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We investigated long-term outcomes of bicuspid aortic valve (BAV) repair, with external annuloplasty, according to aorta phenotype.Between 2003 and 2020, all patients with BAV operated on for aortic insufficiency (AI) and/or aneurysm were included. Repairs included isolated AI repair with subvalvular with or without sinotubular junction (STJ) (single or double) annuloplasty, supracoronary aorta replacement (with or without hemiroot remodeling), and root remodeling with external subvalvular ring annuloplasty.Among 343 patients operated, reparability rate was 81.3% (n = 279; age 46 ± 13.3 years). At 10 years (median follow-up: 3.42 years; interquartile range, 1.1, 5.8), survival was 93.9% (n = 8 deaths, similar to general population), cumulative incidence of reoperation was 6.2% (n = 10), AI grade2 was 5.8% (n = 9), and grade1 was 23.0% (n = 30). BAV repair stabilizing both the annulus and STJ with annuloplasty, compared with nonstabilized STJ repair (single annuloplasty), had lower incidence of reoperation (2.6% vs 22.5%, P = .0018) and AI grade2 (1.2% vs 23.6%, P .001) at 9 years. Initial commissural angle160° was not a risk factor for reoperation, compared with angle ≥160° if symmetrical repair was achieved (2.7% and 4.1%, respectively, at 6 years, P = .85). Multivariable model showed that absence of STJ stabilization (odds ratio, 6.7; 95% confidence interval, 2.1-20, P = .001) increased recurrent AI, but not initial commissural angle160° (odds ratio, 1.01; 95% confidence interval, 0.39-2.63, P = .98). Commissures adjusted symmetrically led to lower transvalvular gradient, compared with nonsymmetrical repair (8.7 mm Hg vs 10.2 mm Hg, P = .029).BAV repair, tailored to aorta phenotype, is associated with excellent durable outcomes if both annulus and STJ are reduced and stabilized with external ring annuloplasty. Commissural angle160° is not associated with reoperation if symmetrical repair is achieved.

OBJECTIVES The aim of this study was to compare short- and longer-term outcomes of David (DV) versus Florida sleeve (FS) procedure in patients requiring valve-sparing aortic root replacement. METHODS Between January 1996 and December 2020 285 patients received a DV procedure (median age 60 years; 26% females) and 57 patients underwent an FS procedure (median age 64 years; 19% females) in our department. Propensity score matching using patient characteristics led to 58 (DV) versus 57 (FS) patients. End points were defined as primary: freedom from aortic valve and/or aortic root-related reoperation and freedom from aortic regurgitation ≥moderate and secondary: early and late survival. RESULTS Thirty-day mortality was 2% (DV) and 0% (FS) (P = 0.319). There was 1 early stroke in each group (P = 0.990). Follow-up was complete in 99% with only 1 patient (FS) lost. The 5- and 10-year freedom from aortic valve and/or aortic root related reoperation was 98 ± 2% and 96 ± 3% in the DV group and 92 ± 5% and 84 ± 9% in the FS group, respectively (P = 0.095). The 5- and 10-year freedom from aortic regurgitation ≥moderate was 88 ± 5% and 80 ± 8% in the DV group and 92 ± 5% and 78 ± 1% in the FS group, respectively (P = 0.782). The 5- and 10-year survival rates were 93 ± 4% and 82 ± 6% (DV) vs 75 ± 7% and 67 ± 10% (FS), respectively (P = 0.058). No case of endocarditis (DV) and 3 cases of endocarditis (FS) (P = 0.055) were observed during follow-up. CONCLUSIONS Both DV and FS resulted in similar early and longer-term outcomes with a trend to slightly better performance and survival in the DV group. Florida sleeve procedure might be an alternative approach for patients with higher-risk profiles requiring valve-sparing aortic root replacement.

Background The aim of this study was to evaluate the longer-term results of bicuspid aortic valve (BAV) repair with or without aortic root replacement. Methods From 1999 to 2017, 142 patients with or without aortic root dilatation who underwent repair of a regurgitant BAV were included in the study. Ninety-four patients underwent isolated BAV repair (Group 1; median age 43 years) and 48 patients underwent valve-sparing aortic root replacement plus BAV repair (aortic valve reimplantation-Group 2; median age 48 years). Median clinical follow-up time was 5.9 years (range 0.5-15) in Group 1 and 3 years (range 0.5-16) in Group 2, respectively. Results In-hospital mortality was 1% in Group 1, and 2% in Group 2 (p = .6). The 5- and 10-year survival was 93 ± 2.9% and 81 ± 5.8% in Group 1 and 96 ± 3.1% and 96 ± 3.1% in Group 2, respectively (p = .31). Eleven patients of Group 1 (1.7%/patient-year) and five patients of Group 2 (2.2%/patient-year) underwent reoperation of the aortic valve (p = .5). The 5- and 10-year freedom from reoperation were 93.0 ± 2.1% and 77.1 ± 7.1% in Group 1 and 93.0 ± 5.0% and 76.7 ± 9.6% in Group 2 (p = .83), respectively. At the latest follow-up, only two patients of Group 1 and 1 patient of Group 2 had AV regurgitation = 2° (p = .7). The cumulative linearized incidence of all valve-related complications (bleeding, stroke, endocarditis, and reoperation) was 2.9%/patient-year in Group 1% and 4%/patient-year in Group 2, respectively (p = .6). Conclusions Isolated BAV repair and combined aortic valve reimplantation plus BAV repair provide good clinical longer-term outcomes with relatively low reoperation rate and durable valve function.

OBJECTIVES The choice of optimal surgical treatment for young and middle-aged adults with aortic valve disease remains a challenge. Mechanical aortic valve replacement (mAVR) is generally preferred despite promising recent outcomes of the Ross procedure. Our goal was to compare the strategies at a nationwide level. METHODS This study was a retrospective analysis of prospectively recorded data from the National Registry of Cardiac Surgery of the Czech Republic. Using propensity score matching, we compared the outcomes of patients undergoing the Ross procedure in 2 dedicated centres with all mAVRs performed in country between 2009 and 2020. RESULTS Throughout the study period, 296 adults underwent the Ross procedure and 5120 had an mAVR. We found and compared 291 matched pairs. There were no in-hospital deaths, and the risk of perioperative complications was similar in both groups. Over the average follow-up period of 4.1 vs 6.1 years, the Ross group had a lower all-cause mortality (0.7 vs 6.5%; P = 0.015). This result remained significant even when accounting for cardiac- and valve-related deaths only (P = 0.048). Unlike the Ross group, the mAVR group had a significantly lower relative survival compared with the age- and sex-matched general population. There was no difference in the risk of reoperation (4.5 vs 5.5%; P = 0.66). CONCLUSIONS The Ross procedure offers a significant midterm survival benefit over mAVR. The procedures have a comparable risk of perioperative complications. Patients after mAVR have reduced survival. Thus, the Ross procedure should be the preferred treatment option for young and middle-aged adults with aortic valve disease in dedicated centres.

Standardization of aortic valve repair techniques with use of a calibrated annuloplasty have led to improved long-term outcomes in dystrophic aortic insufficiency. It can also improve dissemination of techniques and rates of aortic valve repair. Dystrophic aortic insufficiency can be found in three aortic phenotypes: dilated aortic root, dilated ascending aorta and isolated aortic insufficiency. The aortic annulus is invariably dilated above 25 mm in the vast majority of cases of aortic insufficiency, regardless of whether the aorta is dilated or not. A dilated annulus is a risk factor for late failure of aortic valve repair if not addressed at the time of surgery. We perform a calibrated annuloplasty at both sub- and supra-valvular levels in order to restore the ratio of sinotubular junction and annulus. Current evidence shows aortic valve repair reduces valve-related mortality compared to prosthetic valve replacement, with an improved quality of life.

OBJECTIVES Patients with a bicuspid aortic valve (BAV) often present with a dilated ascending aorta. However, the underlying pathogenesis for the observed changes in the aortic wall and the resulting aneurysmal dilation remains a subject of debate. This study aims to compare the histological abnormalities of the ascending aorta in BAV and tricuspid aortic valve (TAV) patients and their correlation with aortic diameter and patient age. METHODS A total of 376 patients from our institution’s clinical database were included in the retrospective analysis. These patients underwent either elective surgery for ascending aorta dilation or emergency surgery for aortic dissection, either isolated or with a structurally diseased aortic valve. After excision, the ascending aorta samples were analysed by a pathologist. RESULTS On histological examination, a higher degree of elastic fibre fragmentation and loss and mucoid extracellular matrix accumulation was present in the samples from TAV patients when compared with that from BAV patients (P CONCLUSIONS Our study demonstrates a greater incidence of severe histological abnormalities in TAV patients when compared with BAV patients.

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.

OBJECTIVES We sought to evaluate the outcome after modified subcoronary Ross/Ross–Konno operation in children and young adults. METHODS Between January 2013 and January 2019, a total of 50 patients with median age of 6.3 years (range 0.02–36.5 years, 58% males), including 10 infants (20%), received modified subcoronary Ross/Ross–Konno operation at our institution. Survival, morbidity, reinterventions, aortic valve function and aortic root dimensions were analysed. RESULTS At a median follow-up of 31.2 months (range 14.4–51 months), there were 1 early death and 1 late death, both in the infant group. The overall survival at 5 years after the operation was 95%. Two patients needed aortic valve replacement, 11 and 15 months after their Ross operation. At 5 years, freedoms from reoperation on the autograft and on the right ventricle to pulmonary artery conduit were 94% and 97%, respectively. Freedom from aortic valve regurgitation greater than mild was 97% at 5 years. Median dimensions of the aortic root at all levels remained in normal range at last visit. Forty-four patients (95%) were in New York Heart Association class I with normal left ventricular function. CONCLUSIONS The initial experience with the subcoronary Ross/Ross–Konno operation in children and young adults showed excellent outcome. The mortality and morbidity among infants remain significant. The described technique is reproducible and might be advantageous in situations when prosthetic supporting techniques interfere with somatic growth.

This report describes our reinforcement technique for the free-standing autograft in the full root Ross operation, using external suture annuloplasty and simplified root wrapping with native aortic wall. After implantation of the autograft in the aortic annulus, an expanded polytetrafluoroethylene suture is fixed outside the root at the basal plane and tied around a Hegar dilator placed into the autograft. By including the tongues of aortic root tissue at the distal anastomosis of the autograft, three tongues of original root wall lie outside the autograft commissures. This technique preserves autograft valve geometry and provides sufficient reinforcement of the free-standing autograft.

Invasive double valve endocarditis (aortic and mitral) involving the fibrous skeleton of the heart requires complex high-risk surgical management. The procedure which was originally suggested by Tirone David, consists of double valve replacement with pericardial or Dacron patches to re-create “neoaortomitral continuity” (1). This operation was named by the Cleveland Clinic group a “Commando procedure”, the Leipzig group use the term “UFO procedure” (2). In patients in whom the posterior mitral leaflet is not affected by the infection and at least the free edge of anterior mitral could be spared, a modification of the Commando procedure was suggested and named the “Hemi-Commando procedure” (3).

Background Current guidelines recommend root replacement when diameter of the sinuses of Valsalva are superior to 45 mm particularly for bicuspid valve. However, in case of tubular aorta aneurysms with moderate root dilatation (40-45 mm diameter), the approach is still debated regarding the increased risk of coronary reimplantation. We present a modified hemi-remodeling aortic repair technique that includes the replacement of the noncoronary sinus, ascending aorta, and valve repair with external ring annuloplasty in patients with bicuspid aortic valve (BAV) and moderately dilated aortic root. Methods Between 2003 and 2017, 18 patients presenting with left-right BAV and an aortic root diameter at 42.3+/-3.3 mm underwent hemi-root and ascending aorta replacement and aortic valve repair with external annuloplasty. Results Postoperatively, 16 (88.9%) had no aortic insufficiency (AI) and 2 (11.1%) had grade I AI, no patients had grade III or grade IV AI. Overall survival and freedom from grade II AI at 4 years and freedom from aortic valve-related reoperation were 100%. Conclusion The standardized modified hemi-remodeling technique we present is a safe and reproducible procedure, with satisfactory durability at follow-up. This technique represents an interesting alternative to full valve sparing root replacement, as it avoids the operative risk of coronary reimplantation, allows shorter cross-clamping time and a better exposition on the valve for a symmetrical repair, placing the commissure at 180°, compared with valve sparing root replacement.

OBJECTIVES Aortic valve (AV) insufficiency with normal root and ascending aorta is most frequently treated by valve replacement with significant prosthetic-related complications and reduced life expectancy. We compared the outcomes of a new standardized isolated AV repair approach using an external aortic annuloplasty ring at the subvalvular level (single ring annuloplasty) and the role of an additional supravalvular ring at the sinotubular junction (double ring annuloplasty). METHODS Single centre data were collected from the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR) between 2003 and 2017. A total of 93 patients (56 single ring and 37 double ring) underwent isolated AV repair. RESULTS The overall 30-day mortality rate and the need for a permanent pacemaker were 1% and 2%, respectively. The overall survival rate at 6 years was similar for sex- and age-matched members of the general population (89% vs 95%; P = 0.1) and did not differ between the double and single ring groups (82% vs 93%; P = 0.4) at 6 years. There were no thromboembolic or bleeding events in the entire cohort. However, at 6 years, the cumulative incidence of valve-related reintervention was 26% in the single ring annuloplasty group compared to 3% in the double ring annuloplasty (P = 0.02) group. Similarly, at 6 years, the cumulative incidence of moderate-to-severe (>2) aortic insufficiency was 30% in the single ring annuloplasty group compared to 0% in the double ring annuloplasty group (P = 0.007). CONCLUSIONS Standardized AV repair with external ring annuloplasty has a survival rate similar to that of the general population. The additional stabilization of the sinotubular junction with a second supravalvular ring (double ring annuloplasty) is associated with better outcomes compared to single subvalvular annuloplasty. It can be considered as a first line intervention for patients with isolated aortic insufficiency and pliable leaflets.

Background The aim of this study was to assess effectiveness, stability, position, and expansibility of an expansible aortic annuloplasty ring with computed tomography (CT). Methods Ten men (median age 51 years) scheduled for aortic root remodeling with implantation of external annuloplasty ring underwent contrast-enhanced CT of the aortic root preoperatively, postoperatively, and at a median of 21 months after operation. A reconstructed transverse double oblique view of the aortic base (AB) and of the new defined annuloplasty ring base (ARB; plane of the lower edge of the ring) in systole and diastole were obtained. The diameters, perimeter, and area were measured. In addition, the distances between AB and ARB in the nadir of each sinus were measured. Results We found 12% reduction of the postoperative AB and 19% of ARB perimeter in both systole ( p = 0.004, p p = 0.001, p p = 0.002, p = 0.001, respectively) and 33% reduction of the ARB area in systole and 32% in diastole ( p Conclusions This study demonstrates imaging evidence of the effectiveness, stability, and pulsatility of the annuloplasty ring in aortic root remodeling in follow-up and describes the exact position of the ring at the base of the aortic root.

Regurgitant aortic valve in case of a suitable morphology and the absence of stenosis does not need to be replaced but its preservation and repair may be attempted. Conserving aortic valve at surgery enables the patient to avoid antithrombotic therapy and minimalize complex valve-related risks for the long term. Aortic regurgitation is a complex result of aortic leaflets pathology and/or dilation pathology of the aortic root and ascending aorta. According to concrete patient pathology, reconstructive surgical interventions address three principal zones (aortic annulus, aortic leaflets, sinotubular junction—ascending aorta). A complex armamentarium of valve-sparing surgical interventions is discussed in detail, including also extraaortic conservative approaches.

The aortic valve may exist in congenitally anomalous variants that differ in the number of valve leaflets. Most important is the bicuspid aortic valve which is relatively frequent congenital disorder. Unicuspid aortic valve is less frequent and quadricuspid aortic valve is rare. All congenitally anomalous aortic valves display aberrant haemodynamic flow pattern and, despite a considerably long asymptomatic interval, are prone to develop into a significant aortic valve disease, either a stenosis or regurgitation (or both). Interrelation of aberrant aortic valve types and aortic dilation aortopathies is well documented though yet not fully understood. A thorough knowledge of congenital aortic anomalies is essential both for proper surgical strategy regarding the valve disease and decision for preventive surgery on a dilated ascending aorta.

Tal Golesworthy was first diagnosed with Marfan syndrome as a 5-year-old at the ophthalmic department of his local NHS hospital in 1962. Like his father, he had characteristic subluxated lenses. As the years passed, apart from height, he thought nothing more of Marfan syndrome until, in 1992, he attended a genetic study at St. Georges Hospital in London. At this examination he was first made aware of his aortic dilation and informed that his aortic root was already at 4.4 cm and would need annual monitoring and probably surgical intervention at some point in the future. The psychological unease this caused was compounded year on year as his aorta steadily dilated. By 2000, when he was 43 years old, his aorta had reached 5.0 cm and he was forced, finally, to face his fear of a total root replacement by conceiving of a personalised external support. He once again went to St. Georges Hospital in March 2000, this time to an Information Day run by the Marfan Association, a patient support group, where Professor Tom Treasure was presenting on aortic root surgery. At the end of Tom’s presentation he raised his arm and asked why we were not imaging the aorta, making a Computer Aided Design (CAD) model of it, using this to manufacture a physical model, using Rapid Prototyping, and there from a bespoke external support that would contain and fit the patient’s aorta. Tom engaged immediately and began with Tal what has become the defining R&D project of his life.

Aortic valve replacement is a procedure unique in its ability to resolve significant and worsening aortic valve disease of any aetiology. The valve substitute can be a mechanical valve (usually a bileaflet valve), bioprosthesis (stented, stentless, sutureless, or transcathetral), allograft, or autograft. Specific advantages and drawbacks of respective type of the valve substitute are discussed in detail. The in-hospital mortality of aortic valve replacement ranges between 2 and 3%. Potential valve-related complications comprise thromboembolic and bleeding events, valve thrombosis, degeneration of bioprostheses, paravalvar leak, and patient–prosthesis mismatch.

Repair of a regurgitant aortic valve, the main value of which is avoiding the valve replacement, has been a challenging issue since the early days of cardiac surgery. Over the period of 60 years, it is interesting and instructive to trace the development of various conceptual and practical approaches aimed on restoration of the aortic valve competence. Refinement of original visionary strategies has had to wait for decades for adequate progress to be made in diagnostic imaging modalities, to the current era of deeper insight in aortic valve physiological and pathological performance.

A one-step supraclavicular approach for the surgical treatment of the aberrant right subclavian artery is described in a case of dysphagia lusoria in a 38-year-old female. The approach allows for safe division of the arteria lusoria and its re-anastomosis to the common carotid artery while the patient benefits from a mini-invasive extrathoracic procedure. doi: 10.1111/jocs.12287 (J Card Surg 2014;29:519-522).

OBJECTIVES: Renal cell carcinoma with a tumour thrombus extending into the right heart chambers necessitates extensive combined urological and cardiac surgery. Maximum safety and exactness in extirpation of the caval and intracardiac thrombus is achieved under deep hypothermic circulatory arrest, at a price of its non-physiological burden and time constraints. We propose a simple surgical manoeuvre enabling selective arch perfusion allowing for a milder hypothermia and liberal interval of circulatory arrest. METHODS: On a routine cardiopulmonary bypass via median sternotomy, the dissection is extended along the aortic arch to identify the origins of the supra-aortic vessels. After standard aortic cross-clamping and cardioplegic cardiac arrest at moderate hypothermia, a second cross-clamp is applied at the aortic arch beyond the left carotid artery. A selective closed aortic arch perfusion is started while the extirpation of the tumour thrombus from the right atriotomy and abdominal cavotomy is being performed under conditions of circulatory arrest. RESULTS: Using selective aortic arch perfusion, successful and uncomplicated extirpation of voluminous caval and intracardiac tumour thrombi was accomplished in 3 presented patients. Unexpectedly difficult thrombus adhering to hepatic veins in 1 patient required 42 min of circulatory arrest. Postoperative courses were uneventful in all 3 patients. CONCLUSIONS: Second aortic cross-clamp to start selective closed aortic arch perfusion provides excellent surgical control of the operative field over a liberal time interval during circulatory arrest under milder hypothermia.

Objective Although the remodeling technique provides the most dynamic valve-sparing root replacement, a dilated annulus (>25 mm) is a risk factor for failure. Aortic annuloplasty aims to reduce the annulus diameter, thus increasing coaptation height to protect the repair. The results of 177 patients with remodeling and external aortic ring annuloplasty were studied. Methods Data were collected from the Aortic Valve repair InternATiOnal Registry. Preoperative aortic insufficiency grade 3 or greater was present in 79 patients (44.7%). The valve was bicuspid in 59 patients (33.3%). External annuloplasty was performed through a homemade Dacron ring (56) or a dedicated expansible aortic ring (121). Results Thirty-day mortality was 2.9% (5). Mean follow-up was 41.1 ± 36.4 months. For the whole series, freedom from valve-related reoperation, aortic insufficiency grade 3 or greater, aortic insufficiency grade 2 or greater, and major adverse valve-related events were 89.5%, 90.5%, 77.4%, and 86.6% at 7 years, respectively, with similar results for tricuspid and bicuspid valves. Since 2007, systematic use of calibrated expansible ring annuloplasty, followed 1 year later by systematic cusp effective height assessment, significantly increased 7-year freedom from valve-related reoperation, aortic insufficiency grade 3 or greater, and major adverse valve-related events up to 99.1% ± 0.9% ( P = .017), 100% ( P = .026), and 96.3% ± 1.8% ( P = .035), respectively, whereas freedom from aortic insufficiency grade 2 or greater remained unaffected (78.1% ± 7.6%). Calibrated annuloplasty and effective height assessment were identified as protective factors from reoperation: hazard ratio, 0.13; 95% confidence interval, 0.02-1.06; P = .057 and hazard ratio, 0.11; 95% confidence interval, 0.01-0.95; P = .044, respectively. Conclusions The standardization of remodeling root repair with calibrated expansible aortic ring annuloplasty and cusp effective height assessment improves valve repair outcomes.

What's known on the subject? and What does the study add? Surgical treatment of renal cell carcinoma (RCC) with tumour thrombus extending into the right atrium remains, despite its complexity and specific technical aspects, the only radical therapeutic option. This single-centre study, unique in size for this rare condition, reports early and late results over a period of 18 years. All patients were operated on using a standardised protocol with use of cardiopulmonary bypass and deep hypothermic circulatory arrest. Overall and cancer-specific cumulative survival was better than in other reports. OBJECTIVE • To evaluate the long-term results of radical surgical management of renal cell carcinoma (RCC) with tumour thrombus extension (TTE) level IV into the right atrium (RCC/TTE IV) in a large single-institution series. PATIENTS AND METHODS • Radical complex urological and cardio-surgical procedure was performed over a period of 18 years (1993–2010) on 21 patients with RCC/TTE IV. A radical nephrectomy was performed followed by sternotomy, institution of cardiopulmonary bypass and extraction of the intracardiac tumour thrombus under direct visual control during deep hypothermic circulatory arrest (DHCA). • Perioperative and postoperative variables, and long-term overall and cancer-specific survival using the Kaplan–Meier method were analysed. RESULTS • In all patients, precise removal of tumour thrombus was accomplished in a bloodless field during DHCA. • The mean (sd) duration of circulatory arrest was 16 (6) min at a mean hypothermia of 20 (3) °C. In-hospital mortality was 9.5% (two patients). • The median survival (including in-hospital mortality) was 25 months. • In Kaplan–Meier analysis, 2- and 5-year overall cumulative survival rate was 57 (95% confidence interval, CI 36–78)% and 37 (95% CI 15–58)%, respectively. • Cancer-specific cumulative survival was 68 (95% CI 49–89)% at 2 years and 51 (95% CI 28–74)% at 5 years. CONCLUSIONS • Late outcome after radical surgical treatment in patients with RCC and TTE reaching up to the right atrium justifies this extensive procedure. • Cardiopulmonary bypass with DHCA allows safe and precise extirpation of all intracaval and intracardiac tumour mass.

Background In patients after aortic valve surgery, the quality of life is hypothesized to be influenced by the type of the valve procedure. A cross-sectional study on the postoperative quality of life was carried out in patients after aortic valve-sparing surgery (with regards to the age of the patient), Ross procedure and mechanical aortic valve replacement. Methods Quality of life was studied in 139 patients after aortic valve surgery divided into four study groups (Y – aortic valve-sparing procedure at the age below 50 years, mean age 36.2 years; O – aortic valve-sparing procedure at the age 50 years and over, mean age 59.2 years; R – Ross procedure, mean age 37.8 years and M – mechanical aortic valve replacement at the age below 50 years, mean age 39.2 years). SF-36 Short Form and valve-specific questionnaires were mailed to the patients after 6 months or later following surgery (median 26.9 months). Results In SF-36, the younger aortic valve repair patients and the Ross patients scored significantly better in 4 of 4 physical subscales and in 2 of 4 mental subscales than the older aortic valve repair and mechanical valve replacement patients. In the valve-specific questionnaire; however, all 3 groups free of anticoagulation (Y, O, and R) displayed greater freedom from negative valve-related concerns. Conclusions Postoperative quality of life is influenced by the type of aortic valve procedure and is negatively linked with mechanical prosthesis implantation and long-term anticoagulation. Aortic valve-sparing strategy should be considered in cases with suitable valve morphology due to favorable clinical results and beneficial impact on the long-term quality of life.

From September 1994 to December 2002, 6,274 cardiosurgery operations were performed at the Department of Cardiac Surgery, University Hospital, Hradec Králové, Czech Republic. Intraaortic balloon counterpulsation (IABP) was applied in 192 cases (3.1%). From this group of 192 counterpulsated patients 103 were successfully treated (53.6%); 89 counterpulsated patients (46.4%) died from the surgical procedure (30-day mortality rate). In 5 cases (2.6%) from the group of 192, the IABP was introduced before the operation. Ischemic changes of the limb were observed in 11 cases (5.7%). Significant bleeding occurred at the site of puncture in 6 cases (3.1%). Dissection of the femoral and iliac arteries was found in 2 patients (1.0%), perforation of the iliac artery in 1 case (0.5%). In 2 cases (1.0%) the balloon was led into the venous system. In case report No. 1 an introduction of the balloon under a sclerotic plaque of the descending aorta and iliac artery is described. In case report No. 2 a placement of the balloon in the venous bloodstream is reported.

Coronary artery bypass grafting resulted in a fatal outcome in two patients with unsuspected cardiac amyloidosis. Despite preoperative symptoms of myocardial ischemia, each case represented a different pathophysiological combination of cardiac amyloidosis and coronary artery disease. Pitfalls preventing correct diagnosis and possible patterns of treatment are discussed.

Cardiac sarcoidosis is a rare entity and may be difficult to diagnose prior to cardiac surgery. We review the imaging and diagnostic studies necessary to make the diagnosis and discuss therapeutic algorithms to manage this disease.

Introduction The aim of this study was to analyze short- and mid-term results of aortic valve repair. Material and methods One hundred consecutive patients (24 females; mean age 50.3 years, range 23–77 years) with aortic regurgitation underwent aortic valve repair between November 2007 and October 2012. Sixty patients had bicuspid aortic valve, and 82 patients demonstrated aortic regurgitation greater than mild (> grade 2). The ascending aorta/aortic root was replaced in 67 patients. Aortic cusp repair was necessary in 74 patients and additional aortic annulus stabilization was required in 48 cases. Follow-up ranged from 1 to 59 months (cumulative of 220 patient-years, median 25 months) and was complete in 100%. Results There was no 30-day mortality and two patients died in the follow-up. The overall 4-year survival was 98% and freedom from cardiac death was 99% at 4 years. During the follow-up eight patients underwent aortic valve-related reoperation due to progression of aortic regurgitation and another six patients showed aortic regurgitation more than mild (> grade 2). In both aspects there was no statistically significant difference between patients without and with aortic root replacement ( p =0.402 and p =0.650). There were no significant bleeding or thromboembolic events during the follow-up. Conclusions Short- and mid-term data analysis revealed an excellent survival and acceptable results of aortic repair, comparable with other larger published studies. We think, therefore, aortic valve repair should be a part of contemporary cardio-surgical armamentarium, especially in younger patients with an appropriate indication.

The Ross procedure is an alternative technique to mechanical prosthesis and recent evidence suggests that it is associated with improved long-term survival and quality of life. However, late pulmonary autograft failure can occur more frequently in patients with significant dilation of the aortic annulus. Here, we present a technical modification of the Ross procedure--a case report of a patient who underwent a Ross procedure in which the gross dilation of the aortic annulus was reduced by implantation of an extra-aortic Coronéo annuloplasty ring. Before discharge, we performed a multidetector computed tomography (MDCT) to verify the effect of extra-aortic annuloplasty on the geometry of the neoaortic root and particularly on the dimension of the aortic annulus. The result of the MDCT demonstrated that the ring sits in the optimal position at the level of aortoventricular base and that aortic annulus is significantly reduced.

Cardiac amyloidosis is a rare and complex pathology resulting in infiltrative restrictive cardiomyopathy and there are only very few clinical pathways through which the diseased amyloidotic heart may be a subject of cardiosurgical intervention. Cardiac surgery may rarely be warranted in very selected cases, and, on the other hand, may be performed mistakenly in misdiagnosed patients with cardiac amyloidosis. In clinical terms, the accumulation of expertise is hampered by the scarcity of its occurrence, heterogeneity of etiological subgroups, late clinical manifestation and polymorphous nature of symptoms. The term amylon was first coined by Matthias Schleiden, German botanist, in 1838, for waxy starch in plants. In 1842 Karl Rokitansky described amyloidosis in connection with hepatosplenomegaly and Rudolf Virchow used in 1854 iodine for staining of amyloid. Today, more than one and half century later, we recognize amyloidosis as a heterogeneous infiltrative disease in which insoluble protein deposits are accumulated in various organs with deleterious effects on their functional integrity. Kidney, heart, blood vessels, central and peripheral nervous systems, liver, intestines, lungs, eyes, skin or bones may be affected (Cohen 1967).

Surgery for isolated pulmonary stenosis or pulmonary regurgitation is extremely rare in adulthood. Etiology of the isolated pulmonary stenosis is almost always congenital. Hemodynamically severe pulmonary stenosis is in most cases resolved in childhood by a percutaneous balloon valvuloplasty. Surgery is indicated in children with dysplastic pulmonary valve or infundibular stenosis. Other reasons of pulmonary stenosis (acquired) are mentioned in the literature (e.g., carcinoid or rheumatic etiology, obstruction by a vegetation), but incidence is very seldom and indication for surgery results extremely rarely.

Severely diseased heart valves that cause signifi cant valvular disease, not amenable to repair due to extensive calcification, infection, or congenital malformation, have to be replaced by artifi cial or biological heart valves. Artificial heart valves (mechanical valves, prostheses) are constructed from plastic materials, titanium or metallic alloys with the sewing ring from various fabrics. In biological valves the valve itself is mostly a biological tissue from other animal species (xenograft) that is mounted on a stent equipped with a sewing ring (bioprosthesis). Less frequent options are the allografts (homografts) and autografts that are implanted without a stent or sewing ring.