical management of a commissural diastasis.

Patients with a bicuspid aortic valve (BAV) frequently require surgical intervention for aortic regurgitation (AR) and/or aneurysm. Valve-preserving surgery and repair of regurgitant BAVs have evolved into an increasingly used alternative to replacement. Anatomic predictors of possible repair failures have been identified and solutions developed. Using current techniques most non-calcified BAVs can be preserved or repaired. Excellent repair durability and freedom from valve-related complications can be achieved if all pathologic components of aortic valve and root including annular dilatation are corrected. Anatomic variations must be addressed using tailored approaches.

BackgroundUnicuspid aortic valve (UAV) is the second most common underlying cause of aortic valve dysfunction in young adults after the bicuspid valve. The valve may be replaced (for example by pulmonary autograft) or repaired using the bicuspidization technique. The aim of our study was to compare short- and mid-term outcomes of Ross procedure with bicuspidization in patients with severe UAV dysfunction.MethodsThis was a multi-center retrospective observational cohort study comparing data from two dedicated Ross centers in the Czech Republic with bicuspidization outcomes provided by AVIATOR registry. As for the Ross group, only the patients with UAV were included. Primary endpoint was mid-term freedom from reintervention. Secondary endpoints were mid-term freedom from major adverse events, endocarditis and pacemaker implantation.ResultsThroughout the study period, 114 patients underwent the Ross procedure (years 2009-2020) and 126 patients underwent bicuspidization (years 2006-2019). The bicuspidization group was significantly younger and presented with a higher degree of dyspnea, a lower degree of aortic valve stenosis and more often with pure regurgitation. The primary endpoint occurred more frequently in the bicuspidization group than in the Ross group – 77.9 vs. 97.9 % at 5 years and 68.4 vs. 75.2 % at 10 years (p < 0.001). There was no difference in secondary endpoints.ConclusionRoss procedure might offer a significantly lower mid-term risk of reintervention than bicuspidization in patients with UAV. Both procedures have comparable survival and risk of other short- and mid-term complications postoperatively.

ObjectiveSutureless aortic valves are an effective option for aortic valve replacement (AVR) showing non-inferiority to standard stented aortic valves for major cardiovascular and cerebral events at 1-year. We report the 1-year hemodynamic performance of the sutureless prostheses compared with standard aortic valves, assessed by a dedicated echocardiographic core lab.MethodsPerceval Sutureless Implant vs. Standard Aortic Valve Replacement (PERSIST-AVR) is a prospective, randomized, adaptive, open-label trial. Patients undergoing AVR, as an isolated or combined procedure, were randomized to receive a sutureless [sutureless aortic valve replacement (Su-AVR)] (n = 407) or a stented sutured [surgical AVR (SAVR)] (n = 412) bioprostheses. Site-reported echocardiographic examinations were collected at 1 year. In addition, a subgroup of the trial population (Su-AVR n = 71, SAVR = 82) had a complete echocardiographic examination independently assessed by a Core Lab (MedStar Health Research Institute, Washington D.C., USA) for the evaluation of the hemodynamic performance.ResultsThe site-reported hemodynamic data of stented valves and sutureless valves are stable and comparable during follow-up, showing stable reduction of mean and peak pressure gradients through one-year follow-up (mean: 12.1 ± 6.2 vs. 11.5 ± 4.6 mmHg; peak: 21.3 ± 11.4 vs. 22.0 ± 8.9 mmHg). These results at 1-year are confirmed in the subgroup by the core-lab assessed echocardiogram with an average mean and peak gradient of 12.8 ± 5.7 and 21.5 ± 9.1 mmHg for Su-AVR, and 13.4 ± 7.7 and 23.0 ± 13.0 mmHg for SAVR. The valve effective orifice area was 1.3 ± 0.4 and 1.4 ± 0.4 cm2 at 1-year for Su-AVR and SAVR. These improvements are observed across all valve sizes. At 1-year evaluation, 91.3% (n = 42) of patients in Su-AVR and 82.3% in SAVR (n = 51) groups were free from paravalvular leak (PVL). The rate of mild PVL was 4.3% (n = 2) in Su-AVR and 12.9% (n = 8) in the SAVR group. A similar trend is observed for central leak occurrence in both core-lab assessed echo groups.ConclusionAt 1-year of follow-up of a PERSIST-AVR patient sub-group, the study showed comparable hemodynamic performance in the sutureless and the stented-valve groups, confirmed by independent echo core lab. Perceval sutureless prosthesis provides optimal sealing at the annulus with equivalent PVL and central regurgitation extent rates compared to sutured valves. Sutureless valves are therefore a reliable and essential technology within the modern therapeutic possibilities to treat aortic valve disease.

No abstract available

OBJECTIVE: To analyze our long-term experience with valve-sparing reimplantation technique in treating aortic root aneurysm, aortic regurgitation, and aortic dissection in patients with tricuspid aortic valve. METHODS: Between March 1998 and October 2018, 303 consecutive patients underwent valve-sparing reimplantation in our institution. The mean age of this cohort was 52.9 ± 15 years. Time to event analysis was performed with the Kaplan-Meier method. Risk of death, reoperation, and aortic regurgitation (AR) recurrence were analyzed using the cox-regression method. RESULTS: In-hospital mortality was 1% (n = 3) of which two were admitted for acute aortic dissection. Median follow-up was 5.81 years ([IQR]: 2.8–10 years). Thirty-nine patients (14.4%) died during follow-up. At 5 and 10 years, overall survival was 92 ± 2%and 75 ± 4.9%, respectively. Seventeen patients required late aortic valve reoperation. Freedom from valve reoperation was 95 ± 2% and 90 ± 3%. Freedom from AR > 2+ and AR > 1+ at 10 years was 91 ± 4% and 71.5 ± 4.6%, respectively. Significant multivariate predictors of death included age, New York Heart Association dyspnea class (NYHA), type A acute dissection (TAAD), and preoperative left ventricular end-diastolic diameter (LVEDD). Significant multivariate predictors of AR recurrence included indication for surgery, previous cardiac surgery, and presence of preoperative AR. Freedom from events like major bleeding, thromboembolic events, and infective endocarditis at 10 years were 97%, 98%, and 96%, respectively. CONCLUSIONS: Aortic valve-sparing with the reimplantation technique has been performed for over two decades in our institution, and the results in patients with tricuspid aortic valve (TAV) are excellent in terms of survival and freedom from valve-related adverse outcomes including valve reoperation. These results continue supporting the use of valve sparing root replacement using the reimplantation technique (VSRR) in patients with aortic aneurysm, irrespective of whether they have preoperative AR or not. VSRR is safe, durable, and reproducible, but further follow-up, well into the second decade is still necessary.

OBJECTIVESThe bicuspid aortic valve (BAV) exists in a wide variety of valve phenotypes. The aim of this study was to assess the anatomical characteristics of the different phenotypes and develop a classification system to aid surgical repair.METHODSIn 178 consecutive patients operated on for aortic insufficiency or aortic dilatation in 2 centres, 11 anatomical parameters of BAV were measured by echocardiography and intraoperatively. All BAV judged potentially repairable were included in the study.RESULTSCommissural orientation correlated positively with fusion length (R2 = 0.6, P CONCLUSIONSThe BAV phenotypes follow a continuous spectrum that extends from symmetrical to very asymmetrical BAV. We describe the main anatomical parameters (including commissure orientation, length of fusion and non-functional commissure height) and their variation across this spectrum. We propose a new repair-oriented classification system based on those parameters that can be used to predict valve repair techniques. This classification needs further validation with regards to surgical techniques and long-term outcomes.

Aortic valve surgery in non-elderly patients represents a very challenging patient population. The younger the patient is at the point of aortic valve intervention, the longer their anticipated life expectancy will be, with longer exposure to valve-related complications and risk for re-operation. Although the latest international guidelines recommend aortic valve repair in patients with aortic valve insufficiency, what we see in the real world is that the vast majority of these aortic valves are replaced. However, current prosthetic valves has now been shown to lead to significant loss of life expectancy for non-elderly patients up to 50% for patients in their 40s undergoing mechanical aortic valve replacement. Bioprostheses carry an even worse long-term survival, with higher rates of re-intervention. The promise of trans-catheter valve-in-valve technology is accentuating the trend of bioprosthetic implantation in younger patients, without yet the appropriate evidence. In contrast, aortic valve repair has shown excellent outcomes in terms of quality of life, freedom from re-operation and freedom from major adverse valve-related events with similar life expectancy to general population as it is also found for the Ross procedure, the only available living valve substitute. We are at a time when the paradigm of aortic valve surgery needs to change for the better. To better serve our patients, we must acquire high quality real-world evidence from multiple centers globally - this is the vision of the AVIATOR registry and our common responsibility.

Background: Assessing the true severity of aortic stenosis (AS) remains a challenge, particularly when echocardiography yields discordant results. Recent European and American guidelines recommend measuring aortic valve calcium (AVC) by multidetector row computed tomography (MDCT) to improve this assessment.Aim: To define, using a standardized MDCT scanning protocol, the optimal AVC load criteria for truly severe AS in patients with concordant echocardiographic findings, to establish the ability of these criteria to predict clinical outcomes, and to investigate their ability to delineate truly severe AS in patients with discordant echocardiographic AS grading.Methods and Results: Two hundred and sixty-six patients with moderate-to-severe AS and normal LVEF prospectively underwent MDCT and Doppler-echocardiography to assess AS severity. In patients with concordant AS grading, ROC analysis identified optimal cut-off values for diagnosing severe AS using different AVC load criteria. In these patients, 4-year event-free survival was better with low AVC load (60–63%) by these criteria than with high AVC load (23–26%, log rank p < 0.001). Patients with discordant AS grading had higher AVC load than those with moderate AS but lower AVC load than those with severe high-gradient AS. Between 36 and 55% of patients with severe LG-AS met AVC load criteria for severe AS. Although AVC load predicted outcome in these patients as well, its prognostic impact was less than in patients with concordant AS grading.Conclusions: Assessment of AVC load accurately identifies truly severe AS and provides powerful prognostic information. Our data further indicate that patients with discordant AS grading consist in a heterogenous group, as evidenced by their large range of AVC load. MDCT allows to differentiate between truly severe and pseudo-severe AS in this population as well, although the prognostic implications thereof are less pronounced than in patients with concordant AS grading.

CENTRAL MESSAGE : We present a video that depicts the continuous spectrum of anatomic relationships in normal, type 1, and type 0 bicuspid aortic valves. [...]

Background: The tricuspid valve is a complex threedimensional (3D) structure. Echocardiography (2D/3D) is the gold standard for evaluating valve function and anatomy. The aim of our study was to compare in vivo with 3D echocardiographic tricuspid valve measurements in patients treated for mitral valve disease. Methods: Among the 139 patients treated for mitral valve disease, 37 had an intraoperative evaluation by 3D trans-esophageal echocardiography. After exposure of the valve, we took several pictures to obtain annular and leaflet measurements. We traced the echocardiographic annular measurements (area, perimeter, septal anterior, and latero-lateral diameters) at six different moments of the cardiac cycle: early, mid, and late, systole and diastole; leaflet lengths and areas were measured only during end-systole and diastole. From the intraoperative pictures, we obtained annular and leaflet measurements and compared them to echocardiographic findings using Pearson’s correlation test. Results: Significant correlations were found between 3D echocardiography and in vivo measurements in terms of valve areas and perimeter (p < 0.01; r = 0.77 and p < 0.01; r=0.61, respectively) while diameters correlated moderately. Correlations of leaflet measurements were poor (R: 0.51–0.61). Multivariate linear regression analysis identified annulus areas and tenting height (p = 0.03 and 0.04, respectively) as significant predictors of tricuspid regurgitation. Conclusion: Our study demonstrated that annulus area and perimeter correlate better than diameters for measuring the tricuspid annulus and have significant influence on functional tricuspid regurgitation. Leaflet analysis remains limited. Further studies will identify their impact on follow-up recurrence of functional tricuspid regurgitation.

Many authors have reported their results of mitral valve (MV) repair (MVr) in acute and healed endocarditis. However, the results published by different authors highlight the fact that the reparability rate for this indication remains low. Over the last three decades, our group has adopted an early and repair-oriented approach to infective endocarditis with the objective to improve the repair rate and the long-term results.‬ ‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬‬ In this paper, we describe our institutional experience on mitral valve repair for infective endocarditis.‬‬‬‬‬‬‬‬‬‬‬‬ Data for this paper were extracted from our institutional database on heart valve disease. From 1991 to 2015, 160 consecutive patients in our institution underwent MV surgery for active IE on native MV. The median follow-up was 122 months. This study was approved by the institutional ethics review board, and written informed consent was waived for this study given its retrospective design. Hospital mortality was 11.6% (n = 18). Early MV reoperation before hospital discharge was required in five (3.1%) patients. At 5, 10, and 15 years, overall survival in the MVr for endocarditis in the group was 79% ± 4%, 65% ± 5%, 57% ± 6%, respectively. Freedom from reoperation at 5, 10, and 15 years was 95% ± 2%, 88% ± 4%, and 81% ± 6%, respectively. Mitral infective endocarditis is an insidious pathology and his surgical approach can be challenging. An early and repair-oriented surgical approach can allow to improve reparability rates with good long-term durability and a low recurrence rate of endocarditis.

OBJECTIVES Our goal was to analyse the influence of preoperative aortic regurgitation (AR) on the necessity of cusp repair during valve-sparing reimplantation (VSR). We focused on patients with tricuspid aortic valves (TAV) and evaluated the impact of AR and cusp repair on long-term outcomes. METHODS From March 1998 to December 2018, a total of 512 consecutive patients underwent VSR at our institution; of these, 303 had a TAV. The mean age was 53 ± 15 years, and the median follow-up was 6.12 years. The rate and type of cusp repair were analysed based on preoperative AR. Time-to-event analysis was performed, as well as risk of death, reoperation and AR recurrence. RESULTS Cusp repair was necessary in 168 (55.4%) patients; the rate rose significantly as AR grade increased (P 2+ and AR >1+ at 10 years was 88 ± 4% and 70.4 ± 4.6%, respectively. Independent predictors of death included age, New York Heart Association functional class and type-A aortic dissection. Predictors of AR greater than mild included previous cardiac surgery and severe preoperative AR. CONCLUSION In patients with TAV receiving VSR, the necessity of cusp repair increased with the degree of preoperative AR. Preoperative AR and cusp repair do not impact long-term survival and aortic valve reoperation, but severe preoperative AR and multiple cusp repair increase the risk of recurrent moderate-to-severe AR. Overall, cusp repair seems to attenuate the negative impact of preoperative AR for at least 1 decade in a majority of patients.

Objectives The objectives were to analyze the long-term outcomes of tricuspid aortic valve repair for isolated severe aortic regurgitation and the impact of different annuloplasty techniques. Methods The study cohort consists of 127 consecutive patients who received aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve between 1996 and 2019 in our institution. Exclusion criteria were aorta dilatation (≥45 mm), connective tissue disease, active endocarditis, type A dissection, and rheumatic disease. Mean age of patients was 55.6 ± 16 years, and 80% were male. Median follow-up was 6.4 years. Time-to-event analysis was performed, as well as risk of death, reoperation, and aortic regurgitation recurrence. Results Cusp repair was performed in 117 patients (92%), and annuloplasty was performed in 126 patients (99%) with Cabrol stitch (73%), reimplantation technique (19.7%), or ring annuloplasty (6.3%). There was no hospital mortality. At 10 and 14 years, overall survival was 81% ± 5% and 71% ± 6%, respectively, and freedom from reoperation was 80% ± 5% and 73% ± 6%, respectively. Age and left coronary cusp repair were independent predictors of reoperation. Freedom from recurrent severe aortic regurgitation (>2+) was 73% ± 5% and 66% ± 7% at 10 and 12 years, respectively. Age, left ventricular end-diastolic diameter, and patch repair were independent predictors of recurrent aortic regurgitation. Type of annuloplasty had no impact on survival or reoperation. Conclusions Aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve is a safe procedure, and durability at 14 years is acceptable. In this study, the annuloplasty technique did not influence repair durability as was found in bicuspid aortic valve repair or aortic valve–sparing surgery. Severity of cusp pathology seems to be the main determinant of repair durability.

International audience; Objective: Sutureless aortic valves are a novel option for aortic valve replacement. We sought to demonstrate noninferiority of sutureless versus standard bioprostheses in severe symptomatic aortic stenosis.Methods: The Perceval Sutureless Implant Versus Standard-Aortic Valve Replacement is a prospective, randomized, adaptive, open-label trial. Patients were randomized (March 2016 to September 2018) to aortic valve replacement with a sutureless or stented valve using conventional or minimally invasive approach. Primary outcome was freedom from major adverse cerebral and cardiovascular events (composite of all-cause death, myocardial infarction, stroke, or valve reintervention) at 1 year.Results: At 47 centers (12 countries), 910 patients were randomized to sutureless (n = 453) or conventional stented (n = 457) valves; mean ages were 75.4 ± 5.6 and 75.0 ± 6.1 years, and 50.1% and 44.9% were female, respectively. Mean ± standard deviation Society of Thoracic Surgeons scores were 2.4 ± 1.7 and 2.1 ± 1.3, and a ministernotomy approach was used in 50.4% and 47.3%, respectively. Concomitant procedures were performed with similar rates in both groups. Noninferiority was demonstrated for major adverse cerebral and cardiovascular events at 1 year, whereas aortic valve hemodynamics improved equally in both groups. Use of sutureless valves significantly reduced surgical times (mean extracorporeal circulation times: 71.0 ± 34.1 minutes vs 87.8 ± 33.9 minutes; mean crossclamp times: 48.5 ± 24.7 vs 65.2 ± 23.6; both P < .0001), but resulted in a higher rate of pacemaker implantation (11.1% vs 3.6% at 1 year). Incidences of perivalvular and central leak were similar.Conclusions: Sutureless valves were noninferior to stented valves with respect to major adverse cerebral and cardiovascular events at 1 year in patients undergoing aortic valve replacement (alone or with coronary artery bypass grafting). This suggests that sutureless valves should be considered as part of a comprehensive valve program.

OBJECTIVES: The optimal management of functional tricuspid regurgitation (FTR) in the setting of mitral valve operations remains controversial. The current practice is both centre specific and surgeon specific with guidelines based on non-randomized data. A prospective randomized trial was performed to evaluate the worth of less-than-severe FTR repair during mitral valve procedures. METHODS: A single-centre randomized study was designed to allocate patients with less-than-severe FTR undergoing mitral valve surgery to be prophylactically treated with or without tricuspid valve annuloplasty (TVP- or TVP+). These patients were analysed using longitudinal cardiopulmonary exercise capacity, echocardiographic follow-up and cardiac magnetic resonance. The primary outcome was freedom from more than or equal to moderate tricuspid regurgitation with vena contracta ≥4 mm. Secondary outcomes were maximal oxygen uptake and right ventricular (RV) dimension and function. RESULTS: A total of 53 patients were allocated to receive concomitant TVP+, and 53 patients were treated conservatively (TVP-). At 5 years, tricuspid regurgitation was observed to be greater than mild in 10 patients in the TVP- group and no patients in the TVP+ group (P < 0.01). Maximal oxygen uptake, RV basal diameter, end-diastolic diameter and end-systolic diameter and fractional area changes were similar in both groups. Cardiac magnetic resonance confirmed no differences in RV end-diastolic volume, RV end-systolic volume and RV ejection fraction. CONCLUSIONS: This single-centre prospective randomized trial demonstrated that prophylactic tricuspid annuloplasty irrespective of annular dilatation at the time of mitral surgery reduced the recurrence of moderate or severe FTR at 5-year follow-up and reduced the pulmonary pressure. Nevertheless, the functional capacity, the RV function and the RV dimension remained similar.

Type 0 bicuspid aortic valves (BAVs) according to Sievers classification1 present 2 symmetrical cusps of same size with a perfectly fused cusp, no raphe, and symmetrical anterior and posterior annulus. These valves have shown improved results after repair compared with type 1,2 where there is an incomplete fusion of the conjoined cusps with a raphe and a certain degree of asymmetry between the fused and nonfused cusps. In recent years, we have observed an increased interest in achieving the symmetry during type 1 BAV repair to approach the type 0 configuration and improved results

I thank Tourmousoglou [1] for his valuable comments on our article [2] and we agree about the doubts he has raised. The use of a tricuspid annulus of more than 40 mm in size has been previously introduced by the Dion group in Leiden [3] and by then, this was the only indication for prophylactic tricuspid annuloplasty and therefore was introduced in the recent guidelines. We believe that a deeper understanding of the anatomy of the tricuspid valve and its possible evolution with time after mitral valve surgery is necessary. [...]

PURPOSE: Infective endocarditis (IE) remains a prevalent and life-threatening disease. The choice to repair or replace the infected valve still remains a matter of debate, especially in aortic valve (AV) infections. We retrospectively analyze our two decades of experience in aortic valve repair (AVr) in IE. Long-term outcomes are described with particular attention to the impact of valve configuration and the use of patch techniques. METHODS: From September 1998 to June 2017, 42 patients underwent AVr in a single center for IE. Techniques include leaflet patch repair and resuspension and aortic annulus stabilization. RESULTS: Hospital mortality was 2.4% (n = 1). The median follow-up was 90.6 months. Survival was 89 ± 9.4% and 76.6 ± 16% at 5 and 10 years, respectively, with no significant differences between tricuspid aortic valve (TAV) and bicuspid aortic valve (BAV). Freedom from reoperation was 100% and 92.9 ± 7.1% in TAV and 81.8 ± 18.2% and 46.8 ± 28.8% in BAV at 5 and 10 years, respectively (TAV vs BAV, p = 0.02). BAV, degree of preoperative aortic insufficiency, and AVr including patch were factors predicting a higher risk of reoperation during the follow-up. CONCLUSION: In our experience, AVr is a safe, feasible, and efficient choice in selected patients with healed or active IE. Durability of the repair is excellent in patients with limited lesions and in patients with TAV even with patch repair. Reoperations occurred principally in patients with BAV and severe preoperative AI, in whom patch repair was performed. In those patients, we actually recommend to replace the valve in case of active endocarditis.

Aortic valve (AV) sparing and repair procedures are advantageous alternatives to valve replacement in patients with aortic aneurysm and/or aortic regurgitation. A successful sparing or repair strategy proceeds first from a clear understanding of the peculiar anatomy and function of the AV and of the possible mechanisms of valve dysfunction. The AV is a functional unit composed of the valve cusps and the functional aortic annulus (FAA). Lesion on any or more of these components can induce aortic insufficiency. A functional classification of aortic regurgitation identifies three main mechanisms of AV regurgitation although more than one type of lesion can coexist in a patient. The goal of AV repair is to restore a normal surface of coaptation by restoring normal geometry between the leaflets and the FAA, while preserving normal mobility of the AV cusps. We present in detail our preferred surgical techniques for valve-sparing root replacement (VSRR) and repair of the AV cusps in the context of tricuspid AV. Further, we discuss the peculiarities of the VSRR and repair techniques in the context of bicuspid AV including our preferred approach to the bicuspid aortic dilatation.