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Background: To determine the value of aortic valve repair rather than replacement for valve dysfunction, we assessed late outcomes of various repair techniques in the contemporary era., Methods: From January 2001 to January 2011, aortic valve repair was planned in 1,124 patients. Techniques involved commissural figure-of-8 suspension sutures (n = 63 [6.2%]), cusp repair with commissuroplasty (n = 481 [48%]), debridement (n = 174 [17%]), free-margin plication (n = 271 [27%]) or resection (n = 75) or both, or annulus repair with resuspension (n = 230 [23%]), root reimplantation (n = 252 [25%]), or remodeling (n = 35 [3.5%])., Results: Planned repair was aborted for replacement in 115 patients (10%); risk factors included greater severity of aortic regurgitation (AR; p = 0.0002) and valve calcification (p < 0.0001). In-hospital outcomes for the remaining 1,009 patients included death (12 [1.2%]), stroke (13 [1.3%]), and reoperation for valve dysfunction (14 [1.4%]). Freedom from aortic valve reoperation at 1, 5, and 10 years was 97%, 93%, and 90%, respectively. Figure-of-8 suspension sutures, valve resuspension, and root repair and replacement were least likely to require reoperation; cusp repair with commissural sutures, plication, and commissuroplasty was most likely (p < 0.05). Survival at 1, 5, and 10 years was 96%, 92%, and 83%. Immediate postoperative AR grade was none-mild (94%), moderate (5%), and severe (1%). At 10 years after repair, AR grade was none (20%), mild (33%), moderate (26%), and severe (21%). Patients undergoing root procedures were less likely to have higher-grade postoperative AR (p < 0.0001)., Conclusions: Valve repair is effective and durable for treating aortic valve dysfunction. Greater severity of AR preoperatively is associated with higher likelihood of repair failure. Commissural figure-of-8 suspension sutures and repair with annular support have the best long-term durability., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: For mitral regurgitation (MR) from degenerative mitral disease in patients with coexisting coronary artery disease, the appropriate surgical strategy remains controversial., Methods: From 1985 to 2011, 1,071 adults (age 70 ± 9.3 years, 77% men) underwent combined coronary artery bypass grafting and either mitral valve repair (n = 872, 81%) or replacement (n=199, 19%) for degenerative MR. Propensity matching (177 patient pairs, 89% of possible matches) was used to compare early outcomes and time-related recurrence of MR after mitral valve repair, mitral valve reoperation, and mortality. Risk factors for death were identified with multivariable, multiphase hazard-function analysis., Results: Patients undergoing valve replacement were older, with more valve calcification and a higher prevalence of preoperative atrial fibrillation and heart failure (all p < .0001). Among matched pairs, mitral replacement versus repair was associated with higher hospital mortality (5.0% vs 1.0%, p = .0001) and more postoperative renal failure (7.0% vs 3.2%, p = .01), reexplorations for bleeding (6.0% vs 3.1%, p = .05), and respiratory failure (14% vs 4.7%, p < .0001). Of matched patients undergoing repair, 18% had MR above 3+ by 5 years. Mitral valve durability was similar between matched groups, but survival at 15 years was 18% after replacement versus 52% after repair. Nomograms from the multivariable equation revealed that in 94% of cases, 10-year survival was calculated to be higher after repair than after replacement., Conclusions: In patients with coexisting degenerative mitral valve and coronary artery diseases, mitral valve repair is expected to confer a long-term survival advantage over replacement despite some recurrence of MR. When feasible, it is the procedure of choice for these patients., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Less-invasive techniques have previously been described for mitral and aortic valve operations; however, few studies have examined their benefit for aortic root and ascending aorta reconstruction. Using propensity matching, we compared outcomes of patients undergoing proximal aortic operations through a J incision compared with full sternotomy., Methods: From January 1995 to January 2014, 8,533 patients underwent proximal aortic operations at Cleveland Clinic. The study population comprised 1,827 patients after those with prior cardiac operations, emergency procedures, endocarditis, or circulatory arrest were excluded; 568 (31%) underwent a J incision. A propensity score based on 57 variables was generated to account for differences in characteristics of full-sternotomy and J-incision patients, producing 483 matched patient pairs (85% of possible) for comparison of outcomes., Results: Among propensity-matched patients, in-hospital mortality (0 [0%] J incision vs 2 [0.41%] full sternotomy; p = 0.2), renal failure (3 [0.62%] vs 6 [1.2%]; p = 0.3), stroke (3 [0.62%] vs 3 [0.62%; p > 0.9), reoperation for bleeding (17 [3.5%] vs 15 [3.1%]; p = 0.7), intraoperative blood products (60 [15%] vs 78 [19%]; p = 0.08), and postoperative transfusions (97 [20%] vs 103 [22%]; p = 0.6) were similar. Intensive care unit (median 24 vs 26 hours) and postoperative hospital stays (median 5.2 vs 6.0 days) were shorter (p < 0.0001) for the J incision, and operative and postoperative direct technical costs were 6% less., Conclusions: A J incision is a feasible technique for primary isolated elective proximal aortic operations, with a low risk of complications similar to those of full sternotomy, but with the advantages of shorter intensive care unit and hospital stays, lower costs, and better cosmesis., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Data regarding the risk of aortic dissection in patients with bicuspid aortic valve and large ascending aortic diameter are limited, and appropriate timing of prophylactic ascending aortic replacement lacks consensus. Thus our objectives were to determine the risk of aortic dissection based on initial cross-sectional imaging data and clinical variables and to isolate predictors of aortic intervention in those initially prescribed serial surveillance imaging., Methods: From January 1995 to January 2014, 1,181 patients with bicuspid aortic valve underwent cross-sectional computed tomography (CT) or magnetic resonance imaging (MRI) to ascertain sinus or tubular ascending aortic diameter greater than or equal to 4.7 cm. Random Forest classification was used to identify risk factors for aortic dissection, and among patients undergoing surveillance, time-related analysis was used to identify risk factors for aortic intervention., Results: Prevalence of type A dissection that was detected by imaging or was found at operation or on follow-up was 5.3% (n = 63). Probability of type A dissection increased gradually at a sinus diameter of 5.0 cm--from 4.1% to 13% at 7.2 cm--and then increased steeply at an ascending aortic diameter of 5.3 cm--from 3.8% to 35% at 8.4 cm--corresponding to a cross-sectional area to height ratio of 10 cm(2)/m for sinuses of Valsalva and 13 cm(2)/m for the tubular ascending aorta. Cross-sectional area to height ratio was the best predictor of type A dissection (area under the curve [AUC] = 0.73)., Conclusions: Early prophylactic ascending aortic replacement in patients with bicuspid aortic valve should be considered at high-volume aortic centers to reduce the high risk of preventable type A dissection in those with aortas larger than approximately 5.0 cm or with a cross-sectional area to height ratio greater than approximately 10 cm(2)/m., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Increased life expectancy and younger patients' desire to avoid lifelong anticoagulation requires a better understanding of bioprosthetic valve failure. This study evaluates risk factors associated with explantation for structural valve deterioration (SVD) in a long-term series of Carpentier-Edwards PERIMOUNT aortic valves (AV)., Methods: From June 1982 to January 2011, 12,569 patients underwent AV replacement with Edwards Lifesciences Carpentier-Edwards PERIMOUNT stented bovine pericardial prostheses, models 2700PM (n = 310) or 2700 (n = 12,259). Mean age was 71 ± 11 years (range, 18 to 98 years). 93% had native AV disease, 48% underwent concomitant coronary artery bypass grafting, and 26% had additional valve surgery. There were 81,706 patient-years of systematic follow-up data available for analysis. Demographics, intraoperative variables, and 27,386 echocardiographic records were used to identify risks for explant for SVD and assess longitudinal changes in transprosthesis gradients using time-varying covariable analyses., Results: Three hundred fifty-four explants were performed, with 41% related to endocarditis and 44% to SVD. Actuarial estimates of explant for SVD at 10 and 20 years were 1.9% and 15% overall, respectively, and in patients younger than 60 years, 5.6% and 46%, respectively. Younger age (p < 0.0001), lipid-lowering drugs (p = 0.002), prosthesis-patient mismatch (p = 0.001), and higher postoperative peak and mean AV gradients were associated with explant for SVD (p < 0.0001). The effect of gradient on SVD was greatest in patients younger than 60 years., Conclusions: Durability of the Carpentier-Edwards PERIMOUNT aortic valve is excellent even in younger patients. Explant for SVD is related to gradient at implantation, especially in younger patients. Strategies to reduce early postoperative AV gradients, such as root enlargement or more efficient prostheses, should be considered., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Patients with severe heart failure might benefit from reduced operative trauma, but rarely undergo less-invasive valve surgery. The present study compared the outcomes of less-invasive heart valve surgery with those of complete sternotomy in such patients., Methods: From January 1995 to July 2010, 871 patients in New York Heart Association class III or IV underwent valve surgery (aortic or mitral, or both). A less-invasive approach was used in 205. Propensity score matching yielded 185 matched pairs for outcomes comparison adjusted for patient characteristics and 139 pairs adjusted further for individual surgeon., Results: Without considering surgeons, myocardial ischemic times (59 ± 27 vs 64 ± 26 minutes, P = .04), cardiopulmonary bypass times (75 ± 35 vs 86 ± 34 minutes, P < .0001), and intensive care unit stays (median, 24 vs 43 hours; P = .007) were shorter for less-invasive surgery. Hospital morbidity, mortality (1.6% [3 of 185] vs 2.7% [5 of 185]; P = .5), and long-term survival (53% and 48% at 12 years; P = .3) were similar. After considering the surgeon, these benefits were not apparent; rather, efficiency, safety, and effectiveness were equivalent to those of complete sternotomy. Thus, myocardial ischemic (63 ± 30 vs 62 ± 25 minutes, P = .8) and cardiopulmonary bypass (80 ± 40 vs 81 ± 31 minutes, P = .5) times were similar, as were intensive care unit stay (median, 28 vs 30 hours; P = .09), postoperative complications, in-hospital mortality (2.2% [3 of 139] vs 3.6% [5 of 139]; P = .5), and long-term survival (57% and 53% at 12 years; P = .5)., Conclusions: In selected patients with severe heart failure, less-invasive valve surgery is a viable option, yielding at least equivalent efficiency, safety, and effectiveness to complete sternotomy. However, achieving these outcomes requires surgeons experienced in less-invasive surgery., (Copyright © 2014. Published by Mosby, Inc.)

Background: Bicuspid aortic valve (BAV) is the most common congenital cardiac malformation, occurring in 1% to 2% of the population. Eventually, 20% develop clinically important valvar regurgitation requiring surgical intervention. Aortic valve repair avoids anticoagulation and prosthetic valve-related complications. This study evaluated long-term durability of BAV repair., Methods: From 1985 to 2011, 728 patients, mean age 42±12 years, underwent BAV repair at Cleveland Clinic. Mean follow-up was 9.0±6.2 years (median, 8.3). Factors associated with repair durability (expressed as aortic valve reoperations and echocardiographically estimated gradients and regurgitation) and survival were identified., Results: Hospital mortality was 0.41% (n=3), and stroke occurred in 0.27% (n=2). Freedom from aortic valve reoperation at 10 years was 78%. Risk of reoperation was highest immediately after operation and fell rapidly to approximately 2.6%/year up to 15 years. Primary reasons for reoperation were cusp prolapse (38%), aortic stenosis or regurgitation (17%), and aortic regurgitation from root aneurysm (15%). Aortic valve gradients showed an early initial peak, rapidly declined, then rose steadily, accompanied by an increase in left ventricular mass. Survival was 94% at 10 years. A risk factor for early death was greater preoperative mitral valve regurgitation, and for late death, older age at operation, more severe symptoms, and poorer left ventricular function., Conclusions: BAV repair is safe and durable with low mortality, low prevalence of reoperation, and good long-term survival. Cusp prolapse from technical errors and natural progression of disease are the most common causes for reoperation, but progressive natural increase in valve gradient accounts for a substantial proportion as well., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: In patients with pulmonary dysfunction, it is unclear whether a less-invasive approach for aortic valve replacement is well tolerated or even beneficial. We investigated whether a partial upper J-incision for aortic valve replacement leads to more favorable outcomes than a full sternotomy in patients with chronic lung disease by using forced expiratory volume in 1 second as a surrogate., Methods: From January 1995 to July 2010, 6931 patients underwent primary isolated aortic valve replacement; 655 had forced expiratory volume in 1 second measured and expressed as percent of predicted (FEV1%; 368 via J-incision, 287 via full sternotomy). Postoperative outcomes were compared among 223 propensity-matched pairs., Results: Patients diagnosed with chronic lung disease had longer median intensive care unit (41 vs 27 hours, P = .001) and postoperative (7.1 vs 6.1 days, P < .0001) lengths of stay than those without chronic lung disease. At normal values of FEV1%, little difference was observed in either of these times for J-incision versus full sternotomy; however, at progressively lower FEV1%, these times lengthened, with increasing benefit for J-incision. Among propensity-matched patients, other postoperative complications were similar. Early survival (93% vs 89% at 1 year, P = .07) was possibly higher in matched patients with J-incision, but late survival was similar (P = .9). Patients with FEV1% less than 50 who underwent J-incision had the greatest survival advantage, which persisted for 5 years., Conclusions: In patients with preoperative respiratory dysfunction, a less-invasive partial upper J-incision for aortic valve replacement can lead to more favorable outcomes than a full sternotomy, including shorter intensive care unit and postoperative lengths of stay and better early survival, which are amplified with decreasing pulmonary function., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: Few series have examined follow-up risks of the David reimplantation operation in patients with connective tissue disorder. Hence, we assessed its midterm safety and effectiveness for Marfan syndrome and other connective tissue disorders, such as Ehlers-Danlos, Loeys-Dietz, and marfanoid syndromes., Methods: Of 313 patients who underwent modified David reimplantation, 178 identified as having connective tissue disorders underwent operation from January 1, 1991, to December 31, 2010. These disorders included Marfan (84%), marfanoid (8.4%), Loeys-Dietz (5.6%), Ehlers-Danlos (1.1%), and other syndromes (1.1%). Concomitant procedures included mitral valve repair in 7.3% and an atrial fibrillation procedure in 3.4%., Results: There were no operative or 30-day deaths. Complications included prolonged ventilation (3%), renal failure (3%), reoperation for bleeding (2.2%), and permanent stroke (0.56%). Eight-year survival was 94% and freedom from aortic valve reoperation at 6 years was 92%. Of the 7 aortic valve reoperations, 3 were attributable to endocarditis and 3 to technical failure. One reoperation was performed at another hospital, and the reason could not be determined. There were no late strokes or hemorrhagic events. At 4 years, approximately 70% of patients had no aortic valve regurgitation, and 18% were in grade 1+., Conclusions: Prophylactic root and valve preservation using David reimplantation is safe and provides excellent midterm effectiveness and low risk of late events except for endocarditis., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Repair of anterior mitral disease is challenging. Objectives of this study were to (1) compare patients with anterior versus posterior disease, (2) identify factors predisposing to replacement rather than repair in anterior disease, (3) determine durability of, and survival after, repair, and (4) compare outcomes with those after posterior repair., Methods: From January 1985 to January 2006, 3,544 patients underwent primary isolated mitral valve surgery for degenerative disease, including 307 isolated anterior (252 repairs, 82%) and 2,754 isolated posterior (2,650 repairs, 96%) leaflet procedures. Logistic regression analysis was used to identify predictors of valve replacement and to generate propensity scores for risk-adjusted comparisons. Durability was assessed by reoperation and return of mitral regurgitation., Results: Patients with anterior disease were older and more symptomatic, with more chordal elongation and greater changes in cardiac morphology and function; advanced age was associated with replacement (p < 0.0001). Unadjusted freedom from reoperation was 89% at 10 years, worse than after posterior repair (p < 0.0001). Return of 3+ to 4+ mitral regurgitation was more common in those with anterior than posterior repair (11% versus 4% at 1 year; p = 0.03). Unadjusted survival was 83% versus 88% 10 years after posterior repair, but propensity-adjusted survival was similar (p >or= 0.5)., Conclusions: Patients with anterior disease have more symptoms and greater changes in cardiac structure and function than do patients with posterior disease. Anterior repair is less durable than posterior, but is associated with comparable, excellent long-term survival. More durable repair techniques, applicable to the broader spectrum of anterior disease, are needed.

Objective: The study objective was to identify characteristics differentiating patients undergoing valve replacement versus valve repair for degenerative mitral valve disease and to use this information to compare survival and reoperation after each procedure., Methods: From 1985 to 2005, 3286 patients underwent isolated primary operation for degenerative mitral valve disease. Valve repair was performed in 3051 patients (93%), and valve replacement was performed in 235 patients (7.2%). A propensity model and score developed for fair comparison of outcomes yielded 195 matched pairs., Results: Patients undergoing replacement were older (70 +/- 12 years vs 57 +/- 13 years) and had more complex valvar pathology, symptoms, and left ventricular dysfunction. Thus, the characteristics of the propensity-matched patients undergoing repair more resembled those of the patients undergoing replacement (older, complex valvar pathology) than patients undergoing typical repair. Eight patients died in the hospital (0.26%) after repair and 5 patients (2.1%) died after replacement (P = .001). Unadjusted survival at 5, 10, and 15 years was 95%, 87%, and 68% after repair and 80%, 60%, and 44% after replacement, respectively (P < .0001); however, among propensity-matched patients, survival was similar (P = .8): 86% versus 83% at 5 years, 63% versus 62% at 10 years, and 43% versus 48% at 15 years. Freedom from reoperation among propensity-matched patients was 94% at 5 and 10 years after repair and 95% and 92% at 5 and 10 years after replacement, respectively (P = .6)., Conclusion: It is reasonable to perform valve repair in elderly patients with complex degenerative mitral valve pathology because it can eliminate the need for anticoagulation and risk of prosthesis-related complications. However, when valve pathology is so complex that repair is infeasible, this study demonstrates that valve replacement does not diminish long-term outcomes.

Background: It is unknown whether pulmonary vein isolation or a complete Cox-Maze procedure is needed to ablate paroxysmal atrial fibrillation in patients with mitral valve disease. Our objective was to assess the impact of different surgical treatments for this arrhythmia in patients undergoing mitral valve surgery., Methods: From July 1993 to January 2004, 152 patients underwent combined surgical treatment of paroxysmal atrial fibrillation and mitral valve disease. Ablation procedures included pulmonary vein isolation alone (n = 31, 20%), pulmonary vein isolation with left atrial connecting lesions (n = 80, 53%), and Cox-Maze (n = 41, 27%). The latter had longer durations of atrial fibrillation than the former (p < 0.0001). Rhythm documented on 1,225 postoperative electrocardiograms was used to estimate prevalence of, and risk factors for, atrial fibrillation across time. Ablation failure was defined as occurrence of atrial fibrillation any time beyond 6 months after operation., Results: Prevalence of postoperative atrial fibrillation peaked at 22% at 2 weeks and declined to 9% at 1 year. Risk factors included older age (p = 0.09), larger left atrium (p = 0.05), and rheumatic (p = 0.003) and degenerative etiologies (p = 0.03). Freedom from ablation failure was 84% at one year. Ablation procedure did not affect prevalence of atrial fibrillation or incidence of ablation failure., Conclusions: Pulmonary vein isolation alone may be adequate treatment for patients with paroxysmal atrial fibrillation undergoing mitral valve surgery, particularly when it is of short duration. A randomized trial is necessary to examine this strategy, especially in patients with longer duration of paroxysmal atrial fibrillation.