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Objectives: Class I triggers for severe and chronic aortic regurgitation surgery mainly rely on symptoms or systolic dysfunction, resulting in a negative outcome despite surgical correction. Therefore, US and European guidelines now advocate for earlier surgery. We sought to determine whether earlier surgery leads to improved postoperative survival., Methods: We evaluated the postoperative survival of patients who underwent surgery for severe aortic regurgitation in the international multicenter registry for aortic valve surgery, Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry, over a median follow-up of 37 months., Results: Among 1899 patients (aged 49 ± 15 years, 85% were male), 83% and 84% had class I indication according to the American Heart Association and European Society of Cardiology, respectively, and most were offered repair surgery (92%). Twelve patients (0.6%) died after surgery, and 68 patients died within 10 years after the procedure. Heart failure symptoms (hazard ratio, 2.60 [1.20-5.66], P = .016) and either left ventricular end-systolic diameter greater than 50 mm or left ventricular end-systolic diameter index greater than 25 mm/m 2 (hazard ratio, 1.64 [1.05-2.55], P = .030) predicted survival independently over and above age, gender, and bicuspid phenotype. Therefore, patients who underwent surgery based on any class I trigger had worse adjusted survival. However, patients who underwent surgery while meeting early imaging triggers (left ventricular end-systolic diameter index 20-25 mm/m 2 or left ventricular ejection fraction 50% to 55%) had no significant outcome penalty., Conclusions: In this international registry of severe aortic regurgitation, surgery when meeting class I triggers led to postoperative outcome penalty compared with earlier triggers (left ventricular end-systolic diameter index 20-25 mm/m 2 or ventricular ejection fraction 50%-55%). This observation, which applies to expert centers where aortic valve repair is feasible, should encourage the global use of repair techniques and the conduction of randomized trials., (Copyright © 2023 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The use of modern techniques for bicuspid aortic valve repair has been shown to provide safe and durable results against recurrent regurgitation. However, an emerging body of evidence is indicating that aortic stenosis might be an additional late complication of these procedures. To date, the pathogenesis and clinical impact of aortic stenosis after bicuspid aortic valve repair are poorly understood., Methods: A retrospective analysis of 367 patients with bicuspid aortic valve repair was performed to identify predictors of reoperation for stenosis. Bicuspid aortic valve repair was performed using a combination of procedures on the leaflet, annulus, and aortic root., Results: During a median follow-up of 8 years, reoperation for stenosis was required in 33 patients (9.0%). Freedom from reoperation for stenosis was 100%, 99.6%, 91.7%, and 74.9% at 1, 5, 10, and 15 years, respectively. The following factors were independently associated with reoperation for aortic stenosis: Leaflet or raphe resection with shaving was a protective factor (hazard ratio, 0.34; 95% confidence interval, 0.16-0.71; P = .004), whereas the use of expanded polytetrafluoroethylene for free-edge running suture (hazard ratio, 2.55; 95% confidence interval, 1.16-5.57; P = .019), supracoronary replacement of the ascending aorta in combination with valve repair (hazard ratio, 5.41; 95% confidence interval, 2.11-13.85; P = .001), and the need for a second aortic crossclamp (hazard ratio, 10.95; 95% confidence interval, 2.80-42.80; P = .001) were associated with increased risk of reoperation for aortic stenosis., Conclusions: While confirming previous findings, our analysis suggests that the inability to restore leaflet mobility and polytetrafluoroethylene for free-edge running suture are risk factors for stenosis. The so-called ascending phenotypes are probably more prone to stenosis. If the first attempt to repair is unsuccessful, the risk of late reoperation for aortic stenosis is high., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: We investigated the predictive value of aortic valve cusp retraction, calcification, and fenestration for aortic valvuloplasty feasibility., Methods: Multicenter data were collected for 2082 patients who underwent surgical aortic valvuloplasty or aortic valve replacement. The study population had retraction, calcification, or fenestration in at least one aortic valve cusp. Controls had normal or prolapsed cusps., Results: All cusp characteristics demonstrated significantly increased odds ratios [ORs] for switch to valve replacement. This effect was strongest for cusp retraction, followed by calcification and fenestration (OR, 25.14; P ≤ .001; OR, 13.50, P ≤ .001; OR, 12.32, P ≤ .001). Calcification and retraction displayed increased odds for developing grade 4 aortic regurgitation compared with grade 0 or 1 combined on average over time (OR, 6.67; P ≤ .001; OR, 4.13; P = .038). Patients with cusp retraction showed increased risk for reintervention at 1- and 2-year follow-up after aortic valvuloplasty (hazard ratio, 5.66; P ≤ .001; hazard ratio, 3.22, P = .007). Cusp fenestration was the only group showing neither an increased risk of postoperative severe aortic regurgitation (P = .57) or early reintervention (P = .88) compared with the control group., Conclusions: Aortic valve cusp retraction, calcification, and fenestration were all related to increased rates of switch to valve replacement. Calcification and retraction were associated with recurrence of severe aortic regurgitation. Retraction was related to early reintervention. Fenestration was neither associated with recurrence of severe aortic regurgitation or reintervention. This indicates that surgeons are well able to distinguish aortic valve repair candidates in patients with cusp fenestration., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: Differences in indication and technique make a randomised comparison between valve-sparing root replacement (VSRR) and personalised external aortic root support (PEARS) challenging. We performed a propensity score (PS)-matched comparison of PEARS and VSRR for syndromic root aneurysm., Methods: Patients in the PEARS 200 Database and Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (undergoing VSRR) with connective tissue disease operated electively for root aneurysm <60 mm with aortic regurgitation (AR) <1/4 were included. Using a PS analysis, 80 patients in each cohort were matched. Survival, freedom from reintervention and from AR ≥2/4 were estimated using a Kaplan-Meier analysis., Results: Median follow-up was 25 and 55 months for 159 PEARS and 142 VSRR patients. Seven (4.4%) patients undergoing PEARS required an intervention for coronary injury or impingement, resulting in one death (0.6%). After VSRR, there were no early deaths, 10 (7%) reinterventions for bleeding and 1 coronary intervention. Survival for matched cohorts at 5 years was similar (PEARS 98% vs VSRR 99%, p=0.99). There was no difference in freedom from valve or ascending aortic/arch reintervention between matched groups. Freedom from AR ≥2/4 at 5 years in the matched cohorts was 97% for PEARS vs 92% for VSRR (p=0.55). There were no type A dissections., Conclusions: VSRR and PEARS offer favourable mid-term survival, freedom from reintervention and preservation of valve function. Both treatments deserve their place in the surgical repertoire, depending on a patient's disease stage. This study is limited by its retrospective nature and different follow-ups in both cohorts., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Objectives: The objectives were to analyze the long-term outcomes of tricuspid aortic valve repair for isolated severe aortic regurgitation and the impact of different annuloplasty techniques., Methods: The study cohort consists of 127 consecutive patients who received aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve between 1996 and 2019 in our institution. Exclusion criteria were aorta dilatation (≥45 mm), connective tissue disease, active endocarditis, type A dissection, and rheumatic disease. Mean age of patients was 55.6 ± 16 years, and 80% were male. Median follow-up was 6.4 years. Time-to-event analysis was performed, as well as risk of death, reoperation, and aortic regurgitation recurrence., Results: Cusp repair was performed in 117 patients (92%), and annuloplasty was performed in 126 patients (99%) with Cabrol stitch (73%), reimplantation technique (19.7%), or ring annuloplasty (6.3%). There was no hospital mortality. At 10 and 14 years, overall survival was 81% ± 5% and 71% ± 6%, respectively, and freedom from reoperation was 80% ± 5% and 73% ± 6%, respectively. Age and left coronary cusp repair were independent predictors of reoperation. Freedom from recurrent severe aortic regurgitation (>2+) was 73% ± 5% and 66% ± 7% at 10 and 12 years, respectively. Age, left ventricular end-diastolic diameter, and patch repair were independent predictors of recurrent aortic regurgitation. Type of annuloplasty had no impact on survival or reoperation., Conclusions: Aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve is a safe procedure, and durability at 14 years is acceptable. In this study, the annuloplasty technique did not influence repair durability as was found in bicuspid aortic valve repair or aortic valve-sparing surgery. Severity of cusp pathology seems to be the main determinant of repair durability., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

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.)

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.)

Unicuspid aortic valves are rare congenital malformations. Surgical repair is feasible in aortic regurgitation, and in some cases of aortic stenosis. The standard surgical approach is a bicuspidization and symmetrization with pericardial patch augmentation of valve leaflets. Herein, we are describing our original technique for bicuspidization of a unicuspid aortic valve in adults without leaflet patch augmentation. We also address the surgical management of a commissural diastasis., (© 2022 Wiley Periodicals LLC.)

Aortic valve and root replacements require an in-depth understanding of the aortic root and annulus. Both structures can be asymmetric at times, and this needs to be recognized and taken into consideration when performing valve-sparing operations or other root-replacement procedures. Moreover, the geometry of the aortic annulus can be altered, and when performing an aortic root replacement this can distort the geometry of a neoaortic valve for instance, and lead to valve dysfunction, which is difficult to reverse. We are describing an altered aortic annulus, which required modification through annulus elevation before proceeding with aortic root replacement with a graft-reinforced pulmonary-autograft., (© 2022 Wiley Periodicals LLC.)

Objectives: To compare long-term outcomes after bicuspid aortic valve (BAV) repair utilizing the Cabrol annuloplasty versus valve sparing Reimplantation technique., Methods: From 1996 to 2018, 340 consecutive patients underwent BAV repair. Eighty underwent Cabrol annuloplasty and 189 underwent Reimplantation. Exclusion criteria were re-repairs (n = 6), active endocarditis (n = 4), no annuloplasty (n = 41) and ring or suture annuloplasty (n = 20). We compared both groups for survival, reoperations, valve related events and recurrent severe aortic regurgitation (AR > 2+). Inverse probability weighting (IPW) was used to balance the 2 groups. Cox regression analysis was used to identify outcome predictors., Results: After weighting, pre- and intraoperative characteristics were similar between groups, except for aorta replacement techniques and operative time, which was longer in the Reimplantation group (P < 0.001). At 12 years, overall survival was similar between groups (IPW: Cabrol 97 ± 2% vs Reimplantation 94 ± 3%, P = 0.52). Freedom from reoperation and freedom from AR > 2+ were significantly lower in the Cabrol group (reoperation IPW: 69 ± 9% vs 91 ± 4%, P = 0.004 and AR > 2+ IPW: 71 ± 8% vs 97 ± 2%, P < 0.001). The Reimplantation technique was the only independent predictor of reoperation (hazard ratio 0.31; confidence interval 0.19-0.7; P = 0.005)., Conclusions: In this study, comparing 2 annuloplasty strategies for BAV repair, we found statistically significant differences in long-term durability favouring the Reimplantation technique, and no differences in overall survival. The results support our current strategy of Reimplantation technique and repair of AR in patients with BAV. Cabrol annuloplasty is obsolete and should be generally abandoned in patients undergoing BAV repair for AR., (© The Author(s) 2021. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Our goal was to analyse the influence of preoperative aortic regurgitation (AR) on the necessity of cusp repair during valve-sparing reimplantation (VSR). We focused on patients with tricuspid aortic valves (TAV) and evaluated the impact of AR and cusp repair on long-term outcomes., Methods: From March 1998 to December 2018, a total of 512 consecutive patients underwent VSR at our institution; of these, 303 had a TAV. The mean age was 53 ± 15 years, and the median follow-up was 6.12 years. The rate and type of cusp repair were analysed based on preoperative AR. Time-to-event analysis was performed, as well as risk of death, reoperation and AR recurrence., Results: Cusp repair was necessary in 168 (55.4%) patients; the rate rose significantly as AR grade increased (P < 0.001). In-hospital mortality was 1% (n = 3). At 5 and 10 years, overall survival was 92 ± 2% and 75 ± 5%, respectively. Freedom from valve reoperation was 95 ± 2% and 90 ± 3%. Freedom from AR >2+ and AR >1+ at 10 years was 88 ± 4% and 70.4 ± 4.6%, respectively. Independent predictors of death included age, New York Heart Association functional class and type-A aortic dissection. Predictors of AR greater than mild included previous cardiac surgery and severe preoperative AR., Conclusion: In patients with TAV receiving VSR, the necessity of cusp repair increased with the degree of preoperative AR. Preoperative AR and cusp repair do not impact long-term survival and aortic valve reoperation, but severe preoperative AR and multiple cusp repair increase the risk of recurrent moderate-to-severe AR. Overall, cusp repair seems to attenuate the negative impact of preoperative AR for at least 1 decade in a majority of patients., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Our goal was to assess the aortic leaflet free margin length (FML) and geometric height (gH) in a normal aortic valve (AV), aorta dilatation and aortic leaflet prolapse., Methods: We measured the FML and gH intraoperatively in 132 patients operated on for aortic insufficiency, aortic dilatation, endocarditis or fibroelastoma. Patients were divided into 3 groups: normal tricuspid AV (group 1, n = 12), aortic dilatation (group 2, tricuspid = 43, bicuspid = 18) and leaflet prolapse (group 3, tricuspid = 32, bicuspid = 27). The FML and gH were compared between the groups and between the leaflets within each group., Results: In a normal tricuspid AV, the mean FML and gH were 34.7 ± 3.1 mm and 18.8 ± 1.7 mm, respectively. In group 2 tricuspid, the FML and gH were greater than those in group 1 (FML 43.7 ± 4.4, P < 0.001; gH 21.2 ± 1.8, P = 0.003). In group 3, tricuspid, the FML of the prolapsing leaflet was greater than the FML of the non-prolapsing leaflet (48.3 ± 5.4 vs 42.2 ± 3.6; P < 0.001). In group 2, bicuspid, FML of both leaflets were similar in group 2, but augmented on the fused leaflet compared to the non-fused leaflet in group 3 (fused 55.4 ± 6.3; non-fused 46.2 ± 6.2; P < 0.001). In groups 2 and 3 bicuspid, the gH of the non-fused leaflet was systematically greater than the fused leaflet (group 2 non-fused 24.6 ± 2.5 vs fused 20.4 ± 2.1; P < 0.001)., Conclusions: In aortic dilatation and leaflet prolapse, FML and, to a lesser extent, gH increased significantly compared to those of normal AV function. FML and gH dimensions also depended on the valve configuration (tricuspid/bicuspid). These data provide new insight into the pathomorphology of AV disease and will serve to further develop new methods of AV repair based on intraoperative measurements of the FML., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The present study examines whether improvements have reduced the negative impact of guideline triggers on postoperative outcomes., Background: European and American guidelines for the management of severe aortic regurgitation (AR) define the triggers for AR surgery. These triggers are based on the results of studies performed in the 1990s analyzing outcomes of patients who underwent AR surgery in the 1980s. Although these triggers are used to indicate surgery, they have all been associated with poorer postoperative outcomes. In the meantime, innovations in operative techniques, including aortic valve repair, have allowed reducing the risk of surgery., Methods: A total of 356 consecutive patients undergoing surgical correction of severe AR were included in this study. Among them, 204 were operated on for a Class I, 17 for a Class IIa, 49 for a Class IIb, and 86 without any guideline triggers. Cox proportional hazards regression models and Kaplan-Meier survival curves were used to compare postoperative outcomes in the different groups. Inverse probability weighing was used to adjust for mismatched baseline characteristics., Results: Adjusted 10-year survival was better among patients without operative triggers (89 ± 4%) or with Class II triggers (85 ± 6%) than in patients with Class I triggers (71 ± 4%, p = 0.010). Similar results were obtained for cardiovascular survival and hospitalizations for heart failure. Spline function analyses indicated that mortality started to increase for left ventricular (LV) ejection fraction <55% and LV end-systolic dimensions >20 to 22 mm/m 2 . LV end-diastolic dimensions did not influence outcomes., Conclusions: Guideline-based Class I triggers for AR surgery carry major risks for long-term outcomes. This suggests that patients with severe AR should be operated on before the onset of these triggers; that is, at an asymptomatic stage, before LV ejection fraction falls below 55% or LV end-systolic dimensions exceeds 20 to 22 mm/m 2 ., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To analyze our long-term experience with valve-sparing reimplantation technique for the treatment of isolated root aneurysm, aneurysm with significant aortic regurgitation, and for isolated aortic regurgitation., Methods: Between 1999 and 2017, 440 consecutive patients underwent valve-sparing reimplantation in our institution. The mean age of this cohort was 49 ± 15 years. Time-to-event analysis was performed with the Kaplan-Meier method, whereas significant predictors of late outcomes were explored with Cox proportional hazard model., Results: In-hospital mortality was 0.7% (n = 3). Four hundred fourteen patients were available for long-term analysis. Median duration of follow-up was 5 years (interquartile range, 2-8.5 years). Thirty-six patients (8.5%) died during follow-up; therefore, survival was 79.7% ± 3.8% at 10 years. During follow-up we observed a linearized rate of 0.37%, 0.73%, and 0.2% patient-year, respectively, for major bleeding, thromboembolic events, and infective endocarditis. Nineteen patients required late aortic valve reoperation and freedom from valve reoperation was 89.6% ± 2.9% at 10 years and was not significantly different between groups or between tricuspid or bicuspid valve phenotypes., Conclusions: Our study shows that valve-sparing reimplantation is associated with low perioperative mortality, a remarkably low rate of valve-related complications, and excellent long-term durability. Further, it can be safely performed also in patients with isolated aortic regurgitation and the durability of valve repair is similar regardless of the indication for surgery of valve phenotype., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Failure to address the functional aortic annulus during bicuspid aortic valve (BAV) repair has led to early repair failures. The pathology of regurgitant BAV involves annular dilatation, which is more pronounced anteriorly and deep toward the muscular interventricular septum. In this study, we assessed the results of BAV repair using a strategy of deep circumferential annular support involving the septum in patients with a dilated annulus (>26 mm) and moderate to severe aortic regurgitation (AR)., Methods: Between February 1999 and June 2015, 100 patients with regurgitant (≥2+) BAV and a dilated ventriculoaortic junction (VAJ) (≥26 mm) underwent repair with an adjunctive circumferential annuloplasty (reimplantation procedure or ring). External root dissection to accommodate the annuloplasty was carried deep onto the anterior aspect of the interventricular septum. Follow up was complete in 96 patients, with a median follow-up of 31 months and a total of 362 patient-years. Cox regression analysis was used to predict recurrence of AR., Results: The mean VAJ diameter was 30 ± 4 mm. Seventy-nine patients exhibited delayed prolapse of the anterior leaflet (conjoined right and left cusps in Siever type 1 or anterior cusp in Siever type 0), and 93 patients underwent reimplantation. In the entire study group, there were no in-hospital deaths, and only 1 patient had 2+ AR on discharge. There was 1 late noncardiac death. At 8 years, freedom from AR ≥2+ was 96.4% and freedom from reoperation was 96.8%. Higher preoperative AR grade, small graft size, and use of a ring were predictive of recurrent AR., Conclusions: Regurgitant BAVs with a dilated annulus display anterior cusp prolapse toward the septum. A deep circumferential annuloplasty may help maintain repair durability., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: To analyse our institutional results in the setting of paediatric aortic valve (AV) repair. Primary end-points were overall survival, freedom from AV reoperation and freedom from AV replacement., Methods: A retrospective analysis of all patients under 18 years of age operated on from 1977 to 2015 in a single tertiary care level institution. Patients were included if they benefited from any type of AV repair procedure, including commissurotomy, leaflet shaving or plication, or leaflet augmentation. All data were gathered from patients' medical records, operative reports and referring paediatric cardiologists. The median follow-up was 50 months (IQR [13-140])., Results: Sixty-six patients were included. Indications for surgery were aortic stenosis, aortic regurgitation and mixed disease in 13 (19%), 36 (55%) and 17 (26%) patients, respectively. According to El Khoury's functional classification, among the 55 patients with some degree of regurgitation there were 5 type Ib regurgitation, 23 type II and 27 type III. During AV repair, additional procedures were performed in 36 patients, VSD closure, subaortic membrane resection and mitral valve repair being the most frequent (18, 8 and 7 patients). RACHS score was predominantly 2 (98.5% of patients). The in-hospital mortality rate was 1.5% (1/66). Major morbidity included 10 pericardial effusions (1 pericardocentesis), 1 low cardiac output syndrome and 1 stroke. There were three late deaths (at 104, 140 and 179 months after repair). All were cardiac related. Overall 5- and 10-year survival rates were 100 and 95.7%. The rates of freedom from AV reoperation and AV replacement at 5 and 10 years were 90.6, 72.1 and 92.5, 82.7%, respectively. During follow-up, there was no occurrence of valve-related complication (endocarditis, thromboembolism and bleeding)., Conclusions: In our experience, AV repair in the paediatric population provides excellent results in terms of both overall survival and valve-related reoperation. It obviates the need for chronic anticoagulation and in most cases delays the time at which more complex surgery such as the Ross procedure should be undertaken., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: The aim of this study was to evaluate the long-term outcomes following the Ross procedure in young adults in our institution., Methods: All adult patients who received a Ross operation between 1991 and 2014 were included in the study. Survival analysis and regression analysis were performed. Survival of the Ross cohort was compared with the age-, gender- and calendar year-matched general population., Results: Three hundred-and-six patients (mean age: 41.7 ± 9.7, male: 74.8%, bicuspid aortic valve: 58.5%, valve stenosis: 68%) were included in the analysis. There were 7 perioperative deaths (2.3%). Nine patients were lost to follow-up from hospital and completeness of the follow-up was 94%. The median follow-up of the remaining 290 patients was 10.6 years. There were 21 late deaths of which only 3 were valve-related. The overall survival at 15 years since surgery is 88 ± 3% that is comparable with the matched population. Freedom from valve-related deaths was 96.8 ± 2% at 16 years. Freedom from autograft and pulmonary homograft reoperation was 74.5 ± 4.3% at 16 years. Preoperative aortic regurgitation was the only significant predictor of autograft failure over time. Freedom from the combined end point of bleeding/thromboembolism/endocarditis/reoperation was 69.2 ± 4% at 16 years. Perioperative mortality following reoperation was 2.6% and the autograft could be spared in 72% of reinterventions., Conclusions: The Ross operation in young adults is associated with an excellent survival in the long term that is comparable with the general population. Although there is a risk of reoperation, incidence of other valve-related events is very low. The use of pulmonary autograft should be considered in any young adult patient requiring aortic valve replacement., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Valve sparing reimplantation can improve the durability of bicuspid aortic valve repair compared with subcommissural annuloplasty, especially in patients with a large basal ring. This study analyses the effect of basal ring size and annuloplasty on valve repair in the setting of a tricuspid aortic valve., Methods: From 1995 to 2013, 382 patients underwent elective tricuspid aortic valve repair. We included only those undergoing subcommissural annuloplasty, valve sparing reimplantation or no annuloplasty and in whom intraoperative transoesophageal echocardiography images were available for retrospective pre- and post-repair basal ring measurements (n = 323, subcommissural annuloplasty: 146, valve sparing reimplantation: 154, no annuloplasty: 23). In a subgroup of patients with available echocardiographic images, basal ring was retrospectively measured at the latest follow-up or prior to reoperation. subcommissural annuloplasty and valve sparing reimplantation were compared after matching for degree of aortic regurgitation and root size., Results: All three groups differed significantly for most of preoperative characteristics. Hospital mortality was 0.9%. The median follow-up was 4.7 years. At 8 years, overall survival was 80 ± 5%. Freedom from reoperation and freedom from aortic regurgitation >1+ were 92 ± 5% and 71 ± 8%, respectively. In multivariate analysis, predictors of aortic regurgitation >1+ were left ventricular end-diastolic diameter (P = 0.003), cusp repair (P = 0.006), body surface area (P = 0.01) and subcommissural annuloplasty (P = 0.05). In subcommissural annuloplasty, freedom from aortic regurgitation >1+ was lower for patients with basal ring ≥28 mm compared with patients with basal ring <28 mm (P = 0.0001). In valve sparing reimplantation, freedom from aortic regurgitation >1+ was independent of basal ring size (P = 0.38). In matched comparison between subcommissural annuloplasty and valve sparing reimplantation, freedom from aortic regurgitation >1+ was not significantly different (P = 0.06), but in patients with basal ring ≥28 mm, valve sparing reimplantation was superior to subcommissural annuloplasty (P = 0.04). Despite similar intraoperative reduction in basal ring size in subcommissural annuloplasty and valve sparing reimplantation, patients with subcommissural annuloplasty exhibited greater increase in basal ring size during the follow-up compared with the valve sparing reimplantation group (P < 0.001)., Conclusions: As with a bicuspid aortic valve, a large basal ring predicts recurrence of aortic regurgitation in patients with tricuspid aortic valve undergoing repair with the subcommissural annuloplasty technique. This recurrence is caused by basal ring dilatation over time after subcommissural annuloplasty. With the valve sparing reimplantation technique, large basal ring did not predict aortic regurgitation recurrence, as prosthetic-based circumferential annuloplasty displayed better stability over time. Stable circumferential annuloplasty is recommended in tricuspid aortic valve repair whenever the basal ring size is ≥28 mm., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Aortic valve (AV) preservation and repair, although effective, is performed in a limited number of centres. Lack of wider application might be due to challenges in dissemination of tacit surgical knowledge. We examined the learning curve in 2 centres that initiated dedicated programs in AV repair., Methods: Prospectively collected data on the first 100 (cohort A) and 150 consecutive patients (cohort B) who underwent AV repair surgery were analyzed. Safety end points included mortality, myocardial infarction or stroke, early AV repeat surgery, re-exploration for bleeding, or pacemaker implantation. Efficiency was assessed according to aortic crossclamp and cardiopulmonary bypass times. Efficacy parameters included residual aortic insufficiency or stenosis. Indices of case complexity included presence of severe aortic insufficiency, nontrileaflet AV, and associated cardiac procedures. Each cohort was divided into 3 equal tertiles (T1, T2, and T3)., Results: Early mortality was ≤ 1% in both cohorts. In cohort A, a total of 12 safety events occurred with a significant reduction in incidence over the tertiles (18%, 15%, and 3%, in T1, T2, and T3, respectively; P = 0.05). In cohort B, 20 safety events occurred in 18 patients with a trend toward reduction of incidence over tertiles (20%, 12%, and 8%, in T1, T2, and T3, respectively; P = 0.14). aortic crossclamp and cardiopulmonary bypass times decreased significantly after T2 in cohort A and T1 in cohort B (P < 0.01). Intraoperative procedural efficacy was similar across tertiles in both cohorts., Conclusions: Procedural safety and efficiency improves with experience whereas efficacy is consistent over time. AV repair is reproducible and appears to have a learning curve of approximately 40-60 cases., (Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Autograft valve preservation at reoperation may conserve some of the advantages of the Ross procedure. However, results of long-term follow-up are lacking. In this retrospective multicenter study, we present our experience with valve-sparing reoperations after the Ross procedure, with a focus on long-term outcome., Methods: A total of 86 patients from 6 European centers, who underwent valve-sparing reoperation after the Ross procedure between 1997 and 2013, were included in the study., Results: Reoperation was performed a median of 9.1 years after the Ross procedure in patients with a median age of 38.4 years (interquartile range: 27.1-51.6 years). Preoperative severe autograft regurgitation (grade ≥3) was present in 46% of patients. In-hospital mortality was 1%. During a median follow-up of 4.3 years, 3 more patients died of noncardiac causes, resulting in a cumulative survival at 8 years of 89% (95% confidence interval: 65%-97%). Fifteen patients required a reintervention after valve-sparing reoperation, mostly owing to prolapse or retraction of autograft cusps. Freedom from reintervention was 76% (95% confidence interval: 57%-87%) at 8 years. The reintervention hazard was increased in patients who had isolated and/or severe aortic regurgitation at valve-sparing reoperation. In patients without reintervention after valve-sparing autograft reoperation (n = 63), severe aortic regurgitation was present in 3% at last follow-up., Conclusions: Valve-sparing autograft reoperations after the Ross procedure carry a low operative risk, with acceptable reintervention rates in the first postoperative decade. Patients with isolated and/or severe autograft regurgitation have an increased hazard of reintervention after valve-sparing reoperation; for these patients, careful preoperative weighing of surgical options is required., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Aortic valve-sparing procedures are alternative options to aortic valve replacement in patients with aortic root aneurysm and/or severe aortic regurgitation reducing the risk of prosthesis-related complications, such as thromboembolism, and have no need for long-term oral anticoagulation. However, these techniques are technically demanding and long-term results are highly dependent on perfect intraoperative restoration of valve function. We describe a systematic approach to aortic valve-sparing aortic root replacement with the reimplantation technique the way it is currently performed in our institution., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: To enhance the reproducibility of aortic valve-sparing reimplantation and annuloplasty, we analyzed the topographic relationship between the ventriculoaortic junction (VAJ), basal ring (BR), and sinotubular junction (STJ). The root base thickness is also quantified., Method: Fifty-eight fresh human aortic valves were analyzed. The root was dissected to the limit where the aortic wall terminates into the cardiac structures (VAJ). Root height was measured externally from the STJ to the VAJ and internally from the STJ to the BR defined as the plane passing through the cusps nadir. The root base thickness was measured at the BR and orthogonal to the internal wall; except at the right coronary sinus, where it was measured between the BR internally and the VAJ externally. Measurements were taken at the middle of the 3 sinuses and commissures., Results: The VAJ is at the same level as the BR from the noncoronary sinus (-0.1 ± 0.9 mm) to the left coronary sinus (0.5 ± 1.3 mm); it is above the BR from the left/right commissure (4.6 ± 1.4 mm) to the right/non commissure (2.5 ± 1.6 mm). The external root height was highest at the non/left commissure (21.5 ± 2.6 mm) followed by the right/non commissure (19.2 ± 2.3 mm) then the left/right commissure (15.7 ± 2.2 mm) (P < .05). The mean root base thickness was 3.2 mm, ranging from 1 ± 0 mm at the left/non commissure to 6.2 ± 1.2 mm at the right coronary sinus (P < .001)., Conclusions: The VAJ is not planar; it is above the level of the BR from the left/right to the right/non commissure. As a consequence, the external height of the non/left commissure is greater than the other 2 commissures. These findings should be taken into consideration when performing aortic valve-sparing reimplantation or external annuloplasty., (Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the short- and long-term outcomes of concomitant aortic (AVr) and mitral (MVr) valve repair., Methods: This retrospective analysis of prospectively collected data identified patients who had undergone AVr and MVr surgery from March 1996 to October 2009. Patients were included if they had undergone combined repair on the aortic and mitral valves. Excluded were those <18 years in whom valve replacement was performed. Data were collected on the short-term morbidity and mortality (<30 postoperative days), long-term survival, and freedom from valve-related events and echocardiographic outcomes., Results: A total of 65 patients underwent AVr and MVr (mean age, 56.4 ± 15.8 years, 46 men). Preoperatively, 30 patients (46.1%) had aortic insufficiency (AI) >2+, 20 patients had AI ≥2+ with aortic dilatation (30.7%), and 4 patients (6.1%) had aortic dilatation only. Of the 65 patients, 57 had tricuspid (87.6%) and 8 had bicuspid aortic valves (12.3%). All patients had mitral insufficiency preoperatively. One in-hospital death occurred (1.5%). At discharge, no patient had AI >2+ versus 30 patients preoperatively (P < .001), and 7 patients had AI >1+ versus 61 patients preoperatively (P < .001). At discharge, the mean left ventricular end-diastolic diameter was 48 ± 7 mm versus 59 ± 9 mm preoperatively (P < .007), and the mean left ventricular end-systolic diameter was 33 ± 5 mm versus 38 ± 14 mm preoperatively (P = .36). The mean clinical follow-up duration was 62 ± 45 months (median, 50; range, 1-177). At the latest follow-up visit, 17 patients were New York Heart Association class ≥2 versus 52 patents preoperatively (P < .001). Four cardiac deaths occurred, and at 1, 5, and 10 years, the freedom from cardiac death was 100%, 93.4% ± 3.7%, and 88.5% ± 5.9%, respectively. Eight valve reinterventions were required, and the freedom from valve reintervention at 1, 5, and 10 years was 95.3% ± 2.6%, 91.6% ± 3.6%, and 78.4% ± 8.0%, respectively. At 1, 5, and 10 years, the freedom from AI 2+ was 98.2% ± 1.7%, 93.4% ± 3.7%, and 88.3% ± 5.8% and the freedom from mitral insufficiency 2+ was 96.4% ± 2.4%, 93.3% ± 3.8%, and 93.3% ± 3.8%, respectively., Conclusions: Concomitant AVr/MVr is associated with acceptable survival and freedom from valve reintervention., (Copyright © 2014. Published by Mosby, Inc.)

A 43-year-old man with Marfan syndrome presented with recurrent aortic root dilatation and aortic regurgitation at ten years after a remodeling (Yacoub) procedure. Herein is described a reoperative valve-sparing procedure employing the reimplantation technique (David procedure) used in the treatment of this patient.

During the past 15 years, important advances in the field of aortic valve repair have transformed it from an infrequent and anecdotal exercise to a feasible and attractive alternative to valve replacement in selected patients with pure aortic insufficiency. These advances include a deeper understanding of the functional anatomy of the aortic valve and pathophysiologic mechanisms of aortic insufficiency; the development of surgical techniques to restore normal geometry to the aortic root and to restore the cusp coaptation; and the development of a common terminology that can be used by all clinicians to describe the lesions, discuss repair techniques, and compare immediate and long-term outcomes after aortic valve repair. This article attempts to describe the important principles of aortic valve repair by focusing on functional anatomy, surgical techniques for cusp repair, and outcome. By analogy with mitral valve repair, we include in the term aortic valve repair not only the repair of the cusp but also the valve-sparing root replacement or any kind of functional aortic annulus stabilization., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: The impetus for aortic valve (AV) repair is to decrease valve-related complications in comparison to prosthetic valve replacement. However, relatively few data are available to confirm this hypothesis. We analyzed valve-related complications in a large series of patients undergoing AV repair., Methods: Between 1995 and 2010, 475 patients underwent elective AV repair for aortic insufficiency or aortic aneurysm. The mean age was 53 years, and 81% were male. Valve-related outcomes were defined as per published guidelines. Survival and freedom from valve-related events were reported using the Kaplan-Meier method and linearized event rates. Clinical follow-up was 98.3% complete with a mean follow-up time of 4.6 years., Results: Thirty-day mortality was 0.8% (n = 4). At 10 years, overall survival was 73% ± 5%, freedom from cardiac death was 81% ± 4%, and freedom from valve-related death was 90% ± 3%. Freedom from significant aortic insufficiency was 84% ± 3%. A total of 28 patients needed early (n = 7) or late (n = 21) AV reoperation; all of them survived reoperation, and 8 had repeat repair. Ten-year freedom from AV reoperation was 86% ± 3%, and freedom from AV replacement was 90% ± 3%. Freedom from AV reoperation was similar in tricuspid and bicuspid valve. During the follow-up period, linearized rate of thromboembolic event, bleeding, and AV endocarditis was 1.1%, 0.23%, and 0.19% per year, respectively. Ten-year freedom from valve-related events including AV reoperation, thromboembolic event, bleeding, and endocarditis was 74% ± 3%., Conclusions: The current findings confirm that AV repair is associated with low mortality, acceptable durability, and a low risk of valve-related events., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: In aortic valve repair, reduction and stabilization of the ventriculo-aortic junction (VAJ) is generally recommended. In this in vitro study, we compare three techniques of annuloplasty: the subcommissural annuloplasty (SCA), the internal ring (IR) and the external ring (ER) annuloplasty., Methods: Ten fresh porcine aortic valve preparations were tested in a pulsatile mock loop. Each sample was tested untreated (baseline: B). The annuloplasty techniques were then performed successively in each sample. Each technique was tested, then removed and the following technique performed. SCA was applied at 50% of interleaflet triangle height; the ER and IR were applied with a moderate reduction (15-20%) of the VAJ. Hydrodynamic, video and echographic parameters were collected. Flow rate and arterial pressure were maintained consistently between groups., Results: Effective orifice area decreased significantly with each annuloplasty technique compared with baseline (P < 0.001). Mean transvalvular pressure drop was significantly higher in the ER and IR vs SCA (P = 0.007). Annuloplasty reduced valve opening and closing time in comparison to baseline. Echocardiography confirmed that the VAJ experienced a greater reduction with the ER and IR vs SCA. A narrowing of the lower third of the sinuses of Valsalva was observed after the ER, and subvalvular narrowing was observed after the IR. Valve coaptation increased with all annuloplasty techniques., Conclusions: The three annuloplasty techniques examined demonstrated differential effects on aortic valve function and root morphology. The ER and IR have greater potential to reduce VAJ diameter in comparison to SCA. The IR induced a subvalvular remodelling of the VAJ, whereas the ER induced a paravalvular remodelling.

Objectives: To assess root replacement and annular stabilization in bicuspid aortic valve repair, we compared results of reimplantation technique versus subcommissural annuloplasty or no annuloplasty., Methods: Between 1995 and 2010, 161 consecutive patients underwent bicuspid aortic valve repair. Patients undergoing subcommissural annuloplasty or no annuloplasty (group 1, n = 87) had larger root dimensions and less aortic insufficiency than did patients undergoing reimplantation technique (group 2, n = 74). We matched groups 1 to 1 on basis of those criteria. After matching (n = 106, n = 53 per group), root dimensions (41.5 ± 5 vs 40 ± 4 mm; P = .2) and degree of insufficiency (2.6 ± 1.2 vs 2.7 ± 1; P = .6) were similar between groups., Results: Techniques of cusp repair were similar between groups. Group 2 had smaller preoperative left ventricular size (P = .02), fewer concomitant procedures (P = .02), and shorter follow-up (41 ± 30 vs 63 ± 40 months; P = .003). There were no in-hospital deaths. At discharge, residual aortic insufficiency was similar between groups, but peak gradient greater than 25 mm Hg was more frequent in group 1 (13% vs 30%; P = .04). At 6 years, overall survival was 98% ± 3% in both groups. Freedoms from reoperation and aortic insufficiency greater than 2+ were significantly better in group 2 (100% vs 90% ± 8%; P = .03; 100% vs 77% ± 14%; P = .002)., Conclusions: In bicuspid aortic valve repair, root replacement with the reimplantation technique stabilizes the ventriculoaortic junction, improves valve mobility (low gradient), and is associated with improved outcomes., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Patients with supracoronary ascending aortic aneurysms can have aortic insufficiency (AI) due to dilatation of the sinotubular junction and/or associated cusp pathology. The incidence and types of cusp lesions as well as the effect of AI severity and cusp repair techniques on outcome in this patient population is not well defined., Methods: Since 1996, 55 patients (mean age: 65 ± 13 years, 17 bicuspid valves) presented with supracoronary ascending aortic aneurysms and AI that was mild/moderate in 27 (49%) and severe in 28 (51%). Associated pathology included cusp prolapse in 18 (33%), cusp restriction in nine (16%) and both in three (5%). All patients underwent aortic replacement and remodeling of the sinotubular junction. Adjunctive techniques included subcommissural annuloplasty in 38(69%) and cusp repair in 28 (51%)., Results: AI severity was not significantly associated with the presence of cusp pathology (p=0.35). Cusp disease was present in 100% of bicuspid aortic valves compared with only 34% of trileaflet valves (p<0.001). There was no hospital mortality and overall survival was 94 ± 4% and 75 ± 10%, respectively, at 5 and 7 years. Freedom from re-operation was 100% at 7 years and freedom from recurrent AI (>2+) was 87 ± 7% at 5 years. Neither the presence of preoperative severe AI, nor the need for cusp repair was predictive of late outcome., Conclusions: Cusp pathology is frequently encountered in patients with ascending aortic dilatation and AI. Severe AI is not a contraindication to valve-preserving surgery, but careful identification and repair of cusp pathology, in addition to sinotubular junction reduction, is critical for durable, long-term outcome., (Copyright © 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

The methods of graft sizing in valve-sparing surgery are criticized for their complexity and subjectivity in application. We propose a simple method for graft sizing in valve-sparing root replacement using the reimplantation technique. Practically, the height of the commissure between the noncoronary cusp and the left coronary cusp give the size of the graft. This new method of graft sizing was successfully applied in the last 27 consecutive patients with good immediate results. Graft sizing with this objective and reproducible simple method results in restoration of normal aortic valve geometry and function., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Cusp prolapse causing aortic insufficiency is associated with unique echocardiographic, clinical, and surgical features. Recognition and appropriate surgical repair of this pathologic condition can not only treat affected patients but also improve results of aortic valve-sparing procedures, for which pre-existing or induced cusp prolapse is an important cause of failure., Methods: Of 428 patients undergoing aortic valve repair, 195 (46%) were treated for cusp prolapse, and 111 (57%) of those had trileaflet aortic valve and make up this cohort. Cusp disease was the sole mechanism for aortic insufficiency (isolated group) in 50 patients whereas aortic dilatation was contributory in 61 (associated group). In total, 144 cusps were repaired in 111 patients. Preoperative echocardiograms, intraoperative findings, and clinical and echocardiographic outcomes were reviewed., Results: On preoperative echocardiography, presence of an eccentric aortic insufficiency jet, regardless of severity, had 92% sensitivity and 96% specificity for the detection of single cusp prolapse. A transverse fibrous band was characteristically identified on the prolapsing cusp (sensitivity 57%; specificity 92%), correctly localizing a prolapsing cusp in all cases. Freedom from aortic valve reoperation at 8 years was 100% in the isolated group and 93% ± 5% in the associated group (p = 0.33). Freedom from recurrent aortic insufficiency (>2+) at 5 years was 90% ± 5% in the isolated and 85% ± 8% in the associated group (P = .54). The choice of surgical technique did not affect aortic insufficiency recurrence at follow-up (P = .6)., Conclusions: Recognition and repair of isolated aortic cusp prolapse provides durable midterm outcome. An eccentric aortic insufficiency jet and a fibrous band can aid in the diagnosis and localization of cusp prolapse associated with ascending aortic disease and may help to improve results of aortic valve-sparing procedures., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Patients with bicuspid aortic valves can present with aortic insufficiency caused by cusp disease or the aortic root pathology. We present our 13-year experience with a functional and systematic approach to bicuspid aortic valve repair., Methods: Between 1995 and 2008, 122 consecutive patients (mean age, 44 +/- 11 years) with bicuspid aortic valves underwent non-emergency valve repair for isolated aortic insufficiency (43%), aortic root dilatation (14%), or both (43%). Preoperative echocardiography identified aortic dilatation (n = 75), cusp prolapse (n = 96), and cusp restriction (n = 45) as mechanisms of aortic insufficiency. Raphé repair (n = 98) was performed by shaving (21%) or resection with primary closure (60%) or pericardial patch (18%). Functional aortic annuloplasty was performed using subcommissural annuloplasty (n = 51), ascending aortic replacement (n = 17), or aortic root replacement (n = 54) using a reimplantation (76%) or remodeling technique (24%)., Results: There was no operative mortality. Five patients underwent early aortic valve reoperation (3 re-repairs). At discharge, 93% of patients had aortic insufficiency grade 0/1 and 7% of patients had grade 2. Seven additional patients underwent aortic valve reoperation during follow-up (2 re-repairs). Overall survival was 97% +/- 3% at 8 years. At 5 and 8 years follow-up, freedom from aortic valve reoperation was 94% +/- 2% and 83% +/- 5%, respectively, and freedom from aortic valve replacement was 96% +/- 2% and 90% +/- 5%, respectively. Freedom from recurrent aortic insufficiency (>2+) was 94% +/- 3% at 5 years. Freedom from thromboembolism and bleeding was 96% +/- 2% at 8 years., Conclusion: A systematic approach to bicuspid aortic valve repair yields good early and midterm results. Repair of bicuspid valves for aortic insufficiency is a feasible and attractive alternative to mechanical valve replacement in young patients., (Copyright 2010 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: The presence of significant preoperative aortic insufficiency (AI) or the need for cusp repair has been suggested as a risk factor for poorer outcomes after aortic valve (AV)-sparing surgery. We analyzed the influence of these factors on the mid-term outcomes of AV surgery., Methods and Results: Between 1996 and 2008, 164 consecutive patients underwent elective AV-sparing surgery. Severe preoperative AI (grade > or =3+) was present in 93 patients (57%), and 54 (33%) had a bicuspid valve. Root repair was performed with either the reimplantation (74%) or the remodeling (26%) technique, and cusp repair was performed in 90 patients (55%). Mean clinical follow-up was 57 months. Hospital mortality was 0.6%. Cusp repair was required in 52% of the patients with preoperative AI < or =2+ and in 57% of those with AI > or =3+ (P=0.6). Cusp repair was required more frequently in bicuspid versus tricuspid valves (91% versus 38%, P<0.001). Overall survival at 8 years was 88+/-8%. Freedom from AV reoperation at 8 years was similar with preoperative AI < or =2+ versus preoperative AI > or =3+ (89+/-11% versus 90+/-7%, P=0.7) and with versus without cusp repair (84+/-17% versus 92+/-8%, P=0.5). Freedom from recurrent AI (grade > or =3+) at 5 years was also similar between groups (90+/-10% versus 89+/-8%, P=0.9, and 90+/-8% versus 89+/-9%, P=0.8, respectively). By multivariate analyses, predictors of recurrent AI > or =2+ were preoperative left ventricle end-diastolic diameter and AI >1+ on discharge echocardiography., Conclusions: With a systematic approach to cusp assessment and repair, AV-sparing surgery for root pathology has an acceptable mid-term outcome, irrespective of preoperative AI or need for cusp repair.

Objective: Valve repair for aortic insufficiency requires a tailored surgical approach determined by the leaflet and aortic disease. Over the past decade, we have developed a functional classification of AI, which guides repair strategy and can predict outcome. In this study, we analyze our experience with a systematic approach to aortic valve repair., Methods: From 1996 to 2007, 264 patients underwent elective aortic valve repair for aortic insufficiency (mean age - 54 +/- 16 years; 79% male). AV was tricuspid in 171 patients bicuspid in 90 and quadricuspid in 3. One hundred fifty three patients had type I dysfunction (aortic dilatation), 134 had type II (cusp prolapse), and 40 had type III (restrictive). Thirty six percent (96/264) of the patients had more than one identified mechanism., Results: In-hospital mortality was 1.1% (3/264). Six patients experienced early repair failure; 3 underwent re-repair. Functional classification predicted the necessary repair techniques in 82-100% of patients, with adjunctive techniques being employed in up to 35% of patients. Mid-term follow up (median [interquartile range]: 47 [29-73] months) revealed a late mortality rate of 4.2% (11/261, 10 cardiac). Five year overall survival was 95 +/- 3%. Ten patients underwent aortic valve reoperation (1 re-repair). Freedoms from recurrent Al (>2+) and from AV reoperation at 5 years was 88 +/- 3% and 92 +/- 4% respectively and patients with type I (82 +/- 9%; 93 +/- 5%) or II (95 +/- 5%; 94 +/- 6%) had better outcomes compared to type III (76 +/- 17%; 84 +/- 13%)., Conclusion: Aortic valve repair is an acceptable therapeutic option for patients with aortic insufficiency. This functional classification allows a systematic approach to the repair of Al and can help to predict the surgical techniques required as well as the durability of repair. Restrictive cusp motion (type III), due to fibrosis or calcification, is an important predictor for recurrent Al following AV repair.

Objective: Leaflet plication (PL), triangular resection (TR), resuspension with running suture of Gore-Tex (GTx) and extension with autologous pericardial patch (PP) are different techniques to repair aortic leaflet prolapse (LP) for aortic insufficiency (AI). In this study, we report and compare the early and mid-term results of these techniques for aortic valve repair., Methods: From 1996 to 2006, 298 patients underwent elective aortic valve (AV) repair. In 146 of them, prolapse of one (n=72) or more than one leaflet (n=74) was found. LP was defined either as a longer or lower leaflet free margin compared to the other leaflet(s) or a relatively low coaptation level of all leaflets. When leaflet tissues were of good quality (thin and pliable), prolapse was treated by GTx (n=39), PL (n=25) or GTx+PL (n=23). When leaflet tissues were of poor quality (thickened, calcified), prolapse was treated by TR or PP (n=13) or TR or PP+GTx (n=47)., Results: There was no hospital mortality. During the initial hospitalization two patients required reoperation for recurrent AI and one for aorto-right ventricular fistula; of them, two were re-repaired. Median follow-up was 35 months (range 9-136). Three patients needed late reoperation for recurrent AI. At 4 years, overall survival was 99+/-1% and freedom from reoperation and from recurrent AI (grade >2) was 94+/-5% and 91+/-7% respectively. Freedom from recurrent AI was similar in patients having one versus more than one LP repair (88+/-11% vs 92+/-8%, p=0.2) and among the different techniques used to repair leaflet of good quality (PL: 95+/-8% vs GTx: 83+/-18% vs PL+GTx: 100%; p=0.37). When leaflet resection was needed, the addition of GTx significantly reduced the recurrence of AI (TR or PP: 82+/-18% vs TR or PP+GTx: 97+/-4%; p=0.026)., Conclusions: Leaflet plication and Gore-Tex resuspension are both effective and durable techniques for aortic leaflet prolapse repair. The addition of Gore-Tex to triangular resection and pericardial patch repair techniques is efficient to reinforce the suture line and to improve the outcome of the repair. Multiple leaflet prolapse is not a prohibitive factor for successful repair even in the absence of a clear reference level such as a normal leaflet, as long as normal anatomical coaptation is achieved.

Quadricuspid aortic valve in adulthood is a rare pathology which often leads to aortic valve regurgitation that requires surgical treatment. Herein are described two patients with severe regurgitation on a quadricuspid aortic valve and with dilated left ventricle, who where successfully repaired using a technique of tricuspidation of the valve at the level of the abnormal commissure. In each patient, the repair was stabilized and leaflet coaptation increased by subcommissural annuloplasty stitches at the level of the three commissures. After one year and six months' follow up, respectively, both patients presented with trivial aortic regurgitation and good mobility of the three leaflets.