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Objectives: The Ross procedure is currently receiving renewed interest. Its function and durability depend on preservation of pulmonary valve anatomy; limited data exist on normal pulmonary valve geometry. The objective was to compare aortic and pulmonary root and cusp dimensions in adults with normal tricuspid aortic and pulmonary valves., Methods: We reviewed 507 coronary computed tomography studies, selecting those with adequate visibility of both pulmonary and aortic roots for further analysis. Diastolic aortic and pulmonary root and cusp dimensions were measured. Root dimensions at different phases of the cardiac cycle were measured in 3 patients., Results: We analysed studies of 50 patients with the mean age of 54 years [standard deviation (SD): 16]. In end-diastole, pulmonary root had a smaller sinutubular to basal ring ratio than the aortic root [0.82 (SD: 0.09) vs 1.14 (SD: 0.12), P < 0.001]. Aortic and pulmonary cusps had similar dimensions; however, pulmonary cusp effective height was lower [5.9 mm (SD: 1.6) vs 8.4 mm (SD: 1.2), P < 0.001]. Pulmonary basal ring perimeter was largest at end-diastole and smallest at end-systole, with the relative difference of 23.5% (SD: 2.7)., Conclusions: The pulmonary root has a similar cusp size compared to the aortic root, but a different shape, resulting in a lower pulmonary cusp effective height. The perimeter of the pulmonary basal ring changes during the cardiac cycle. These findings suggest that stabilizing the autograft to normal aortic, rather than pulmonary, root dimensions should result in normal autograft cusp configuration. Computed tomography angiography could become a tool for personalized planning of the Ross procedure., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Bicuspid aortic valves may be associated with coronary anomalies. We report a case of a regurgitant bicuspid aortic valve and concomitant single coronary ostium, which we treated by valve repair and coronary transfer., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Liposarcomas (LPSs) are rare malignant tumors of adipocytic origin, primarily occurring in the extremities and retroperitoneum, with thoracic involvement being exceptionally rare. This case report details the surgical management and outcomes of a recurrent intrathoracic LPS in a 65-year-old male with a history of previous mediastinal tumor resection. CT imaging revealed a recurrent tumor extending into the left pleura. The patient underwent a posterolateral thoracotomy for complete tumor excision and limited replacement of the descending aorta. Postoperative recovery was smooth, and histology confirmed dedifferentiated LPS (G2) with areas of highly differentiated LPS. LPSs encompass a heterogeneous group of tumors with various subtypes, including atypical lipomatous tumor/well-differentiated liposarcoma (ALT/WDLPS), dedifferentiated liposarcoma (DDLPS), myxoid liposarcoma (MLPS), and pleomorphic liposarcoma (PLPS). Treatment primarily involves complete surgical resection, while the roles of radiotherapy and chemotherapy remain debated. Immunotherapy shows potential benefits, particularly for DDLPS patients expressing PD-L1. Prognosis varies significantly by subtype, with DDLPS and PLPS associated with poorer outcomes compared to MLPS and ALT/WDLPS. Long-term follow-up is crucial for managing LPSs due to their high recurrence rate. This case highlights the effectiveness of surgical intervention in recurrent intrathoracic LPSs and underlines the need for continued research into adjuvant therapies to improve patient outcomes., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Leivaditis et al.)

Capnocytophaga canimorsus is a rare cause of serious infections with a high mortality of 10% to 30%. It is usually found in the oral cavity of cats and dogs and can cause severe sepsis in immunocompromised patients. An 81-year-old female Caucasian patient presented with C. canimorsus sepsis after a dog bite in her finger three days before presentation to our emergency department. She initially was presented to us with sepsis, thrombopenia, and schistocytes in her laboratory findings, suggesting the differential diagnoses of the multiple subtypes of thrombotic microangiopathy. She was admitted to the medical intensive care unit of the University Hospital of Saarland because of septic shock with circulatory insufficiency. The patient received plasmapheresis, antibiotics, and dialysis, under which she improved significantly. The fingertip of the affected finger developed necrosis and had to be amputated. Furthermore, the patient was diagnosed with a mitral valve endocarditis, a very rare complication of C. canimorsus infection. It was treated conservatively with antibiotics and was no longer detectable 8 weeks after the diagnosis. Surgical intervention was not needed. The case describes well that it is still difficult to distinguish between thrombotic thrombocytopenic purpura (TTP), disseminated intravascular coagulation (DIC), and sepsis-induced coagulopathy (SIC), especially in the early phases of acute disease, especially in C. canimorsus- induced sepsis., Competing Interests: The authors declare that there are no conflicts of interest for this case report., (Copyright © 2024 Jeannine L. Kühnle et al.)

Background: Bicuspid aortic valves (BAV) are frequently associated with ascending aortic aneurysms. The etiology is incompletely understood, but genetic factors, in addition to flow perturbations, are likely involved. Since loss of contractility and elaboration of extracellular matrix in the vessel wall are features of BAV-associated aortopathy, phenotypic modulation of smooth muscle cells (SMCs) may play a role., Methods: Ascending aortic tissue was collected intra-operatively from 25 individuals with normal (i.e., tricuspid) aortic valves (TAV) and from 25 individuals with BAVs. For both TAV and BAV, 10 patients had non-dilated (ND) and 15 patients had dilated (D) aortas. SMCs were isolated and cultured from a subset of patients from each group. Aortic tissue and SMCs were fluorescently immunolabeled for SMC phenotypic markers (i.e., alpha-smooth muscle actin (ASMA, contractile), vimentin (synthetic) and p16INK4a and p21Cip1 (senescence). SMCs were also analyzed for replicative senescence in culture., Results: In normal-sized and dilated BAV aortas, SMCs switched from the contractile state to either synthetic or senescent phenotypes, as observed by loss of ASMA (ND: P = 0.001, D: P = 0.002) and associated increases in vimentin (ND: P = 0.03, D: P = 0.004) or p16/p21 (ND: P = 0.03, D: P<0.0001) compared to TAV. Dilatation of the aorta exacerbated SMC phenotypic switching in both BAV and TAV aortas (all P<0.05). In SMCs cultured from normal and dilated aortas, those isolated from BAV reached replicative senescence faster than those from TAV aortas (all P = 0.02). Furthermore, there was a stark inverse correlation between ASMA and cell passage number in BAV SMCs (ND: P = 0.0006, D: P = 0.01), but not in TAV SMCs (ND: P = 0.93, D: P = 0.20)., Conclusions: The findings of this study provide direct evidence from cell culture studies implying that SMCs switch from the contractile state to either synthetic or senescent phenotypes in the non-dilated BAV aorta. In cultured SMCs from both non-dilated and dilated aortas, we found that this process may precede dilatation and accompany aneurysm development in BAV. Our findings suggest that therapeutically targeting SMC phenotypic modulation in BAV patients may be a viable option to prevent or delay ascending aortic aneurysm formation., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Balint et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: This study was performed to determine cusp causes of aortic regurgitation in patients with tricuspid aortic valves without significant aortic dilatation and define cusp pathologies amenable to surgical repair (aortic valve repair [AVr]) versus aortic valve replacement., Methods and Results: We retrospectively reviewed surgical reports of consecutive adults with tricuspid aortic valves undergoing surgery for clinically significant aortic regurgitation within a prospective registry from January 2005 to September 2019. Valvular mechanisms were determined by systematic in vivo intraoperative quantification methods. Of 516 patients, 287 (56%) underwent repair (AVr; mean±SD age, 59.9±12.4 years; 81% men) and 229 (44%) underwent replacement (aortic valve replacement; mean±SD age, 62.8±13.8 years [ P =0.01 compared to AVr]; 67% men). A single valvular mechanism was present in 454 patients (88%), with cusp prolapse (46%), retraction (24%), and perforation (18%) being the most common. Prolapse involved the right cusp in 86% of cases and was more frequent in men ( P <0.001). Two-dimensional transesophageal echocardiography accuracy for predicting mechanisms was 73% to 82% for the right cusp, 55% to 61% for the noncoronary cusp, and 0% for the left-coronary cusp. Cusp prolapse, younger age, and larger patient size were associated with successful AVr (all P <0.03), whereas retraction, perforation, older age, and concomitant mitral repair were associated with aortic valve replacement (all P <0.03)., Conclusions: Right cusp prolapse is the most frequent single valvular mechanism in patients with tricuspid aortic valve aortic regurgitation, followed by cusp retraction and perforation. The accuracy of 2-dimensional transesophageal echocardiography is limited for left and noncoronary cusp mechanistic assessment. Prolapse is associated with successful AVr, whereas retraction and perforation are associated with aortic valve replacement. With systematic intraoperative quantification methods and current surgical techniques, more than half of tricuspid aortic valve aortic regurgitation cases may be successfully repaired.

Pulmonary metastasectomy (PM) is consensually performed in a parenchyma-sparing manner to preserve functionally healthy lung tissue. However, this may increase the risk of local recurrence at the surgical margin. Laser assisted pulmonary metastasectomy (LPM) is a relatively recent innovation that is especially useful to resect multiple metastatic pulmonary nodules. In this study we investigated the rate of local recurrence after LPM and evaluated the influence of various clinical and pathological factors on local recurrence. Retrospectively, a total of 280 metastatic nodules with different histopathological entities were studied LPM from 2010 till 2018. All nodules were resected via diode-pumped neodymium: yttrium-aluminum-garnet (Nd:YAG) 1,318 nm laser maintaining a safety margin of 5 mm. Patients included were observed on average for 44 ± 17 months postoperatively. Local recurrence at the surgical margin following LPM was found in 9 nodules out of 280 nodules (3.21%). Local recurrence at the surgical margin occurred after 20 ± 8.5 months post operation. Incomplete resection (p =  < 0.01) and size of the nodule (p = < 0.01) were associated with significantly increased risk of local recurrence at the surgical margin. Histology of the primary disease showed no impact on local recurrence. Three and five-year survival rates were 84% and 49% respectively. Following LPM, the rate of local recurrence is low. This is influenced by the size of the metastatic nodules and completeness of the resection. Obtaining a safety margin of 5 mm seems to be sufficient, larger nodules require larger safety margins., (© 2024. The Author(s).)

Objectives: In patients with aortic root aneurysm, the aortic basal ring is frequently dilated. It has been speculated that the muscular part of the basal ring dilates most. The purpose of this study was to analyse the segmental dilatation of the basal ring, comparing normal and dilated roots in patients with tricuspid aortic valves., Methods: Retrospective analysis of computed tomography studies in patients with normal and dilated aortic roots was performed. Lengths of segments of the basal ring corresponding to each of the 3 sinuses, and to the muscular and fibrous parts were measured. Fractions of these segments relative to the total basal ring perimeter were calculated., Results: We analysed 152 normal and 126 dilated aortic roots and 86 propensity-matched pairs. Basal ring dilatation was present in all segments of dilated aortic roots with subtle differences between the segments corresponding to the 3 sinuses. The muscular part of the basal ring dilated proportionately to its fibrous part, with no difference in fractions of measured muscular part in normal and dilated roots [42.2% (interquartile range 4.3%) vs 42.1% (interquartile range 6.3%)]., Conclusions: Basal ring dilatation was present in all segments corresponding to the 3 sinuses in dilated aortic roots. Both muscular and fibrous parts dilated equally, supporting the need to stabilize the entire basal ring when performing aortic valve repair surgery., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

This consensus of nomenclature and classification for congenital bicuspid aortic valve and its aortopathy is evidence-based and intended for universal use by physicians (both pediatricians and adults), echocardiographers, advanced cardiovascular imaging specialists, interventional cardiologists, cardiovascular surgeons, pathologists, geneticists, and researchers spanning these areas of clinical and basic research. In addition, as long as new key and reference research is available, this international consensus may be subject to change based on evidence-based data1.

Objectives: Aortic valve repair requires the creation of a normal geometry of cusps and aortic root. Of the different dimensions, geometric cusp height is the most difficult to change while annular and sinotubular dimensions can be easily modified. The objective of this study was to investigate, by computer simulation, ideal combinations of annular and sinotubular junction size for a given geometric height., Methods: Based on a literature review of anatomical data, a computational biomechanics model was generated for a tricuspid aortic valve. We aimed to determine the ideal relationships for the root dimensions, keeping geometric height constant and creating different combinations of the annular and sinotubular junction dimensions. Using this model, 125 virtual anatomies were created, with 25 different combinations of annulus and sinotubular junction. Effective height, coaptation height and mechanical cusp stress were calculated with the valves in closed configuration., Results: Generally, within the analysed range of geometric heights, changes to the annular diameter yielded a stronger impact than sinotubular junction diameter changes for optimal valve configuration. The best results were obtained with the sinotubular junction being 2-4 mm larger than the annulus, leading to higher effective height, normal coaptation height and lower stress. Within the range tested, stenosis did not occur due to annular reduction., Conclusions: In tricuspid aortic valves, the geometric height can be used to predict ideal post-repair annular and sinotubular junction dimensions for optimal valve configuration. Such an ideal configuration is associated with reduced cusp stress., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Cutibacterium acnes , an integral component of the skin's customary bacterial flora, represents a Gram-positive anaerobic bacterium characterized by its low virulence. Despite its low virulence, the pathogen can cause profound-seated infections as well as infections linked to medical devices. We report a case study of a prosthesis endocarditis accompanied by a paraaortic abscess caused by C. acnes , a development occurring five years prior to composite aortic root and valve replacement. At the point of admission, the patient presented with a combination of symptoms hinting at a subacute progression, such as weight loss, chest pain, and limitations of cardiopulmonary functionality. An anaerobic pathogen, namely C. acnes , was detected in a singular blood culture vial. Since first-line imaging modalities such as echocardiography did not reveal any signs of inflammation, and in the case of a suspected diagnosis for IE, did not show high pretest probability, further diagnostic imaging such as 18F-FDG PET CT was put to use. Here, a highly elevated glucose metabolism around the aortic valve ring was detected, pointing to an inflammatory process. The patient received adjusted intravenous antibiotic therapy over a course of six weeks; he then underwent surgical therapy via re-replacement of the aortic root and valve using a composite conduit. Advanced microbiological analyses, including the amplification of PCR and valve sequencing via 16S rDNA, mainly detected one pathogen: C. acnes . Delayed onset with mild symptoms and laboratory findings is characteristic of infective endocarditis by C. acnes . Due to its high rate of complications, mortality, and morbidity, an infection should not be disregarded as contamination. Recommendations from different studies underline a combination of a positive blood culture and microbiological evidence to differentiate between contamination and true infection in the case of an infection involving C. acnes . Serial blood cultures with prolonged incubation, advanced microbiological analyses, and modified Duke criteria including second-line imaging techniques should be utilized for further evaluation.

Pressure recovery (PR) is essential part of the post stenotic fluid mechanics and depends on the ratio of EOA/A A , the effective aortic valve orifice area (EOA) and aortic cross-sectional area (A A ). In patients with advanced ascending aortic aneurysm and mildly diseased aortic valves, the effect of A A on pressure recovery and corresponding functional aortic valve opening area (ELCO) was evaluated before and after valve-sparing surgery (Dacron graft implantation). 66 Patients with ascending aortic aneurysm (mean aortic diameter 57 +/- 10 mm) and aortic valve-sparing surgery (32 reimplantation technique (David), 34 remodeling technique (Yacoub)) were routinely investigated by Doppler echocardiography. Dacron graft with a diameter between 26 and 34 mm were implanted. EOA was significantly declined after surgery (3.4 +/- 0.8 vs. 2.6 +/- 0.9cm 2 ; p < 0.001). Insertion of Dacron prosthesis resulted in a significant reduction of A A (26.7 +/- 10.2 vs. 6.8 +/- 1.1cm 2 ; p < 0.001) with increased ratio of EOA/A A (0.14 +/- 0.05 vs. 0.40 +/- 0.1; p < 0.001) and pressure recovery index (PRI; 0.24 +/- 0.08 vs. 0.44 +/- 0.06; p < 0.0001). Despite reduction of EOA, ELCO (= EOA corrected for PR) increased from 4.0 +/- 1.1 to 5.0 +/- 3.1cm 2 (p < 0.01) with reduction in transvalvular LV stroke work (1005 +/- 814 to 351 +/- 407 mmHg × ml, p < 0.001) after surgery. These effects were significantly better in patients with Yacoub technique than with the David operation. The hemodynamic findings demonstrate a valve-vessel interaction almost entirely caused by a marked reduction in the ascending A A with significant PR gain. The greater hemodynamic benefit of the Yacoub technique due to higher EOA values compared to the David technique was evident and may be of clinical relevance., (© 2023. Springer Nature Limited.)

Objectives: Aortic stenosis or regurgitation in patients with a unicuspid valve morphology requires interventions early in life. We have performed either primary valve repair or the Ross procedure. The goal of this study was to compare the midterm results of repair and pulmonary autograft replacement., Methods: Between December 1998 and April 2022, a total of 345 patients (77% male; mean age 34 ± 9.7 years) underwent treatment of a unicuspid aortic valve. Patients were excluded if they were <18 years (n = 84) or >54 years (n = 3) at the time of the operation. The remaining cohort was divided into 2 groups: 167 (64%) patients underwent valve repair; 91 (36%) patients underwent pulmonary autograft replacement.The indications for surgery were aortic regurgitation (n = 104), aortic stenosis (n = 45), combined disease (n = 103) and endocarditis (n = 6). Fifty-one patients had root dilatation (>43 mm) with aortic regurgitation (repair n = 23; Ross n = 28). Mean follow-up was 5.9 years (SD: 5 years) [range 0.1-22.3 years]., Results: There were 1 early and 3 late deaths; 47 patients required reintervention. Survival at 10 years was 95% in the Ross group and 97% after valve repair (P = 0.769). Freedom from reintervention at 10 years was 98% in the Ross group and 80% after valve repair (P = 0.012). A receiver operating characteristics curve analysis showed a trend towards better durability in patients < 26 years., Conclusions: The ideal treatment of the unicuspid aortic valve remains debatable. Repair of a unicuspid valve can be considered a bridge to pulmonary autograft replacement, at least in younger patients. The appropriate times to replace and to repair require further investigation., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: The aim of this retrospective study was to assess the long-term results of root remodelling with tricuspid aortic valves and the effects of concomitant cusp repair and annuloplasty., Methods: Between October 1995 and December 2021, 684 patients with root aneurysm and regurgitant tricuspid valves were treated by root remodelling. The mean age was 56.5 [standard deviation (SD): 14] years, and 538 (77.6%) were male. Relevant aortic regurgitation was present in 68.3%. Concomitant procedures were performed in 374 patients. The long-term results were analysed. The mean follow-up of 7.2 (SD: 5.3) years (median 6.6 years); it was 95% complete (4934.4 patient-years)., Results: Cusp prolapse was repaired in 83%, and an annuloplasty was added in 353 instances (51.6%). Hospital mortality was 2.3%, and survival was 81.7% (SD: 1.2) and 55.7% (SD: 5.8) at 10 and 20 years; age and measurement of effective height were independent predictors for death. Freedom from Aortic insufficiency (AI) II was 90.5 (SD: 1.9) at 10 years and 76.7 (SD: 4.5) at 20 years. Cusp repair of all cusps showed a lower freedom from recurrent AI ≥II at 10 years (P < 0.001). Suture annuloplasty showed a lower freedom from recurrent AI II at 10 years (P = 0.07). Freedom from reoperation was 95.5 (SD: 1.1) and 92.8 (SD: 2.8) at 10 and 20 years. The addition of an annuloplasty showed no difference (P = 0.236). Cusp repair had no effect on valve durability (P = 0.390)., Conclusions: Root remodelling leads to good long-term stability. The addition of cusp repair improves the valve stability over time. The addition of suture annuloplasty improves early valve competency; it showed no effect on freedom from reoperation up to 10 years., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Root remodeling is one form of valve-preserving root replacement for aortic regurgitation and root aneurysm. The objective of this review was to summarize our experience with root remodeling encompassing 28 years., Methods: We performed root remodeling in 1,189 patients (76% male, mean age 53±14 years) between October 1995 and September 2022. The original valve morphology was unicuspid in 33 (2%), bicuspid in 472 (40%) and tricuspid in 684 (58%) patients. Fifty-four patients (5%) had Marfan's syndrome. Objective measurement of valve configuration was performed in 804 (77%) and an external suture annuloplasty was added in 524 patients (44%). Cusp repair was performed in 1,047 (88%) patients, most commonly for prolapse (n=972; 82%). Mean follow-up was 6.7±5.5 years [1 month to 28 years]. Follow-up was 95% complete (7,700 patient-years)., Results: Survival was 71% at 20 years; freedom from cardiac death was 80%. Freedom from aortic regurgitation ≥2 was 77% at 15 years. Freedom from reoperation was 89% and was higher in tricuspid aortic valves (94%) compared to bicuspid (84%) and unicuspid valves (P<0.001). Since the introduction of effective height measurement, freedom from reoperation has remained stable at 15 years (91%). With the addition of a suture annuloplasty, freedom from reoperation was 94% at 12 years. The difference with or without annuloplasty (91%) was not significant (P=0.949)., Conclusions: Root remodeling is a viable option in valve-preserving root replacement. Concomitant cusp prolapse is frequent and can be corrected reproducibly by intraoperative measurement of effective height. The long-term benefit of an annuloplasty still needs to be defined., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2023 Annals of Cardiothoracic Surgery. All rights reserved.)

Objectives: After a Ross procedure, autograft failure can occur. At reoperation, repair of the autograft preserves the advantages of the Ross procedure. The aim of this retrospective study was to assess mid-term results after reoperation of a failed autograft., Methods: Between 1997 and 2022, 30 consecutive patients (83% male; age 41 ± 11 years) underwent autograft reintervention between 60 days and 24 years (median 10 years) after a Ross procedure. The initial technique varied, full-root replacement (n = 25) being the most frequent. The indication for reoperation was isolated autograft regurgitation (n = 7), root dilatation (>43 mm) with (n = 17) or without (n = 2) autograft regurgitation, mixed dysfunction (n = 2) and endocarditis (n = 2). In 4 instances, the valve was replaced by valve (n = 1) or combined valve and root replacement (n = 3). Valve-sparing procedures consisted of isolated valve repair (n = 7) or root replacement (n = 19), and tubular aortic replacement. Cusp repair was performed in all but 2. Mean follow-up was 5.4 ± 6 years (35 days to 24 years)., Results: Mean cross-clamp and perfusion times were 74 ± 26 and 132 ± 64 min. There were 2 perioperative deaths (7%; both valve replacement) and 2 patients died late (32 days to 1.2 years postoperatively). Freedom from cardiac death at 10 years was 96% after valve repair and 50% after replacement. Two patients required reoperation (1.68 and 16 years) following repair. One underwent valve replacement for cusp perforation, the other, root remodelling for dilatation. Freedom from autograft reintervention at 15 years was 95%., Conclusions: Autograft reoperations after the Ross procedure can be performed as valve-sparing operations in the majority of cases. With valve-sparing, long-term survival and freedom from reoperation are excellent., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: Ascending aortic aneurysms are associated with pre-existing conditions, including connective tissue disorders (i.e., Marfan syndrome) and bicuspid aortic valves. The underlying mechanisms remain uncertain. Even less is known regarding ascending aortic aneurysms in individuals with normal (i.e., tricuspid) aortic valves (TAV), and without known aneurysm-associated disorders. Regardless of etiology, the risk of aortic complications increases with biological age. Phenotypic modulation of smooth muscle cells (SMCs) is a feature of ascending aortic aneurysms, whereby contractile SMCs are replaced with synthetic SMCs that are capable of degrading the aortic wall. We asked whether age itself causes dysfunctional SMC phenotype modulation, independent of aortic dilatation or pre-existing aneurysm-associated diseases., Methods: Non-dilated ascending aortic samples were obtained intra-operatively from 40 patients undergoing aortic valve surgery (range: 20-82 years old, mean: 59.1 ± 15.2). Patients with known genetic diseases or aortic valve malformations were excluded. Tissue was divided, and a portion was formalin-fixed and immunolabeled for alpha-smooth muscle actin (ASMA), a contractile SMC protein, and markers of synthetic (vimentin) or senescent (p16/p21) SMCs. Another fragment was used for SMC isolation ( n = 10). Cultured SMCs were fixed at cell passage 2 and stained for phenotype markers, or were cultured indefinitely to determine replicative capacity., Results: In whole tissue, ASMA decreased (R 2 = 0.47, P < 0.0001), while vimentin increased (R 2 = 0.33, P = 0.02) with age. In cultured SMCs, ASMA decreased (R 2 = 0.35, P = 0.03) and vimentin increased (R 2 = 0.25, P = 0.04) with age. p16 (R 2 = 0.34, P = 0.02) and p21 (R 2 = 0.29, P = 0.007) also increased with age in SMCs. Furthermore, the replicative capacity of SMCs from older patients was decreased compared to that of younger patients ( P = 0.03)., Conclusion: By investigating non-dilated aortic samples from individuals with normal TAVs, we found that age itself has a negative impact on SMCs in the ascending aortic wall, whereby SMCs switched from the contractile phenotype to maladaptive synthetic or senescent states with increased age. Therefore, based on our findings, modification of SMC phenotype should be studied as a therapeutic consideration against aneurysms in the future, regardless of etiology., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Balint, Bernstorff, Schwab and Schäfers.)

Objectives: Our goal was to evaluate the outcome of valve-sparing root replacement (VSRR) and to compare the outcomes to those of patients having composite valve-graft conduit aortic root replacement (CVG-ARR) in a cohort of patients with aortic root aneurysm ± valve insufficiency, without valvular stenosis. Although valve-sparing procedures are preferable in young patients, there is a lack of comparative data in comparable patients., Methods: The VSRR procedures were performed in 2005 patients, and 218 patients underwent a CVG-ARR procedure. Exclusion criteria included aortic dissection, endocarditis and valvular stenosis. Propensity score matching (3:1 ratio) was applied to compare VSRR (reimplantation 33% and remodelling 67%) and CVG-ARR., Results: We matched 218 patients with CVG-ARR to 654 patients with VSRR (median age, 56.0; median follow-up was 4 years in both groups; interquartile range 1-5 years). Early mortality was 1.1% of those who had VSRR versus 2.3% in those who had CVG-ARR. Survival was 95.4% [95% confidence interval (CI) 94-97%] at 5 years in patients who had VSRR versus 85.4% (95% CI 82-92%) in those who had CVG-ARR; P = 0.002. Freedom from reintervention at 5 years was 96.8% (95% CI 95-98%) with VSRR and 95.4% (95% CI 91-99%) with CVG-ARR (P = 0.98). Additionally, there were more thromboembolic, endocarditis and bleeding events in the patients who had CVG-ARR (P = 0.02)., Conclusions: This multicentre study shows excellent results after valve-sparing root replacement in patients with an ascending aortic aneurysm with or without valve insufficiency. Compared to composite valve-graft aortic root replacement, survival is better and valve-related events are fewer. Consequently, valve-sparing procedures should be considered whenever a durable repair is feasible. We advocate a valve-sparing strategy even in more complex cases when performed in experienced centres., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Background: Isolated repair of the regurgitant tricuspid aortic valve has become an increasingly practiced alternative to replacement, even though durability data are scarce. We analyzed the midterm results of tricuspid aortic valve repair to determine whether the mechanism of regurgitation or operative technique influences the results., Methods: Between December 1997 and August 2014, 264 patients underwent isolated tricuspid aortic valve repair in our institution. The mean age was 59 ± 16 years; 77% (n = 203) were male. Clinical and operative data were recorded. The patients were observed clinically and echocardiographically., Results: Survival was 76.7% ± 3.5% after 10 years and 57.2% ± 11.5% after 15 years (median, 224 months). Intraoperative measurement of effective height was significantly associated with improved long-term survival (P = .001). Cumulative freedom from reoperation was 88.1% ± 2.1% after 5 years and 73.3% ± 4.2% after 10 years. Freedom from recurrent aortic regurgitation 2+ was 85.9% ± 5.2% after 5 years and 66.9% ± 5.2% after 10 years. Freedom from reoperation was significantly higher in patients with cusp prolapse compared with retraction as the primary regurgitation mechanism (P = .041). The use of circular annuloplasty had no significant influence on survival or durability., Conclusions: Long-term survival after tricuspid aortic valve repair is good, considering the age of the patients. Repair of cusp retraction has a poorer durability compared with repair of prolapse. The use of effective height in tricuspid aortic valve repair is associated with improved survival., (Copyright © 2023 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

We sought to determine whether there are differences in transforming growth factor-beta (TGFß) signaling in aneurysms associated with bicuspid (BAV) and unicuspid (UAV) aortic valves versus normal aortic valves. Ascending aortic aneurysms are frequently associated with BAV and UAV. The mechanisms are not yet clearly defined, but similarities to transforming growth factor-beta TGFß vasculopathies (i.e. Marfan, Loeys-Dietz syndromes) are reported. Non-dilated (ND) and aneurysmal (D) ascending aortic tissue was collected intra-operatively from individuals with a TAV (N = 10ND, 10D), BAV (N = 7ND, 8D) or UAV (N = 7ND, 8D). TGFß signaling and aortic remodeling were assessed through immuno-assays and histological analyses. TGFß1 was increased in BAV/UAV-ND aortas versus TAV (P = 0.02 and 0.04, respectively). Interestingly, TGFß1 increased with dilatation in TAV (P = 0.03) and decreased in BAV/UAV (P = 0.001). In TAV, SMAD2 and SMAD3 phosphorylation (pSMAD2, pSMAD3) increased with dilatation (all P = 0.04) and with TGFß1 concentration (P = 0.04 and 0.03). No relationship between TGFß1 and pSMAD2 or pSMAD3 was observed for BAV/UAV (all P &gt; 0.05). pSMAD3 increased with dilatation in BAV/UAV aortas (P = 0.01), whereas no relationship with pSMAD2 was observed (P = 0.56). Elastin breaks increased with dilatation in all groups (all P &lt; 0.05). In TAV, elastin degradation correlated with TGFß1, pSMAD2 and pSMAD3 (all P &lt; 0.05), whereas in BAV and UAV aortas, elastin degradation correlated only with pSMAD3 (P = 0.0007). TGFß signaling through SMAD2/SMAD3 contributes to aortic remodeling in TAV, whereas TGFß-independent activation of SMAD3 may underlie aneurysm formation in BAV/UAV aortas. Therefore, SMAD3 should be further investigated as a therapeutic target against ascending aortic dilatation in general, and particularly in BAV/UAV patients., (© 2022. The Author(s).)

Background: Unicuspid 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., Methods: This 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., Results: Throughout 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., Conclusion: Ross 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., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Gofus, Karalko, Fila, Ondrášek, Schäfers, Kolesár, Lansac, El-Hamamsy, de Kerchove, Dinges, Hlubocký, Němec, Tuna and Vojáček.)

Objectives: Root reimplantation has been the favoured approach for patients with heritable aortic disorder requiring valve-sparring root replacement. In the past few years, root remodelling with annuloplasty has emerged as an alternative to root reimplantation in the general population. The aim of this study was to examine the late outcomes of patients with heritable aortic disorder undergoing valve-sparring root replacement and compare different techniques., Methods: Using the AVIATOR registry (Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry), data were collected from 5 North American and European centres. Patients were divided into 4 groups according to the technique of valve-sparing used (root reimplantation, root remodelling with ring annuloplasty, root remodelling with suture annuloplasty and root remodelling alone). The primary endpoints were freedom from aortic regurgitation (AR) ≥2 and freedom from reintervention on the aortic valve. Secondary endpoints were survival and changes in annular dimensions over time., Results: A total of 237 patients were included in the study (reimplantation = 100, remodelling + ring annuloplasty = 76, remodelling + suture annuloplasty = 34, remodelling alone = 27). The majority of patients had Marfan syndrome (83%). Preoperative AR ≥2 was present in 41% of the patients. Operative mortality was 0.4% (n = 1). No differences were found between techniques in terms of postoperative AR ≥2 (P = 0.58), reintervention (P = 0.52) and survival (P = 0.59). Changes in aortic annulus dimension were significantly different at 10 years (P < 0.05), a difference that started to emerge 4 years after surgery., Conclusions: Overall, valve-sparring root replacement is a safe and durable procedure in patients with heritable aortic disorder. Nevertheless, root remodelling alone is associated with late annular dilatation. The addition of an annuloplasty, however, results in similar freedom from AR, reintervention, survival and changes in annulus size compared to reimplantation., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: We have proposed an external stabilization technique to minimize autograft dilatation after the Ross operation. This study analyzed autograft function and root dimensions after root replacement with and without external root support., Methods: Between October 1995 and February 2021, 185 adult patients (73% male; age, 38 ± 9 years) underwent a Ross operation as full-root replacement, 136 with support and 49 without support. Autograft function and root dimensions were determined echocardiographically. Median follow-up was 3.4 years (interquartile range, 1.13-14.74 years) and was 95% complete. Survival and freedom from reoperation were calculated. Changes in autograft root dimensions were analyzed using mixed-effect models., Results: Survival (95%) and freedom from autograft reoperation (94%) at 15 years were higher with than without support (P = .003 or P = .004). In the first 5 years, patients with support showed an indexed root size progression of 0.712 mm/(y ∙ m) (P = .003) compared with 1.554 mm/(y ∙ m) (P = .001) without. Progression rates were higher for patients without stabilization (P = .045). After 5 years, progression rates were similar in both groups at 0.248 mm/(year ∙ m) (P < .001) but with persistent a difference between the groups., Conclusions: The Ross procedure as full-root replacement is associated with a relevant rate of autograft dilatation and reoperation. The use of external root stabilization may reduce autograft dilatation and is associated with improved survival and durability., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background  Quadricuspid aortic valve is rare and occasionally associated with aortic regurgitation and ascending aortic dilatation. Recent studies suggest an association of aortic regurgitation with ascending aortic medial degeneration. Case Description  Histologic evaluation of ascending aortic tissue of two individuals with regurgitant quadricuspid aortic valve, one dilated, one non-dilated, yielded comparable degeneration in the Media. Conclusion  Regurgitation of quadricuspid aortic valve may lead to the degeneration of Tunica media of the ascending aorta., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: Bicuspid aortic valves may be associated with ascending aortic aneurysm, or develop severe aortic regurgitation with variable aortic dilatation. If aortic dilatation involves the root, valve-preserving root replacement is a treatment option, and we prefer root remodeling for this purpose. The objective of this study is to review our experience encompassing 25 years., Methods: Between November 1995 and August 2021, 472 patients (429 male; age 9-80 years; mean 48±13 years) were treated by bicuspid aortic valve repair and root remodeling. Aortic regurgitation was present in 322 cases. The primary indication for surgery was aortic regurgitation (n=317), aortic aneurysm (n=143) or acute type A aortic dissection (n=12). In 271 instances, a suture annuloplasty was added. Cusp calcification was present beyond the raphe in 80 cases, and a pericardial patch was used for partial cusp replacement in 44 cases. Follow-up was 92.8% complete with a mean of 71±68 months (median 61 months)., Results: Hospital mortality was 0.4% and survival at 20 years was 76.9%. Reoperation was necessary for recurrent aortic regurgitation in 26 patients; nine patients underwent reoperation for stenosis. The overall freedom of reoperation was 90.5% after ten years and 76.6% after 20 years. Annuloplasty was associated with a higher proportion of competent aortic valves at discharge (P=0.001), and had no effect on ten-year freedom from reoperation. The use of a pericardial patch for cusp repair was a predictor for reoperation (P=0.003). The presence of cusp calcification was a predictor for the development of aortic stenosis and reoperation (P=0.032)., Conclusions: Bicuspid aortic valve repair combined with root remodeling leads to excellent ten- and 20-year results. Cusp calcification and partial cusp replacement are associated with an increased probability of valve failure requiring reoperation., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare., (2022 Annals of Cardiothoracic Surgery. All rights reserved.)

Background: Valve failure may occur after valve-sparing aortic root replacement. Little is known about the exact mechanisms of failure. This study analyzed reoperations after aortic root remodeling to determine failure modes, operative risk, and long-term outcome., Methods: Between November 1995 and December 2019, 1084 patients were treated by root remodeling. Of these, 54 (49 male; aged 8 to 79 years) underwent reoperation for valve failure (1 week to 16 years postoperatively). The indications for reoperation were aortic regurgitation (n = 39), aortic stenosis (n = 6), endocarditis (n = 7), or ventricular septal defect (n = 2). The main causes of valve failure were cusp repair failure (n = 29), endocarditis (n = 7), and cusp retraction (n = 8). The patients were treated by valve replacement (n = 40) or cusp repair (n = 14). In 6 individuals, combined replacement of valve and root was performed. All 54 patients were followed up (mean, 69 ± 54 months after reoperation), and 1 patient was lost to follow-up., Results: No patient died in the hospital or had atrioventricular block development; 12 patients died late, with 10- and 15-year survivals of 87% ± 5.1% and 64% ± 10.6%, respectively. Of the 14 patients who underwent repeat cusp repair, 7 (50%) are still alive with stable valve function, 17 months to 15 years after their reoperation. Eleven patients required a second reoperation leading to a freedom from repeat reintervention rate of 68% ± 9.7% at 15 years., Conclusions: The main causes of failure of root remodeling are cusp related. Reoperations can be performed with low morbidity and mortality. In selected patients, isolated cusp repair may be an option., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The Ross-Konno operation is effective for enlargement of a hypoplastic aortic annulus and left ventricular outflow tract. It is, however, an invasive operation with the potential for early and late cardiac morbidity. We propose a new technique of annular and outflow tract enlargement that avoids the septal incision while effectively opening up the outflow tract and aortic annulus., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

The purpose of this paper is to describe all available evidence on the distinctive features of a group of 4 life-threatening acute aortic pathologies gathered under the name of acute aortic syndrome (AAS). The epidemiology, diagnostic strategy, and management of these patients has been updated. The authors propose a new and simple diagnostic algorithm to support clinical decision making in cases of suspected AAS, thereby minimizing diagnostic delays, misdiagnoses, and unnecessary advanced imaging. AAS-related entities are reviewed, and a guideline to avoid imaging misinterpretation is provided. Centralization of patients with AAS in high-volume centers with high-volume surgeons is key to improving clinical outcomes. Thus, the role of multidisciplinary teams, an "aorta code" (streamlined emergent care pathway), and aortic centers in the management of these patients is boosted. A tailored patient treatment approach for each of these acute aortic entities is needed, and as such has been summarized. Finally, a set of prevention measures against AAS is discussed., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. All rights reserved.)