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Background: Conventional stented valves (CV) remain gold standard for aortic valve disease. Bovine prostheses have been improved and rapid deployment valves (RDV) have arrived in the recent decade. We compare clinical and hemodynamic short-term outcome of six bovine valves., Methods: We retrospectively evaluated 829 consecutive patients (all-comers) receiving bovine aortic valve replacement (AVR). Four CV from different manufacturers (Mitroflow, Crown, Perimount, Trifecta) and two RDV (Perceval, Intuity) were compared in terms of pre-, intra-, and postprocedural data. A risk model for mortality was created., Results: All valves reduced gradients. From 23 mm, all CV showed acceptable gradients. Twenty-one millimeter Mitroflow/Perceval and 19 mm Crown showed above-average gradients. As baseline data differed, we performed propensity matching between aggregated isolated CV and RDV groups. Cardiopulmonary bypass (CPB), clamp, and surgery times were shorter with RDV (87.4 ± 34.0 min vs 111.0 ± 34.2, 54.3 ± 21.1 vs 74.9 ± 20.4, 155.2 ± 42.9 vs 178.0 ± 46.8, p  < 0.001). New pacemaker rate (10.1 vs 1.3%, p  = 0.016) and the tendency toward neurologic events (8.9 vs 2.5%, p  = 0.086) were higher using RDV, induced mainly by the Perceval. Early mortality was equal (2.5 vs 1.3%, p  = 0.560). Revision for bleeding, dialysis, blood products, length-of-stay, gradients, and regurgitation was also equal. Risk analysis showed that low valve size, low ejection fraction, endocarditis, administration of red cells, and prolonged CPB time were predictors of elevated mortality., Conclusion: Isolated bovine AVR has low mortality. Valves ≥ 23 mm show comparable gradients while the valve model matters < 23 mm. RDV should be used with care. Procedure-related times are shorter than those of CV but pacemaker implantation and neurologic events are more frequent (Perceval). Early mortality is low and valve performance comparable to CV., Competing Interests: None., (Thieme. All rights reserved.)

Objectives: To increase the safety of aortic valve replacement, we developed the 'Caput medusae' method, where the prosthesis is prefixed with circumferential tourniquets prior to knot tying. We assumed that an even distribution of forces may help reduce tissue damage. To confirm this theoretically, we compared forces between knots and tourniquets., Methods: The experimental set-up included a device with movable acrylic plates, a mounted valve and a set of sutures. Traction forces were measured with a luggage scale. Two different tourniquets were compared individually and as bundles of 15. Force-path curves were generated. Knotting and tourniquet forces of 18 staff surgeons were then compared. Both modalities were measured 10 times on 2 days, resulting in 40 observations per surgeon, or 360 observations per modality., Results: Polyvinyl chloride tourniquets were stiffer than silicone, expressed by a 1.5- to 1.7-fold higher regression-line slope. Fifteen simultaneous tubes produced force increments 7.9-8.9 times higher than their single counterparts. Overall knotting force was 13.64 ± 5.76 vs tourniquet 1.08 ± 0.48 N. Male surgeons' knotting forces were higher compared to female staff (14.76 ± 6.01 vs 10.73 ± 3.74 N; P < 0.001) while tourniquet forces did not differ (1.09 ± 0.47 vs 1.05 ± 0.49 N; P = 0.459). Dedicated valve surgeons (n = 10) tightened the tourniquets more strongly than inexperienced surgeons (1.20 ± 0.52 vs 0.94 ± 0.37 N; P < 0.001); knotting was similar. Multivariable analysis confirmed only valve experience as a predictor of tourniquet strength (experienced surgeons exerted higher force)., Conclusions: Tourniquets exert less force on the tissue than knots. When distributed over the circumference, they can reduce local tension and avoid potential paravalvular leakage. Complete or partial use of tourniquets may thus be an additional option to enhance surgical safety., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Interrupted pledget-armed braided sutures are widely used for valve implantation. In a 74-year-old woman with aortic valve endocarditis and shallow annular abscess, annulus dehiscence resulted after resection. As resistance was too high for sufficient primary approximation, a snug fit of the valve by means of circumferential application of curbed tourniquets resembling Medusa's head after suture placement was achieved. Closest possible approximation of the upper and lower part of the annulus with the prosthesis prior to final fixation was thus possible, so that application of too much tension on a single suture could be avoided., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background  Endovascular valve in stented biological valve implantation (valve-in-valve transcatheter aortic valve implantation [TAVI ViV]) is increasingly becoming a valid option for bioprosthesis degeneration. TAVI implantation in small stented biological valves below 23 mm is controversially discussed. Reduced opening area and high gradients are typical objections against this procedure in cases of small bioprosthesis. Systematic studies about the hemodynamic performance of endovascular valves in small stented bioprosthesis, however, do not exist. Methods  Stented biological valves of 21 mm size were analyzed in a pulse duplicator (cardiac output 4.9 L/min). Edwards Perimount Magna (EP; Edwards Lifesciences, Irvine, California, United States), Medtronic Mosaic (MM; Medtronic Inc., Minneapolis, Minnesota, United States), and Sorin Mitroflow (SM; Milan, Italy) were investigated (three valves, each type). Mean transvalvular gradients were measured before and after implantation of Edwards Sapien 23 mm (SAP) as ViV. Results  There were no marked differences of mean transvalvular gradients before and after ViV (EP21: 12.3 mm Hg; EP21 + SAP: 11.1 mm Hg; SM21: 13.5 mm Hg; SM21 + SAP: 14.9 mm Hg; MM21: 21.4 mm Hg; MM21 + SAP: 15.1 mm Hg). MM valves fabricated from porcine cusps showed higher initial gradients in contrast to valves constructed with pericardium (EP and SM). After ViV, however, this difference was reduced. Conclusion  This in vitro study shows that hemodynamic performance of endovascular valves as ViV in small bioprosthesis does not differ significantly from the performance of the initial implanted prosthesis. Hemodynamic performance of porcine cusp valves could even be optimized. It can thus be speculated that TAVI ViV also offers a reasonable option for patients with typical stented bioprosthetic degeneration to substantially prolong adequate function with one initial surgical and one consecutive interventional procedure even in small valves., (Georg Thieme Verlag KG Stuttgart · New York.)

Endovascular valves have become a valid option for patients not qualifying for conventional surgery. Biological valves mounted in a stent are currently used. After implantation, however, geometrical distortion of the valve can occur. We tested whether biological valves suitable for transcatheter implantation exhibit hemodynamic deficits after deployment in a distorted position. Two types of valves [bovine pericardium (BP) and porcine cusps], of 21 and 23 mm diameter, respectively were investigated. Mean transvalvular gradient (TVG), effective orifice area (EOA), and regurgitation fraction (REG) were measured prior to and after the 20% distortion of the original diameter. All valves exhibited an increase of TVG and reduction of EOA whereas REG increased only in BP valves after distortion. The 21 mm valves demonstrated a more pronounced alteration than the 23 mm valves. Even moderately distorted implantation of a biological valve results in a marked functional alteration. The susceptibility of pericardial valves is higher than that of porcine valves probably owing to better coaptation properties of native cusps even under deformed conditions when compared to valves constructed with pericardium. Care should therefore be taken during implantation of endovascular valves in order to avoid fixed hemodynamic deficits. Native valves may preferably be used as they demonstrate a more robust behavior regarding suboptimal implantation.

After almost 20 years aortic root reconstruction modalities have evolved into reasonable and useful surgical measures. Short and long term results match those of aortic composite replacement. Three major restitution strategies have found widespread acceptance: Root replacement with valve reimplantation (David-Procedure), root remodeling (Yacoub-procedure), or commissural resuspension. In the wake of these modalities also isolated aortic valve repair techniques have found renewed interest in order to broaden the indication for reconstructive surgery. Some euphemistic and hence biased interpretation, however, should be considered when looking at the clinical results. Reimplantation and remodeling procedures as well as several valve repair maneuvers are technically demanding unfolding their potential only in the hands of an experienced surgeon. Definite guidelines regarding the appropriate method of restitution required to serve best in the patient's individual situation are not yet at hand although they are about to emerge.

Various techniques of stentless aortic valve implantation with or without wall components exist. We investigated the in-vitro performance of stentless valves without or with aortic wall removal mimicking root versus subcoronary implantation. Glutaraldehyde-preserved stentless aortic valves (gpSVG), cryo-preserved human homografts (cpHG), cryo-preserved xenografts (cpXG), and fresh xenografts (fXG) were used. Valves were mounted as full roots or trimmed in a mock circuit. Mean transvalvular gradient (MTVG, mmHg) was measured. Distensibility was quantified using post-systolic backflow volume (BV, ml) - after valve closure. Function was visualized by means of a high-speed camera. Glutaraldehyde-preserved valves exhibited higher MTVG than cryo-preserved or fresh substitutes. After trimming, cpHG, cpXG, and fXG demonstrated marked reduction of MTVG (cpHG: 7.6-5.2 mmHg; cpXG: 6.7-4.9 mmHg; fXG: 8.4-5.2 mmHg). In contrast, after trimming gpSVG exhibited a significant increase of MTVG (7.1-9.2 mmHg). BV remained constant. Visualization indicated maintained distension of all valves and types of all sizes after trimming. In fresh and cryo-preserved grafts, aortic wall trimming resulted in significantly improved systolic performance while glutaraldehyde-preserved stentless valves demonstrated systolic impairment after wall resection. Subcoronary implantation of fresh or cryo-preserved aortic valves may therefore be preferred. In contrast, glutaraldehyde-preserved valves are dependent on wall suspension and may therefore be implanted as a root.

Objective: Biological valves exhibit characteristic curves (CC) regarding transvalvular gradient, resistance, and effective orifice area when correlated with a physiological cardiac output range (CO). The slope of the curve of transvalvular resistance over a typical CO range characterizes the clinical performance of the valve. These information may support an individualized decision towards the most adequate valve type., Methods: In an extracorporeal mock circuit two types of stented biological aortic valves (constructed pericardial valves, Edwards Perimount: EP; porcine cusp valves, Medtronic Mosaic: MM) of 21, 23, and 25 mm were investigated. Mean transvalvular gradient was measured over a range of 1.9 to 7.2l/min CO at a simulated heart rate of 70 beats/min. Transvalvular resistance was calculated and presented as characteristic curves in a log-log-plot against cardiac output., Results: EP valves of all sizes demonstrated low slopes (resistance range; slope: 21 mm: 53-79 dynes s cm(-5); 0.29; 23 mm: 44-56 dynes s cm(-5); 0.12; 25 mm: 38-45 dynes s cm(-5); 0.12) while MM valves exhibited steep slopes (resistance range; slope: 21 mm: 46-169 dynes s cm(-5); 0.97; 23 mm: 36- -146 dynes s cm(-5); 0.95; 25 mm: 27-64 dynes s cm(-5); 0.68)., Conclusions: While constructed pericardial valves demonstrate sufficient hemodynamic performance especially in the higher CO range porcine cusp valves exhibited minor resistance in the lower CO range. Patients who exercise regularly may therefore profit from a pericardial valve while patients with a small body surface area and little exercise who therefore remain in the lower CO range may be adequately treated with a porcine cusp valve.

Reconstruction of the aortic valve and replacement of the ascending aorta instead of use of a composite graft is the preferred method in patients, who demonstrate an ascending aneurysm accompanied by aortic root enlargement and aortic valve insufficiency with morphologically intact cusps. Two techniques inaugurated by David and Yacoub have gained widespread acceptance. However, both approaches are technically demanding. We present a simplified alternative technique for aortic valve reconstruction by means of a reduction plasty of the aortic root without the necessity of transection maneuvers.

Objectives: Severe sclerosis of the native aortic annulus can result in a tilted implantation position of mechanical prostheses. In this study, the effects of tilting and rotation on the hemodynamic performance of standard bileaflet valves were assessed in an extracorporeal mock circulatory system., Methods: A pulsatile mock circulation driven by a Berlin Heart system was developed. Main physiological components of the human circulation were mimicked. SJM-AHPJ prostheses (21, 23, 25 mm) were mounted in an artificial aortic root containing physiologically oriented coronary ostia. All experiments were performed under constant conditions (stroke volume 60 ml, heart rate 70 bpm, systolic pressure 130 mmHg). Hydrostatic pressures were measured via fluid-filled catheters, transvalvular flow by ultrasonic probes. Data were digitally recorded at 50 Hz. Multiple pressure, volume, energy, and dimension parameters were derived off-line. Each valve was tested in a 0 degrees (untilted) versus 20 degrees (tilted) position at three axial rotation angles (0 degrees, 45 degrees, 90 degrees ). Tilting was performed independent of rotation by elevation of the prosthesis in the non-coronary sinus., Results: In all valves and all rotation angles, tilting resulted in a size-dependent significant increase of mean pressure gradient (range, 28-35% [21 mm valve], 59-96% [23 mm valve], 124-220% [25 mm valve]), valvular resistance (39-51, 84-121, 177-332%), regurgitation volume (84-148, 32-131, 93-118%), and systolic energy loss (113-146, 30-132, 69-213%), as well as a decrease of total stroke volume (2-5, 0-11, 3-10%), effective stroke volume (6-11, 9-14, 14-22%), cardiac output (6-11, 8-14, 13-22%), and effective opening area (16-24, 32-37, 47-57%). The strongest impairment of hemodynamic performance was seen at 90 degrees rotation with reference to total and effective stroke volume, cardiac output, mean pressure gradient, and regurgitation fraction., Conclusions: Tilting of bileaflet valves resulted in a significant impairment of systolic and diastolic hemodynamics. Superiority of larger valves diminished in the tilted position. The strongest tilting effect was seen at 90 degrees rotation. Such a position should therefore be avoided or surgically corrected by rotating the valve.