Minimally invasive versus conventional methods for aortic root surgery: Choosing the right approach.

OBJECTIVE: Partial upper sternotomy is preferred for isolated aortic valve replacement because of its optimal surgical visibility and favorable cosmetic outcomes; however, it is not commonly used for aortic root surgery, and the conventional median sternotomy is still the preferred method for most surgeons. We aimed to compare the safety and effectiveness of a minimally invasive approach (partial sternotomy [PS]) and conventional approach (median sternotomy [FS]) for aortic root surgery. METHODS: Patients who underwent aortic root surgery at our hospital from 2016 to 2021 were retrospectively enrolled and divided into two groups. After propensity score matching, the conventional group included 156 patients and the minimally invasive group-57 patients. RESULTS: Bicuspid aortic valves were observed in 63 (40.4%) and 33 (57.9%) patients in the FS and PS groups, respectively. Valve-sparing surgery was performed on 69 (44.2%) and 30 (52.6%) patients in the FS and PS groups, respectively. The minimally invasive approach was beneficial in terms of blood loss during the first 24 h after surgery (p = 0.029) and postoperative blood transfusion (p = 0.023). The survival rates and freedom from reoperation or severe aortic regurgitation after the David procedure were comparable between the standard and minimally invasive groups (p = 0.25; p = 0.66) at mid-term follow-up. CONCLUSIONS: A minimally invasive approach for aortic root surgery can be safely performed as the standard approach. Partial upper sternotomy has the advantage of lower blood loss in the early postoperative period and does not negatively affect the results of valve-sparing root replacement.

Transapical Approach to Septal Myectomy for Hypertrophic Cardiomyopathy.

A 63-year-old symptomatic female with apical hypertrophic cardiomyopathy and diastolic disfunction was admitted to the hospital. What is the best way to manage this patient? This study is a literature review that was performed to answer this question. The following PubMed search strategy was used: 'Hypertrophic obstructive cardiomyopathy' [All Fields] OR 'apical myectomy' [All Fields], NOT 'animal [mh]' NOT 'human [mh]' NOT 'comment [All Fields]' OR 'editorial [All Fields]' OR 'meta-analysis [All Fields]' OR 'practice-guideline [All Fields]' OR 'review [All Fields]' OR 'pediatrics [mh]'. The natural history of the disease has a benign prognosis; however, a watchful strategy was associated with the risk of adverse cardiovacular events. Contrastingly, transapical myectomy was associated with low surgical risk and acceptable outcomes. In our case, the patient underwent transapical myectomy with an unconventional post-operative period. Control echocardiography showed marked left ventricular (LV) cavity enlargement: LV end-diastolic volume, 74 mL; LV ejection fraction, 65%; and LV stroke volume index increased to 27 mL/m2. The patient was discharged 7 days after myectomy. At 6 months post-operation, the patient was NYHA Class I, with a 6 min walk test score of 420 m. Therefore, transapical myectomy may be considered as a feasible procedure in patients with apical hypertrophic cardiomyopathy and progressive heart failure.

Redo aortic root surgery post-Ross procedure.

Background: Despite numerous advantages of the Ross procedure, it presents a risk of late autograft and right ventricular outflow tract conduit failure. This study aimed to analyze the outcomes of autograft dysfunction reoperations using autograft-sparing and root replacement techniques. Methods: Between 2015 and 2023, 49 patients underwent redo root surgery in our institution. Autograft valve-sparing procedures (VSP) were performed in 20 cases and the Bentall procedure (BP) in 29 patients. The short and long-term clinical outcomes along with echocardiographic results of VSP and BP were investigated. Results: Overall early mortality rate was 2.0% with no significant difference between the groups. Severe autograft valve insufficiency at the time of redo (OR 4.07, P = 0.03) and patient age (OR 1.07, P = 0.04) were associated with a valve replacement procedure instead of VSP. The median follow-up duration was 34 months. No late deaths occurred in either group. Freedom from VSP failure and aortic prosthesis dysfunction were 93.8% and 94.1% in the VSP and BP groups, respectively. No reoperations were necessary in either group. Conclusion: Redo aortic root surgery can be safely performed in patients with autograft failure. Both root replacement and autograft valve-sparing procedures demonstrated acceptable results at mid-term follow-up. Early redo surgery pre-empting severe aortic insufficiency increases the likelihood of preservation of the dilated autograft valve.

The David procedure through a right anterior minithoracotomy.

A right anterior minithoracotomy is the least-frequently utilized approach in minimally invasive aortic valve surgery; moreover, this access is rarely used for aortic root procedures. With careful patient selection, some technical considerations, e.g. institution of peripheral cardiopulmonary bypass, and a sufficient learning curve, the right anterior minithoracotomy can become a convenient access for surgical interventions on the aortic root. We present the case of a 31-year-old female patient with Marfan syndrome and severe aortic regurgitation due to an aortic root aneurysm. We demonstrate a step-by-step guide through the David procedure via a right anterior minithoracotomy.

Minimally invasive mitral valve repair and ablation of concomitant atrial fibrillation in a patient with severe hemophilia A.

Minimally invasive mitral valve repair and ablation of atrial fibrillation, combined with FVIII level-controlled replacement therapy, can be safely performed in patients with severe hemophilia.

The Bio-Bentall procedure with concomitant hemiarch replacement through a right anterolateral minithoracotomy.

A right anterior minithoracotomy is a surgical approach that can be an excellent alternative to a median sternotomy. However, for aortic root interventions, the median sternotomy is still the gold standard. Most surgeons are slow to master this method because the visualization is poor and less convenient. These problems can be solved by careful selection of patients and using some technical tricks. The patient is a male with a severe aortic valve lesion and an aneurysm of the ascending aorta involving the proximal arch. We demonstrate step-by- step how to perform a minimally invasive Bio-Bentall procedure with a "hemiarch" replacement through a right anterolateral thoracotomy.

Results of concomitant cryoablation for atrial fibrillation during mitral valve surgery.

OBJECTIVES: Concomitant atrial fibrillation ablation during mitral valve (MV) surgery using radio frequency energy sources has been reported previously with excellent outcomes. However, data regarding the effectiveness of concomitant cryoablation remain limited. This study aimed to assess the efficacy of concomitant cryoablation in patients scheduled for MV surgery. METHODS: Between 2012 and 2020, 242 adult patients who underwent MV surgery and concomitant cryoablation were included. Data on rhythm, medication status and clinical events were assessed at 3, 6 and 12 months, then annually thereafter. RESULTS: Early mortality was 0.4%. The mean follow-up period duration was 43.9 months. The survival rates at 1, 3 and 5 years were 97.3%, 94.3% and 87.7%, respectively. The rates of freedom from atrial arrhythmia paroxysms at 1, 3 and 5 years were 79.0%, 64.0% and 60.5%, respectively. Atrial arrhythmia recurrence was associated with isolated left atrial lesion set (P = 0.038), large right atrial size (P = 0.002), lower surgeon experience (P = 0.003) and atrial fibrillation paroxysms in the early postoperative period (P = 0.002). CONCLUSIONS: Concomitant cryoablation during MV surgery is a safe and reproducible technique. The procedure provides acceptable freedom from atrial arrhythmias recurrences during long-term follow-up. The biatrial lesion set has advantages over the left atrium pattern in terms of atrial arrhythmias freedom. Surgeon experience significantly influences atrial fibrillation ablation success. Randomized trials are needed to compare radiofrequency and cryoablation.

Early post-septal myectomy outcomes for hypertrophic obstructive cardiomyopathy.

BACKGROUND: We aimed to evaluate early outcomes of septal myectomy in patients with hypertrophic cardiomyopathy. METHODS: We retrospectively analyzed data collected over a 9-year period from 583 patients who underwent septal myectomy for hypertrophic cardiomyopathy at our institution. RESULTS: The mean age was 55.7 ± 13.1 years, and 338 (58%) patients were in New York Heart Association class III or IV. There were 11 (1.9%) early deaths, including 3 (0.5%) intraoperative deaths. Early mortality was lowest after isolated septal myectomy (0.8%) and highest after concomitant mitral valve replacement (6.1%). There were 4 (0.7%) and 9 (1.5%) patients with left ventricular wall rupture and ventricular septal defect, respectively, after myectomy. New pacemaker implantation caused by atrioventricular disturbances was required in 29 (5.0%) patients, and was associated with previous alcohol septal ablation (odds ratio 3.34, 95% confidence interval 1.02-11.0, P = 0.047). Left ventricular wall rupture, intraoperative residual (15.5% moderate, 0.3% severe) mitral regurgitation, and pre-discharge residual outflow tract gradient >30 mm Hg (4.6%) occurrences were surgeon-dependent. CONCLUSIONS: The early results are consistent with example targets reported in the 2020 American College of Cardiology/American Heart Association guidelines for septal reduction therapy outcomes. Septal myectomy safety and efficacy are surgeon-dependent. Previous alcohol septal ablation increases the risk of permanent pacemaker implantation due to postoperative complete atrioventricular block. Therefore, continuous education, mentoring, and learning by doing may play an important role in achieving reasonable septal myectomy safety and efficacy.

Rigid Ring Versus Flexible Band for Tricuspid Valve Repair in Patients Scheduled for Mitral Valve Surgery: A Prospective Randomised Study.

BACKGROUND: Tricuspid valve repair for functional regurgitation is effectively performed with different annuloplasty devices. However, it remains unclear whether there are advantages associated with rigid rings compared to flexible bands. This prospective randomised study aimed to compare results of using a flexible band ring versus a rigid ring for functional tricuspid regurgitation in patients undergoing mitral valve surgery. METHODS: A single-centre randomised study was designed to allocate patients with functional tricuspid regurgitation undergoing mitral valve surgery to be treated with a flexible band or rigid ring. These patients were analysed by echocardiographic follow-up. The primary outcome was freedom from recurrent tricuspid regurgitation at 12-months follow-up. Secondary outcomes were 30-day mortality, survival, freedom from tricuspid valve reoperation, right ventricular reverse remodelling, and rate of major adverse events. RESULTS: A total of 308 patients were allocated to receive concomitant tricuspid valve annuloplasty with the flexible band or rigid ring. There was no between-group difference in freedom from recurrent tricuspid regurgitation: 97.3% in Rigid group (95% CI, 93.0-98.8) and 96.2% in the Flexible group (95% CI, 92.0-98.5) at 12-months follow-up (log-rank, p=0.261). Early mortality, survival, freedom from tricuspid valve reoperation, and global right ventricle systolic function were also comparable in both groups of patients. However, the flexible band had advantage in restoring regional right ventricle function (Doppler-derived systolic velocities of the annulus [S], tricuspid annular plane systolic excursion) at 12-months follow-up. CONCLUSION: Both the rigid ring and flexible band offered acceptable outcomes for functional tricuspid regurgitation correction without significant differences, as assessed at 12-months follow-up.

Ross for Valve replacement In AduLts (REVIVAL) pilot trial: rationale and design of a randomised controlled trial.

INTRODUCTION: In non-elderly adults, aortic valve replacement (AVR) with conventional prostheses yield poor long-term outcomes. Recent publications suggest a benefit of the Ross procedure over conventional AVR and highlight the need for high-quality randomised controlled trial (RCTs) on the optimal AVR. We have initiated a pilot trial assess two feasibility criteria and one assumption: (1) evaluate the capacity to enrol six patients per centre per year in at least five international centre, (2) validate greater than 90% compliance with allocation and (3) to validate the proportion of mechanical (≥65%) vs biological (≤35%) valves in the conventional arm. METHODS AND ANALYSIS: Ross for Valve replacement In AduLts (REVIVAL) is a multinational, expertise-based RCT in adults aged 18-60 years undergoing AVR, comparing the Ross procedure versus one of the alternative approaches (mechanical vs stented or stentless bioprosthesis). The feasibility objectives will be assessed after randomising 60 patients; we will then make a decision regarding whether to expand the trial with the current protocol. We will ultimately examine the impact of the Ross procedure as compared with conventional AVR in non-elderly adults on survival free of valve-related life-threatening complications (major bleeding, systemic thromboembolism, valve thrombosis and valve reoperation) over the duration of follow-up. The objectives of the pilot trial will be analysed using descriptive statistics. In the full trial, the intention-to-treat principle will guide all primary analyses. A time-to-event analysis will be performed and Kaplan-Meier survival curves with comparison between groups using a log rank test will be presented. ETHICS AND DISSEMINATION: REVIVAL will answer whether non-elderly adults benefit from the Ross procedure over conventional valve replacement. The final results at major meetings, journals, regional seminars, hospital rounds and via the Reducing Global Perioperative Risk Multimedia Resource Centre. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT03798782 PROTOCOL VERSION: January 29, 2019 (Final Version 1.0).

Edge-to-Edge Repair Versus Secondary Cord Cutting During Septal Myectomy in Patients With Hypertrophic Obstructive Cardiomyopathy: A Pilot Randomised Study.

BACKGROUND: To evaluate whether the Alfieri technique improves clinical and haemodynamic results and compare it with transaortic mitral valve secondary cord cutting in patients scheduled for septal myectomy for severely symptomatic hypertrophic obstructive cardiomyopathy. METHODS: Forty-eight (48) patients with moderate-to-severe systolic anterior motion (SAM)-mediated mitral regurgitation were randomly assigned to the Alfieri or Cutting groups in addition to septal myectomy. The primary endpoint was postoperative mean transmitral pressure gradient (TPG). The secondary endpoints were residual left ventricular outflow tract (LVOT) gradient after procedure, residual mitral regurgitation (MR), postoperative SAM, repeating bypass, and survival. RESULTS: There were no 30-day mortality and ventricular septal defects. The postoperative LVOT gradient was 15.4±7.6 mmHg and 11.1±4.9 mmHg (p=0.078) in the Alfieri and Cutting groups, respectively. The Alfieri technique was associated with higher peak (7.8±3.3 vs 4.7±2.8 mmHg; p=0.014) and mean (3.9±1.7 vs 2.1±1.6 mmHg; p=0.013) TPG. The Cutting group was associated with higher mild MR rate at discharge (six vs no patients; p=0.009). One (1) patient (4.2%) in the Alfieri group required pacemaker implantation owing to conduction disturbances (p=0.312). Two-year (2-year) freedom from late mortality and sudden cardiac death rates were 95.5%±4.4% and 100% for the Alfieri and Cutting groups, respectively (log rank, p=0.317). No patients had New York Heart Association functional class III or IV or moderate or severe MR. The maximum LVOT gradient was 20.4±15.2 mmHg and 16.7±10.4 mmHg, respectively (p=0.330). There were no reoperations during follow-up. CONCLUSIONS: Both techniques with septal myectomy effectively eliminated SAM-induced MR and LVOT obstructions in hypertrophic cardiomyopathy patients.

Allografts and xenografts for right ventricular outflow tract reconstruction in Ross patients.

OBJECTIVES: Pulmonary allografts (AG) are the gold standard for right ventricular outflow tract (RVOT) reconstruction during the Ross procedure. However, there is limited availability of AG in some countries, and the use of alternative grafts for RVOT reconstruction remains controversial. This study aimed to compare the rates of freedom from RVOT graft dysfunction for AG and diepoxide-treated pericardial xenografts (DPXG). METHODS: Between 1998 and 2015, 793 adult patients underwent the Ross procedure in our centre. Using propensity score matching, the clinical outcomes and echocardiographic results of AG and DPXG were compared. RESULTS: Propensity score matching resulted in 2 groups (AG and DPXG) of 122 patients each. No difference was found in early mortality (2.5%) in both groups. The freedom from RVOT graft dysfunction curves were comparable between the AG and DPXG groups (P = 0.186) and the 8-year rates of freedom from graft dysfunction were 91.8% and 82.2%, respectively. The survival rates at 8 years were 90.5% and 90.1%, and the rates of freedom from RVOT reintervention at 8 years were 100% and 96.8% for the AG and DPXG groups, respectively. At discharge and follow-up, transprosthetic gradients were significantly higher in the DPXG group. The rate of the RVOT gradient progression was also higher in the DPXG group than in the AG group (1.80 ± 0.06 vs 1.39 ± 0.04 mmHg/year, P < 0.001). CONCLUSIONS: There was no difference in freedom from RVOT graft dysfunction by 8 years when using AG and DPXG in adult Ross patients, nor in survival and freedom from RVOT conduit reintervention. Long-term results need further evaluation.

Surgical Atrial Fibrillation Ablation With and Without Left Atrium Reduction for Patients Scheduled for Mitral Valve Surgery: A Prospective Randomised Study.

BACKGROUND: The influence of left atrium (LA) enlargement on atrial arrhythmia recurrence (AAR) after surgical ablation in patients with mitral valve (MV) disease remains unresolved. OBJECTIVE: Left atrial size is critical to the success of concomitant atrial fibrillation (AF) ablation in patients scheduled for MV surgery. However, a large LA should not be a limiting factor when evaluating surgical candidates with AF if they receive appropriate treatment during concomitant ablation. This randomised study assessed whether adding LA reduction (LAR) to the maze procedure for MV surgery patients can improve freedom from AAR. METHODS: From September 2014 to September 2017, 140 patients were randomly assigned into two groups. The maze group underwent MV surgery with concomitant surgical AF ablation (n=70). The maze + LA reduction group underwent MV surgery with concomitant AF ablation and LA reduction procedure (n=70). Rhythm outcomes were estimated by Holter monitoring, according to Heart Rhythm Society guidelines. RESULTS: The concomitant LA reduction procedure did not increase early mortality and complications rates. Significant differences in freedom from AAR were observed at 24 months (maze, 78.4%; maze + LAR group, 92.3%; p=0.025). A significant difference in LA volume was detected at discharge (p<0.0001); however, it was not significantly different at 24 months (p=0.182). CONCLUSIONS: Adding LA reduction to the maze procedure led to improvements in freedom from AAR for patients with AF and LA enlargement scheduled for MV surgery. A concomitant LA reduction procedure did not increase mortality and perioperative risk.

Myectomy versus alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVES: There is very little evidence comparing the safety and efficacy of alcohol septal ablation versus septal myectomy for a septal reduction in patients with hypertrophic obstructive cardiomyopathy. This study aimed to compare the immediate and long-term outcomes of these procedures. METHODS: Following propensity score matching, we retrospectively analysed outcomes in 105 patients who underwent myectomy and 105 who underwent septal ablation between 2011 and 2017 at 2 reference centres. RESULTS: The mean age was 51.9 ± 14.3 and 52.2 ± 14.3 years in the myectomy and ablation groups, respectively (P = 0.855), and postoperative left ventricular outflow tract gradients were 13 (10-19) mmHg vs 16 (12-26) mmHg; P = 0.025. The 1-year prevalence of the New York Heart Association class III-IV was higher in the ablation group (none vs 6.4%; P = 0.041). The 5-year overall survival rate [96.8% (86.3-99.3) after myectomy and 93.5% (85.9-97.1) after ablation; P = 0.103] and cumulative incidence of sudden cardiac death [0% and 1.9% (0.5-7.5), respectively P = 0.797] did not differ between the groups. The cumulative reoperation rate within 5 years was lower after myectomy than after ablation [2.0% (0.5-7.6) vs 14.6% (8.6-24.1); P = 0.003]. Ablation was associated with a higher reoperation risk (subdistributional hazard ratio = 5.9; 95% confidence interval 1.3-26.3, P = 0.020). At follow-up, left ventricular outflow tract gradient [16 (11-20) vs 23 (15-59) mmHg; P < 0.001] and prevalence of 2+ mitral regurgitation (1.1% vs 10.6%; P = 0.016) were lower after myectomy than after ablation. CONCLUSIONS: Both procedures improved functional capacity; however, myectomy better-resolved classes III-IV of heart failure. Septal ablation was associated with higher reoperation rates. Myectomy demonstrated benefits in gradient relief and mitral regurgitation elimination. The results suggest that decreasing rates of myectomy procedures need to be investigated and reconsidered.

Single-Centre Experience of Surgical Myectomy for Hypertrophic Obstructive Cardiomyopathy.

BACKGROUND: Septal myectomy is the gold standard treatment for hypertrophic obstructive cardiomyopathy. This study aimed to evaluate the results from patients with hypertrophic cardiomyopathy who had undergone septal myectomy. METHODS: Data were analysed that has been prospectively collected over 7 years from 345 patients with hypertrophic cardiomyopathy who underwent septal myectomy at Meshalkin National Medical Research Center. RESULTS: Six (6) patients (1.7%) died within 30 days of surgery. The mean (standard deviation, SD) resting left ventricular outflow tract gradients reduced from 83.4 (24.2) mmHg preoperatively to 16.2 (8.5) mmHg at discharge (p < 0.001). Of the 345 patients, 329 (95.4%) attended the most recent follow-up assessments, and of these, 254 (77.2%) were categorised as New York Heart Association (NYHA) class I, 64 (19.5%) class II, and 11 (3.3%) class III. The mean overall long-term survival rate after septal myectomy was 95.7% (SD 1.7%) (95% CI, 90.0-97.9). This did not differ from the age-matched and gender-matched general population (log-rank, p = 0.109). At the last follow-up assessments, six of 67 patients who had undergone concomitant Cox-Maze IV procedures had late atrial tachyarrhythmia recurrences. A preoperative short-axis view of left atrial diameter of 57.5 mm (hazard ratio, 1.30 (95% CI, 1.03-1.65), p < 0.001) predicted late atrial tachyarrhythmias (p < 0.002). CONCLUSIONS: At this hypertrophic cardiomyopathy centre, septal myectomy is associated with low operative and early mortality rates (<2%), a low risk of early adverse events, and acceptable intermediate-term clinical and haemodynamic results.

Successful Treatment of an Aortotomy Site Aspergillus Infection.

Aspergillus aortitis is a rare, often fatal infection. Here, we report successful treatment of an aortotomy site that became infected by Aspergillus spp. after valve replacement. Surgical debridement, combined with antifungal therapy, allowed a favorable outcome.

Septal Myectomy With Vs Without Subvalvular Apparatus Intervention in Patients With Hypertrophic Obstructive Cardiomyopathy: A Prospective Randomized Study.

Surgical septal myectomy is a standard treatment option for patients with hypertrophic obstructive cardiomyopathy. Subvalvular abnormalities of the mitral valve might play an important role in residual left ventricular outflow tract obstruction. This randomized study aimed to compare the surgical outcomes of septal myectomy with vs without subvalvular interventions. Between July 2015 and December 2016, 80 eligible patients were randomly assigned to undergo septal myectomy with vs without subvalvular intervention. The peak gradient was 92.3 ± 16.9 and 88.1 ± 15.4 mm Hg, respectively (P = 0.281). The mean septum thickness was 26.8 ± 4.5 and 26.1 ± 4.2 mm, respectively (P = 0.504). Moderate or severe systolic anterior motion syndrome-mediated mitral regurgitation was observed in all patients. There was no residual mitral regurgitation in the group with subvalvular intervention, while 15% of patients in the control group had regurgitation (P = 0.013). Residual systolic anterior motion syndrome was observed in 5% and 27.5% of patients, respectively (P = 0.007). The median postoperative gradient was 13 (interquartile range 9-16) mm Hg and 8 (interquartile range 4-12) mm Hg, respectively (P = 0. 0.019). At the 12-month follow-up, all patients were alive. There were 87.5% vs 77.5%, and 12.5% vs 22.5% of patients categorized as having New York Heart Association functional classes I and II, respectively (P = 0.378). The prevalence rate of residual mitral regurgitation was 10% and 32.5%, respectively (P = 0.010). Concomitant subvalvular intervention during septal myectomy more effectively eliminates left ventricular outflow tract obstruction, providing better freedom from residual mitral regurgitation without clinical benefit 1 year after surgery.

Factors impacting long-term pulmonary autograft durability after the Ross procedure.

OBJECTIVE: Although the Ross procedure provides excellent long-term survival and a high quality of life, its use has been limited to relatively few centers. In this study, we evaluated long-term Ross procedure results in adults to assess the predictors of pulmonary autograft durability. METHODS: Between 1998 and 2015, 793 consecutive adult patients underwent the Ross procedure. The total root replacement technique was used in all patients. RESULTS: The early mortality rate was 2.9%. The mean follow-up duration was 6.5 ± 3.2 years, and the 10-year survival rate was 90.4%. Longitudinal mixed-effects ordinal regression identified a combination of bicuspid aortic valve and aortic insufficiency (odds ratio, 2.19; P < .001) as predictors for progression of autograft valve insufficiency at follow-up. The cumulative incidence of autograft reoperations at 10 years was 8.6%. Competing risk regression identified bicuspid aortic valve insufficiency as the independent predictor of autograft reoperation (subdistribution hazard ratio, 2.16; P = .030). Moreover, patients with bicuspid aortic valve and aortic insufficiency had greater increases in annulus (P < .001), sinus (P < .001), and ascending aorta (P < .001) diameters over time. CONCLUSIONS: For patients undergoing the Ross procedure, a combination of bicuspid aortic valves and aortic insufficiency is the main risk factor for late autograft dilatation and dysfunction.

Myectomy with mitral valve repair versus replacement in adult patients with hypertrophic obstructive cardiomyopathy: a systematic review and meta-analysis.

We evaluated the differences in mitral valve (MV) plasty (MVP) and MV replacement (MVR) with respect to death, postoperative MV dysfunction, reoperation rates and thromboembolic events (DFRE) in patients with hypertrophic obstructive cardiomyopathy and systolic anterior motion of the anterior mitral leaflet-mediated MV regurgitation (HOCM & MR). We followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, searching PubMed, Cochrane library and ClinicalTrials.gov for studies that evaluated DFRE in adults with HOCM & MR after MVP/MVR. We used a risk of bias assessment tool for non-randomized studies, and analyses were performed using Cochrane Review Manager 5.3.5 for I2 statistics, funnel plots and forest plot and the generic inverse variance method for hazard ratios (HRs). We developed qualitative and quantitative syntheses of 35 and 23 studies, respectively, including levels of evidence of ½/3/4/5 = 3/1/11/11/9 and ½/3/4/5 = 0/1/11/11/0, respectively, from January 1980 to August 2017. A statistically significant difference between MVP and MVR favoured MVP for the prevention of DFRE in patients with HOCM & MR, on the basis of a significant reduction of the HR for DFRE: HR = 0.68 (0.57, 0.82), I2 = 68% (P = 0.002). The findings were as follows: (i) MVP should be the first-line treatment in patients with HOCM & MR (accuracy LEVEL A) and (ii) MVR may be harmful if it is used as the first-line treatment (accuracy LEVEL A).