Small Aortic Root Research Articles

Comprehensive surgical technique for the neonatal and infant Ross Konno procedure – technical pearls

The Ross Konno procedure is a technically demanding operation in neonates and infants, particularly in small babies and those with significant aortic annular and left ventricular outflow tract hypoplasia. There are several key technical considerations for harvesting the pulmonary autograft with care to preserve the left main coronary artery and the septal perforating arteries in addition to ensuring an optimal muscle cuff on the base of the autograft. Accommodation of the autograft deep within the native aortic valve annulus by performing an appropriate Konno incision and ensuring correct suture placement is essential. Adequate epicardial mobilisation and subsequent reimplantation of the coronary arteries into the autograft neo-aortic root is also a key consideration given the significant radial displacement of the coronary arteries required to accommodate the often much larger autograft into the space of a previously very small aortic root. Although the overall technical details of the Ross Konno procedure have previously been described by others the specific granular technical detail and meticulous approach required for a successful procedural outcome in neonates and infants remains to be fully elucidated. Key technical considerations such as suture spacing, positioning of the autograft with in the Konno incision and management of the coronary arteries require detailed description. We describe our institutional approach to the Ross Konno procedure in neonates and infants to clarify these important technical considerations.

Aortic root enlargement versus stentless valve implantation for avoidance of patient-prosthesis mismatch in patients with small aortic root: protocol for a systematic review

IntroductionAvoiding patient-prosthesis mismatch (PPM) in patients with small aortic annulus (SAA) during aortic valve replacement (AVR) is still a challenging surgical problem. Among surgical options available, aortic root enlargement (ARE)...

Sex-Related Outcomes of Transcatheter Aortic Valve Implantation With Self-Expanding or Balloon-Expandable Valves: Insights from the OPERA-TAVI Registry

Evidence regarding gender-related differences in response to transcatheter aortic valve implantation according to the valve type is lacking. This study aimed to evaluate the impact of gender on the treatment effect of Evolut PRO/PRO+ (PRO) or SAPIEN 3 Ultra (ULTRA) devices on clinical outcomes. The Comparative Analysis of Evolut PRO vs SAPIEN 3 Ultra Valves for Transfemoral Transcatheter Aortic Valve Implantation (OPERA-TAVI) is a multicenter, multinational registry including patients who underwent the latest-iteration PRO or ULTRA implantation. Overall, 1,174 of 1,897 patients were matched based on valve type and compared according to gender, whereas 470 men and 630 women were matched and compared according to valve type. The 30-day and 1-year outcomes were evaluated. In the PRO and ULTRA groups, men had a higher co-morbidity burden, whereas women had smaller aortic root. The 30-day (device success [DS], early safety outcome, permanent pacemaker implantation, patient-prosthesis mismatch, paravalvular regurgitation, bleedings, vascular complications, and all-cause death) and 1-year outcomes (all-cause death, stroke, and heart failure hospitalization) did not differ according to gender in both valve groups. However, the male gender decreased the likelihood of 30-day DS with ULTRA versus PRO (p for interaction = 0.047). A higher risk of 30-day permanent pacemaker implantation and 1-year stroke and a lower risk of patient-prosthesis mismatch was observed in PRO versus ULTRA, regardless of gender. In conclusion, gender did not modify the treatment effect of PRO versus ULTRA on clinical outcomes, except for 30-day DS, which was decreased in men (vs women) who received ULTRA (vs PRO).

Aortic root enlargement and replacement of the ascending aorta in type 0 aortic valve stenosis.

This case report aims to describe an aortic root enlargement in combination with the replacement of the ascending aorta in a patient presenting with severe aortic valve stenosis. A 68-year-old woman with severe aortic stenosis due to a type 0 bicuspid aortic valve and an aortic aneurysm underwent surgery for treatment. The annulus was preoperatively measured with 19mm. Enlargement was performed by using a tissue patch to create a neo-noncoronary sinus and enlarge the root. Patients with a small aortic root face an increased risk of patient prosthesis mismatch. Enlarging the aortic root can mitigate this, but it extends cross-clamp and overall operative times. This case shows the need for carefully planned surgical interventions to optimize outcomes in complex anatomies. Each step of the performed surgery is well-established, however the combination and the creation of a neo-noncoronary sinus is not described so far.

Cost-utility analysis of sutureless and rapid deployment versus conventional aortic valve replacement in patients with moderate to severe aortic stenosis in Thailand.

Sutureless and rapid deployment aortic valve replacement (SUAVR) has become an alternative to conventional aortic valve replacement (CAVR) for aortic stenosis (AS) treatment due to its advantages in reducing surgery time and improving outcomes. This study aimed to assess the cost-utility of SUAVR vs. CAVR treatment for patients with moderate to severe AS in Thailand. A two-part constructed model was used to estimate the lifetime costs and quality-adjusted life years (QALYs) from both societal and healthcare perspectives. Data on short-term mortality, complications, cost, and utility data were obtained from the Thai population. Long-term clinical data were derived from clinical studies. Costs and QALYs were discounted annually at 3% and presented as 2022 values. The incremental cost-effectiveness ratio (ICER) was calculated to determine additional cost per QALY gained. Deterministic and probabilistic sensitivity analyses were performed. SUAVR treatment incurred higher costs compared with CAVR treatment from both societal (THB 1,733,355 [USD 147,897] vs THB 1,220,643 [USD 104,150]) and healthcare provider perspectives (THB 1,594,174 [USD 136,022] vs THB 1,065,460 [USD 90,910]). In addition, SUAVR treatment resulted in lower health outcomes, with 6.20 life-years (LYs) and 4.95 QALYs, while CAVR treatment achieved 6.29 LYs and 5.08 QALYs. SUAVR treatment was considered as a dominated treatment strategy using both perspectives. Sensitivity analyses indicated the significant impact of changes in utilities and long-term mortality on the model. SUAVR treatment is not a cost-effective treatment strategy compared with CAVR treatment for patients with moderate-severe AS in Thailand, as it leads to higher costs and inferior health outcomes. Other important issues related to specific patients such as those with minimally invasive surgery, those undergoing AVR with concomitant procedures, and those with calcified and small aortic root should be taken into account.

Use of Sutureless Valve in Aortic Root Enlargement

The small aortic annulus is a surgical challenge in patients undergoing aortic valve replacement which may lead to patient prosthesis mismatch. Management options include aortic root enlargement, aortic root replacement, and the use of sutureless valves. In this case series, we report our results with aortic root enlargement, sutureless valve implantation, and benchtop modelling of the radial forces exerted. Five patients underwent aortic root enlargement and insertion of the Perceval valve as part of the management strategy to enlarge their effective orifice area. We further investigate this strategy with a benchtop model to quantify the radial forces exerted by the Perceval valve on the aortic annulus. Radial and hoop forces on the aortic annulus and inner ring of the Perceval valve were recorded using a Mylar force tester. Five female patients with native annulus between 18mm-20mm underwent root enlargement and insertion of a Perceval S valve. The postoperative course was uncomplicated for all patients except for one who required a permanent pacemaker insertion. Transvalvular pressure gradients remained low at up to 4 years of follow-up (12 mmHg-21 mmHg), with no evidence of paravalvular leak. Benchtop testing demonstrated radial forces exerted at the annulus in all-size Perceval S valves to be within physiological variables, whereas compressive forces required to deform the valves were supraphysiological. The deployment of a sutureless valve within a surgical enlarged aortic root is a feasible solution in patients with a small aortic root.

Effect of minimally invasive versus conventional aortic root replacement on transfusion and postoperative wound complications in patients: A meta-analysis.

We examined whether small incision aortic root replacement could reduce the amount of blood transfusion during operation and the risk of postoperative complications. An extensive e-review of the 4 main databases (PubMed, Cochrane, Web of Science and EMBASE) was carried out to determine all the published trials by July 2023. The search terms used were associated with partial versus full sternotomy and aortic root. This analysis only included the study articles that compared partial and full sternotomy. After excluding articles based on titles or abstracts, selected full-text articles had reference lists searched for any potential further articles. We analysed a total of 2167 subjects from 10 comparable trials. The minimally invasive aortic root graft in breastbone decreased the duration of hospitalization (MD, -2.58; 95% CI, -3.15, -2.01, p < 0.0001) and intraoperative red blood cell transfusion (MD, -1.27; 95% CI, -2.34, -0.19, p = 0.02). However, there were no significant differences in wound infection (OR, 0.88; 95% CI, 0.16, 4.93, p = 0.88), re-exploration for bleeding (OR, 0.96; 95% CI, 0.60, 1.53, p = 0.86), intraoperative blood loss (MD, -259.19; 95% CI, -615.11, 96.73, p = 0.15) and operative time (MD, -7.39; 95% CI, -19.10, 4.32, p = 0.22); the results showed that the microsternotomy did not differ significantly from that of the routine approach. Small sternotomy may be an effective and safe substitute for the treatment of the aorta root. Nevertheless, the wide variety of data indicates that larger, well-designed studies are required to back up the current limited literature evidence showing a benefit in terms of complications like postoperative wound infections or the volume of intraoperative red blood cell transfusion.

Early outcomes of the "Chimney" commando procedure in the small aortic and mitral annuli.

Commando procedure, the surgical replacement of the mitral and aortic valves combined with reconstruction of the fibrosa fibrous body, is a technical challenge in patients with small aortic and mitral annuli. In this study, we evaluated the safety and early outcomes of the "Chimney" modality of the Commando procedure, in patients with small aortic and mitral annuli, after prior valve surgery, using a self-assembled valved conduit. From April 2021 to April 2022, 30 consecutive cases of the "Chimney" Commando procedure, with a self-assembled valved conduit and other combined cardiac procedures, were fully performed for re-operative patients with small aortic roots. Data were obtained through a medical record review, at the Asian Heart Hospital in Wuhan, China. The patient's mean age was 52.7 ± 13.53 years, with 93.3% females. All patients had a previous heart valve surgery, 90% of which had double valve replacement (DVR). Hospital death occurred in 3.3% (n = 1) of the patients, due to malignant arrhythmias and multiorgan failure. Postoperative echocardiogram exams showed that the sizes of the aortic and mitral valve prostheses were 24.23 ± 1.60 mm and 28.33 ± 1.21 mm, respectively. All patients had intact intervalvular fibrosa (IVF) repair and no patient had any aberration in the left heart chamber communication. With the exception of one postoperative sick sinus syndrome and one re-sternotomy for bleeding, there were no significant postoperative complications, such as mortality, renal failure requiring ongoing dialysis, or mediastinitis. Echocardiography exams in the sixth postoperative month showed that the mean gradients of the aortic and mitral valves were 16.26 ± 6.44 mmHg and 11.24 ± 4.90 mmHg, respectively. In comparison with the standard Commando operation, the early outcomes and safety of the "Chimney" Commando procedure proved to be a feasible therapeutic option for patients with small aortic and mitral annuli, after prior valve operations. This approach enables the enlargement of the aortic and mitral annuli and the implantation of the necessary valve prosthesis.

Aortic valve replacement in small aortic root- Bi-leaflet mechanical valve is superior to a Mono-leaflet mechanical valve.

Patient prosthetic mismatch is a serious but avoidable complication of surgical aortic valve replacement (SAVR) complicated by a small aortic annulus. This study aims to compare early and midterm outcomes following aortic valve replacement (AVR) with a mono-leaflet (ML) valve and a bi-leaflet (BL) valve in a small aortic root. From January 1st, 2017 to December 31st, 2019, 98 patients diagnosed with small aortic root underwent isolated aortic valve replacement with either TTK Chitra valve (Mono-leaflet/ ML group) or St. Jude medical valve (Bi-leaflet/ BL group) of size 17/ 19mm. Echocardiography was analyzed from medical records and telephonic follow-up. Baseline parameters were comparable. The ML group had 42 patients and the BL group had 56 patients. Aortic cross-clamp time, the incidence of severe patient prosthetic mismatch (p = 0.002) and mean, peak pressure gradients were high in the ML group. Duration of ventilation, intensive care unit (ICU) stay, the incidence of stroke, need for intra-aortic balloon pump, permanent pacemaker, dialysis, and left ventricular mass index in echocardiography were comparable between the two groups postoperatively. There was no early mortality in both group. Survival at the end of 5years was 57 ± 14.4% in the ML group; 91.8 ± 4% in the BL group (p = 0.005). Univariate and multivariate analysis revealed elderly age as a risk factor for mortality. We conclude that aortic valve replacement without any root widening procedure, using a small-sized mechanical valve provides acceptable early outcomes. Bi-leaflet mechanical valves provide better hemodynamics and survival percentage.

Coronary Perfusion After Valve-in-Valve Transcatheter Aortic Valve Implantation in Small Aortic Root: In Vitro Experimental Assessment.

Coronary flow obstruction following transcatheter aortic valve-in-valve implantation (VIV-TAVI) is associated with a high mortality risk. The aim of this work was to quantify the coronary perfusion after VIV-TAVI in a high-risk aortic root anatomy. 3D printed models of small aortic root were used to simulate the implantation of a TAVI prosthesis (Portico 23) into surgical prostheses (Trifecta 19 and 21). The aortic root models were tested in a pulsatile in vitro bench setup with a coronary perfusion simulator. The tests were performed at baseline and post-VIV-TAVI procedure in aligned and misaligned commissural configurations under simulated hemodynamic rest and exercise conditions. The experimental design provided highly controllable and repeatable flow and pressure conditions. The left and right coronary mean flow did not differ significantly at pre- and post-VIV-TAVI procedure in any tested configurations. The commissural misalignment did not induce any significant alterations to the coronary flow. High-risk aortic root anatomy did not trigger coronary ostia obstruction or coronary flow alteration after transcatheter aortic valve implantation in a surgical bioprosthesis as shown from in-vitro flow loop tests.

Transcarotid Transcatheter Aortic Valve Replacement for Severe Aortic Valve Stenosis with Narrow Aortic Root and Shaggy Aorta: A Case Report

Objective: Transcarotid access for transcatheter aortic valve replacement (TAVR) is a minimally invasive alternative approach if femoral access becomes unfavorable; however, it remains off-label use in Japan.Case Presentation: An 85-year-old female patient with severe aortic valve stenosis presented to our hospital and was diagnosed with acute heart failure. The Society of Thoracic Surgery score and the European System for Cardiac Operative Risk Evaluation 2 were 9.5% and 11.2%, respectively. Computed tomography revealed a small aortic annulus (annulus axis diameter: 18.5 mm × 22.8 mm, perimeter: 67.5 mm, area: 359 mm2), small aortic roots (Valsalva: noncoronary cusp, 22.7 mm; right coronary cusp, 22.8 mm; left coronary cusp, 24.3 mm; sinotubular junction: 18.5 mm × 22.8 mm), and a shaggy aorta with bilateral subclavian artery stenoses. Optimal medical therapy did not work well; therefore, we performed balloon aortic valvuloplasty (BAV). However, BAV did not improve aortic stenosis and worsened aortic regurgitation. The heart team decided to perform transcarotid TAVR owing to the presence of almost no plaque in the left common carotid artery (CCA), and brain magnetic resonance angiography revealed good communications between the anterior and posterior communicating arteries. On the 10th hospital day, transcarotid TAVR was performed, and Sapien 3 20-mm valve was directly implanted during the 30-min clamp time of the left CCA. The procedure was successful, and the clinical course following TAVR was good. Finally, she was discharged to her home on the 24th hospital day.Conclusion: We experienced a successful transcarotid TAVR case. Transcarotid access is a feasible approach in a case requiring an alternative approach.

Are small-sized mechanical valves adequate for patients with small aortic roots?

Concerns have been raised over patient outcomes following implantation of small aortic valves (size: 19 and 17 mm). However, in patients with a smaller body surface area, these valves may be adequate. The aim of th study was to assess the hemodynamic and functional performance of these valves and their impact on clinical outcomes in patients with a small aortic root. This was a prospective observational study that included all consecutive patients undergoing aortic valve replacement (AVR) with a small-sized aortic valve over a 3-year period. Patients were followed up at 1 week, 6 weeks, and 1 year. Functional and clinical evaluation along with echocardiography was carried out for hemodynamic assessment. In-hospital mortality and hemodynamic outcomes at 1-year follow-up were recorded. Isolated AVR with a size 17 mm valve was carried out in 15 (25%) and with a 19 mm valve in 45 (75%) patients. The mean annular size was 19.12 ± 2.03 mm. The mean indexed effective orifice area was 1.08 ± 0.16 cm2/m2. Satisfactory decrease in peak and mean trans-prosthetic gradient were evident (peak gradient preoperatively was 92.15 ± 26.2 mmHg, and 25.68 ± 12.28 mmHg at 1 year, mean gradient was 55.31 ± 17.41 mmHg preoperatively and 13.71 ± 7.39 mmHg at 1 year). The functional status of patients also showed significant improvement post AVR. Left ventricular ejection fraction pre-operatively was 59.67% ± 10.38% and 59.57% ± 7.98% at 1-week, 59.15% ± 8.17% at 6 weeks, and 59.59% ± 7.48% at 1 year. When confronted with a small aortic root, AVR with a small-sized prosthesis provides a satisfactory hemodynamic and functional outcome. In patients with small body surface area, implantation of a small-sized valve is a viable option.

Successful aortic root enlargement procedure in low resource setting: Two rare cases.

BackgroundSmall aortic root is an unexpected incident during surgical aortic valve replacement in which the prosthesis valve size does not match the case being treated.Case presentationTwo patient-prosthesis mismatches with aortic valve problems underwent surgical aortic valve replacement. Based on calculating the body surface area (BSA) and effective orifice area (iEOA), the selection of prosthesis valve size was determined. When minor aortic root surgery was performed, it was discovered that the procedure of aortic root enlargement had to be conducted. The surgery went smoothly, but both patients had different outputs. The first patient was dead, while the second patient had a better quality of life.DiscussionEvery surgical aortic valve replacement preparation of aortic root enlargement procedure needs to be prepared for the worst-case scenario.ConclusionAortic root enlargement procedure must be anticipated in aortic valve replacement, especially for the patients with small aortic roots, both isolated and with concomitant valve procedure.

The figure-of-8 aortic valve suturing technique optimizes the effective orifice area of a small aortic annulus-an ex vivo study.

Surgical aortic valve replacement (SAVR) in small annuli carries an elevated risk for the patient-prosthesis mismatch. In this study, we systematically investigated the influence of different implantation techniques including annular enlargement (AE) on the functional result after SAVR in small annuli using a standardized ex vivo model. SAVR using the PERIMOUNT Magna Ease® (PME) 21 mm was performed in small porcine aortic roots using 4 implantation techniques: non-everting pledgeted (NE) suture, single interrupted (SI) suture, continuous suture (CS), figure-of-8 (F8) suture, as well as the PME 23 mm after AE using the Nunez method and the NE suture technique (PME23 AE). The effective orifice area (EOA), mean pressure gradient and leakage volume were evaluated using a mock circulation loop in accordance with ISO regulations. Experiments were conducted on 31 porcine aortic roots. PME21 using F8 and PME23 after AE achieved a significantly larger EOA than using NE. PME23 after AE showed a larger EOA than the PME21 using any suture technique, except the F8 [for stroke volume of 74 ml: PME21 NE: 1.68 (1.63-1.72) cm2, PME21 SI: 1.76 (1.68-1.81) cm2 (P = 0.17), PME21 CS: 1.76 (1.65-1.79) cm2 (P = 0.14), PME21 F8: 1.81 (1.70-1.85) cm2 (P = 0.005); PME23 AE: 1.83 (1.73-1.92) cm2 (P < 0.001)]. SI and CS did not result in larger EOA compared with the NE technique. PME21 using SI had a significantly larger leakage volume than using NE and there was no significant difference between other techniques [for stroke volume of 74 ml: PME21 NE: 3.51 (1.85-4.53) ml/stroke, PME21 SI: 6.00 (4.02-7.06) ml/stroke (P < 0.001), PME21 CS: 4.04 (3.60-4.49) ml/stroke (P = 0.10), PME21 F8: 3.16 (1.99-3.62) ml/stroke (P = 0.74), PME23 NE: 2.89 (2.45-4.72) ml/stroke (P = 0.51)]. The F8 technique with the PME21 achieved a similar EOA as the 1 size larger PME23 using NE after AE. These results suggest that the F8 technique may be an effective surgical modification to improve the haemodynamic result in a small annulus without additional AE.

Y-incision Aortic Root Enlargement With Modified Aortotomy Upsizing the Annulus by 5 Valve Sizes

A very small aortic root and annulus (≤17 mm) needs extensive aortic annular enlargement in adult patients. This report describes a technique that enlarged the aortic annulus by 5 valve sizes from 16 to 17 mm to size 27 bovine pericardial valve, as well as a modification of the aortotomy with the roof technique to make the aortotomy closure easier and more hemostatic while enlarging the sinotubular junction and proximal ascending aorta effectively for future valve-in-valve transcatheter aortic valve replacement.

Association of HIV Serostatus and Inflammation With Ascending Aortic Size.

BackgroundThe prevalence and extent of subclinical large vessel vasculopathy is not well defined among people living with HIV. We aimed to evaluate associations between aortic root and ascending aortic sizes measured by 2‐dimensional transthoracic echocardiography and HIV serostatus, and to identify risk factors for larger aortic sizes among men with HIV, including levels of circulating inflammatory markers.Methods and ResultsUsing clinical and echocardiographic data from the MACS (Multicenter AIDS Cohort Study), adjusted multivariable linear and logistic regression was performed. Four segments of the proximal aorta were measured: aortic annulus, aortic root at the sinuses of Valsalva, sinotubular junction, and ascending aorta. HIV infection was associated with significantly larger aortic root (0.03 cm [95% CI, 0.002–0.06 cm]) and ascending aorta (0.04 cm [95% CI, 0.01–0.06 cm]) diameters. Higher standardized nadir CD4 (cluster of differentiation 4) T‐cell count was significantly associated with smaller aortic root (−0.03 cm [95% CI, −0.05 to −0.01 cm]), sinotubular junction (−0.03 cm [95% CI, −0.05 to −0.01 cm]), and ascending aorta (−0.03 cm [95% CI, −0.05 to −0.004 cm]) diameters. Higher levels of standardized TNF‐α (tumor necrosis factor‐α) were associated with larger diameters of the aortic annulus (0.02 cm [95% CI, 0.003–0.04 cm]) and sinotubular junction (0.02 cm [95% CI, 0.002–0.04 cm]). There were no other cardiovascular or HIV disease severity–related risk factors associated with the aortic dimensions.ConclusionsHIV infection is an independent risk factor for greater ascending aortic sizes. Lower nadir CD4 T‐cell count and higher TNF‐α levels are associated with larger aortic sizes in men with HIV.RegistrationURL: https://www.clinicaltrials.gov; Unique identifier: NCT00046280.

Aortic Root Replacement of Small Roots to Prepare for Transcatheter Aortic Valve Replacement

Small aortic root is a significant limitation of optimal hemodynamics for surgical aortic valve replacement due to a small annulus and application of transcatheter aortic valve replacement due to low coronary ostia and limited space at the root. We sutured a bioprosthetic valve that was up-sized by 2 to 3 valve sizes in the skirt portion of a Valsalva graft (Terumo Medical Corp) and implanted the coronary button high, close to sinotubular junction, to achieve optimal hemodynamics and prepare patients for future transcatheter aortic valve replacement.

Aortic Valve Neocuspidization Using Xenologous Pericardium Versus Bioprosthetic Valve Replacement

BackgroundSurgical aortic valve replacement (SAVR) for patients with aortic valve stenosis (AS) with small aortic root is associated with a higher rate of prosthesis–patient mismatch and suboptimal clinical outcomes. Aortic valve neocuspidization using xenologous pericardium (xAVNeo) has shown a favorable hemodynamic performance. The aim was to compare 6-year clinical outcomes of xAVNeo with SAVR. MethodsBetween 2003 and 2018, 412 patients with severe AS and small aortic root received either xAVNeo (n = 114) or bioprosthesis (n = 298). After propensity matching the cohort included 222 patients. The primary endpoints were early mortality, 6-year mortality, and freedom from reoperation. Mean follow-up averaged 3.4 ± 3.1 years and was 95% complete. ResultsEarly mortality was 8.1% for the SAVR group versus 9.9% for the xAVNeo group (odds ratio, 1.25; 95% confidence interval, 0.51-2.89). The estimated survival probabilities at 6 years for the SAVR and xAVNeo cohorts were 89.9% and 88.8%, respectively (odds ratio, 1.07; 95% confidence interval, 0.49-2.34). Progressive degeneration of the neocusps resulted in a mean gradient increase from 6.1 ± 2.3 mm Hg to 22.7 ± 11.5 mm Hg (P < .0001); cusp sclerosis was the most common indication for reoperation in the xAVNeo group with a linearized rate of 1.92% versus 0.26% per patient-year (rate ratio, 7.41; 95% confidence interval, 0.95-333.7). The freedom from reoperation was 84.8% at 6 years, inferior to that of the SAVR group (100%). ConclusionsEarly clinical outcomes and 6-year survival rates after xAVNeo and SAVR were comparable. However xAVNeo using bovine pericardium was associated with a higher rate of structural valve deterioration and inferior freedom from reoperation when compared with SAVR.

Echocardiographic parameters in 50 healthy English bulldogs: preliminary reference intervals

Introduction/objectivesThe objective of the study was to provide echocardiographic reference intervals for English bulldogs (EBs) and to assess if age, sex, body weight (BW), and heart rate have an influence on echocardiographic variables. AnimalsWe prospectively enrolled client-owned EBs that were considered healthy based on unremarkable history, normal physical examination, six-lead electrocardiography, and transthoracic echocardiography. Materials and methodsBreed-related reference intervals were provided, and associations between age, sex, BW, and heart rate and echocardiographic variables were tested using a multivariate analysis. Allometric scales were generated for echocardiographic variables showing correlation with BW. Moreover, echocardiographic variables obtained in our population of EBs and previous published reference ranges were compared. ResultsEchocardiographic reference intervals were generated from 50 healthy adult EBs. As per the multivariate analysis, left atrial diameter (p = 0.015), left ventricular internal end diastolic diameter (p = 0.002), aortic valve annulus (p = 0.032), and pulmonary valve annulus (p = 0.017) resulted influenced by BW, and reference intervals were generated using allometric scales. Our study suggests that EBs tend to have a smaller aortic root and sphericity index than other breeds. In addition, EBs seem to have smaller indexed left ventricular volumes and higher left ventricular ejection fraction than boxers and Doberman. ConclusionPreliminary reference intervals in the EBs are reported, which might be helpful for accurate echocardiographic interpretation and screening purposes in this breed.

Long-Term Results (up to 20 Years) of 19 mm or Smaller Prostheses in the Aortic Position. Does Size Matter? A Propensity-Matched Survival Analysis

Background: The long-term performance of prostheses in the small aortic root is still unclear. Methods: Patients who received a 21 mm or smaller aortic valve between 2000–2018 were retrospectively analyzed. Propensity matching was used in order to account for baseline differences in 19 mm vs. 21 mm valve subgroups. Results: Survival at 10 years was 55.87 ± 5.54% for 19 mm valves vs. 57.17 ± 2.82% for 21 mm ones in the original cohort (p = 0.37), and 58.69 ± 5.61% in 19 mm valve recipients vs. 53.60 ± 5.66% for 21 mm valve subgroups in the matched cohort (p = 0.55). Smaller valves exhibited significantly more patient–prothesis mismatch (PPM) than larger ones (87.30% vs. 57.94%, p < 0.01). All-cause mortality was affected by PPM at 10 years (52.66 ± 3.28% vs. 64.38 ± 3.87%, p = 0.04) in the unmatched population. This difference disappeared, however, after matching: survival at 10 years was 51.82 ± 5.26% in patients with PPM and 63.12 ± 6.43% in patients without PPM. (p = 0.14) Conclusions: There is no survival penalty in using 19 mm prostheses in the small aortic root in the current era. Although PPM is more prevalent in smaller sized valve recipients, this does not translate into reduced survival at 10 years of follow-up.