Management of severe aortic stenosis in the presence of an 8 mm right coronary stent protrusion.

Management of a protruding coronary stent into the aortic root in patients undergoing evaluation for transcatheter aortic valve replacement can be challenging. We describe a patient treated with stent trimming and surgical aortic valve replacement, highlighting the importance of a multidisciplinary evaluation and selection process in this complex scenario.

Pledgeted versus nonpledgeted sutures in aortic valve replacement: Insights from a prospective multicenter trial.

Objective: The objective of this study was to compare short- and midterm clinical and echocardiographic outcomes according to the use of pledgeted sutures during aortic valve replacement. Methods: Patients with aortic stenosis or regurgitation requiring aortic valve replacement were enrolled in a prospective cohort study to evaluate the safety of a new stented bioprosthesis. Outcomes were analyzed according to the use of pledgets (pledgeted group) or no pledgets (nonpledgeted group). The primary outcome was a composite of thromboembolism, endocarditis, and major paravalvular leak at 5 years of follow-up. Secondary outcomes included multiple clinical endpoints and hemodynamic outcomes. Propensity score matching was performed to adjust for prognostic factors, and subanalyses with small valve sizes (<23 mm) and suturing techniques were performed. Results: The pledgeted group comprised 640 patients (59%), and the nonpledgeted group 442 (41%), with baseline discrepancies in demographic characteristics, comorbidities, and stenosis severity. There were no differences between groups in any outcome. After propensity score matching, the primary outcome occurred in 41 (11.7%) patients in the pledgeted and 36 (9.8%) in the nonpledgeted group (P = .51). The effective orifice area was smaller in the pledgeted group (P = .045), whereas no difference was observed for the mean or peak pressure gradient. Separate subanalyses with small valve sizes and suturing techniques did not show relevant differences. Conclusions: In this large propensity score-matched cohort, comprehensive clinical outcomes were comparable between patients who underwent aortic valve replacement with pledgeted and nonpledgeted sutures up to 5 years of follow-up, but pledgets might lead to a slightly smaller effective orifice area in the long run.

Kissing Balloon "Valvuloplasty" of Obstructed Mechanical Aortic Valve: When You Are Running Out of Options.

We report an unusual case where "stuck" bileaflet aortic prosthetic valve occluders were partly released by performing emergency balloon dilatation with 2 noncompliant balloons by a percutaneous femoral approach. (Level of Difficulty: Advanced.).

Strut Inversion During Valve-in-Valve Transcatheter Aortic Valve Replacement: An Unknown Complication?

A 74-year-old man presented with failure of a bioprosthetic aortic valve implanted 7 years earlier, with a mean gradient of 44 mm Hg across the aortic valve. During valve-in-valve transcatheter aortic valve replacement, we came across an unusual complication of strut inversion at the lower end of the valve. (Level of Difficulty: Advanced.).

Heart surgery by the locals in resource-limited settings: The experience from Ethiopia.

Background: In developing countries, despite its demand is high, heart surgery is not always accessible to the neediest patients. We aimed to describe the early outcomes of heart surgeries that were performed by a local cardiac surgical team in Addis Ababa, Ethiopia. Methods: Data were collected through chart abstraction of patients who underwent heart surgery from the period of June 2017 to July 2021 by the same local cardiac surgical team at 3 centers in Addis Ababa, Ethiopia. Data were analyzed using the Statistical Package for the Social Sciences for Windows version 20.0. Results: A total of 290 patients who underwent heart surgery during the specified period were included in the study. Of the total, 192 patients underwent valve surgery (177 were patients with rheumatic valvular disease and 15 were valve surgeries with other causes) with a 30-day mortality rate of 9 (4.7%), 33 patients underwent coronary artery bypass graft with a 30-day mortality rate of 3 (9.1%), 58 patients underwent repair for congenital heart diseases with no 30-day mortality. Specifically, button Bentall was done for 1 patient; maze procedure was done for 2 patients along with mitral valve surgery, and a total of 7 out of 290 (2.4%) underwent redo heart surgery. The overall procedure-related mortality was 4.1%. Conclusions: In addition to operating on a large number of cardiac patients, the local cardiac surgical team was able to do complex surgical procedures such as button Bentall, left maze procedure, redo valve surgeries, and coronary artery bypass graft surgery in a resource-limited setup. The overall patient outcome was comparable to reports from other centers.

Survival and freedom from reoperation after the Ross procedure in a Russian adult population: A single-center experience.

Objectives: To evaluate our 12-year experience with the Ross procedure in adults. Methods: A retrospective analysis of 215 cases of the Ross procedure was performed. The mean age of the patients was 36 ± 11.1 years, and the male to female ratio was 75% to 25%, respectively. The pulmonary autograft was placed into the aortic position using the full-root replacement technique and its modified versions. The right ventricular outflow tract was reconstructed using a pulmonary homograft in all cases. Results: The 30-day mortality after the operation was 0.9% (2 patients). The median duration of follow-up was 6.1 years (interquartile range, 6.5 years) and was complete in 86% of cases. The survival at 12 years was 94.7% and was comparable with the survival rate of the general population matched for age and sex. At the end of the follow-up, freedom from reoperation due to pulmonary autograft and homograft dysfunction was 89.1% and 99%, respectively. Conclusions: In our series, the Ross procedure resulted in low early mortality and excellent survival in adults. The long-term survival was not statistically different from the survival of the general population. The pulmonary homograft offered an excellent durability and freedom from reoperation.

A 3-hour fast-track extubation protocol for early extubation after cardiac surgery.

Objectives: Early extubation after cardiac surgery improves outcomes and reduces cost. We investigated the effect of a multidisciplinary 3-hour fast-track protocol on extubation, intensive care unit length of stay time, and reintubation rate after a wide range of cardiac surgical procedures. Methods: We performed an observational study of 472 adult patients undergoing cardiac surgery at a large academic institution. A multidisciplinary 3-hour fast-track protocol was applied to a wide range of cardiac procedures. Data were collected 4 months before and 6 months after protocol implementation. Cox regression model assessed factors associated with extubation time and intensive care unit length of stay. Results: A total of 217 patients preprotocol implementation and 255 patients postprotocol implementation were included. Baseline characteristics were similar except for the median procedure time and dexmedetomidine use. The median extubation time was reduced by 44% (4:43 hours vs 3:08 hours; P < .001) in the postprotocol group. Extubation within 3 hours was achieved in 49.4% of patients in the postprotocol group compared with 25.8% patients in the preprotocol group; P < .001. There was no statistically significant difference in the intensive care unit length of stay after controlling for other factors. Early extubation was associated with only 1 patient requiring reintubation in the postprotocol group. Conclusions: The multidisciplinary 3-hour fast-track extubation protocol is a safe and effective tool to further reduce the duration of mechanical ventilation after a wide range of cardiac surgical procedures. The protocol implementation did not decrease the intensive care unit length of stay.

Fusion of Bovine Tissue Aortic Valve Leaflets in a Patient With Left Ventricular Assist Device.

Patients with both a prosthetic aortic valve and prolonged left ventricular assist device support can develop rapid deterioration of their valve prosthesis. In patients with myocardial recovery who are undergoing explantation of their ventricular assist device, preoperative and intraoperative evaluation of the valve prosthesis should be performed to ensure adequate function. (Level of Difficulty: Advanced.).

Use of a sutureless aortic valve in reoperative aortic valve replacement.

Objectives: Management of degenerated bioprosthetic aortic valves remains a challenge. Valve-in-valve transcatheter aortic valve replacement (AVR) has limited utility in the presence of small annuli/prosthetic valves. Sutureless valves may offer an advantage over traditional redo AVR by maximizing effective orifice area due to their unique design as well as ease of implant. Methods: Twenty-two patients undergoing redo AVR received a sutureless valve in our institution over the past 5 years. All patients were determined to be poor candidates for valve-in-valve transcatheter AVR due to a combination of small annulus size, low coronary heights, and/or underlying valve characteristics (ie, mechanical valves). Results: Median time from implant to redo AVR was 8 years. One patient died within 30 days. In the 13 patients who had a 21 mm or smaller valve explanted, 5 small, 7 medium, and 1 large Perceval valves were implanted (all with larger internal diameters than the explanted valve). The average postoperative gradient of the cohort valves was 14.8 mm Hg compared with 38.8 mm Hg preoperatively. Conclusions: In addition to their ease of use and rapid deployment, sutureless bioprosthetic aortic valves offer significant physiological advantages in patients with degenerated prosthetic aortic valves and small anatomical annuli. It can also simplify the surgical approach to redo AVR following a Bentall procedure. If long-term durability is confirmed, sutureless valves should be considered in a broader population of patients for both redo and primary aortic valve replacement surgery.

Mechanical Non-ST-Segment Elevation Myocardial Infarction Secondary to Left Ventricular Outflow Tract Pseudoaneurysm: A Unique Entity.

We present a unique case of acute coronary syndrome (ACS) secondary to external coronary artery compression from a left ventricular outflow tract pseudoaneurysm in a postsurgical aortic valve replacement (AVR) patient, subsequently sealed with a pericardial patch. We highlight this rare presentation of ACS in postsurgical AVR patients and the importance of multimodality imaging and treatment of this unique, potentially serious sequela. (Level of Difficulty: Intermediate.).

Durability of a bovine pericardial aortic bioprosthesis based on Valve Academic Research Consortium-3 echocardiographic criteria.

Objectives: The Carpentier-Edwards Perimount Magna Ease (Edwards Lifesciences) pericardial bioprosthesis has demonstrated satisfying hemodynamics at midterm follow-up, but its durability remains unclear. We report our 10-year experience with this third-generation valve implanted in the aortic position, with particular attention to structural valve deterioration. Methods: From 2007 to 2016 at our center, 338 patients underwent aortic valve replacement using the Perimount Magna Ease pericardial bioprosthesis. Patients were prospectively followed (mean 6.6 ± 2.6 years) with clinical evaluation and yearly echocardiography. Follow-up was 98% complete (7 patients lost) for a total of 2238 valve-years. Bioprosthesis structural valve deterioration was determined by strict echocardiographic assessment based on the Valve Academic Research Consortium 3 criteria. Results: Overall operative mortality was 1.2%. Actuarial survival including early deaths averaged 80.9% ± 2.2% and 66.7% ± 4.4% after 5 and 10 years of follow-up, respectively. Actuarial freedom from explantation due to structural valve deterioration at 5 and 10 years was 99.6% ± 0.4% and 88.8% ± 5.0%, respectively, and actuarial freedom of structural valve deterioration at 5 and 10 years was 98.5% ± 0.7% and 44.0% ± 6.4%, respectively. More precisely, actuarial freedom of structural valve deterioration stage 3 was 99.6% ± 0.4% at 5 years and 88.3% ± 5.0% at 10 years, whereas freedom of structural valve deterioration stage 2/3 was 98.5% ± 0.7% and 60.9% ± 7.0%, respectively. Conclusions: With a low rate of explantation due to structural valve deterioration events at 10 years, and particularly a low rate of moderate or severe structural valve deterioration based on echocardiographic Valve Academic Research Consortium 3 criteria, the Carpentier-Edwards Perimount Magna Ease pericardial bioprosthesis remains a reliable choice for a tissue valve in the aortic position.

Bioprosthetic aortic valve replacement in patients aged 50 years old and younger: Structural valve deterioration at long-term follow-up. Retrospective study.

Background: Structural valve deterioration (SVD) remains the major determinant of bioprosthesis durability. The aim of this study was to investigate the SVD incidence, predictors and outcomes in patients aged 50 years and younger after bioprosthetic aortic valve replacement (bAVR). Methods: We retrospectively analyzed 73 consecutive patients ≤50 years old who underwent bioprosthetic AVR at our center between 2005 and 2015. Median age at surgery was 44 (interquartile range [IQR]: 39-47) years. Follow-up was 93.2% complete at a median time of 7.2 (IQR: 5.5-9.5) years. Cumulative follow-up was 545.5 valve-years. Bioprosthesis SVD was determined by strict echocardiographic assessment. Results: The overall survival-rate at 10/15 years and freedom from SVD at 10/12.5 years were 89.6 ± 5.2%/81.5 ± 9.1% and 73.5 ± 8.2%/41.9 ± 18.9%, respectively. SVD occurred at a median time of 8.2 (IQR: 6.0-9.9) years after bAVR. Age was not found as an independent predictor for SVD at the multivariable model, despite a higher rate of SVD in the age group ≤30 years. Freedom from reoperation due to SVD at 10/15 years was 71.3 ± 14.1%/13.6 ± 12.3%. Reoperation was performed at a median time of 10.0 (IQR: 8.9-11.9) years since first bAVR and was associated with a 100% 12-month survival. Conclusions: In our study, the rate and time of SVD occurrence were comparable to those of other studies' older age groups. Strict echocardiographic monitoring of valve performance is mandatory to set the appropriate timing of eventual reoperation. This attitude can improve outcomes of bAVR in younger patients.

Serial changes of coronary flow reserve over one year after transcatheter aortic valve implantation in patients with severe aortic stenosis.

Background: Impaired coronary flow reserve (CFR) portends a poor prognosis in patients with aortic stenosis. The present study aims to investigate how CFR changes over one year after transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis, and to explore factors related to the changes. Methods: Consecutive patients undergoing TAVI were registered. CFR in the left anterior descending artery was measured by transthoracic echocardiography on three occasions pre-TAVI, one-day post-TAVI, and one-year post-TAVI. Results: A total of 59 patients were enrolled, 46 of whom completed one-year follow-up. CFR was impaired in 35 (59.3%) patients pre-TAVI, but the impairment was only seen in 2 patients (4%) one-year post-TAVI. CFR value improved from 1.75 (1.50-2.10) cm/s pre-TAVI, to 2.00 (1.70-2.30) one-day post-TAVI, and further to 2.60 (2.30-3.10) one-year post-TAVI (P < 0.001). The median difference in CFR between pre-TAVI and one-year post-TAVI was 0.90 (0.53-1.20). Patients with significant improvement of CFR (more than the median value of 0.9) had larger aortic valve area (1.55 [1.38-1.92] vs. 1.36 cm2 [1.26-1.69], P = 0.042) and greater improvement in left ventricular ejection fraction (3.10 [-1.67-4.24] vs. -1.46 [-3.42-1.48] percentage points, P = 0.019) than those without. Conclusions: CFR is impaired in a considerable proportion of patients with severe aortic stenosis, but improvement is seen immediately after TAVI, and one year later. Patients with significant improvement of CFR had larger aortic valve area and greater increase in left ventricular ejection fraction after TAVI.

Defining value in cardiac surgery: A contemporary analysis of cost variation across the United States.

Objective: Isolated coronary artery bypass grafting and aortic valve replacement are common cardiac operations performed in the United States and serve as platforms for benchmarking. The present national study characterized hospital-level variation in costs and value for coronary artery bypass grafting and aortic valve replacement. Methods: Adults undergoing elective, isolated coronary artery bypass grafting or aortic valve replacement were identified in the 2016-2018 Nationwide Readmissions Database. Center quality was defined by the proportion of patients without an adverse outcome (death, stroke, respiratory failure, pneumonia, sepsis, acute kidney injury, and reoperation). High-value hospitals were defined as those with observed-to-expected ratios less than 1 for costs and greater than 1 for quality, whereas the converse defined low-value centers. Results: Of 318,194 patients meeting study criteria, 71.9% underwent isolated coronary artery bypass grafting and 28.1% underwent aortic valve replacement. Variation in hospital-level costs was evident, with median center-level cost of $36,400 (interquartile range, 29,500-46,700) for isolated coronary artery bypass grafting and $38,400 (interquartile range, 32,300-47,700) for aortic valve replacement. Observed-to-expected ratios for quality ranged from 0.2 to 10.9 for isolated coronary artery bypass grafting and 0.1 to 11.7 for isolated aortic valve replacement. Hospital factors, including volume and quality, contributed to approximately 9.9% and 11.2% of initial cost variation for isolated coronary artery bypass grafting and aortic valve replacement. High-value centers had greater cardiac surgery operative volume and were more commonly teaching hospitals compared to low-value centers, but had similar patient risk profiles. Conclusions: Significant variation in hospital costs, quality, and value exists for 2 common cardiac operations. Center volume was associated with value and partly accounts for variation in costs. Our findings suggest the need for value-based care paradigms to reduce expenditures and optimize outcomes.

Multimodality imaging in the diagnosis of bioprosthetic aortic valve endocarditis: A case report.

Introduction: Prosthetic valve infective endocarditis (PVE) is a diagnostic challenge even in the era of multimodality cardiovascular imaging. Case presentation: The patient was a 67-year-old male with a three-year history of bioprosthetic aortic valve replacement who presented with persistent fever and negative blood cultures. The initial transthoracic echocardiography revealed a thickened aortic root. An abscess formation was visualized upon subsequent three-dimensional transesophageal echocardiography and positron emission tomography/computerized tomography (PET/CT). The patient underwent an urgent necrotic tissue debridement and a redo Bentall surgery. The real-time polymerase chain reaction of excised tissues was positive for Streptococcus. Clinical discussion: The diagnosis of PVE and its complications requires the integration of clinical, microbiological, and serial imaging data. Although advanced imaging modalities like PET/CT allow a timely diagnosis and management, their routine use in resource-limited scenarios is difficult. Conclusion: Multimodality cardiovascular imaging plays an important role in the diagnosis of PVE. Serial echocardiographic and clinical assessments are possible alternatives when the access to advanced cardiovascular imaging modalities is limited.

Extent of aortic replacement and operative outcome in open proximal thoracic aortic aneurysm repair.

Objectives: There are few data to delineate the risk differences among open aortic procedures. We aimed to investigate the influence of the procedural types on the outcomes of proximal thoracic aortic aneurysm repair. Methods: Among 1900 patients who underwent aortic replacement in our institution between 2005 and 2019, 1132 patients with aortic aneurysm who underwent a graft replacement of proximal thoracic aorta were retrospectively reviewed. Patients were divided into 4 groups based on the extent of the aortic replacement: isolated ascending aortic replacement (n = 52); ascending aortic replacement with distal extension with hemiarch, partial arch, or total arch replacement (n = 126); ascending aortic replacement with proximal extension with aortic valve or root replacement (n = 620); and ascending aortic replacement with distal and proximal extension (n = 334). "Eventful recovery," defined as occurrence of any key complications, was used as the primary end point. Odds ratios for inability to achieve uneventful recovery in each procedure were calculated using ascending aortic replacement as a reference. Results: Overall, in-hospital mortality and stroke occurred in 16 patients (1.4%) and 24 patients (2.1%). Eventful recovery was observed in 19.7% of patients: 11.5% in those with ascending aortic replacement, 36.5% in those with partial arch or total arch replacement, 16.6% in those with proximal extension with aortic valve or root replacement, and 20.4% in those with distal and proximal extension (P < .001). With ascending aortic replacement as the reference, a multivariable logistic regression revealed partial arch or total arch replacement (odds ratio, 10.0; 95% confidence interval, 1.8-189.5) was an independent risk factor of inability to achieve uneventful recovery. Conclusions: Open proximal aneurysm repair in the contemporary era resulted in satisfactory in-hospital outcomes. Distal extension was associated with a higher risk for postoperative complications.

Comprehensive characterization of the postoperative pericardial inflammatory response: Potential implications for clinical outcomes.

Objective: There is a paucity of data on the inflammatory response that takes place in the pericardial space after cardiac surgery. This study provides a comprehensive assessment of the local postoperative inflammatory response. Methods: Forty-three patients underwent cardiotomy, where native pericardial fluid was aspirated and compared with postoperative pericardial effluent collected at 4, 24, and 48 hours' postcardiopulmonary bypass. Flow cytometry was used to define the levels and proportions of specific immune cells. Samples were also probed for concentrations of inflammatory cytokines, matrix metalloproteinases (MMPs), and tissue inhibitors of metalloproteinases (TIMPs). Results: Preoperatively, the pericardial space mainly contains macrophages and T cells. However, the postsurgical pericardial space was populated predominately by neutrophils, which constituted almost 80% of immune cells present, and peaked at 24 hours. When surgical approaches were compared, minimally invasive surgery was associated with fewer neutrophils in the pericardial space at 4 hours' postsurgery. Analysis of the intrapericardial concentrations of inflammatory mediators showed interleukin-6, MMP-9, and TIMP-1 to be highest postsurgery. Over time, MMP-9 concentrations decreased significantly, whereas TIMP-1 levels increased, resulting in a significant reduction of the ratio of MMP:TIMP after surgery, suggesting that active inflammatory processes may influence extracellular matrix remodeling. Conclusions: These results show that cardiac surgery elicits profound alterations in the immune cell profile in the pericardial space. Defining the cellular and molecular mediators that drive pericardial-specific postoperative inflammatory processes may allow for targeted therapies to reduce immune-mediated complications.

Modeling the impact of delaying transcatheter aortic valve replacement for the treatment of aortic stenosis in the era of COVID-19.

OBJECTIVE: The aim of this study was to model the short term and 2-year overall survival (OS) for intermediate-risk and low-risk patients with severe symptomatic aortic stenosis (AS) undergoing timely or delayed transcatheter aortic valve replacement (TAVR) during the 2019 novel coronavirus (COVID-19) pandemic. METHODS: We developed a decision analysis model to evaluate 2 treatment strategies for both low-risk and intermediate-risk patients with AS during the COVID-19 novel coronavirus pandemic. RESULTS: Prompt TAVR resulted in improved 2-year OS compared with delayed intervention for intermediate-risk patients (0.81 vs 0.67) and low-risk patients (0.95 vs 0.85), owing to the risk of death or the need for urgent/emergent TAVR in the waiting period. However, if the probability of acquiring COVID-19 novel coronavirus is >55% (intermediate-risk patients) or 47% (low-risk patients), delayed TAVR is favored over prompt intervention (0.66 vs 0.67 for intermediate risk; 0.84 vs 0.85 for low risk). CONCLUSIONS: Prompt transcatheter aortic valve replacement for both intermediate-risk and low-risk patients with symptomatic severe AS results in improved 2-year survival when local healthcare system resources are not significantly constrained by the COVID-19.

Implications of Coexisting Aortic Regurgitation in Patients With Aortic Stenosis.

Background: Aortic regurgitation (AR) is a common comorbidity in patients with aortic stenosis (AS), but coexisting AR has often been excluded from major clinical studies on AS. The impact of coexisting AR on the natural history of AS has not been well-described. Objectives: The authors compared clinical outcomes in medically managed patients with moderate-to-severe AS with or without coexisting AR. Methods: Consecutive patients (N = 1,188) with index echocardiographic diagnosis of moderate-to-severe AS (aortic valve area <1.5 cm2) were studied. All patients were medically managed and were divided into those with coexisting AR (at least moderate severity) and those without. Adverse composite clinical outcomes were defined as mortality or admissions for congestive cardiac failure on subsequent follow-up. The authors compared differences in clinical profile and outcomes between the groups. Results: There were 88 patients (7.4%) with coexisting AR and AS. These patients did not differ significantly in age, but had lower body mass index (22.9 ± 3.8 vs 25.3 ± 5.1 kg/m2), lower diastolic blood pressure (68.7 ± 10.7 vs 72.2 ± 12.3 mm Hg), larger end-diastolic volume index (68.8 ± 18.8 vs 60.4 ± 17.8 mL/m2) and larger left ventricular mass index (118.6 ± 36.4 vs 108.9 ± 33.1 g/m2). The prevalence of cardiovascular risk factors did not differ significantly. Coexisting AR was associated with increased incidence of adverse outcomes (log-rank 4.20; P = 0.040). On multivariable Cox regression, coexisting AR remained independently associated with adverse outcomes (HR: 1.36; 95% CI: 1.02-1.82) after adjusting for age, AS severity, left ventricular ejection fraction, and year of study. Conclusions: In patients with AS, coexisting AR was associated with changes in echocardiographic profile and adverse outcomes.

Aortic valve endocarditis in patients with bicuspid and tricuspid aortic valves.

Objective: To determine the long-term survival and rate of reoperation after surgical treatment of infective endocarditis (IE) in patients with a bicuspid aortic valve (BAV) and patients with a tricuspid aortic valve (TAV). Methods: Between 1997 and 2017, 210 patients underwent surgical treatment for native aortic valve endocarditis, including 51 patients with BAV (24%) and 159 patients with TAV (76%). Data were obtained from the Society of Thoracic Surgeons data warehouse and hospital medical record review, supplemented with surveys and national death index data for more complete follow-up. Results: Compared with the TAV IE group, the BAV IE group was significantly younger (42 years vs 54 years) and had lower incidence rates of hypertension, coronary artery disease, and congestive heart failure (CHF). There were no significant between-group differences in postoperative stroke, sepsis, pacemaker requirement, or in-hospital mortality (2.0% vs 4.4%). Liver disease was a risk factor for operative mortality (odds ratio [OR], 13; 95% CI, 3.3-30; P = .0002). The 10-year survival rate was 64% for the BAV group versus 46% for the TAV group (P = .0191). Significant risk factors for long-term mortality were intravenous drug use (hazard ratio [HR], 4.5; P < .0001), preoperative renal failure requiring dialysis (HR, 4.13; P < .0001), CHF (HR, 1.7; P = .04), and liver disease (HR, 2.6; P = .02). The HR for BAV was 0.67 (95% confidence interval [CI], 0.3-1.4). The 10-year postoperative cumulative incidence of reoperation was significantly higher in the BAV patients compared with the TAV patients (5.7% vs 4.5%; P = .045) with an HR of 2.4 (95% CI, 0.8-7.1; P = .11) for BAV. Conclusions: BAV patients develop IE requiring surgery at a younger age than TAV patients, but have significantly better long-term survival. Early detection of BAV is important to prevent IE and provide aggressive surgical treatment should IE occur.