Aortic Valve Pathology Research Articles

EVALUATION OF THE RESULTS OF AORTIC VALVE NEOCUSPIDIZATION WITH AUTOLOGOUS PERICARDIUM USING THE OZAKI TECHNIQUE IN AORTIC ROOT SURGERY

HighlightsThe main surgical interventions for aortic valve pathology at the aortic root site are aortic valve replacement and redo replacement. The Ozaki procedure emerged in the last decade; it involves replacement of the aortic valve using autologous pericardium. Despite the fact that many centers perform the Ozaki procedure frequently, there are few studies on the comparative evaluation of its efficacy. This necessitated the present study, which compares three groups of patients operated on using different techniques. Aim. To compare the short- and medium-term results of the Ozaki procedure and aortic valve replacements using mechanical and biological valves.Methods. The retrospective study included 189 patients operated on for aortic malformation at the Cardiac Surgery Department of Sechenov University from 2017 to 2022. Three groups of patients were formed: patients undergoing Ozaki procedure were included in the Ozaki group (70 patients), patients undergoing aortic valve replacement using mechanical prosthesis were included in the Mechanical valve group (62 patients), and patients undergoing aortic valve replacement using biological prosthesis were included in the Biovalve group (57 patients). The Ozaki procedure was performed in case the diameter of the aortic annulus was ≤ 25 mm. All mid-term outcomes were assessed after at least 6 months (mean follow up period was 20 months). The primary end points were mean and peak aortic valve gradient, 30-day mortality in the short-term postoperative period, and midterm mortality (≥ 6 months).Results. The mean gradient in the Ozaki, Biovalve, and Mechanical valve groups were 10.67 ± 7.15, 15.94 ± 21, and 17.87 ± 7.52 mm Hg. The peak gradient in the Ozaki group decreased from 81.7 ± 32.5 to 21.01 ± 13.22 mm Hg (in the in-hospital setting). 6 months after surgery, the peak gradient values were 18.98 ± 16.17 mm Hg. The in-hospital mortality rates in the Ozaki, Mechanical valve and Biovalve groups were 2.86, 5.26, and 6.45%, respectively. The overall mid-term mortality in three groups was 6/189, 3.17% (95% CI: 1.5–6.07), p = 0.172.Conclusion. In the short- and mid-term period, Ozaki procedure is superior to aortic valve replacement techniques in terms of aortic valve pressure gradient and comparable in terms of mortality.

Long-term outcomes in thoracic aortic surgery: 11 year single centre experience

ObjectivesThoracic aortic aneurysms and dissections provide a complex surgical cohort termed thoracic aortic surgery. Regular follow-up at specialist clinics with cross-sectional imaging is recommended. Identifying risk factors that lead to re-operations as well as the requirement for and appropriate length of follow-up remain points of debate.MethodsPatients undergoing thoracic aortic surgery performed at a single centre from January 2012 to December 2022 were retrospectively reviewed. The clinical information, operative details, histological reports, post-operative outcomes and follow up were collected from electronic patient records. Statistical analysis was performed using Microsoft Excel and R Studio.Results409 patients met the inclusion criteria for the study with a median follow-up of 3.8 years (IQR 1.6–7.6). The prevalence of all cause re-operations was 10.8% (n = 44). The median time to re-operation was 1.8 years. 68% of the reoperations occurred within the first 5 years. Multi and univariate logistic regression identified young age, arteritis and/or aortitis as the main risk factors associated with increased risk of re-operation. Connective tissue disease and systemic inflammatory diseases approached but didn’t meet statistical significance. Bicuspid aortic valve pathology was associated with reduced risk of re-operation.ConclusionsPatients undergoing thoracic aortic surgery have a high rate of re-operation. The first 5 years represent a high-risk period and follow-up with cross-sectional imaging during that time by specialist aortic services is essential. Patient with aortitis remain at high risk and should be treated by appropriate by specialist aortic services with subspecialty interest and expertise on treating patients with aortitis.Graphical

Surgical Treatment of the Aortic Coarctation in Adults: Extra Anatomical Ascending-to-descending Aortic Bypass and Concomitant Procedures

Objectives: Aortic coarctation is defined as the narrowing of the aortic lumen secondary to hypertrophy of the posterolateral aortic wall’s media layer. The coarctation is locates between the junction from ductus arteriosus to the left subclavian artery and left hemi aortic arch. Aortic coarctation provokes many severe and lethal complications, such as severe aortic stenosis, aortic aneurysms, pseudoaneurysms, stroke, and premature coronary artery disease, unless it had not been repaired in the meantime the initiation of the symptoms. Methods: We presented the consecutive nine patients who underwent aortic coarctation open surgical repair between 2015 and 2020 which initiated ascending-to-descending aortic bypass and then concomitant operations for the secondary cardiac pathology such as ascending aortic aneurysm, Type A aortic dissection and sinus valsalva aneurysm required in some cases. Patients were a median age of 26 years old (range, 19–41 years). About 11% of the patients (n=1) presented to our emergency room with severe chest pain and acute Type 2 aortic dissection was diagnosed by the surgical team, and he underwent operation immediately. The supracoronary aortic replacement and ascending to descending aortic bypass procedures were performed sequentially. About 44% of the patients (n=4) were diagnosed as isolated aortic coarctation and only ascending –to- descending aortic bypass was performed electively. About 22% of the patients (n=2) had ascending aortic aneurysm without aortic valve pathology. These patients underwent supracoronary aortic replacement as concomitant procedure to ascending to descending aortic bypass. About 22% of the patients (n=2) had bicuspid aortic valve and sinus Valsalva aneurysm; therefore, the Bentall procedure was implemented concomitantly. Results: There were not any early deaths reported. Any neurologic complications including neither paraplegia nor stroke revealed during post-operative follow-up. About 88% of patients (n=8) were discharged with stable hemodynamic parameters in 2 weeks. About 11% of these patients (n=1) who underwent Bentall procedure concomitantly had third-degree atrioventricular block as a serious rhythm problem then a permanent pacemaker implanted. This patient had been discharged with stable hemodynamic parameters and pacemaker settings were controlled by the cardiology department. Conclusion: The extra anatomical ascending-to-descending aortic bypass is a safe and feasible method for the open surgical coarctation repair, and it provides concomitant procedures for other cardiac pathologies, which require open surgical treatment.

Безпосередні та віддалені результати модифікованої операції Росса

The aim – to present our experience with a modified Ross procedure (RP) – total aortic root reinforcement (TARR) – which significantly reduces intraoperative risks and improves long-term outcomes.Materials and methods. The immediate and long-term results of 312 RPs performed between 2005 and 2023 were analyzed and compared, including 202 surgeries using the TARR technique and 110 with the standard technique. Statistical methods included regression-correlation analysis, prognostic modeling with stepwise binary logistic regression, ROC analysis, t-tests, and the information value (IV) test.Results. Hospital mortality was 2.2 %, and overall mortality was 3.2 %. Survival rates were: 100 % at 1 year, 98.6 % at 10 years (97.2–100; 95 % confidence interval, CI), and 97.8 % at 20 years (95.8–99.7; 95 % CI). Hospital and overall mortality were significantly lower in the TARR group compared to the standard method – 1 % versus 4.5 % (p = 0.007) and 1 % versus 7.3 % (p = 0.0013), respectively. Predictors of mortality included patient age (younger than 5.75 months), preoperative mechanical ventilation, Ross – Konno procedure, and use of the standard RP. The follow-up period averaged 79.8 ± 52 months (3-208 months) and was completed for 288 (95.3 %) patients. The systolic gradient on the autograft in the early postoperative period significantly decreased from a preoperative value of 57.0 mm Hg [36; 72] (6; 177) to 7 mm Hg [4; 11] (3; 19) (p = 0.0023). In the long-term period, it was 8 mm Hg [5; 13] (2; 59). Neo-aortic insufficiency (neoAI) was observed in the long-term period as follows: grade 0-1 in 263 (91.3 %) patients, grade 2 in 23 (8 %) patients, and grade 3 or higher in 2 (0.7 %) patients. Predictors of neoAI development included older age at surgery, use of the standard technique, and preoperative aortic insufficiency. There were 3 (1 %) reoperations on the autograft, with freedom from autograft reoperation rates of 100 %, 98.3 %, and 96.2 % at 5, 10, and 15 years post-surgery, respectively. The TARR technique reduced the risks of hospital and long-term mortality (p = 0.0027; OR 13.7 [7.56; 24.97]) as well as neo-aortic insufficiency and the need for reoperation (p = 0.002, odds ratio 4 [1.020; 19.506]).Conclusions. The modified Ross procedure effectively addresses aortic valve pathology in patients of various ages, ensuring high survival and quality of life. The TARR modification provides low surgical-stage risks, optimal hemodynamic properties of the pulmonary valve as an aortic valve prosthesis, the autograft’s capacity for growth while maintaining function, and minimal risks of autograft dysfunction.

Mid-term outcome and quality of life after Bentall procedure: single-center experience

The aim – to evaluate the mid-term results and quality of life of patients who underwent Bentall procedure.Materials and methods. The research included 55 patients who underwent planned surgical treatment at the Heart Institute of Ministry of Health of Ukraine from 2015 to 2023. The mean age of the 55 patients (53 (96.36 %) males), who underwent the Bentall procedure (composite graft replacement of the aortic root), was 52.36 ± 1.56 years. We analyzed basic characteristics of the patients, intraoperative and postoperative data. The quality of life was assessed before and in the mid-term period after operations by the Medical Outcomes Study Short Form 36 (MOS SF-36) questionnaire.Results. An average duration of the follow-up period was (3.61 ± 0.28) (СІ 3.05–4.16) years ranging from 1.0 to 9.0 years. Overall, in-hospital mortality and 30-day mortality was 1.89 % (n = 1). The only case of death was caused by the acute respiratory distress syndrome. The 5-year survival rate was 94.61 ± 3.10 % for all patients. It is reasonable to say that all 3 cases of death were due to a non-cardiac cause, i.e. stroke, malignancy and acute abdomen. The average duration of the operations was 244.48 ± 7.67 minutes, the total duration of artificial blood circulation was 138.73 ± 6.47 minutes, aorta clamping time – 95.82 ± 4.79 minutes. The mean duration of hospital staying was 16.98 ± 0.91 days, intensive care unit – 4.84 ± 0.33 days. The number of patients extubated up to 8 hours after surgery was 41 (74.55 %) patients. The operation significantly improved parameters of the quality of life. Conclusions. Patients after Bentall procedure have low overall in-hospital mortality and 30-day mortality (1 (1.89 %)). The 5-year survival rate was 94.61 ± 3.10 %. All three case of death during follow-up period were due to non-cardiac causes. Excellent mid-term results prove that Bentall procedure must be a routine surgery for patients with aortic root aneurysm, mixed aortic valve pathology and anatomically altered aortic valve leaflets. The operation significantly improved quality of life of patients in all domains.

Postoperative assessment of interstitial myocardial fibrosis in aortic valve pathologies: insights from a cardiac magnetic resonance study

Abstract Background Data on the characteristics of diffuse myocardial fibrosis (DMF) among patient undergoing valve surgery for aortic regurgitation (AR), high-gradient aortic stenosis (HG-AS), and low-flow low-gradient aortic stenosis with low ejection fraction (LFLG-AS) are limited. Purpose To assess the postoperative characteristics of DMF and to compare post- and pre-operative cardiac magnetic resonance imaging (CMR) data. Methods Patients diagnosed with AR (38), HG-AS (62), and LFLG-AS (39), who met criteria for surgical intervention, were prospectively included. Pseudo-severe AS was excluded. Post-operative CMR was performed 6 to 8 months after surgery, and a comparison between post- and pre-operative data was made (delta=Δ). Quantitative analysis included assessment of extracellular volume fraction (ECV), indexed ECV (iECV), and myocardial mass (MM). Results There were differences in baseline characteristics among patients with AR, HG-AS, and LFLG-AS concerning age (54±14 vs 63±8 vs 67±8 years, respectively; p<0.01), male gender (75% vs 50% vs 82%, respectively; p<0.01), NYHA functional class III and IV (37.5% vs 55.2% vs 30.8%, respectively; p=0.03), EuroSCORE II (1.16±0.5 vs 1.26±0.46 vs 3.39±2.65%, respectively; p<0.01), and STS (0.74±0.29 vs 1.11±0.5 vs 3.21±2.11%, respectively; p<0.01). Global ECV was similar between groups (29.2±5.6 vs 27.0±3.6 vs 29.4±5.9%, respectively; p=0.01), MM was different between groups (215±76 vs 161±51 vs 203±51g, respectively; p<0.01), and iECV was different between groups and significantly higher in AS patients (50.1±31.0 vs 21±8 vs 34.2±10.2ml/m², respectively; p<0.01). All patients underwent valve surgery and there were differences regarding extracorporeal circulation time (94±25 vs 97±20 vs 75±41min, respectively; p<0.01), and 30-day mortality (0% vs 3% vs 15%, respectively; p<0.01). Post-surgery data from patients with AR (32), HG-AS (62), and LFLG-AS (21) demonstrated a comparable decrease across all groups concerning preoperative MM (ΔMM: -39.3±41.5 vs -33.4±30.9 vs -23.4±34.2g, respectively; p=0.36) (Figure 1). In contrast, iECV decreased post-surgery only in AR, remaining stable in HG-AS and LFLG-AS (ΔiECV: -19.1±22.5 vs -1.4±7.4 vs 0.9±12ml/m², respectively; p<0.01). Thus, postoperative ECV maintained commensurate values in AR, while increasing in HG-AS and LFLG-AS (ΔECV: -0.1±4.5 vs 1.5±5.1 vs 2.9±4.9%, respectively; p=0.09). Δ left ventricular ejection fraction (LVEF) was similar across groups (ΔLVEF: -1.5±10.6 vs 1.1±11.7 vs 2.6±16%, respectively; p=0.44). Conclusion In the postoperative period, a decrease in MM was observed in all groups of aortic valve pathologies. However, only patients with AR showed a simultaneous and proportional reduction in DMF mass, explaining the patterns of ECV variation. Thus, the reduction of DMF in the postoperative period appears to vary according to the phenotypes presented, and patients with AR exhibit early reverse remodeling despite having high levels of DMF.Delta iECV, LV mass and ECV measures

Natural biomaterials in the management of the aortic valve pathology. Biomedical and clinical aspects: A review.

Heart valve diseases are a prevalent cardiovascular pathology worldwide, affecting nearly 2.5% of the population. Degenerative aortic stenosis is the most common form of heart valve disease. The treatment options include surgical or transcatheter procedures. There are two main categories of valve prostheses available: mechanical heart valves constructed from synthetic materials and bioprosthetic heart valves made from natural biomaterials. The choice of valve type depends on various factors, including the underlying medical condition, suitability for anticoagulation, valve durability, and the patient's age and preferences. Mechanical heart valves have the advantage of long-term durability. However, patients receiving mechanical implants are subjected to lifelong anticoagulation therapy with an increased risk of thromboembolism and bleeding. Natural biomaterials do not require long-term anticoagulation. However, they experience degenerative changes leading to structural valve deterioration that may require reoperation. The purpose of this article is to review the role of natural biological materials used for aortic valve replacement or repair, assess their biomedical and clinical advantages and limitations, and analyze the direction and perspectives of future development.

Sutureless Aortic Valve Replacement with Perceval Bioprosthesis Superior to Transcatheter Aortic Valve Implantation: A Promising Option for the Gray-Zone of Aortic Valve Replacement Procedures-A State-of-the-Art Systematic Review, Meta-Analysis, and Future Directions.

Background: The management of patients with aortic valve pathologies can sometimes fall into a "gray zone", where the optimal treatment approach is not straightforward. The comparative benefits of sutureless aortic valve replacement (SUAVR) using the Perceval bioprosthesis versus transcatheter aortic valve implantation (TAVI) for the "gray zone" of aortic valve replacement procedures remain a topic of debate. To further explore this issue, we conducted a study with pairwise, single-arm, and Kaplan-Meier-based meta-analyses to compare the outcomes of SUAVR with the Perceval bioprosthesis versus TAVI, as well as to evaluate the efficacy, safety, and durability of SUAVR with the Perceval bioprosthesis over mid-term and long-term follow-up periods. Methods: The PubMed, PubMed Central, OVID Medline, Cochrane Library, Embase, and Web of Science databases were systematically searched. All study types were included, except study protocols and animal studies, without time restrictions. The final search was carried out in May 2024. Results: No statistically significant differences were observed in permanent pacemaker implantation (PPI) rates between the two groups. SUAVR showed a lower incidence of new-onset myocardial infarction but was associated with higher rates of new-onset atrial fibrillation and major bleeding. TAVI had higher rates of left bundle branch block and major vascular complications. Conclusions: Our findings show that SUAVR has a lower incidence of complications and a favorable mid-term overall survival compared to TAVI. SUAVR has more advantages compared to TAVI and can be considered a valuable and promising option for the "grey zone" of aortic valve pathologies.

Histidine-Tryptophan-Ketoglutarate Cardioplegia Yields Different Results in Aortic Valve Surgery Depending on Patient Gender: A Pilot Study.

Histidine-tryptophan-ketoglutarate (HTK) cardioplegia induces cardiac arrest through membrane hyperpolarization. Aortic valve pathology leads to pathophysiological changes in left ventricular vascularization that may prevent adequate cardioplegic distribution. The objective of the study was to ascertain whether the use of Bretschneider cardioplegia in aortic valve surgery yields different outcomes for male and female patients. Our study compares the perioperative data of 300 adult patients who underwent aortic valve replacement between June 2023 and June 2024 at the Emergency Cardiac Disease and Transplant Institute, Tîrgu Mures, Romania. Concomitant procedures, age under 18 years, retrograde or combined cardioplegia, and emergency surgery were excluded. The main outcome was operative mortality, and secondary outcomes were postoperative complications and paraclinical data such as ejection fraction and cardiac enzymes. Male patients comprised 190 (62%) of the sample. The most common age group was 61-70 years in both groups. The mortality rate was 6 (5.4%) for women compared to 9 (4.7%) for men. Preoperative left ventricular ejection fraction was the primary covariate determining 30-day postoperative mortality. Left ventricular ejection fraction decreased by 2.2% in men and 1.1% in women 30 days after surgery. The myocardial adaptation to aortic valve pathology exhibits gender-specific differences. However, the utilization of HTK cardioplegia obviates this disparity.

Long-term outcomes following the Ross procedure in neonates and infants: A multi-institutional analysis

ObjectivesFor neonates and infants with aortic valve pathology, the Ross procedure historically has been associated with high rates of morbidity and mortality. Data regarding long-term durability are lacking. MethodsThe international, multi-institutional Ross Collaborative included 6 tertiary care centers. Infants who underwent a Ross operation between 1996 and 2016 (allowing a minimum 5 years of follow-up) were retrospectively identified. Serial echocardiograms were examined to study evolution in neoaortic size and function. ResultsPrimary diagnoses for the 133 patients (n = 30 neonates) included isolated aortic stenosis (14%, n = 19), Shone complex (14%, n = 19), and aortic stenosis plus other (excluding Shone complex; n = 95, 71%), including arch obstruction (n = 55), left ventricular hypoplasia (n = 9), and mitral disease (moderate or greater stenosis or regurgitation, n = 31). At the time of the Ross procedure, median age was 96 days (interquartile range, 36-186), and median weight was 4.4 kg (3.6-6.5). In-hospital mortality occurred in 13 of 133 patients (10%) (4/30 [13%] neonates). Postdischarge mortality occurred in 10 of 120 patients (8%) at a median of 298 days post-Ross. Post-Ross neoaortic dilatation occurred, peaking at 4 to 5 SDs above normal at 2 to 3 years before returning to near-baseline z-score at a median follow-up of 11.5 [6.4-17.4] years. Autograft/left ventricular outflow tract reintervention was required in 5 of 120 patients (4%) at a median of 10.3 [4.1-12.8] years. Freedom from moderate or greater neoaortic regurgitation was 86% at 15 years. ConclusionsNeonates and infants experience excellent postdischarge survival and long-term freedom from autograft reintervention and aortic regurgitation after the Ross. Neoaortic dilatation normalizes in this population in the long-term. Increased consideration should be given to Ross in neonates and infants with aortic valve disease.

Assessment of Cardiac Anomalies in Pediatric Patients with Pectus Carinatum

Background: Pectus carinatum (PC) is an anterior thoracic visible deformity manifested by protrusion of the sternum. It can be an isolated chest deformity or it can be seen together with genetic pathologies. Methods: We analyzed the cardiac findings of 40 children who were diagnosed with pectus carinatum at Kahramanmaras Sutcu Imam University’s Thoracic Surgery Outpatient Clinic between 1 February 2021 and 1 February 2022 and 97 healthy controls in similar age groups. Results: The Pectus Carinatum patients had higher rates of cardiac malposition, MVP (Mitral valve prolapse), MI (mitral insufficiency), TVP (tricuspid valve prolapse), CHD (congenital heart disease), and aortic valve pathology. Conclusıons: Our study showed that the prevalence of cardiac pathologies in the pediatric PC patients was higher than that in the control group consisting of healthy children. Thus, it may be recommend the referral of pediatric PC patients to cardiology outpatient clinics for the early diagnosis of potential cardiac pathologies.

Minimally invasive approaches versus conventional sternotomy for aortic valve replacement in patients with aortic valve disease: a systematic review and meta-analysis of 17269 patients.

Aortic valve replacement (AVR) is a common procedure for aortic valve pathologies, particularly in the elderly. While traditional open AVR is established, minimally invasive techniques aim to reduce morbidity and enhance treatment outcomes. The authors' meta-analysis compares these approaches with conventional sternotomy, offering insights into short and long-term mortality and postoperative results. This study provides valuable evidence for informed decision-making between conventional and minimally invasive approaches for AVR. Till August 2023, PubMed, Embase, and MEDLINE databases were searched for randomized controlled trials (RCT) and propensity score matched (PSM) studies comparing minimally invasive approaches [mini-sternotomy (MS) and right mini-thoracotomy (RMT)] with full sternotomy (FS) for AVR. Various outcomes were analyzed, including mortality rates, bypass and clamp times, length of hospital stay, and complications. Risk ratios (RR) and the weighted mean differences (WMD) with corresponding 95% CIs were calculated using Review Manager. Forty-eight studies were included having 17269 patients in total. When compared to FS, there was no statistically significant difference in in-hospital mortality in MS (RR:0.80; 95% CI:0.50-1.27; I2=1%; P=0.42) and RMT (RR:0.70; 95% CI:0.36-1.35; I2=0%; P=0.29). FS was also linked with considerably longer cardiopulmonary bypass duration than MS (MD:8.68; 95% CI:5.81-11.56; I2=92%; P=0.00001). The hospital length of stay was determined to be shorter in MS (MD:-0.58; 95% CI:-1.08 to -0.09; I2=89%; P=0.02) with no statistically significant difference in RMT (MD:-0.67; 95% CI:-1.42 to 0.08; I2=84%; P=0.08) when compared to FS. While mortality rates were comparable in minimally invasive approaches and FS, analysis shows that MS, due to fewer respiratory and renal insufficiencies, as well as shorter hospital and ICU stay, may be a safer approach than both RMT and FS.

Egr3 is a mechanosensitive transcription factor gene required for cardiac valve morphogenesis.

Biomechanical forces, and their molecular transducers, including key mechanosensitive transcription factor genes, such as KLF2, are required for cardiac valve morphogenesis. However, klf2 mutants fail to completely recapitulate the valveless phenotype observed under no-flow conditions. Here, we identify the transcription factor EGR3 as a conserved biomechanical force transducer critical for cardiac valve formation. We first show that egr3 null zebrafish display a complete and highly penetrant loss of valve leaflets, leading to severe blood regurgitation. Using tissue-specific loss- and gain-of-function tools, we find that during cardiac valve formation, Egr3 functions cell-autonomously in endothelial cells, and identify one of its effectors, the nuclear receptor Nr4a2b. We further find that mechanical forces up-regulate egr3/EGR3 expression in the developing zebrafish heart and in porcine valvular endothelial cells, as well as during human aortic valve remodeling. Altogether, these findings reveal that EGR3 is necessary to transduce the biomechanical cues required for zebrafish cardiac valve morphogenesis, and potentially for pathological aortic valve remodeling in humans.

Echocardiographic image monitoring during Impella use: our experience

Abstract Funding Acknowledgements None. Introduction Impella CP is a type of percutaneous left ventricular (LV) mechanical circulatory support located inside LV and placed through the aortic valve. There is little information about the incidence of valvular complications related to its use or other complications assessable by echocardiography. Purpose To determine the existence of complications assessable by echocardiography in patients treated with Impella CP in our centre. Methods Retrospective analysis of patients treated with Impella CP in 2020 and 2021 in our centre. Baseline clinical characteristics were studied and pre- and post-procedure echocardiograms of these patients were reviewed. Results A total of 32 echocardiograms were analysed in 16 patients with a mean age of 70 years. Clinical and echocardiographic features are described in table 1. After device removal, the presence or degree of aortic regurgitation did not change in the patients, including 2 patients who had moderate aortic regurgitation pre-implantation. However, on echocardiograms after device removal, intraventricular thrombus was detected in 2 patients, who also had severe LV systolic dysfunction and who had the longest duration in days of implantation (6 and 7 days). The mean number of days of implantation was 1.68 days. Conclusion Echocardiography is a useful tool for the management and detection of complications during the time of support with Impella CP, such as valve dysfunction and the presence of intraventricular thrombus. In our centre, the use of Impella is not related to the onset or worsening of aortic valve pathology.

A hybrid approach to aortic aneurysm repair after surgical removal of the aortic coarctation in a patient with bicuspid aortic valve pathology: a clinical case

Today the aortic coarctation is considered one of the relatively most frequent congenital defects of the cardiovascular system, occuring with a frequency of 3 cases per 10,000 newborns. Despite fairly good results of radical correction, adverse long-term consequences may occur, such as persistent hypertension, recoarctation, aortic aneurysm, its dissection or even rupture. In this clinical case, a successful correction of a sac-shaped aneurysm of the aorta in adolescence was demonstrated after removal of the aortic coarctation together with bicuspid aortic valve replacement due to the combined valve disease with advantage of insufficiency.

A parametric study on pulse duplicator design and valve hemodynamics.

In vitro assessment is mandatory for artificial heart valve development. This study aims to investigate the effects of pulse duplicator features on valve responsiveness, conduct a sensitivity analysis across valve prosthesis types, and contribute on the development of versatile pulse duplicator systems able to perform reliable prosthetic aortic valve assessment under physiologic hemodynamic conditions. A reference pulse duplicator was established based on literature. Further optimization process led to new designs that underwent a parametric study, also involving different aortic valve prostheses. These designs were evaluated on criteria such as mean pressure differential and pulse pressure (assessed from high-fidelity pressure measurements), valve opening and closing behavior, flow, and regurgitation. Finally, the resulting optimized setup was tested under five different hemodynamic settings simulating a range of physiologic and pathologic conditions. The results show that both, pulse duplicator design and valve type significantly influence aortic and ventricular pressure, flow, and valve kinematic response. The optimal design comprised key features such as a compliance chamber and restrictor for diastolic pressure maintenance and narrow pulse pressure. Additionally, an atrial reservoir was included to prevent atrial-aortic interference, and a bioprosthetic valve was used in mitral positionto avoid delayed valve closing effects. This study showed that individual pulse duplicator features can have a significant effect on valve's responsiveness. The optimized versatile pulse duplicator replicated physiologic and pathologic aortic valve hemodynamic conditions, serving as a reliable characterization tool for assessing and optimizing aortic valve performance.

An Interdisciplinary Approach to Biobanking in Cardiac Surgery: Protocol of a Prospective, Single-Center Research Project Involving Longitudinal Biobanking

Cross-sectional and longitudinal profiling of full sets of nucleic acids, peptides, or proteins as well as metabolites expressed in biospecimens acquired via a cardiovascular disease-oriented biobank may aid in the elucidation of the disease pathways and mechanisms underlying individual cardiovascular diseases, such as degenerative valvular heart disease. This may promote the development of novel and effective, personalized diagnostic and therapeutic strategies to efficiently reduce cardiovascular mortality and morbidity as well as its health and economic burden. This brief report aims to describe the unique, standardized, interdisciplinary, and interprofessional approach to cross-sectional and longitudinal cardiovascular biobanking and databasing at the University Hospital Augsburg. Moreover, we present the study protocol of a specific, well-defined, prospective, single-center research project involving cross-sectional and longitudinal cardiovascular biobanking. The aim of this project is to gain a better insight into the molecular mechanisms underlying aortic valve disease-induced cardiomyopathy and the long-term effect of surgical correction of the aortic valve pathology on the left ventricular myocardial molecule profile.

Immediate and medium-term results of aortic valve replacement with biological prosthesis in elderly patients: experience of one center

Objective. To analyze the immediate and medium-term results of prosthetics of the aortic valve (AV) using biological prosthesis in elderly patients.
 Material and methods. The study included 198 patients with AV pathology [85 men (42.9 %)/113 women (57.1 %)]. The median age was 70 [66–73] years. There were 175 (88.4 %) patients with sclerodegenerative AV, 5 (2.5 %) – with infectious endocarditis and 30 patients (15.2 %) had bicuspid AV.
 Results. The hospital mortality was 4.5 %. The causes of mortality were multiple organ failure syndrome, in 1 case – developed peritonitis. In 14 patients (7.1 %) there was a rhythm disturbance in the form of AF, in 9 (4.5 %) – a complete AV block, in connection with which a permanent pacemaker was implanted. Four patients (2 %) underwent resternotomy for bleeding. Two patients (1 %) underwent pericardiocentesis. 8 (4 %) patients developed a stroke. No wound complications were detected. In the long-term period, 31 patients died. The causes of mortality were the following: cardiovascular diseases – 13 patients, malignant neoplasms – 5 patients, gastrointestinal diseases – 2, urinary system disease – 1 patient, COVID-19 – 1 patient, unknown cause – 9 patients. Thus, the five-year survival rate after the surgery was 63 %, respectively. During the follow-up period, 2 patients (2.9 %) underwent repeated intervention on AV.
 Conclusions. The five-year freedom from re-operation was 97.1 %. The five-year survival rate was 63 % due to the presence of a history of severe concomitant pathology as well as the middle age of patients 70 years.

Autologous inclusion technique versus Dacron inclusion technique in modified Ross surgery in adults: a retrospective single-center study

The Ross procedure has been shown to have excellent long-term outcomes. However, pulmonary autografts remain at risk of dilation in the long-term period. Therefore, the autologous inclusion technique (AIT) and the Dacron inclusion technique (DIT) have been developed. No direct comparison up to date has been reported of these two techniques.Aim: To compare immediate and medium-term results performing various modified techniques of the Ross operation.Material and Methods. The following retrospective study included 43 patients (AIT: 22; DIT: 21) aged 18 years and older with an aortic valve (AV) pathology who underwent modified Ross procedures (AIT and DIT) from January 2014 to December 2019, performed by a single surgeon. The main endpoints were: in-hospital mortality, postoperative AV pressure gradients, time of myocardial ischemia and cardiopulmonary bypass, postoperative complications (resternotomy due to bleeding, perioperative myocardial infarction, stroke, sternal infection, conduction disorder requiring implantation of a permanent pacemaker, acute renal failure requiring hemodialysis) and mid-term outcomes (freedom from reoperation, freedom from aortic dilatation ≥ 5 cm). The median follow-up period was 23 (12–68) months.Results. The main indication for surgery was aortic regurgitation in 32 patients (74.4%). Bicuspid aortic valve was diagnosed in 29 (67.4%) patients. There were 33 (76.7%) males with an average age of 40 ± 11.7 years. There were no lethal outcomes in both groups. There was also no significant difference in postoperative complications. The peak and mean gradients on the AV were significantly lower in the AIT group than in the DIT group (6 and 4 mmHg vs 8 and 7 mmHg, p = 0.04). Five-year overall survival, freedom from reoperation on AV and PV, and freedom from dilatation of the ascending aorta ≥ 5 cm after modified Ross operation were 97.4%, 100%, and 100%, respectively. There was no statistically significant difference between groups in terms of overall survival (p = 0.66).Conclusion. Both techniques, autologous inclusion and Dacron inclusion, provide excellent immediate and mid-term outcomes in terms of overall survival, freedom from reoperation and freedom from aortic dilation

Simulation-based design of bicuspidization of the aortic valve

ObjectiveSevere congenital aortic valve pathology in the growing patient remains a challenging clinical scenario. Bicuspidization of the diseased aortic valve has proven to be a promising repair technique with acceptable durability. However, most understanding of the procedure is empirical and retrospective. This work seeks to design the optimal gross morphology associated with surgical bicuspidization with simulations based on the hypothesis that modifications to the free edge length cause or relieve stenosis. MethodsModel bicuspid valves were constructed with varying free edge lengths and gross morphology. Fluid-structure interaction simulations were conducted in a single patient-specific model geometry. The models were evaluated for primary targets of stenosis and regurgitation. Secondary targets were assessed and included qualitative hemodynamics, geometric height, effective height, orifice area, and billow. ResultsStenosis decreased with increasing free edge length and was pronounced with free edge length less than or equal to 1.3 times the annular diameter d. With free edge length 1.5d or greater, no stenosis occurred. All models were free of regurgitation. Substantial billow occurred with free edge length 1.7d or greater. ConclusionsFree edge length 1.5d or greater was required to avoid aortic stenosis in simulations. Cases with free edge length 1.7d or greater showed excessive billow and other changes in gross morphology. Cases with free edge length 1.5d to 1.6d have a total free edge length approximately equal to the annular circumference and appeared optimal. These effects should be studied in vitro and in animal studies.