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Annuloplasty should always accompany mitral valve repair in order to achieve proper annular remodeling and stabilization. Numerous types of annuloplasty rings-that differ from rigid to semi-rigid and flexible devices, from complete to partial, and from flat to saddle-shaped rings-are clinically available. A deeper understanding of mitral valve function, in conjunction with several recent studies, suggest it is advisable to prefer annuloplasty rings that mimic the physiological mitral annulus shape and three-dimensional (3D) dynamic changes in order to reduce haemodynamic stress on valve components and optimize leaflet coaptation, perhaps improving valve repair durability too. This paper aims to focus on 3D annuloplasty rings, with dynamic features: MEMO 3D™ and MEMO 4D™ (Sorin Medical, New York, New York), as well as Physio Flex (Edwards Lifesciences, Irvine, California).

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Background/Objectives: Robotically assisted mitral valve (MV) surgery is the least invasive surgical approach to the MV. The aim of the present study is to report our experience with robotically assisted MV repair, trying to define how experience could impact on postoperative results. Methods: This is a retrospective study on 144 patients who underwent robotic MV repair from November 2011 to March 2023. Patients were divided in two groups: Group 1, including 39 patients (November 2011-January 2013) operated using the Da Vinci Si system, and Group 2, including 105 patients operated (February 2020-March 2023) using the new Da Vinci Xi system. Results: Mean age was 58 ± 10 years. Increased use of external aortic clamp was observed in Group 2. A significant reduction of surgical times was observed: cardiopulmonary bypass time was 155 ± 44 min in Group 1 and 121 ± 36 min in Group 2 (p = 0.002), whereas cross-clamp time was 112 ± 25 min in Group 1 and 68 ± 39 min in Group 2 (p < 0.001). In-hospital mortality was 0.7%, and 10-year survival was 96 ± 2%. Freedom from reoperation was 100%. A higher percentage of complex and most complex MV repairs were performed in Group 2 (36% in Group 1 vs. 52% in Group 2, p = 0.001). Conclusions: Robotic-assisted MV repair is associated with excellent results. Experience is a key element to overcome the limitations of this technology. Finally, the robotic platform could improve results in difficult MV repair.

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AIMS: Septal myectomy is the treatment of choice for hypertrophic obstructive cardiomyopathy (HOCM). Around 30-60% of patients with HOCM have a secondary mitral valve regurgitation due to systolic anterior motion (SAM). We report our experience with extended septal myectomy and its impact on the incidence of concomitant mitral valve procedures. METHODS: This is a retrospective study on 84 patients who underwent SM from January 2008 to February 2022. Surgical procedure was performed according to the concept of 'extended myectomy' described by Messmer in 1994. Follow-up outcomes in terms of survival, hospital admissions for heart failure or MV disease, cardiac reoperations, and pacemaker (PMK) implantation were recorded. RESULTS: Mean age was 61 ±â€Š15 years. Mitral valve surgery was performed in seven cases (8%); particularly only one patient without degenerative mitral valve disease underwent mitral valve surgery, with a plicature of the posterior leaflet. In-hospital mortality was 5%. Mitral valve regurgitation greater than mild was present in four patients (5%) at discharge. Twelve-year survival was 78 ±â€Š22%. Cumulative incidence of rehospitalization for heart failure and rehospitalization for mitral valve disease was 10 ±â€Š4 and 2.5 ±â€Š2.5%, respectively. PMK implantation was 5% at discharge, with a cumulative incidence of 15 ±â€Š7%. Freedom from cardiac reoperations was 100%. CONCLUSION: Septal myectomy for HOCM is associated with good outcomes. Although concomitant surgery on the mitral valve to address SAM and associated regurgitation has been advocated, these procedures were needed in our practice only in patients with intrinsic mitral valve disease. Adequate myectomy addresses the underlying pathophysiology in most patients.

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OBJECTIVES: In the last decades, 4 different scores for the prediction of mortality following surgery for type A acute aortic dissection (TAAD) were proposed. We aimed to validate these scores in a large external multicentre cohort. METHODS: We retrospectively analysed patients who underwent surgery for TAAD between 2000 and 2020. Patients were enrolled from 10 centres from 2 European countries. Outcomes were the early (30-day and/or in-hospital) and 1-year mortality. Discrimination, calibration and observed/expected (O/E) ratio were evaluated. RESULTS: A total of 1895 patients (31.7% females, mean age 63.72 ± 12.8 years) were included in the study. Thirty-day mortality and in-hospital mortality were 21.7% (n = 412) and 22.5% (n = 427) respectively. The German Registry of Acute Aortic Dissection Type A (GERAADA) score shows to have the best discrimination [area under the curve (AUC) 0.671 and 0.672] in predicting as well the early and the 1-year mortality, followed by the International Registry of Acute Aortic Dissection (IRAD) model 1 (AUC 0.658 and 0.672), the Centofanti (AUC 0.645 and 0.66) and the UK aortic score (AUC 0.549 and 0.563). According to Hosmer-Lemeshow and Brier tests, the IRAD model I and GERAADA, respectively, were well calibrated for the early mortality, while the GERAADA and Centofanti for the 1-year mortality. The O/E analysis showed a marked underestimation for patients labelled as low-risk for UK aortic score and IRAD model I for both outcomes. CONCLUSIONS: The GERAADA score showed the best performance in comparison with other scores. However, none of them achieved together a fair discrimination and a good calibration for predicting either the early or the 1-year mortality.

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INTRODUCTION: The most common minimally invasive approach for aortic valve replacement (AVR) is the partial upper mini-sternotomy. The aim of this study is to understand which preoperative computed tomography (CT) features are predictive of longer operations in terms of cardio-pulmonary bypass timesand cross-clamp times. METHODS: From 2011 to 2022, we retrospectively selected 246 patients which underwent isolated AVR and had a preoperative ECG-gated CT scan. On these patients, we analysed the baseline anthropometric characteristics and the following CT scan parameters: aortic annular dimensions, valve calcium score, ascending aorta length, ascending aorta inclination and aorta-sternum distance. RESULTS: We identified augmented body surface area (>1.9 m2), augmented annular diameter (>23 mm), high calcium score (>2500 Agatson score) and increased aorta-sternum distance (>30 mm) as independent predictors of elongated operation times (more than two-fold). CONCLUSIONS: Identifying the preoperative predictive factors of longer operations can help surgeons select cases suitable for minimally invasive approaches, especially in a teaching context.

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OBJECTIVE: During the last decade, special concerns have been raised about the anatomic relationships among the sinotubular junction, ventricular-aortic junction, and virtual basal ring to improve the results of root reconstruction. The aim of this study is to evaluate the in vivo anatomy of the aortic root after reimplantation with the Valsalva graft and the anatomic relationship between its components. METHODS: We analyzed 10 consecutive patients with tricuspid aortic valves who underwent reimplantation with the Valsalva graft between September and December 2019. Surgical clips were applied as markers at the level of proximal annular knots and at the distal reimplanted commissures on the neo-sinotubular junction. Electrocardiogram-gated computed tomography scan of the aortic root was performed. Coordinates of the markers were exported on a 3-dimensional modeling software, and the distances between the virtual basal ring and the Dacron graft basal landmarks were measured. RESULTS: The mean heights of Dacron graft basal landmarks from virtual basal ring were right-left commissure 7.1 ± 5.1 mm; right sinus 4.7 ± 4.1 mm; right-noncoronary commissure 2.8 ± 2.2 mm; noncoronary sinus 1.4 ± 1.6 mm; left-noncoronary commissure 2.2 ± 2.3 mm; and left sinus 2.0 ± 0.9 mm. The mean planar distances of basal Dacron graft landmarks from virtual basal ring (thickness) were right-left commissure 5.3 ± 3.1 mm; right sinus 2.8 ± 1.4 mm; right-noncoronary commissure 2.2 ± 1.5 mm; noncoronary sinus 1.5 ± 1.5 mm; left-noncoronary commissure 1.3 ± 1.0 mm; and left sinus 3.4 ± 2.5 mm. CONCLUSIONS: After reimplantation, despite a complete dissection of the root, slight asymmetry of graft proximal seating exists. The inner annuloplasty is on the virtual basal ring, and the proximal edge of the Dacron graft is on the ventricular-aortic junction at a slightly different thickness and height along the annular circumference. At the level of the right sinus and left/right commissure, the Dacron graft is higher than the virtual basal ring and the relative wall thickness is increased. The annular stabilization is unaffected.

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OBJECTIVES: Over the past 20 years, valve-sparing aortic root replacement has aroused increasing interest because of a progressive attitude towards the preservation of natural tissue. Aortic reimplantation is the most used technique to spare the valve, allowing simultaneously aortic root replacement and aortic annular stabilization. The reimplantation into a graft with sinuses guarantees an optimal anatomic and functional reconstruction with established good results at 15 years. The aim of this study is to report the world longest follow-up (up to 20 years) of aortic valve reimplantation using the Valsalva graft. METHODS: From February 2000 to December 2021, 265 consecutive patients with aortic root aneurysm received aortic valve reimplantation using the Valsalva graft. From 2018, leaflet plication with the routine use of calliper was performed. For each patient, we performed both intraoperative and post-procedural transoesophageal echocardiography. All patients were followed with clinical assessment and echocardiography. The mean duration of follow-up was 85 ± 63 months. RESULTS: The study cohort had a median age of 55 ± 18 and 87.2% were male. The aortic root aneurysm was associated to bicuspid aortic valve in 18.9% of patients and to Marfan syndrome in 10.6% of cases. 55.9% had an aortic regurgitation ≥ 2+. Overall survival at 15 was 87.6 ± 3.4. Freedom from cardiac death was stable at 99.6 ± 0.4 at 5, 10 and 15 years. Freedom from recurrent AR ≥3+ and freedom from reoperation remained stable at 10 and 15 years at 92.2 ± 2.1 and 95.9 ± 1.6, respectively. There was a minimal incidence of infective endocarditis (0.8%), thromboembolism (2.2%) and haemorrhage (2.0%). Six out of 7 patients requiring reoperation had surgery in the first period of our experience (last in 2004). Early suboptimal results had a negative effect on residual aortic regurgitation. Moreover, we hypothesized that the routine use of calliper may have contributed to a further improvement of the outcome, even if these data need to be confirmed by a longer follow-up. CONCLUSIONS: The first long-term follow-up after aortic valve reimplantation using the Valsalva graft demonstrated excellent results. These long-term results gradually improved with learning curve, remaining stable during the second decade of observation. The systematic use of calliper may have contributed to a further improvement of the outcome.

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Objective: Bicuspid aortic valve repair can be achieved with the reimplantation technique or external ring annuloplasty. Reimplantation could be an "overtreatment" in nonaneurysmatic aortic roots. External ring repair, on the contrary, could be an "undertreatment" in dilated roots. The aim of this retrospective study is to compare the 2 techniques in patients with borderline aortic root dimensions, analyzing early results, aortic regurgitation recurrence, and root dilation over time. Methods: We selected patients with bicuspid aortic valve and ectasia of the aortic root (40-48 mm) who underwent reimplantation or external ring repair. We compared the 2 techniques, analyzing immediate postoperative and follow-up echocardiography. Only patients with at least 1 year of follow-up were included. Results: We obtained 2 groups of 21 patients (reimplantation) and 22 patients (external ring). Median follow-up time was 36 (40) months. There were no deaths during the follow-up periods. Three patients required reoperation in the external ring group because of recurrent aortic regurgitation, with a freedom from reoperation of 77.8% at 7 years (no reoperation was required in the reimplantation group). In the external ring group, we observed an immediate postoperative root diameter reduction and no significative expansion during follow-up (+0.4 mm/year, P = .184). Conclusions: Excellent results of reimplantation technique are confirmed and stable over time. Root diameter seems to remain stable over time when external ring technique was performed. The greater incidence of reoperation after external ring could be due to the progressive learning curve (256 patients vs 52 patients). Longer follow-up studies are needed.

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Aortic annuloplasty has demonstrated to be a protective factor in valve-sparing root replacement and aortic valve repair. Both reimplantation for aortic root aneurysms and external ring annuloplasty for isolated aortic regurgitation have demonstrated good long-term results. The aim of this anatomical study is to compare aortic reimplantation with Valsalva graft with aortic external ring annuloplasty in bicuspid aortic valves, analyzing their morphological features with CT scan. We selected 56 patients with bicuspid aortic valve who underwent reimplantation procedure with Valsalva graft or external ring annuloplasty; after propensity-matching, 2 homogeneous groups of 10 patients each were obtained. Through multiplanar ECG-gated CT-Scan reconstructions, pre- and postoperative, aortic annular, and valve geometrical characteristics were compared (diameters, perimeter, area and ellipticity index for the annulus; effective height, coaptation length and commissural height for the valve). Aortic root volume was also analyzed. Postoperative comparison of the two groups showed similar geometric features of the aortic annulus in terms of major and minor diameters, perimeter, area and ellipticity index. Analysis of valve's parameters showed similar results in terms of effective height and coaptation length (respectively 10.9 ± 2.1 mm and 7.5 ± 1.9 mm in External Ring group and 10.1 ± 2.0 mm and 7.6 ± 1.6 mm in the Reimplantation group). Both techniques achieve an efficient annuloplasty with similar anatomical results on bicuspid the aortic valves. The stability of these results needs to be confirmed by long-term clinical and echocardiographic follow-up.

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Left ventricular aneurysms (LVA) are a complication of myocardial infarction, that rarely involve the posterior wall; surgical repair of posterior LVA poses a technical challenge when associated with concomitant mitral regurgitation. We describe a minimally invasive treatment of ischemic MR and concomitant patch exclusion of posterior LVA through a right minithoracotomy. Using a transatrial approach, the aneurysm is closed with a "U" shaped dacron patch, whose base is anchored to the mitral annulus. Two patients were operated by this method with excellent results.

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OBJECTIVES: Bentall procedure is the gold standard for aortic root pathologies when valve repair is not feasible. The development of durable bioprosthetic valves and improved vascular conduits allowed the implementation of bioprosthetic composite grafts; hereby, we performed a retrospective analysis of long-term follow-up of Bentall procedure using the Valsalva graft and the Perimount Magna Ease prosthesis. METHODS: From June 2000 to March 2019, 309 patients received an aortic root and valve replacement with a bioprosthetic composite graft. The mean age was 69 ± 6.9 years, and the majority were men (88%); most of them were affected by aortic stenosis (86%) and the mean aortic root diameter was 48.6 ± 5.5 mm. RESULTS: Freedom from cardiac death was 76.8% [confidence interval (CI) 32.5-94.0] at 16 years. Freedom from thromboembolism, haemorrhage, structural valve deterioration and infective endocarditis was 98.2% (CI 96.0-98.9), 95.2% (CI 87.1-98.2), 87.5% (CI 63.2-97.1) and 79.6% (CI 45.3-95.6) at 16 years, respectively. Freedom from reoperation was 74.7% (CI 41.9-90.6). CONCLUSIONS: These data indicate that, in experienced centres, the Bentall procedure is a safe and effective intervention. This is the first long-term follow-up that analyses the results after implantation of a composite graft made with the Perimount Magna Ease aortic valve and the Valsalva graft.

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INTRODUCTION: Progressive saphenous vein graft (SVG) failure remains a key limitation to the long-term success of coronary artery bypass grafting (CABG). SVG disease after the first year is dominated by intimal hyperplasia, which predisposes the SVG to thrombosis and accelerated atherosclerosis. The objective of this study was to review and summarize the latest experimental and clinical data on the use of mechanical external stents for vein grafts. METHODS: In January 2020, the PubMed database was searched using the terms "external stent", "CABG", "saphenous vein graft" and "intimal hyperplasia". The results were reviewed and only randomized experimental and clinical studies that analyzed the effect of external stenting on venous intimal hyperplasia were included in the analysis, together with studies that investigated the clinical benefit of external stenting. RESULTS: Eight experimental and four clinical trials met the search criteria. Controlled trials in different large animal models concluded that external stenting significantly reduced intimal hyperplasia 3-6 months post implantation, and reduced both thrombosis rates and the development of lumen irregularities. Data from randomized controlled trials with a follow-up period of 1-4.5 years supported the pre-clinical findings and demonstrated that external stents significantly reduced vein graft disease. CONCLUSION: Strong evidence indicates that supporting the vein with external stents is safe and leads to clear advantages at both the anatomical and cellular levels. With the further accumulation of consistent positive results, external stenting of SVG may become the standard of care in future CABG.

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OBJECTIVES: The shape of the aortic annulus is still under debate. Recent findings suggest a possible gradual spectrum of circularity from tricuspid aortic valves (TAVs), to type 1 bicuspid aortic valves (BAVs) to type 0 BAVs. BAVs have been recently classified in a symmetrical (type A), asymmetrical (type B) or very asymmetrical (type C) phenotype according to the commissural orientation (CO) (160°-180°, 140°-159° and 120°-139°, respectively). The aim of this study is to verify in BAVs the correlation between the aortic annular shape and the CO of valve cusps and to suggest a new anatomical and geometric classification of BAVs based on CO and annular shape. METHODS: We retrospectively selected 191 consecutive patients who underwent both electrocardiography-gated computed tomography scan of the aortic root and transthoracic echocardiography between January 2016 and June 2019. The population was divided into 2 groups: 54 BAVs and 137 TAVs. We analysed the subgroup of BAV patients and divided them into group A, group B and group C depending on the CO. The shape of the aortic annulus was considered 'circular' or 'elliptic' according to the ellipticity index (EI).We studied the possible correlation between CO and annular shape in BAVs. We also analysed the subgroup of TAV patients studying their annular shape and EI. RESULTS: After univariate linear regression, BAV patients showed a significant correlation between the CO and the EI (R = -0, 445, R2 = 0, 198, P = 0.001). As the CO decreases, the EI increases and approaches an elliptical shape. After grouping BAVs according to the CO, a mean EI of 1.10 ± 0.07 was found in group A, 1.13 ± 0.08 in group B, 1.18 ± 0.07 in group C, P = 0.0097 indicating a gradual spectrum of ellipticity with the decrease of CO. TAVs subgroup showed a mean EI of 1.27 ± 0.09, suggesting that the more the CO is reduced in BAVs, the more the annulus probably tends towards the very elliptical shape of TAVs. CONCLUSIONS: This study shows a linear correlation between CO and annular shape in BAVs. In particular, the aortic annulus follows a continuous spectrum of ellipticity depending on the CO. These findings lay the groundwork for a new anatomical classification of BAVs based on CO and annular shape.

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PURPOSE OF REVIEW: Until the year 2000, the publications concerning aortic valve sparing (AVS) did not exceed 20 articles; in the following years almost 300 publications have appeared. Over 35 years from the introduction of valve sparing techniques and 500 years after the death of Leonardo da Vinci, this review highlights the significant steps in modern imaging techniques and the excellent clinical results in the field of reconstructive aortic root surgery. RECENT FINDINGS: AVS operations underwent significant modifications over the last few years making it reproducible with satisfactory outcomes. The extraordinary potential of imaging opens new boundless horizons in the perspective of an increasingly patient-tailored surgical planning. The basic surgical concepts include the preservation and resuspension of the aortic valve in a near-normal environment (with the creation of functionally suited neo-aortic sinuses) and the re-establishment of a normal relationship of the aortic root components. SUMMARY: Today is possible to perform a reimplantation procedure with the creation of neo-sinuses or a remodeling procedure with the addition of annular support. Both procedures can now guarantee an anatomical root reconstruction and an increased long-term durability. AVS operations have become established alternatives to Bentall procedures for patients with aortic root pathology, especially in young patients.

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OBJECTIVES: Aortic valve-sparing operations have been shown to produce fewer valve-related complications than valve replacement. The aortic root is a morphological and functional unit in which the annulus plays an important role on dynamism, shape and geometry of the valve with different results in bicuspid aortic valves (BAVs) or tricuspid aortic valves (TAVs). The aim is to evaluate the differences in the size and shape of the aortic annulus between native BAVs and TAVs using ECG-gated computed tomography (CT) after a reimplantation procedure. METHODS: We selected 35 patients scheduled for aortic valve reimplantation who underwent good-quality preoperative and postoperative ECG-gated contrast-enhanced CT scan of the aortic root. Twenty-three patients had TAV, 8 patients type 1 BAV and 4 patients type 0 BAV. Major diameter and minor diameter, perimeter (P) and area (A) were measured. The shape of the aortic annulus was considered 'circular' or 'elliptic' according to the Ellipticity Index. We also selected a subgroup of 18 patients (9 TAVs and 9 BAVs) to evaluate annular shape and size variations through the cardiac cycle and to study the expansibility both in the preoperative and in the postoperative phases. RESULTS: Preoperative CT scans showed an elliptic shape of TAVs (Ellipticity Index 1.3 ± 0.1), a circular shape of type 0 BAVs (1.1 ± 0.1) and an intermediate behaviour of type 1 BAVs, suggesting a possible gradual spectrum of circularity from TAVs to type 1 BAVs to type 0 BAVs. Postoperative CT scans did not show any significant difference in annular shape among the 3 groups, which demonstated a similar roundness, obviating the preoperative differences. Analysing the expansibility of the aortic annulus during the cardiac cycle, we observed that it was completely absent in the preoperative phase in BAVs, while in the postoperative phase, both TAVs and BAVs showed a small but similar expansibility after the annular reduction. CONCLUSIONS: There is a possible gradual spectrum in terms of shape, from native TAVs, to type 1 BAVS to type 0 BAVs. These differences are eliminated in the postoperative phase, suggesting an active role of the annuloplasty on the geometry of the aortic annulus. The preoperative analysis showed a complete inelasticity of BAVs, which was partly restored in the postoperative phase.

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OBJECTIVES: This study applied advanced 4-dimensional flow magnetic resonance imaging processing to assess differences in aortic flow dynamics after valve sparing root replacement, with and without reconstruction of the Valsalva sinuses. METHODS: We enrolled patients after valve sparing root replacement with a straight tubular prosthesis (n = 10) or with a prosthesis with Valsalva neosinuses (n = 10); age-matched subjects without cardiovascular diseases served as controls (n = 10). 4-Dimensional flow magnetic resonance imaging acquisitions were performed on a 3.0T magnetic resonance imaging unit. In-house processing was used to segment the aortic lumen and extract the volumetric 4-dimensional flow velocity field. Velocity flow streamlines were computed to compare the amount of rotational flow and wall shear stress. Occurrence of abnormal wall shear stress (WSS) was estimated within the descending aorta of each surgical group. RESULTS: Physiologic-like sinus vortices were visible in the aortic root when using the prosthesis with neosinuses, whereas straight tubular graft revealed localized intrados malrotations (P = .003 for organized vortical structures vs neosinuses graft and P < .001 vs control). In the ascending aorta, recreation of the sinuses resulted in significantly lower velocity and WSS than in the straight tubular graft (P < .001) and controls (P < .001), these alterations were attenuated in the mid-descending aorta. Incidence of abnormal WSS was markedly higher in the straight tube grafts than neosinus of Valsalva grafts. CONCLUSIONS: Re-creation of the sinuses of Valsalva during valve-sparing root replacement is associated with more physiologic flow and significantly lower WSS in the aortic root. Lower WSSs in the distal thoracic aorta is a novel finding with potential implications on distal aortic remodeling.

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Composite valve graft implantation described by Bentall and De Bono is a well-documented technique of aortic root replacement used for a large spectrum of pathologic conditions involving the aortic valve and the ascending aorta. While mechanical valves were initially used, biological prostheses were later introduced in order to avoid long-term anticoagulation and its related complications. The increasing age of patients who undergo aortic root surgery, and data supporting the use of a biological aortic valve in the younger population, have significantly increased the need for a composite biological valved conduit. However, parallel to the increased use of biological valve in the context of a Bentall operation, aortic valve-sparing (AVS) operation have also been performed in a growing number of patients. Sarsam and David described the remodeling and the reimplantation procedures more than 25 years ago with the aim of sparing otherwise normal aortic valves in the presence of a root aneurysm. Important achievements in this discipline have occurred over the past decade including development and refinement of valve preserving aortic root replacement techniques, development of a classification system for aortic insufficiency, surgical approaches to cusp disease with different cusp anatomy. Both procedures can now provide excellent root reconstruction and adequate clinical results in terms of late valve durability. The AVS technique offers several advantages over the Bentall procedure, such as no need for oral anticoagulation and lifestyle adjustments. AVS operations have become established alternatives to Bentall procedures for patients with aortic root pathology. However, data comparing the safety and durability of these approaches are lacking.

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The original monograph on valvular prostheses in Surgical Technology International was published in 1993. It represents a milestone and a reference point for critically organizing information on a complex and rapidly evolving topic. The last update was published in 2010. Since then, there have been significant developments regarding both "traditional" surgical prosthesis and valves for transcatheter implantation. Both bioprostheses and mechanical prostheses continue to evolve with respect to both their design and materials to further optimize hemodynamics and prevent a patient-prosthesis mismatch. Each type of prosthesis has its own Achilles's heel: limited durability leading to structural failure for bioprostheses, and the need for anticoagulation for mechanical prostheses. After a long period of only marginal improvements, new techniques for tissue preservation and manufacturing seem to have placed surgeons on the verge of a minor revolution regarding bioprostheses. In addition, in the realm of mechanical prostheses, the many promises of silicon-free pyrolitic carbon still need to be confirmed, while an extremely cautious approach with new anticoagulants has left patients out of the non-dose-adjusted revolution, which has radically improved the quality of life of other patients, such as those suffering from atrial fibrillation. On the other hand, transcatheter therapies are maturing, and the next few years will probably see an even stronger shift in the treatment of patients away from surgical theaters to cath labs, or perhaps to a new mixed theater (which could lead to a new mixed surgeon/catheter expert professional). This paper provides device descriptions and images of the technologies that are considered to be predominant, at least for the moment, to help orient surgeons and to serve as a reference for students. This report would not have been possible without the prior work of Profs. Denton Cooley and Eric Jamieson.

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OBJECTIVES: This study was undertaken to evaluate the flow dynamics in the aortic root after valve-sparing root replacement with and without neosinuses of Valsalva reconstruction, by exploiting the capability of 4D Flow imaging to measure in vivo blood velocity fields and 3D geometric flow patterns. METHODS: Ten patients who underwent valve-sparing root replacement utilizing grafts with neosinuses or straight tube grafts (5 cases each) were evaluated by 4D Flow imaging at a mean of 46.5 months after surgery. We used in-house processing tools to quantify relevant bulk flow variables (flow rate, stroke volume, peak velocity and mean velocity), wall shear stresses and the amount of flow rotation characterizing the region enclosed by the graft and the aortic valve leaflets. RESULTS: Despite bulk flows with similar peak velocities, flow rates and stroke volumes (P = 0.31-1.00), the neosinuses graft was associated with a lower mean velocity (P < 0.03) and magnitude of wall shear stress along the axial direction of the vessel wall (P < 0.05) at the proximal root level but remained comparable along the circumferential direction (P = 0.22-1.0) to the straight tube graft. Flow rotation was evidently and systematically higher in the neosinuses grafts, characterized by streamline rotations higher than 270°, nearly triple that of tubular grafts (10.3 ÷ 14.0% of all aortic streamline vs 2.2 ÷ 5.7%, P = 0.008). CONCLUSIONS: Recreation of the sinuses of Valsalva during valve-sparing root replacement is associated with significantly lower wall shear stress and organized vortical flows at the level of the sinus that are not evident using the straight tube graft. These findings need confirmation in larger studies and could have important implications in terms of aortic valve durability.

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