Perceval valve-in-valve implant for full root xenograft failure.

Aortic root replacement with a biological conduit results in excellent hemodynamics but has limited durability. We report a series of six patients who underwent successful Perceval-S surgical aortic valve implantation following surgical deterioration of a biological valve composite conduit and discuss the technical details and the importance of appropriate valve sizing for this procedure.

Heart Transplantation Following Fontan Failure: Long-Term Survival Analysis.

Objectives: Fontan circulation presents significant challenges for patients with congenital heart disease, often necessitating heart transplantation (HTX) due to deteriorating functionality across multiple organ systems. However, the impact of prior Fontan palliation on HTX outcomes remains poorly understood, with early mortality rates suggesting a heightened risk. The aim of our study is to evaluate the long-term results after heart transplantation in patients with univentricular congenital heart disease previously palliated with Fontan circulation. Methods: A retrospective analysis was conducted on patients who underwent HTX for congenital heart disease. Patients were categorized into two groups based on the pre-HTX circulation pathway: the Failing Fontan Group (FFG) and the Biventricular Congenital Group (BCG). Data were collected from patients between 1987 and 2018. Early and late outcomes, including survival rates, were assessed and critically analyzed. Results: Of the 66 patients, 29 (43%) had a failing Fontan palliation (FFG), and 37 had biventricular congenital diseases (BCG) before heart transplantation. Early mortality (30-day) was not statistically different between the two group. The overall survival rate was 82.6 ± 13.9% at 1 year, 79.0 ± 14.9% at 5 years, 67.2 ± 17.6% at 10 years and 63.2 ± 18.2 ± at 15 years for the FFG, and 86.1 ±11.4% at 1 year, 79.5 ± 13.7% at 5 years, 75.7 ± 14.9% at 10 years, 75.7 ± 14.9% at 15 years for the BCG, with no statistically significant difference (Mantel Cox p value: 0.69, 0.89, 0.52 and 0.39, respectively). Regarding Cox-regression analysis, the long-term survival rate was not affected either by previous Fontan surgery or by the era of heart transplantation (before vs. after the year 2000). Conclusions: Although heart transplantation after Fontan palliation showed a higher risk in the early post-operative period, the medium- and long-term survival rates are comparable with biventricular circulation patients. Despite the failing Fontan patients being a challenging set of candidates for transplantation, it is a reasonable option in their treatment.

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the Italian congenital cardiac surgery system: a national survey.

OBJECTIVES: Italy has been one of the countries most severely affected by the coronavirus disease 2019 (COVID-19). The Italian government was forced to introduce quarantine measures quickly, and all elective health services were stopped or postponed. This emergency has dramatically changed the management of paediatric and adult patients with congenital heart disease. We analysed data from 14 Italian congenital cardiac surgery centres during lockdown, focusing on the impact of the pandemic on surgical activity, patients and healthcare providers and resource allocation. METHODS: Fourteen centres participated in this study. The period analysed was from 9 March to 4 May. We collected data on the involvement of the hospitals in the treatment of patients with COVID-19 and on limitations on regular activity and on the contagion among patients and healthcare providers. RESULTS: Four hospitals (29%) remained COVID-19 free, whereas 10 had a 39% reduction in the number of beds for surgical patients, especially in the northern area. Two hundred sixty-three surgical procedures were performed: 20% elective, 62% urgent, 10% emergency and 3% life-saving. Hospital mortality was 0.4%. Compared to 2019, the reduction in surgical activity was 52%. No patients operated on had positive test results before surgery for severe acute respiratory syndrome coronavirus 2, the virus responsible for COVID-19. Three patients were infected during the postoperative period. Twenty-nine nurses and 12 doctors were infected. Overall, 80% of our infected healthcare providers were in northern centres. CONCLUSIONS: Our study shows that the pandemic had a different impact on the various Italian congenital cardiac surgery centres based on the different patterns of spread of the virus across the country. During the lockdown, the system was able to satisfy all emergency clinical needs with excellent results.

Sutureless aortic valve replacement in high risk patients neutralizes expected worse hospital outcome: A clinical and economic analysis.

BACKGROUND: Aortic valve replacement (AVR) by sutureless prostheses is changing surgeon options, although which patients benefit most, as well as their possible economic impact is still to be defined. METHODS: Perceval-S prosthesis (LivaNova) is reserved, at the documented Institution, for patients at perceived high surgical risk. This retrospective analysis of outcome and resource consumption compared Perceval with other tissue valves. To clarify the comparison, only patients respecting 'instructions-for- use' of Perceval were reviewed. INCLUSION CRITERIA: > 65 years, +/- coronary artery bypass grafting, patent foramen ovale closure or myectomy. EXCLUSION CRITERIA: bicuspid, combined valve or aortic sur- gery. Costs were calculated per patient on a daily basis including preoperative tests, operating costs (hourly basis), disposables, drugs, blood components and personnel. RESULTS: The sutureless group (SU-AVR) had a higher risk profile than the sutured group (ST-AVR). Cardiopulmonary bypass (CPB) and cross-clamp times were significantly shorter in SU-AVR (isolated AVR: cross-clamp 52.9 ± 12.6 vs. 69 ± 15.3 min, p < 0.001; CPB 79.4 ± 20.3 vs. 92.7 ± 18.2 min, p < 0.001). Hospital mortality was 0.9% in SU-AVR and nil in ST-AVR, p = 0.489; intubation 7 (IQR 5-10.7) and 7 h (IQR 5-9), p = 0.785; intensive care unit 1 (IQR 1-1) and 1 day (IQR 1-1), p = 0.258; ward stay 5.5 (IQR 4-7) and 5 days (IQR 4-6), p = 0.002; pacemaker 5.7% (6/106) and 0.9% (1/109), p = 0.063, respectively. Hospital costs (excluding the prosthesis) were $12,825 (IQR 11,733-15,334) for SU-AVR and $12,386 (IQR 11,217-14,230) in ST-AVR, p = 0.055. CONCLUSIONS: Despite higher operative risks in SU-AVR, hospital mortality, morbidity and resource consumption did not differ. Operative times were shorter with the sutureless device and this improve- ment, along with more frequent ministernotomy, may have improved many postoperative aims.

Sutureless prosthesis for failed small Mitroflow valves: the Perceval-after-Mitroflow procedure.

Because of its favourable haemodynamic characteristics and easy implantability, Mitroflow aortic valve bioprosthesis has been the valve of choice for many surgeons in patients with small aortic annulus. Disappointingly, early structural valve deterioration and high transvalvular gradients have been reported mostly in older patients with small prostheses. Reimplanting a new stented prosthesis sutured in a narrow and damaged annulus is technically challenging and demanding mainly in high-risk patients. Valve-in-valve transcatheter aortic valve implantation has been proposed as a viable option; however, it presents significant limitations because of residual high transprosthetic pressure gradients and risk of coronary occlusion. We report a series of 8 patients, with medium-term follow-up, who underwent successful Perceval-S surgical sutureless aortic implant after the removal of a degenerated small Mitroflow valve. No early mortality occurred, but 1 patient died 4 months postoperatively due to gastrointestinal disease. No major complications occurred. Early and mid-term postoperative pressure gradients were low (mean gradients 13.1 ± 3.3 mmHg and 10.2 ± 3.8 mmHg, respectively). In operable patients with a degenerated Mitroflow valve, these favourable clinical and haemodynamic results suggest that the sutureless solution is a simple, valid and safer alternative to conventional redo valve replacement or to valve-in-valve transcatheter aortic valve implantation.

Impact of prosthesis-patient mismatch on cardiac events and midterm mortality after aortic valve replacement in patients with pure aortic stenosis.

BACKGROUND: Prosthesis-patient mismatch (PPM) occurs when the effective orifice area (EOA) of the prosthesis being implanted is too small in relation to body size, thus causing abnormally high transvalvular pressure gradients. The objective of this study was to examine the midterm impact of PPM on overall mortality and cardiac events after aortic valve replacement in patients with pure aortic stenosis. METHODS AND RESULTS: The indexed EOA (EOAi) was estimated for each type and size of prosthesis being implanted in 315 consecutive patients with pure aortic stenosis. PPM was defined as an EOAi < or =0.80 cm2/m2 and was correlated with overall mortality and cardiac events. PPM was present in 47% of patients. The 5-year overall survival and cardiac event-free survival were 82+/-3% and 75+/-4%, respectively, in patients with PPM compared with 93+/-3% and 87+/-4% in patients with no PPM (P< or =0.01). In multivariate analysis, PPM was associated with a 4.2-fold (95% CI, 1.6 to 11.3) increase in the risk of overall mortality and 3.2-fold (95% CI, 1.5 to 6.8) increase in the risk of cardiac events. The other independent risk factors were history of heart failure, NHYA class III-IV, severe left ventricular hypertrophy, and absence of normal sinus rhythm before operation. CONCLUSIONS: PPM is an independent predictor of cardiac events and midterm mortality in patients with pure aortic stenosis undergoing aortic valve replacement. As opposed to other risk factors, PPM may be avoided or its severity may be reduced with the use of a preventive strategy at the time of operation.

Factors affecting left ventricular remodeling after valve replacement for aortic stenosis. An overview.

Although a small percentage of patients with critical aortic stenosis do not develop left ventricle hypertrophy, increased ventricular mass is widely observed in conditions of increased afterload. There is growing epidemiological evidence that hypertrophy is associated with excess cardiac mortality and morbidity not only in patients with arterial hypertension, but also in those undergoing aortic valve replacement. Valve replacement surgery relieves the aortic obstruction and prolongs the life of many patients, but favorable or adverse left ventricular remodeling is affected by a large number of factors whose specific roles are still a subject of debate. Age, gender, hemodynamic factors, prosthetic valve types, myocyte alterations, interstitial structures, blood pressure control and ethnicity can all influence the process of left ventricle mass regression, and myocardial metabolism and coronary artery circulation are also involved in the changes occurring after aortic valve replacement. The aim of this overview is to analyze these factors in the light of our experience, elucidate the important question of prosthesis-patient mismatch by considering the method of effective orifice area, and discuss surgical timings and techniques that can improve the management of patients with aortic valve stenosis and maximize the probability of mass regression.

Time series analysis of physiologic left ventricular reconstruction in ischemic cardiomyopathy.

OBJECTIVE: The history of left ventricular reconstruction has demonstrated that the full spectrum of recoverable physiologic parameters is essential for a good functional result. We report the long-term outcome of a new surgical technique that arranges myocardial fibers in a near-normal disposition, also recovering left ventricular twisting. METHODS: Between May 2006 and October 2013, 29 consecutive patients with previous anterior myocardial infarction and heart failure symptoms underwent physiologic left ventricular reconstruction surgery and coronary revascularization. Patients were examined by means of standard echocardiography and 2-dimensional speckle tracking at 8 time steps until 7 years after surgery. Ten geometric and functional parameters were evaluated at each step and analyzed by the linear mixed model test. RESULTS: Hospital mortality was 0%. The mean percentage of indexed end-diastolic and end-systolic volume reduction was 45.7% and 50.9%, respectively. Ejection fraction and all of the volumes were significantly different in the postoperative period with a steady correction during time. Diastolic parameters were not worsened by surgical reconstruction. Ejection fraction and deceleration time showed a significant improvement during time. Left ventricular torsion increased immediately after the surgical correction from 2.8 ± 4.4 degrees to 8.7 ± 3.9 degrees (P = .02) and was still present 4 years after surgery. CONCLUSIONS: Surgical conduction of ventricular reconstruction should be standardized to achieve the full spectrum of recoverable physiologic parameters. The renewal of ventricular torsion should be pursued as an adjunctive element of ventricular efficiency, mainly in ventricles that work at a critical level in the Frank-Starling relationship and pressure-volume loop.

Determinants of postinfarction remodeling affect outcome and left ventricular geometry after surgical treatment of ischemic cardiomyopathy.

OBJECTIVE: To identify the effects of the time between myocardial infarction and surgery, the site of infarction, mitral involvement on ventricular geometry, and clinical outcome in the treatment of ischemic cardiomyopathy in patients with heart failure. METHODS: Sixty-nine consecutive patients with ischemic cardiomyopathy, indexed end-systolic volume > or =50 mL/m(2), ejection fraction < or =35%, and heart failure underwent surgery 81.9 +/- 100.8 months after myocardial infarction, using different techniques of ventricular restoration. Thirteen geometric parameters were studied pre- and postoperatively. Paired and unpaired t tests and general linear model for multivariate analysis were used to analyze subgroups. Logistic regression and Kaplan-Meier survival curves with pairwise log-rank were used to correlate covariates to clinical outcome. RESULTS: Longer time to surgery and posterior necrosis linearly correlated with higher left ventricular volumes (r(2) =.66) and diameters (r(2) =.40). High grade of mitral regurgitation was always present in posterior infarctions. Hospital mortality was 4.3%. Complicated postoperative course was predicted by mitral surgery (P =.004) and longer time to surgery (P =.04). Survival was significantly lower in the posterior infarction (P =.0002) and mitral surgery (P =.001) subgroups. At a mean follow-up of 1.9 +/- 1.3 years, functional status and geometrical restoration are influenced by the studied covariates. CONCLUSIONS: Longer time to surgery after myocardial infarction, its posterior location, and significant mitral regurgitation can affect left ventricular remodeling, surgical restoration, and clinical outcome in patients with ischemic cardiomyopathy.

Uncommon presentation and surgical correction of unroofed coronary sinus syndrome.

A 59-year-old man with signs and symptoms of congestive heart failure, occurring a few months after an infective episode, underwent cardiac investigations revealing severe biventricular dysfunction, persistent left superior vena cava with almost completely unroofed coronary sinus, and critical stenosis of the proximal right coronary artery. Surgical correction of the congenital malformation associated with revascularization of the right coronary allowed a prompt recovery of clinical conditions and ventricular function.

Mass regression in aortic stenosis after valve replacement with small size pericardial bioprosthesis.

BACKGROUND: The aim of the study was to determine whether left ventricular mass regression is influenced by valve size after the implantation of a Carpentier-Edwards Perimount (CEP) pericardial bioprosthesis for pure aortic stenosis. METHODS: Patients receiving 19-mm, 21-mm, and 23-mm CEP aortic valves underwent echocardiography preoperatively and at least 1 year after surgery (mean, 2.3 +/- 1 years) and the echocardiograms were compared within and between groups. RESULTS: The study involved a total of 88 patients: 34 receiving 19-mm CEPs, 29 receiving 21-mm CEPs, and 25 receiving 23-mm CEPs. The mean postoperative prosthetic gradients were respectively 20.6 +/- 6.6 mm Hg, 17.9 +/- 5.8 mm Hg, and 13.2 +/- 4.1 mm Hg (p = 0.0001); the mean postoperative valve areas were respectively 1.24 +/- 0.16 cm(2), 1.45 +/- 0.2 cm(2), and 1.63 +/- 0.21 cm(2) (p = 0.0001). In comparison with the preoperative echocardiographic measurements absolute left ventricular mass significantly decreased by -54.1 +/- 48.8 g, -54.1 +/- 55.1 g, and -74.4 +/- 57.4 g respectively with no statistically significant between-group difference (analysis of variance) but ventricular septum and posterior wall thickness significantly decreased in each group (p < 0.05). CONCLUSIONS: The implantation of 19-mm, 21-mm, and 23-mm CEP aortic prostheses significantly reduces left ventricular mass without any size-related differences.

Mid-term results of cardiac autotransplantation as method to treat permanent atrial fibrillation and mitral disease.

OBJECTIVES: The results of current surgical options for the treatment of permanent atrial fibrillation (AF) associated with mitral surgery are widely different, particularly in very enlarged left atria. The aim of this study was to assess the mid-term efficacy of cardiac autotransplantation for this goal, through a consistent reduction of left atrium volume and a complete isolation of the pulmonary veins. METHODS: From April 2000 to September 2002, 30 patients (male/female 5/25) underwent cardiac autotransplantation for the treatment of mitral valve disease and concomitant permanent AF (>1 year). Surgical technique of bicaval heart transplantation was modified maintaining the connection of inferior vena cava in all but three cases. Twenty-eight patients had mitral valve replacement and two had mitral valve repair. Associated procedures were: aortic valve replacement (6 cases), tricuspid valve repair (2 cases), coronary re-vascularization (2 cases) and right atrium volume reduction (4 cases). RESULTS: No hospital death occurred; 1 patient died 3 months post-operatively for pneumonia. At a mean follow-up of 21.1+/-7.7 months (range 6-35), 26 patients (89.7%) were in sinus rhythm and 3 (10.3%) in AF. Santa Cruz Score was 0 in 3 patients, 2 in 2 patients and 4 in the remaining 24 patients (82.7%). Mean left atrial diameter and volume decreased from 65.1+/-16.4 mm (range 50-130 mm) to 49.9+/-8.4 mm (range 37-78) (P < 0.001) and from 118.3+/-68.4 ml (range 60-426) to 69.4+/-34.1 ml (range 31-226) (P = 0.001), respectively, after the operation. CONCLUSIONS: Cardiac autotransplantation is a safe and effective option for the treatment of permanent AF in patients with mitral valve disease and severe dilation of left atrium.

Cardiac autotransplantation for the treatment of permanent atrial fibrillation combined with mitral valve disease.

OBJECTIVE: The results of current surgical options for the treatment of permanent atrial fibrillation associated with mitral valve surgery are widely different, particularly for extremely dilated left atria. The aim of this study is to assess the efficacy of cardiac autotransplantation in restoring a normal sinus rhythm via a consistent reduction in the left atrium volume associated with a complete isolation of the pulmonary veins. METHODS: From April 2000 to April 2002, 28 patients (men/women, 5/23) underwent cardiac autotransplantation for the treatment of mitral disease and concomitant permanent atrial fibrillation (>1 year). A modified surgical technique derived from bicaval heart transplantation procedures maintained the connection of the right atrium with the inferior vena cava in all but 3 cases. In 2 patients, the mitral valve was repaired, and it was replaced in 26 patients. Associated procedures were 6 aortic valve replacements, 2 tricuspid valve annuloplasties, and 2 coronary revascularizations. RESULTS: No hospital deaths were recorded, but 1 patient died of pneumonia 3 months postoperatively. At a mean follow-up period of 17.2 +/- 6.7 months (range, 6-30 months), 24 patients (88.9%) were in sinus rhythm, and 3 (11.1%) were in atrial fibrillation. The Santa Cruz Score was 0 for 3 patients, 2 for 1 patient, and 4 for the remaining 23 patients (85.2%). The mean left atrial diameter decreased from 65.4 +/- 17.1 mm (range, 50-130 mm) before the operation to 48.4 +/- 5.6 mm (range, 37-78 mm) postoperatively (P <.001), and the mean left atrial volume decreased from 119 +/- 70.5 mL (range, 60-426 mL) to 69.1 +/- 35.1 mL (range, 31-226 mL) (P <.0001). CONCLUSION: Cardiac autotransplantation is a safe and effective surgical option for the treatment of permanent atrial fibrillation in patients with long-lasting mitral valve disease and severe enlargement of the left atrium.

Ross procedure for severe congenital aortic regurgitation in a three-month-old patient.

We here describe the case of an infant with severe aortic regurgitation due to a congenital dysplastic aortic valve. Surgical treatment (autograft replacement of the aortic valve) was carried out when the patient was 3 months old. The technical aspects and the results of instrumental examination during follow-up are discussed.

Off-pump coronary surgery in a single center experience: from selective to systematic use.

BACKGROUND: The feasibility of the systematic use of the off-pump technique for myocardial revascularization was investigated. METHODS: From September 1997 to June 2001, 1221 isolated coronary artery bypass grafting operations were performed consecutively: 771 (group A) were completed with cardiopulmonary bypass, and 450 (group B) without. Since July 2000 all patients were considered as potential candidates for off-pump coronary artery bypass. In group B, a specific original instrumentation was used for coronary stabilization. RESULTS: The differences in the preoperative data were: a higher age, a higher incidence of chronic obstructive pulmonary disease and a left ventricular ejection fraction < 30% in group B; a higher incidence of critical left main stenosis in group A. More grafts per patient were completed in group A (3.0 +/- 1.4 vs 2.2 +/- 0.9, p < 0.001). The hospital mortality (group A 1.0%, group B 0.7%) and the incidence of perioperative myocardial infarction (group A 2.5%, group B 1.1%) and that of cerebrovascular accidents (group A 1.4%, group B 0.9%) were comparable. Bleeding (610 +/- 370 vs 496 +/- 215 ml, p < 0.001), the transfusion rate (36 vs 19.7%, p < 0.001), the intubation time (13.4 +/- 3.5 vs 8.3 +/- 5 hours, p < 0.001), the intensive care unit stay (1.7 +/- 2.7 vs 1.2 +/- 2.1 days, p < 0.001) and the hospital stay (5.8 +/- 3 vs 5.1 +/- 3.2 days, p < 0.001) were lower in group B. At follow-up, the mortality (2.5 vs 1.1%), the rate of recurrence of angina (2.5 vs 2.0%), and those of re-angiography (4.1 vs 5.3%) and of new revascularization (1.6 vs 1.1%) were similar. The actuarial survival rates were 99.8, 98.6 and 96.3% in group A, and 98.8, 96.7 and 96.7% in group B at 1, 2 and 3 years of follow-up respectively (log rank p = 0.3387). CONCLUSIONS: The increase in the use of off-pump coronary artery bypass up to its systematic empolyment is feasible. The early and intermediate results are satisfactory.

[Off-pump myocardial revascularization in patients with multivessel coronary disease]. / Rivascolarizzazione miocardica senza circolazione extracorporea in pazienti con malattia coronarica multivasale.

BACKGROUND: Some criticisms have been addressed to off-pump coronary surgery technique concerning the possibility of its systematic use with the respect of the completeness of revascularization. We report our experience with off-pump revascularization in patients with multivessel coronary disease. METHODS: Between September 1997 and April 2003, 868 patients with multivessel coronary disease were scheduled for off-pump surgical revascularization. From September 2000, the percentage of patients operated on without cardiopulmonary bypass has been stably > 90%. Fifteen patients (1.7%) had a conversion to cardiopulmonary bypass for anatomical reasons (n = 6) or clinical instability (n = 9). RESULTS: An average of 2.5 +/- 0.8 (range 1-5) anastomoses per patient were completed. Bilateral mammary artery was used in 573 patients (66%); totally arterial revascularization was accomplished in 479 patients (55.2%). In-hospital mortality rate was 0.6% (5 patients). Total incidence of non-fatal postoperative complications (bleeding requiring re-exploration, perioperative myocardial infarction, stroke, new onset of acute renal failure) was 3.5%. Mean postoperative hospital stay was 4.8 +/- 3.8 days. At a mean follow-up of 21.6 +/- 15.6 months (range 1-65 months), the postoperative actuarial survival rates were 97.3, 93.7 and 86.7% at 1, 3 and 5 years postoperatively. Actuarial freedom rates from new revascularization were 98.7, 96.6 and 96.6% at 1, 3 and 5 years postoperatively. CONCLUSIONS: Early- and intermediate-term results of this study demonstrate the feasibility of off-pump revascularization in all patients with multivessel coronary disease, respecting the criterion of complete myocardial revascularization.

[Myocardial revascularization without extracorporeal circulation in patients with multivessel coronary disease]. / Rivascolarizzazione miocardica senza circolazione extracorporea in pazienti con malattia coronarica multivasale.

BACKGROUND: Some criticisms have been addressed to off-pump coronary surgery technique concerning the possibility of its systematic use with the respect of the completeness of revascularization. We report our experience with off-pump revascularization in patients with multivessel coronary disease. METHODS: Between September 1997 and April 2003, 868 patients with multivessel coronary disease were scheduled for off-pump surgical revascularization. From September 2000, the percentage of patients operated on without cardiopulmonary bypass has been stably > 90%. Fifteen patients (1.7%) had a conversion to cardiopulmonary bypass for anatomical reasons (n = 6) or clinical instability (n = 9). RESULTS: An average of 2.5 +/- 0.8 (range 1-5) anastomoses per patient were completed. Bilateral mammary artery was used in 573 patients (66%); totally arterial revascularization was accomplished in 479 patients (55.2%). In-hospital mortality rate was 0.6% (5 patients). Total incidence of non-fatal postoperative complications (bleeding requiring re-exploration, perioperative myocardial infarction, stroke, new onset of acute renal failure) was 3.5%. Mean postoperative hospital stay was 4.8 +/- 3.8 days. At a mean follow-up of 21.6 +/- 15.6 months (range 1-65 months), the postoperative actuarial survival rates were 97.3, 93.7 and 86.7% at 1, 3 and 5 years postoperatively. Actuarial freedom rates from new revascularization were 98.7, 96.6 and 96.6% at 1, 3 and 5 years postoperatively. CONCLUSIONS: Early- and intermediate-term results of this study demonstrate the feasibility of off-pump revascularization in all patients with multivessel coronary disease, respecting the criterion of complete myocardial revascularization.

Perceval sutureless valve in freestyle root: new surgical valve-in-valve therapy.

Aortic root replacement with biological conduit (homograft, autograft, or xenograft) is a valuable tool, but biological valves are often prone to degeneration. Reoperations usually require root removal and repetition of the Bentall procedure to maintain the same orifice area. A less radical option is to limit replacement to the valve. In cases of calcified or very small roots, standard valve implantation cannot be performed, and bailout with a sutureless valve may be a particularly useful option. Here we have described a case of leaflet rupture in a calcified small Freestyle root (Medtronic Inc, Minneapolis, MN) in which we performed a valve-in-valve (V-in-V) procedure with a Perceval-S prosthesis (Sorin Group, Saluggia, Italy).