Transseptal Puncture Learning Curve for Transcatheter Edge-to-Edge Mitral Valve Repair.

OBJECTIVE: This study examined the learning curve for transseptal puncture (TSP) during transcatheter edge-to-edge mitral valve repair (TEER) performed by a dedicated mitral valve structural heart team. Effective TSP is mandatory for TEER but can be time-consuming and associated with complications including pericardial effusion and cardiac tamponade. METHODS: TSP was performed on 107 consecutive patients (76 ± 1 years, 52% male) undergoing TEER between 2014 and 2019. TSP was performed by each structural heart team member (1 cardiologist, 2 cardiac surgeons) on a rotating case-by-case basis. No team member had prior independent TSP experience. Data collected included total procedure time, TSP time (time elapsed between procedure start and septal crossing), and number of TSP attempts before successful puncture. Cumulative sum (CUSUM) of deviations from the mean across sequential cases were used to examine learning curves. RESULTS: Median total procedure time was 107 min, and the median TSP time was 14 min. Greater case number was significantly associated with both lower TSP time (r s = -0.22, P = 0.022) and lower total procedure time (r s = -0.29, P = 0.003). The majority of patients required only 1 TSP attempt (79%). There was a significant quadratic relationship between case number and the CUSUM for TSP time, with the learning curve peaking at 49 cases. CONCLUSIONS: TSP for TEER has a substantial learning curve, requiring >50 cases to achieve acceptable efficiency. Even once proficiency is demonstrated, TSP remains a time-consuming component of TEER. Improvements in transseptal access technology may significantly decrease the time needed to master TSP and may improve the safety and precision of the procedure.

A Failed Cardiac Surgery Program in an Underserved Minority Population County Reimagined: The Power of Partnership.

Background Prince George's County Maryland, historically a medically underserved region, has a population of 909 327 and a high incidence of cardiometabolic syndrome and hypertension. Application of level I evidence practices in such areas requires the availability of highly advanced cardiovascular interventions. Donabedian principles of quality of care were applied to a failing cardiac surgery program. We hypothesized that a multidisciplinary application of this model supported by partnership with a university hospital system could result in improved quality care outcomes. Methods and Results A 6-month assessment and planning process commenced in July 2014. Preoperative, intraoperative, and postoperative protocols were developed before program restart. Staff education and training was conducted via team simulation and rehearsal sessions. A total of 425 patients underwent cardiac surgical procedures. Quality tracking of key performance measures was conducted, and 323 isolated coronary artery bypass grafting procedures were performed from July 2014 to December 2019. Key risk factors in our patient demographic were higher than the Society of Thoracic Surgeons national mean. Risk-adjusted outcome data yielded a mortality rate of 0.3% versus 2.2% nationally. The overall major complication rate was lower than expected at 7.1% compared with 11.5% nationally. Readmission rate was less than the Society of Thoracic Surgeons mean for isolated coronary artery bypass grafting (4.0% versus 10.1%, P<0.0001). Significant differences in 6 key performance outcomes were noted, leading to a 3-star Society of Thoracic Surgeons designation in 7 of 8 tracking periods. Conclusions Excellent outcomes in cardiac surgery are attainable following program renovation in an underserved region in the setting of low volume. The principles and processes applied have potential broad application for any quality improvement effort.

Triple Valve Replacement in a Patient with Severe Combined Aortic and Mitral Stenosis.

With recent advancements and evidence in favor of transcatheter approach for valve replacements including valve-in-valve procedures, it has become a favorable choice particularly in critically ill patients. Additionally, transcatheter mitral valve-in-valve replacement (TMViVR) is emerging as a less invasive substitute for patients with early dysfunctional bioprosthetic valve. We describe the clinical course of a 52-year-old male whose initial presentation to the hospital for dyspnea on exertion secondary to combined severe aortic and mitral stenosis got complicated requiring three valvular replacement procedures with favorable outcomes.

Long-term Performance of Fresh Autologous Pericardium for Mitral Valve Leaflet Repair.

BACKGROUND: Glutaraldehyde-fixed autologous or bovine pericardial patches used for mitral valve leaflet reconstruction have been associated with late calcification. Fresh autologous pericardium (FAP) may be a durable alternative. METHODS: Transthoracic echocardiography was used to assess valve function (regurgitation, mean pressure gradient, patch pliability, and calcification) in patients undergoing FAP mitral leaflet repairs. Pliability was scored between 1 (similar to native leaflets) and 4 (rigid). Calcification was scored between 1 (echobrightness similar to native leaflets) and 4 (very bright). RESULTS: Between 2002 and 2018, 62 consecutive patients (50% male, 51 ± 2 years, 69% infective endocarditis) underwent mitral valve repair with FAP, and Patch placement was on the anterior (31 of 62), posterior (27 of 62), or both (1 of 62) leaflets. Late echocardiographic follow-up was available for 43 of 62 patients (median follow-up, 3.6 years; range, 0.5-6 years). Average pliability scores were unchanged between discharge (1.2 ± 0.1) and follow-up (1.2 ± 0.2, P = .79). Average brightness scores increased modestly (predischarge, 1.6 ± 0.1; follow-up, 1.8 ± 0.1; P = .01). Three patients had recurrent severe mitral regurgitation, and 2 underwent reoperation, 1 at 1 year postoperatively for recurrent endocarditis and 1 at 6 years postoperatively for degenerative disease progression. At reoperation, patches were pliable, free from calcification, and comparable in thickness to adjacent native leaflet. One patient developed suture line leak, which was repaired. No other evidence of patch dehiscence, retraction, or aneurysm was observed. The 10-year freedom from reoperation of 82% and survival rate of 84% are comparable to repair with glutaraldehyde-fixed or bovine pericardial patches. CONCLUSIONS: FAP is an excellent substrate for complex mitral valve leaflet patch repairs and can be used with the expectation of durable, long-term valve function, without evidence of late patch calcification, stiffness, or aneurysmal degeneration.

Degenerative Mitral Valve Repair Simplified: An Evolution to Universal Artificial Cordal Repair.

BACKGROUND: Resectional and artificial cordal repair techniques are effective strategies for degenerative mitral valve (MV) repair. However, resectional repair requires a tailored approach using various techniques, whereas cordal repair offers a simpler, easily reproducible repair. The approach described in this study approach has evolved from resectional to cordal over time, and outcomes are compared between the eras. METHODS: Clinical and echocardiographic outcomes of all patients undergoing MV repair for degenerative mitral regurgitation (MR) from January 2004 to September 2017 were reviewed. Patients were stratified by era: from January 2004 to June 2011 (era 1; n = 405), resectional techniques were used in 62% and artificial cordal techniques were used in 38%. From July 2011 to September 2017 (era 2; n = 438), artificial cordal repair was used in 98% of patients. The primary outcome was repair failure, defined as greater than moderate MR or MV reoperation. RESULTS: Of 847 patients with degenerative MR, successful repair was achieved in 843 patients (99.5% repair rate). Leaflet prolapse was posterior in 66%, anterior in 8%, and bileaflet in 26%. Cardiopulmonary bypass time and cross-clamp times were shorter in era 2 (CPB: 109 [IQR, 92-128] minutes vs 97 [IQR, 76-121] minutes; P < .001; cross-clamp: 88 [IQR, 73-106] minutes vs. 79 [IQR, 61-99] minutes; P < .001). Predismissal echocardiography demonstrated no MR or trace MR in 95%, mild MR in 4.7%, and moderate MR in 0.3% of patients. Operative mortality was similar in the eras (0.5% vs 0.5%; P > .999). The rates of 5-year freedom from repair failure (95.1% vs 95.5%; P = .707), stroke (96.8% vs 95.3%; P = .538), and endocarditis (99.3% vs 99.7%; P = .604) were similar between the eras. CONCLUSIONS: Artificial cordal repair for all patients with degenerative MR simplifies MV repair and yields equivalent, excellent outcomes compared with a tailored resectional approach.

Impact of intraoperative high-volume autologous blood collection on allogeneic transfusion during and after cardiac surgery: a propensity score matched analysis.

BACKGROUND: Perioperative use of allogeneic blood products is associated with higher morbidity, mortality, and hospital costs after cardiac surgery. Blood conservation techniques such as acute normovolemic hemodilution (ANH) report variable success. We hypothesized that large-volume ANH with limited hemodilution would reduce allogeneic blood transfusion compared to the standard practice. STUDY DESIGN AND METHODS: Retrospective observational study of cardiac surgery patients at the University of Maryland Medical Center between January 2014 and September 2017. Using the institutional Society of Thoracic Surgeons database 91 autologous and 981 control patients who underwent coronary artery bypass grafting, aortic valve replacement, or both were identified. After propensity matching of 13 preoperative characteristics, 84 autologous and 84 control patients were evaluated. Our primary endpoint was avoidance of blood transfusion during index hospitalization, and secondary endpoints were postoperative bleeding and major adverse outcomes. RESULTS: The median harvest volumes in the ANH and control groups were 1100 mL and 400 mL, respectively. Of the ANH group, 25% received any transfusion versus 45.2% of the control group after propensity score matching (p < 0.006). When controlling for preoperative platelet count, the transfusion rate ratios for ANH were 0.58 (95% confidence interval, 0.39-0.88) for RBCs and 0.63 (0.44-0.89) for non-RBC components, which were both found to be statistically significant. There was no difference found in major adverse events. CONCLUSION: These results suggest that large-volume ANH is beneficial in reducing both RBC and non-RBC component usage in cardiac surgery. A further prospective validation is warranted.

Preoperative Venoarterial Extracorporeal Membrane Oxygenation Slashes Risk Score in Advanced Structural Heart Disease.

BACKGROUND: Cardiac surgery for structural heart disease has poor outcomes in the presence of cardiogenic shock or advanced heart failure. We applied venoarterial extracorporeal membrane oxygenation (ECMO) to restore end-organ function and resuscitate patients before high-risk cardiac operation. METHODS: Twelve patients with cardiogenic shock and end-organ failure were evaluated for cardiac surgery. The average Society of Thoracic Surgeons mortality risk was 24% ± 13%. Patients were peripherally cannulated on ECMO for 7 ± 4 days, before undergoing operation for prosthetic mitral stenosis (n = 4), ruptured papillary muscle (n = 4), ischemic ventricular septal defect (n = 3), or severe aortic stenosis (n = 1). RESULTS: Mean age was 61 ± 8 years. Comorbidities included acute renal failure (n = 11), inotrope requirement (n = 10), intraaortic balloon pump (n = 8), severe acidosis (n = 6), high-dose vasopressor requirement (n = 8), and cardiac arrest (n = 1). With ECMO support, vasopressor requirement, central venous pressure, creatinine, lactate, pH, pulmonary hypertension, and The Society of Thoracic Surgeons mortality risk and EuroSCORE (European System for Cardiac Operative Risk Evaluation) II all improved significantly. Care was withdrawn in 1 patient on ECMO with initially unknown anoxic brain injury. No patients required dialysis at discharge. Complications included 1 permanent stroke. All operative patients survived to hospital discharge. Average length of follow-up was 420 days, with 2 patient deaths at 76 and 230 days and 6 patients surviving over 1 year. CONCLUSIONS: ECMO can be used as a bridge to heart valve or septal defect surgery in severely decompensated patients. Through recovery of end-organ function, ECMO may allow surgical correction of structural heart disease in patients considered inoperable or convert a salvage situation to an elective operation.

Transmitral Septal Myectomy for Hypertrophic Obstructive Cardiomyopathy.

BACKGROUND: Intrinsic abnormalities of the mitral valve are common in patients with hypertrophic cardiomyopathy and may need to be addressed at operation. METHODS: Consecutive patients undergoing transmitral septal myectomy were retrospectively reviewed. The ventricular septum was exposed through a left atriotomy, and the anterior leaflet of the mitral valve was detached from its annulus. An extended myectomy was performed to the base of the papillary muscles. After myectomy, the anterior leaflet was reattached and concomitant mitral valve repair or replacement was performed. In some cases, we performed a modified anterolateral commissural closure suture, which served to reposition the lateral aspect of the anterior leaflet out of the left ventricular outflow tract ("curtain stitch"). RESULTS: Twenty patients who underwent this procedure were identified (70% women; mean age 63 years). Mitral regurgitation was moderate in 55% and severe in 40%. Preoperative peak left ventricular outflow tract gradient was 92 ± 43 mm Hg. Mitral valve repair (n = 11) or replacement (n = 9) was performed. Predischarge transthoracic echocardiography demonstrated a left ventricular outflow tract gradient of 10 ± 5 mm Hg. There was no operative mortality. Follow-up was 100% complete and averaged 22 ± 25 months. No patient required reoperation, and there was no recurrence of left ventricular outflow tract obstruction or mitral regurgitation greater than mild. CONCLUSIONS: Potential advantages of transmitral myectomy include a panoramic view of the septum and mitral subvalvular apparatus and the ability to simultaneously address mitral valve pathology. Consideration should be given to using the transmitral approach to septal myectomy as the preferred approach for the surgical treatment of hypertrophic cardiomyopathy.

Early Operation in Patients With Mitral Valve Infective Endocarditis and Acute Stroke Is Safe.

BACKGROUND: To determine if preoperative embolic stroke is associated with an increased risk of postoperative stroke among patients undergoing early operation for mitral valve (MV) infective endocarditis (IE), we compared outcomes among patients presenting with and without acute stroke. METHODS: From 2003 to 2015, 243 consecutive patients underwent surgery for active MV IE. Patients were categorized into 2 groups: 72% (174 of 243 patients) with no preoperative acute stroke (clinical, radiographic or both) and 28% (69 of 243 patients) with stroke. Both preoperative and postoperative strokes were confirmed in all patients with brain computed tomography or magnetic resonance imaging and comprehensive examination by a neurologist. RESULTS: Among patients presenting with stroke, 33% (23 of 69 patients) were asymptomatic and had only positive imaging findings. The median time from admission to operation was 5 days. The overall rate of new postoperative stroke was 4% (10 of 243 patients). The rate of postoperative stroke was not different between the 2 groups: 4% (7 of 174 patients) among patients with no preoperative stroke and 4% (3 of 69 patients) with stroke (p = 0.9). One patient developed a hemorrhagic conversion of an acute infarct. Operative mortality was 7% (13 of 174 patients) among patients with no preoperative stroke and 7% (5 of 69 patients) among patients with stroke (p = 0.9). CONCLUSIONS: MV surgery for IE and acute stroke can be performed early with a low risk of postoperative neurologic complications. When indicated, surgical intervention for MV IE complicated by acute stroke should not be delayed.

Percutaneous Rescue for Critical Mitral Stenosis Late After Mitral Valve Repair.

We report a case of catastrophic hemodynamic compromise secondary to pannus ingrowth and severe mitral stenosis occurring years after repair of a nonrheumatic mitral valve. The initial repair included closure of a posterior leaflet cleft and implantation of an annuloplasty ring. We describe a hybrid treatment strategy for this severely compromised patient, which included initial placement of a right ventricular assist device followed by percutaneous balloon mitral valvuloplasty and, eventually, a definitive mitral valve reoperation. This case report reinforces the importance of routine clinical and echocardiographic follow-up for patients after mitral valve repair, and it includes the description of a novel therapeutic approach.

Undersized Rigid Nonplanar Annuloplasty: The Key to Effective and Durable Repair of Functional Tricuspid Regurgitation.

BACKGROUND: Previous clinical experiences have demonstrated high early and late recurrence rates after repair of functional tricuspid regurgitation (TR). We investigated the results of functional TR repair with undersized rigid nonplanar annuloplasty rings. METHODS: From January 2007 to December 2013, 216 consecutive patients with moderate or greater functional TR were treated with undersized (size 26 mm or 28 mm) rigid nonplanar annuloplasty rings. RESULTS: The mean age was 69 ± 13 years. There was a previous history of cardiac operation in 25% (54 of 216 patients). Tricuspid regurgitation was graded as severe in 47% (102 of 216) and moderate in 53% (114 of 216). Concomitant operations included mitral valve procedures in 92% (198 of 216), coronary artery bypass grafting in 21% (45 of 216), aortic valve procedures in 9% (20 of 216), and cryomaze procedures in 35% (76 of 216). Size 26 mm rings were used in 38% of patients (81 of 216), and size 28 mm in 62% (135 of 216). The perioperative mortality rate was 6% (14 of 216). On predischarge echocardiography, TR grade was none or mild in 94% (176 of 187 patients), moderate in 4% (7 of 187), and severe in 2% (4 of 187). At a mean follow-up of 33.0 ± 24.0 months, TR grade was none or mild in 81% of patients (130 of 160), moderate in 16% (26 of 160), and severe in 2% (4 of 160). There were no reoperations for recurrent TR, and no patients have had tricuspid stenosis or annuloplasty ring dehiscence. CONCLUSIONS: Treatment of functional TR with undersized (26 mm or 28 mm) nonplanar rigid annuloplasty rings is safe and highly effective, with a near absence of recurrent severe TR at midterm follow-up.

A review of the LARIAT device: insights from the cumulative clinical experience.

Atrial fibrillation (AF) is the most common arrhythmic disorder world-wide, accounting for 15 % of all strokes. Management of stroke risk in AF is complicated by intolerance of anti-coagulation (AC) therapy and difficulty maintaining therapeutic range in patients treated with warfarin. The left atrial appendage (LAA) is a source of thrombus in AFrelated thrombo-embolic events and surgical LAA exclusion (LAAO) is commonly performed during cardiac surgery in AF patients. Surgical approaches are limited by a high incidence of incomplete closure with a potential for consequent thrombo-embolic events as well as the morbidity of an open-heart procedure. More recently, percutaneous approaches to LAAO have been developed. The LARIAT device is an epicardial LAA exclusion system that enables percutaneous suture ligation of the LAA via combined, pericardial and trans-septal access. The device has 510k Federal Drug Administration (FDA) clearance for soft-tissue ligation and has been studied in canine models in pre-clinical studies as well as published series of clinical experience with LARIAT LAAO. The history, patient selection, procedural technique and complications of LARIAT LAAO are reviewed here. Additionally, insights and procedural improvements that have been elucidated from clinical series and outcomes from the collective experience are discussed. The LARIAT's epicardial approach to LAA ligation is unique compared with other percutaneous LAA exclusion devices, however more data regarding device safety and efficacy is needed for the LARIAT to emerge as an established therapy for stroke prevention in AF.

Surgical Management of Caseous Calcification of the Mitral Annulus.

Caseous calcification of the mitral annulus is a rare variant of mitral annular calcification where liquefaction and caseation result in formation of a mass at the border of the calcified annulus. Limited reports of operative therapy for caseous calcification of the mitral annulus describe wide excision and gross débridement of the mass, a technique that can cause perioperative stroke. We present a strategy of limited incision and drainage of the liquid material, closure of the incision, and subsequent suture obliteration of the cavity and mitral valve repair or replacement. In our experience, this technique is safe and has not been associated with perioperative stroke.

Contemporary outcomes of operations for tricuspid valve infective endocarditis.

BACKGROUND: Tricuspid valve infective endocarditis (TVIE) is uncommon. Patients are traditionally treated with antibiotics alone, and indications for operation are not clearly established. We report our operative single-center experience. METHODS: We retrospectively reviewed 56 patients who underwent operations for TVIE between January 2002 and December 2012. RESULTS: Methicillin-resistant Staphylococcus aureus was present in 41% of patients, septic pulmonary emboli in 63%, moderate/severe tricuspid regurgitation in 66%, and 86% were intravenous drug abusers. Patients underwent early operation if there was concomitant left-sided endocarditis with indications for operation (n = 18), atrial septal defect (n = 6), infected pacemaker lead (n = 4), or prosthetic TVIE (n = 1). The remaining 27 patients were treated with intravenous antibiotics. Five patients completed a 6-week course of intravenous antibiotics before requiring an operation for symptomatic severe tricuspid regurgitation or persistent bacteremia. Twenty-two patients did not complete the antibiotic therapy and underwent operation for symptomatic severe tricuspid regurgitation (n = 15), persistent fevers/bacteremia (n = 3), or patient-specific factors (n = 4). Valve repair was successful in 57% of patients. Overall operative mortality was 7.1%. No operative deaths occurred in patients with isolated native TVIE. Recurrent TVIE was diagnosed in 21% (5 of 24) of the replacement group and in 0% (0 of 32) in the repair group. Use of repair was strongly protective against recurrent TVIE (p < 0.01). CONCLUSIONS: In contrast to previously published reports of high operative mortality with TVIE, this experience demonstrates improved outcomes with low morbidity and mortality, particularly for native isolated TVIE. Future prospective comparisons between surgically and medically treated patients may help to further define indications and timing for operation for patients with TVIE.

Prospective assessment of the CryoMaze procedure with continuous outpatient telemetry in 136 patients.

BACKGROUND: Only 40% of patients with atrial fibrillation (AF) undergoing cardiac surgery are treated with surgical AF correction. We prospectively studied endocardial cryoablation of the Cox-maze III lesion set following prespecified rhythm assessment with outpatient telemetry. METHODS: Between 2007 and 2011, 136 patients underwent surgical AF correction using an argon-powered cryoablation device. Patients wore continuous electrocardiogram monitoring prior to and at 6, 12, and 24 months after surgery. The average length of monitoring was 6.5±1 days prior to surgery and 11±4 days at each time point after surgery. Patients were assessed for cardiac rhythm, interval cardioversion or ablation procedures, pacemaker placement, and the use of warfarin or antiarrhythmic medications. The primary endpoint of this study was freedom from AF at 1 year. RESULTS: Mean patient age was 66±12 years, 50% (69 of 138) were male and 41% (55 of 134) had persistent AF. CryoMaze was done in conjunction with mitral valve operation in 95% (131 of 138) and other procedures in 41% (56 of 138). Follow-up was 96% complete at 1 year and 90% at 2 years. Freedom from AF was 76% at 1 year. Perioperative mortality and stroke rates were both 1.5% (2 of 138). Perioperative pacemaker implantation was required in 7% (9 of 136). In univariate analysis, younger age, female gender, decreased height and weight, smaller preoperative and postoperative left atrial diameter, intermittent AF, and freedom from AF at discharge were associated with freedom from AF at 1 year. Actuarial 2- and 4-year (Kaplan-Meier) survival were 93% and 80%, respectively. CONCLUSIONS: The CryoMaze procedure is safe and is associated with 76% freedom from AF at 1 year.

Repeat sternotomy: no longer a risk factor in mitral valve surgical procedures.

BACKGROUND: The incidence of reoperative mitral valve (MV) surgical procedures is increasing, representing more than 10% of all MV operations in the United States. Previous clinical series have reported mortality rates of 5% to 18% and reentry injury rates of 5% to 10% for reoperative MV operations. METHODS: Between January 2004 and June 2012, 1,312 MV operations were performed on 1,275 patients. We excluded 234 patients who underwent small incision primary right thoracotomy, 11 redo operations with first or second operation other than sternotomy, and 10 emergent operations, leaving 1,056 MV operations for analysis (first-time sternotomy, 926 [88%]; repeat sternotomy, 130 (12%]). Preoperative computed tomography was performed for all repeat sternotomy patients. Patients at risk for reentry injury were identified, and protective strategies were applied systemically before resternotomy procedures. RESULTS: Among 130 patients undergoing reoperative MV operations, 35% (46/130) had prior coronary artery bypass grafting (CABG), 15% (19/130) aortic valve operations, and 61% (80/130) MV operations. Sixteen percent (21/130) had more than one previous sternotomy. Operative mortality was 4.6% (43/926) for first-time procedures and 4.6% (6/130) for reoperative MV operations. Intraoperative injury (innominate vein) occurred during repeat sternotomy in 2 (1.5%) patients. Stroke occurred in 3 patients (2%) who underwent repeat sternotomy and in 22 (2%) who underwent first-time sternotomy. On multivariable analysis, preoperative New York Heart Association function class, concomitant CABG, dialysis, and higher pulmonary artery pressures were associated with operative mortality, and repeat sternotomy was not. CONCLUSIONS: With careful planning and execution, outcomes for reoperative MV operations in contemporary practice are favorable and are identical with those for first-time operations.

Mitral valve surgery in elderly patients with mitral regurgitation: repair or replacement with tissue valve?

PURPOSE OF REVIEW: The fastest growing demographic in North America is the elderly. Significant mitral regurgitation is present in more than 10% of this population. There are sparse clinical data to inform decisions regarding the optimal timing of operation and the appropriate operative intervention for this large population of patients with severe mitral regurgitation. RECENT FINDINGS: Mitral valve surgery can be safely performed in most elderly patients with severe mitral regurgitation. The best outcomes occur when operative intervention is performed early, before advanced symptoms of heart failure develop. In elderly patients with mitral regurgitation, mitral valve repair is associated with superior early and late results compared with replacement. Survival after mitral valve repair among elderly patients is equivalent to a normal age-matched population. SUMMARY: Elderly patients with severe mitral regurgitation should be referred for operation before significant symptoms develop. Mitral valve repair is favoured over replacement whenever feasible and is associated with satisfactory early and long-term results. If repair is impossible or the likelihood of durable repair seems low, valve replacement with a bioprosthetic valve should be performed. Further prospective clinical trials are essential to define the role of screening for this prevalent condition and to identify which subgroups of elderly patients will benefit most from early surgical intervention.