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We aimed to compare the outcomes of transcatheter aortic valve implantation (TAVI) with surgical aortic valve replacement (SAVR) in an elderly but nonfrail, minimally co-morbid population. Although data comparing these 2 procedures in intermediate- and low-risk patients are mounting, no distinction has been made between co-morbidity and age/gender as driving forces for surgical risk. Patients undergoing isolated TAVI or SAVR between May 2008 and March 2015 were documented. Data for 225 patients (TAVI 132, SAVR 93) aged ≥75 and <86 years and fulfilling minimal-risk criteria were analyzed. Patients who underwent TAVI were older (80.7 vs 77.4 years, p <0.0001) and had a higher mean Society of Thoracic Surgeons score (2.16% vs 1.72%, p <0.0001). Mild prosthetic valve regurgitation (odds ratio [OR] 4.9, 95% confidence interval [CI] 3.34 to 7.20) was more likely after TAVI, as were renal complications (predominantly stage I acute kidney injury; OR 2.86, 95% CI 1.79 to 4.55) and new pacemaker implantation (OR 3.33, 95% CI 1.76 to 6.26) at 30 days; however, life-threatening bleeding (OR 0.58, 95% CI 0.36 to 0.93) and reintervention for bleeding (OR 0.03, 95% CI 0.01 to 0.13) were less likely. Survival was comparable between groups at 30 days (99.2% vs 100%, p = 1.0) and 1 year (96.2% vs 96.8%, OR 0.85, 95% CI 0.20 to 3.63, p = 0.823), but it was poorer for patients who underwent TAVI at 2 years (OR 0.31, 95% CI 0.16 to 0.61). In conclusion, the short-term outcomes of TAVI in elderly, low-risk, minimally co-morbid patients appear to be similar to those of SAVR, with access-specific complications. Although these results point toward the potential for more liberal use of TAVI in minimal-risk patients, poorer midterm survival remains a concern, requiring further exploration., (Copyright © 2018. Published by Elsevier Inc.)

Objective: The aim of the study was to evaluate the operative and functional results after individual, patient-tailored aortic root repair in marfanoid patients., Methods: Among 518 patients who underwent operation between 2002 and January 2016, using patient-tailored aortic root repair with isolated sinus replacement, 42 patients fulfilled the original Ghent criteria. None/trivial, mild, moderate, and severe insufficiency grades were present in 5, 16, 10, and 11 patients, respectively., Results: The repair was adjusted to the existing aortic annulus diameter. Replacement of 1, 2, or 3 sinuses of Valsalva was performed in 1, 14, and 27 patients, respectively. Concomitant cusp repair was performed in 17 patients (40.5%), and 10 patients (23.8%) underwent arch repair (total in 3). All patients survived surgery, and the follow-up (mean, 6.1 ± 3.1; range, 0.8-14.2 years) was 100% complete. No patient had a change in the form or size of the aortic neo-root, especially the size of aortic annulus and sinotubular junction during the follow-up time. No and trivial/mild insufficiency were present in 22 and 18 patients, respectively, and 2 patients with recurrent aortic insufficiency caused by cusp pathology underwent aortic valve replacement 43 and 66 months after the primary surgery, respectively. Thus, the estimated survival free from aortic valve/root reoperation for any reason at 5 and 8 years was 96.8% ± 3.2% and 91.4% ± 6.0%, respectively., Conclusions: Patient-tailored root repair using isolated sinus replacement is an effective and durable method of valve-sparing repair in select marfanoid patients with a satisfactory quality of aortic cusps, which seems to be decisive for long-term valve function., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Isolated repair of the regurgitant bicuspid aortic valve (BAV) has yielded suboptimal durability, with annular dilatation being important risk factor for recurrent aortic regurgitation. We hypothesized that adding a suture annuloplasty (SA) should lead to improved repair stability., Methods: Between July 1999 and September 2014, 268 patients (mean age, 41 ± 13 years, 249 male) underwent isolated BAV repair. From January 2009 to September 2014, 164 consecutive patients (study group) underwent SA using either braided polyester (n = 37) or expanded polytetrafluorethylene (PTFE) (n = 127). Patients who underwent surgery prior to January 2009 served as controls (n = 104). All patients were followed (98.9% complete, 1 week to 181 months)., Results: Annular size was larger in the study group (p < 0.001) and age was lower (p < 0.001). There were no differences between the groups regarding other clinical data. Hospital mortality was 0.7% (n = 2), 10-year survival was 94.2%. Thirty-six patients required valve-related reoperations (8 days to 94 months postoperatively; controls = 32, study = 4). Complications related to SA (ventricular septal defect, interference with coronary artery) occurred in 6 (3.7%) patients, in 4 (10.8%) patients with polyester SA and in 2 (1.6%) patients with PTFE. In the control group freedom from reoperation at 5 and 10 years was 73.2% and 63.7%, respectively. With SA, 5-year stability was significantly improved to 92.6% (p = 0.0006); it was 96.7% for PTFE versus 83.5% for polyester SA (p = 0.0132)., Conclusions: Annular dilatation is a risk factor for failure after repair of regurgitant BAV. Its elimination through the use of SA significantly improves repair stability. With PTFE as material for SA optimal repair stability and minimal local complications are achieved., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Previous experience with repair of the regurgitant bicuspid aortic valve (BAV) has shown a strong influence of commissural orientation on repair durability. We have modified commissural orientation by asymmetric plication of the fused sinuses. We analyzed the results of the modified technique., Methods: Between 2009 and 2014, 35 patients with BAV and commissural orientation of no more than 160° underwent aortic valve repair, including plication of the fused sinuses and circular annuloplasty. The control group consisted of 21 historic controls undergoing operations between 2000 and 2008 but without sinus plication; subcommissural plication was used as annuloplasty. The groups were similar in most respects; differences existed in preoperative annular diameter, prevalence of complete fusion, use of a pericardial patch, and plication of the fused cusp., Results: At discharge the degree of aortic regurgitation (AR) was significantly lower in the study group (p = 0.004). Survival after 5 years was 100% in the study group and 95.2% in the control group after 5 and 10 years. Five-year freedom from reoperation in the study group was 93.0% and 57.1% in the control group (p = 0.0013); freedom from valve replacement was 95.8% and 79.3% (p = 0.036). Freedom from recurrent AR grade II or higher was 67.1% in the study group and 33.3% in the control group (p = 0.0024). Mean postoperative peak gradient was significantly lower in the study group (14.3 ± 6.5 mm Hg versus 28.9 ± 18.5 mm Hg, p = 0.003)., Conclusions: Plicating the fused sinuses and thus reducing root circumference in the fused part changes commissural orientation of the BAV which leads to better short- and midterm stability in BAV repair., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Residual/progressive aortic regurgitation (rAR, pAR) after valve-sparing aortic root replacement (V-SARR) can lead to reoperations. We sought to characterize risk factors of mild rAR and pAR after V-SARR in a multicenter cohort. The effect of additional cusp repair on valve function was analyzed using propensity matching., Methods: A total of 1,015 patients after V-SARR were identified with (n = 288, 28%) or without additional cusp/commissure repair (n = 727, 72%) at four cardiac units in Germany. A total of 764 patients fulfilling transthoracic echocardiography follow-up-criteria comprised the study cohort. Logistic regression was used for risk factor analysis with endpoints rAR, new onset AR, and pAR. t tests and analyses of variance were used for between-group differences. The effects of additional cusp repair on valve function were studied comparing propensity-matched quintiles., Results: The incidence of rAR was 29%, with influencing factors aneurysm size (p = 0.07) and preoperative aortic valve function (p = 0.08). It was found more often among nonsyndromic patients (34% vs. 14%; OR, 0.4; p < 0.001). Progression of rAR was detectable in 30% after a mean of 4.3 years. The progression rate of rAR ∼ 0.3 grades per patient-year within the first 5 years. When quintiles identified by propensity score were compared, additional cusp repair was linked to new onset AR (p = 0.016) while it was not linked to rAR (p = 0.14) or pAR (p = 0.5)., Conclusions: The incidences of rAR and pAR are considerable after V-SARR. Patients should be operated on before large aneurysms are present. New onset AR after an initially good functional result is more likely after an additional cusp repair, while rAR and pAR are not influenced by cusp repair., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)