Background and aim of the study: High-risk patients referred for aortic valve replacement (AVR) may benefit from sutureless technology in order to reduce mortality and morbidity. Herein is described the authors' initial experience and short-term results of the sutureless 3f Enable aortic bioprosthesis.

Methods: A total of 28 patients (19 females, nine males; mean age 76.8 +/- 5.1 years; range: 66 to 86 years) with symptomatic aortic valve disease underwent AVR with the 3f Enable bioprosthesis between May 2010 and May 2011. Preoperatively, the mean logistic EuroSCORE was 13.7 +/- 10.8%. Concomitant procedures included mitral valve replacement (n = 1), tricuspid valve repair (n = 3) and coronary artery bypass grafting (n = 5). Echocardiography was performed preoperatively, at postoperative day 1, at discharge, and at follow up.

Results: The in-hospital mortality was 3.5% (1/28). Seventeen patients underwent minimally invasive AVR via an upper partial ministernotomy (n = 13) or a right anterior minithoracotomy (n = 4) approach. The cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC) times were 99.4 +/- 22.9 and 65.9 +/- 18.0 min, respectively, for isolated AVR, and 138.8 +/- 62.2 and 100.5 +/- 52.2 min, respectively, for combined procedures. One patient underwent aortic root replacement for an intimal aortic lesion after sutureless implantation. At a median follow up of four months (range: 2-10 months), survival was 96.5%, freedom from reoperation was 96.5%, and the mean transvalvular pressure gradient was 11.1 +/- 5.4 mmHg.

Conclusion: AVR with the 3f Enable bioprosthesis in high-risk patients is a safe and feasible procedure that is associated with a low mortality and excellent hemodynamic performance.

Background and aim of the study: Detailed analyses of risk-adjusted outcomes after mitral valve surgery have documented significant survival decrements with tissue valves at any age. Several recent studies of prosthetic aortic valve replacement (AVR) also have suggested a poorer performance of tissue valves, although analyses have been limited to small matched series. The study aim was to test the hypothesis that AVR with tissue valves is associated with a lower risk-adjusted survival, as compared to mechanical valves.

Methods: Between 1986 and 2009, primary isolated AVR, with or without coronary artery bypass grafting (CABG), was performed with currently available valve types in 2148 patients (1108 tissue valves, 1040 mechanical). Patients were selected for tissue valves to be used primarily in the elderly. Baseline and operative characteristics were documented prospectively with a consistent variable set over the entire 23-year period. Follow up was obtained with mailed questionnaires, supplemented by National Death Index searches. The average time to death or follow up was seven years, and follow up for survival was 96.2% complete. Risk-adjusted survival characteristics for the two groups were evaluated using a Cox proportional hazards model with stepwise selection of candidate variables.

Results: Differences in baseline characteristics between groups were (tissue versus mechanical): median age 73 versus 61 years; non-elective surgery 32% versus 28%; CABG 45% versus 35%; median ejection fraction 55% versus 55%; renal failure 6% versus 1%; diabetes 18% versus 7% (p<0.01). Unadjusted Kaplan-Meier survival was significantly lower with tissue than mechanical valves; however, after risk adjustment for the adverse profiles of tissue valve patients, no significant difference was observed in survival after tissue or mechanical AVR. Thus, the hypothesis did not hold, and risk-adjusted survival was equivalent, of course qualified by the fact that selection bias was evident.

Conclusion: With selection criteria that employed tissue AVR more frequently in elderly patients, tissue and mechanical valves achieved similar survival characteristics across the spectrum of patient risk. Further studies of the relative outcomes of mechanical versus tissue valves across the spectrum of patient age seem indicated.

Background and aim of the study: The study aim was to compare the effects of mitral valve (MV) repair and replacement with partial (posterior leaflet only) chordal preservation on left ventricular (LV) performance in chronic degenerative mitral regurgitation (MR) by assessing ventricular energetics.

Methods: Contractility (end-systolic elastance), afterload (effective arterial elastance), and ventricular efficiency (ventriculoarterial coupling and the ratio of stroke work to pressure-volume area were determined using transthoracic echocardiography data obtained before and at one month after surgery in 29 patients undergoing MV repair, and in 12 patients undergoing partial chordal-sparing MV replacement. A two-way analysis of variance with repeated measures was used for comparisons among patients who underwent MV surgery (valve repair versus valve replacement).

Results: The LV diastolic volume index was decreased significantly in both groups (p<0.0001), whereas the LV systolic volume index did not change significantly (p=0.956). Despite the similar remarkable decrease in ejection fraction (p<0.0001) in both groups, end-systolic elastance remained unchanged (p=0.312). Effective arterial elastance was increased significantly in both groups (p<0.0001). Ventriculoarterial coupling and the ratio of stroke work to pressure-volume area deteriorated similarly in both groups (p<0.0001 and p<0.0001).

Conclusion: Compensation of LV geometry after correction of chronic MR preserved ventricular contractility. Furthermore, the results of MV repair were not superior to those of MV replacement with partial chordal preservation in the early postoperative period. This suggested that partial chordal-sparing MV replacement is an effective method for the treatment of chronic MR in selected patients.

Background and aim of the study: The study aim was to evaluate the long-term hemodynamic performance of ATS bileaflet valves in the aortic position.

Methods: A total of 132 patients (mean age 54 +/- 13 years) who underwent aortic valve replacement (AVR) using ATS valves between October 1994 and May 2001 was analyzed. Of these patients, 77 underwent isolated AVR (AVR group), while 55 underwent concomitant mitral valve replacement (DVR group). The mean follow up duration was 135 +/- 39 months (maximum 180 months).

Results: The overall mortality was 19.7% (26/132), but no early mortality occurred. Cumulative survival rates at 12 years were 87.0 +/- 3.8% in the AVR group and 71.4 +/- 6.3% in the DVR group (p = 0.093). The AVR group showed a higher cardiovascular event-free survival at 12 years than the DVR group (82.3 +/- 4.7% versus 65.1 +/- 7.3%; p = 0.047). During follow up, the transaortic mean pressure gradient (TMPG) was maintained in the AVR group but increased in the DVR group (p = 0.044). The TMPG at follow up was higher in patients who underwent AVR with small valves (< or =21 mm) than in those receiving large valves (p = 0.001). The tricuspid regurgitation (TR) grade was increased over time in both groups, and was greater in the DVR group (2.1 +/- 1.1 versus 1.4 +/- 1.0; p < 0.001). The progression of late TR correlated with the TMPG (gamma = 0.261, p = 0.022).

Conclusion: The study results showed that ATS valves had acceptable long-term outcomes. A high TMPG was observed more frequently in the DVR group and in patients who underwent AVR with a small valve. A high TMPG might be related to the progression of late TR.

Background and aim of the study: Female gender has recently been suggested to predict a beneficial outcome and lower mortality following transcatheter aortic valve implantation (TAVI). The study aim was to address gender differences in outcome following TAVI and potentially to replicate these findings.

Methods: The present single-center prospective registry of 326 patients with severe aortic stenosis treated by TAVI between 2008 and 2011 consisted of 181 women and 145 men.

Results: The procedural risk was not significantly different between men and women at baseline. For all-cause mortality no difference was observed at 30 days and at 12 months after TAVI.

Conclusion: While several baseline characteristics between men and women treated by TAVI were shown to be different among the study population, no difference was observed in survival between both genders.

Background and aim of the study: Aortic stenosis, the most frequent valvulopathy in the Western world, is characterized by an important extracellular matrix (ECM) remodeling and a process of calcification in the aortic valves. One physiopathological assumption is that transforming growth factor-beta1 (TGF-beta1) acts through ECM remodeling and plays a role in calcification, implicating also microparticles (MPs). Another recent notion is the active involvement of inflammatory mediators in the calcification process of aortic stenosis.

Methods: A total of 105 aortic valves was collected from patients suffering from calcified aortic stenosis with either tricuspid valve (AS) or bicuspid aortic valve (BAV), rheumatic aortic stenosis (RA), endocarditis, or aortic regurgitation (AR). Each valve was incubated for 24 h in culture medium and the supernatants (conditioned media) were used to measure the concentrations of leukotriene B4 (LTB4) and TGF-beta1 and to quantify the number of MPs released. Valvular calcification was evaluated using biphotonic absorptiometry.

Results: LTB4 concentrations were significantly higher in media conditioned by AS valves compared to those conditioned by RA and endocarditis valves. In addition, LTB4 concentrations correlated significantly with the calcium content of the aortic valves. In contrast, the concentrations of TGF-beta1 and MPs in the conditioned media did not differ significantly between the various groups of valves, and there was no significant correlation between calcification and either TGF-beta1 or the number of MPs released from the aortic valves.

Conclusion: Taken together, these results indicate that inflammatory signaling through LTB4 may be more closely linked to calcification and aortic stenosis than signaling through TGF-beta1 and MPs.

Background and aim of the study: Aortic root surgery is a technically demanding procedure that is performed infrequently by most surgeons, with national mortality rates over 10%. The study aim was to identify the barriers to training residents in this operation.

Methods: By using univariate and multivariate logistic regression analysis, all consecutive adults (n = 356) undergoing aortic root reconstruction at The Mount Sinai Medical Center between 2007 and 2011 were retrospectively compared according to whether a resident or faculty surgeon performed the procedure. Surveys were then conducted to determine reasons why residents did not perform cases, and to evaluate outcomes of aortic root surgery performed by recent graduates of the program.

Results: Surgical techniques among patients included: root replacement (81%, n = 290) using homograft, composite bioprosthetic or mechanical valved conduits; Ross procedures (17%, n = 53); and other root surgery such as valve-sparing procedures (2%, n = 7). Residents performed 32% (n = 66/204) of cases when they were scrubbed. The incidence of mortality was lower for cases performed by residents (2%, n = 2) compared to faculty (4%, n = 12) (p=0.335), and no significant differences in cardiopulmonary bypass or cross-clamp times, early morbidity or late survival were observed. The most common reasons given why scrubbed residents did not perform cases were a mismatch between the skill of the resident and case complexity (46%, n = 94), followed by the faculty surgeon's preference (41%, n = 83). Recent program graduates had collectively performed 30 aortic root procedures independently as faculty surgeons, and with no mortality; however, most expressed a continued preference for more senior help on such cases.

Conclusion: Residents can safely perform aortic root surgery under appropriate supervision. The greatest challenge involved in improving resident training in aortic root surgery lies in routinely matching resident skills with case complexity and teaching expertise.

Background and aim of the study: The role of the Ross procedure in adults is controversial. In comparison with prosthetic aortic valve replacement (AVR), its greater technical complexity has been associated with increased operative mortality. The aim of the present study was to evaluate the impact of surgeon experience on early outcomes after the Ross procedure.

Methods: Using multivariate analysis, the details of 530 consecutive patients who had undergone the Ross operation between 1987 and 2013 were analyzed according to whether they had surgery during the early, middle, or later phases of a single-surgeon experience.

Results: Cumulative sum analysis revealed an initial learning curve of around 100 cases. There was no operative mortality in the later phase of 305 cases, compared to 3% (3/100) in the early phase and 2.4% (3/125) in the middle phase (p = 0.04). The mean EuroSCORE did not change significantly across the series (2.3-3.2%, p = 0.4), whereas the patient mix did change. A decreasing incidence of comorbidities, such as acute endocarditis (from 10% to 1.3%, p = 0.02), congestive heart failure (from 8% to 2.3%, p = 0.03) and coronary artery disease (from 11% to 2.3%, p = 0.001), occurred in parallel with increasing case complexity. Isolated Ross procedures were performed less frequently later in the series (42%, n = 130) compared to the early stage (68%, n = 68; p < 0.001), and concomitant ascending aortic or arch replacement were significantly more likely to be performed in later patients (33.8%, n = 103) compared to early-stage patients (1%, n = 1; p <0.001). Independent predictors of operative mortality and major morbidity included endocarditis (odds ratio (OR) 5.2, 95% confidence interval (CI) 1.3-21.5), diabetes (OR 4.3, 95% CI 1.2-15.5), and concomitant coronary artery bypass (OR 3.2, 95% CI 1.2-8.4). Residents or junior faculty performed the surgery in 26 cases, under direct supervision and without patient mortality.

Conclusion: The Ross procedure can be performed with early outcomes comparable to that of isolated AVR in adults. The impact of the learning curve on patient outcomes may be mitigated by careful patient selection and experienced supervision.

Transcatheter aortic valve implantation (TAVI) offers a less invasive treatment alternative to surgical aortic valve replacement for high-risk patients. Although the procedure can be performed at low risk, life-threatening complications may arise in single cases during or even months after the procedure. Here, the details are presented of two patients who underwent TAVI by a transfemoral approach with Medtronic CoreValve prostheses and suffered myocardial ischemia months later. The patients' anatomy with small aortic root, narrow sinus of Valsalva and small distance between the annulus base and coronary arteries and/or the relative oversizing of the CoreValve prosthesis with a high positioning may have contributed to this late complication. Hence, caution is mandatory in this type of patient, with exact pre-procedural planning and close follow up required.