Long-term clinical outcomes of the Toronto stentless porcine valve: 15-year results from dual centers.

BACKGROUND AND AIM OF THE STUDY: The purpose of this study is to examine the long-term durability of the Toronto stentless porcine valve (SPV) in the aortic position (St Jude Medical, Minneapolis, MN). METHODS: We assessed the long-term clinical outcomes of 515 patients with aortic valve replacement (AVR) with the Toronto SPV from 1987 to 2001 at two centers, excluding early (<30 days) death. Median follow-up was 11.5 years (maximum 19.0 years). RESULTS: Average age was 64.2 ± 10.8 years, and females were 34% (173/515). The incidence of prosthesis-patient mismatch was low, 10.9%. Overall survival was 90.7 ± 1.3%, 75.4 ± 2.0%, and 56.8 ± 3.2% at 5, 10, and 15 years, respectively after surgery. Over the follow-up duration, 116 patients (23%) underwent repeated AVR: 90 for structural valve deterioration (SVD), 12 for endocarditis, 10 nonstructural valve dysfunction (10 aortic regurgitation due to aorta dilatation), and four for other reasons. The cumulative incidence of repeated AVR with death as a competing risk was 1.4% (95% confidence interval [CI], 0.6-2.7), 11.1% (95% CI, 8.4-14.2), and 34.4% (95% CI, 28.8-40.2) at 5, 10, and 15 years, respectively. Reoperative mortality was 5.2% (6/116). In SVD, the regurgitation type was dominant (82%). CONCLUSIONS: The Toronto SPV is associated with excellent survival and durability during the first decade of follow-up. However, regurgitation type of SVD increases from 10 years after operation with acceptable reoperative mortality. These findings may assist with prosthesis selection and reintervention strategy for failing stentless bioprosthesis.

Novel mediators of aneurysm progression in bicuspid aortic valve disease.

Bicuspid aortic valve (BAV) disease is a congenital abnormality that is associated with ascending aortic aneurysm yet many of the molecular mechanisms remain unknown. To identify novel molecular mechanisms of aneurysm formation we completed microarray analysis of the proximal (severely dilated) and distal (less dilated) regions of the ascending aorta from five patients with BAV. We identified 180 differentially expressed genes, 40 of which were validated by RT-qPCR. Most genes had roles in inflammation and endothelial cell function including cytokines and growth factors, cell surface receptors and the Activator Protein 1 (AP-1) transcription factor family (FOS, FOSB and JUN) which was chosen for further study. AP-1 was differentially expressed within paired BAV aneurysmal samples (n = 8) but not Marfan patients (n = 5). FOS protein was significantly enriched in BAV aortas compared to normal aortas but unexpectedly, ERK1/2 activity, an upstream regulator of FOS was reduced. ERK1/2 activity was restored when BAV smooth muscle cells were cultured in vitro. An mRNA-miRNA network within paired patient samples identified AP-1 as a central hub of miRNA regulation. FOS knockdown in BAV SMCs increased expression of miR-27a, a stretch responsive miRNA. AP-1 and miR-27a were also dysregulated in a mouse model of aortic constriction. In summary, this study identified a central role for AP-1 signaling in BAV aortic dilatation by using paired mRNA-miRNA patient sample. Upstream analysis of AP-1 regulation showed that the ERK1/2 signaling pathway is dysregulated and thus represents a novel chain of mediators of aortic dilatation in BAV which should be considered in future studies.

Surgical Enlargement of the Aortic Root Does Not Increase the Operative Risk of Aortic Valve Replacement.

BACKGROUND: Surgical aortic root enlargement (ARE) during aortic valve replacement (AVR) allows for larger prosthesis implantation and may be an important adjunct to surgical AVR in the transcatheter valve-in-valve era. The incremental operative risk of adding ARE to AVR has not been established. We aimed to evaluate the early outcomes of patients undergoing AVR with or without ARE. METHODS: From January 1990 to August 2014, 7039 patients underwent AVR (AVR+ARE, n=1854; AVR, n=5185) at a single institution. Patients with aortic dissection and active endocarditis were excluded. Mean age was 65±14 years and 63% were male. Logistic regression and propensity score matching were used to adjust for unbalanced variables in group comparisons. RESULTS: Patients undergoing AVR+ARE were more likely to be female (46% versus 34%, P<0.001) and had higher rates of previous cardiac surgery (18% versus 12%, P<0.001), chronic obstructive pulmonary disease (5% versus 3%, P=0.004), urgent/emergent status (6% versus 4%, P=0.01), and worse New York Heart Association status (P<0.001). Most patients received bioprosthetic valves (AVR+ARE: 73.4% versus AVR: 73.3%, P=0.98) and also underwent concomitant cardiac procedures (AVR+ARE: 68% versus AVR: 67%, P=0.31). Mean prosthesis size implanted was slightly smaller in patients requiring AVR+ARE versus AVR (23.4±2.1 versus 24.1±2.3, P<0.001). In-hospital mortality was higher after AVR+ARE (4.3% versus 3.0%, P=0.008), although when the cohort was restricted to patients undergoing isolated aortic valve replacement with or without root enlargement, mortality was not statistically different (AVR+ARE: 1.7% versus AVR: 1.1%, P=0.29). After adjustment for baseline characteristics, AVR+ARE was not associated with an increased risk of in-hospital mortality when compared with AVR (odds ratio, 1.03; 95% confidence interval, 0.75-1.41; P=0.85). Furthermore, AVR+ARE was not associated with an increased risk of postoperative adverse events. Results were similar if propensity matching was used instead of multivariable adjustments for baseline characteristics. CONCLUSIONS: In the largest analysis to date, ARE was not associated with increased risk of mortality or adverse events. Surgical ARE is a safe adjunct to AVR in the modern era.

Long-Term Outcomes of the Ross Procedure Versus Mechanical Aortic Valve Replacement: Propensity-Matched Cohort Study.

BACKGROUND: The ideal aortic valve substitute in young and middle-aged adults remains unknown. We sought to compare the long-term outcomes of patients undergoing the Ross procedure and those receiving a mechanical aortic valve replacement (AVR). METHODS: From 1990 to 2014, 258 patients underwent a Ross procedure and 1444 had a mechanical AVR at a single institution. Patients were matched into 208 pairs through the use of a propensity score. Mean age was 37.2±10.2 years, and 63% were male. Mean follow-up was 14.2±6.5 years. RESULTS: Overall survival was equivalent (Ross versus AVR: hazard ratio, 0.91, 95% confidence interval, 0.38-2.16; P=0.83), although freedom from cardiac- and valve-related mortality was improved in the Ross group (Ross versus AVR: hazard ratio, 0.22; 95% confidence interval, 0.034-0.86; P=0.03). Freedom from reintervention was equivalent after both procedures (Ross versus AVR: hazard ratio, 1.86; 95% confidence interval, 0.76-4.94; P=0.18). Long-term freedom from stroke or major bleeding was superior after the Ross procedure (Ross versus AVR: hazard ratio, 0.09; 95% confidence interval, 0.02-0.31; P<0.001). CONCLUSIONS: Long-term survival and freedom from reintervention were comparable between the Ross procedure and mechanical AVR. However, the Ross procedure was associated with improved freedom from cardiac- and valve-related mortality and a significant reduction in the incidence of stroke and major bleeding. In specialized centers, the Ross procedure represents an excellent option and should be considered for young and middle-aged adults undergoing AVR.

Late outcomes of mitral valve repair for mitral regurgitation due to degenerative disease.

BACKGROUND: The pathological spectrum of degenerative diseases of the mitral valve (MV) that causes mitral regurgitation (MR) is broad, and there is limited information on late outcomes of MV repair in various subgroups of patients and pathologies. This study examines this issue. METHODS AND RESULTS: All 840 patients who had MV repair for MR due to degenerative diseases from 1985 to 2004 were prospectively followed with clinical and echocardiographic evaluations at biennial intervals up to 26 years, median of 10.4 years. Clinical, hemodynamic, and pathological variables were evaluated for their association with outcomes. Age, left ventricular ejection fraction, and functional class were predictors of late cardiac- and valve-related deaths by multivariable analysis. MV repair failed to restore life span to normal in patients with functional class IV. Thirty-eight patients had repeat MV surgery, and the probability of reoperation at 20 years was 5.9%. During the follow-up, recurrent severe MR developed in 37 patients, and moderate MR developed in 61. Age, isolated prolapse of the anterior leaflet, the degree of myxomatous changes in the MV, lack of mitral annuloplasty, and duration of cardiopulmonary bypass were associated with increased risk of recurrent MR. At 20 years, the freedom from recurrent severe MR was 90.7%, and the freedom from moderate or severe MR was 69.2%. CONCLUSIONS: MV repair for degenerative MR restored life span to normal except in patients with symptoms at rest and impaired left ventricular function. Advanced age and complex mitral valve pathologies increased the risk of late recurrent MR.

Native and prosthetic valve infective endocarditis: clinicopathologic correlation and review of the literature.

BACKGROUND: The incidence of infective endocarditis is 1.5-4.95 cases per 100,000 individuals per year, with a mortality of 14-46% 1-year post infection. The management and decision to operate on selected patients remains controversial. Our study reviews cases of native and prosthetic valve endocarditis in a surgical population, in an attempt to identify and compare clinical and microbiologic features between the two groups. In addition, we compared our findings with other published series to identify if there are changes with these parameters over time. METHODS: A retrospective analysis of patient records at one institution over an 11-year period identified cases of explanted native (NVE) and prosthetic (PVE) valves with confirmed infective endocarditis (IE) on pathological analysis. Patient records were reviewed to identify patient demographics, risk factors, microbiology and outcomes. Gross features and histological sections were reviewed in all cases. RESULTS: Two hundred and nine valves were explanted over the study period, 164 of which were native actively infected valves (average age 50.7 + 16.4 years, 77% of males) and 45 prosthetic actively infected valves (average age 55.2 + 16.2 years, 71% of males). Prominent risk factors in the NVE group were bicuspid aortic valve, dental procedures and intravenous drug use, while rheumatic heart disease and diabetes mellitus were most common in the PVE group. Streptococcus and staphylococcus were the most common organisms in both groups. In-hospital mortality was not significantly different between the two groups. CONCLUSIONS: Surgical intervention remains a part of the management of IE. Despite early recognition and advanced surgical techniques, risk factors have not dramatically changed between the other reviewed studies (patients enrolled from 1978-2004), with the exception of diabetes mellitus becoming more prevalent over time. In addition, despite the change of preprocedural antibiotics prior to dental and other procedures, there does not appear to be an increase in IE cases with previous procedural intervention in our cohort compared to others series, which were published before 2008. Mortality in our cohort was not statistically significant between the NVE and PVE groups, and may be due to careful patient selection for redo surgery in the PVE group. Compared to previous studies, mortality rates remain the same over the last decade.

Aortic Valve-Sparing Operations.

Aortic valve-sparing operations were developed >3 decades ago and have become part of the surgical armamentarium to treat patients with aortic root and ascending aortic aneurysms. Although remodeling of the aortic root is physiologically sounder than reimplantation of the aortic valve, most surgeons seem to prefer the latter. This review summarizes the views of one of the pioneers of aortic valve-sparing operation and includes their development, the various modifications that occurred over the years, comparative outcomes with aortic root replacement with valved conduits, outcomes from several recently reported series, and the future directions. The author argues that comparisons between aortic valve-sparing operations and aortic root replacement with valved conduits based on retrospective studies are inappropriate because these 2 types of surgery are performed in patients with different aortic valve pathology. Late outcomes after aortic valve-sparing operations have not been consistent among various reports and raise the question of surgical expertise and patients' selection. Aortic valve-sparing operations are the best treatment for young patients with aortic root aneurysm and normal aortic cusps. Further studies are needed to define their role in the management of patients with diseased aortic cusps.

Mitral valve surgery in patients with Marfan syndrome.

OBJECTIVE: To review the pathology of the mitral valve (MV) and long-term outcomes of surgery in patients with Marfan syndrome (MFS). PATIENTS AND METHODS: From 1988 through 2020, 60 patients with MFS had surgery to correct mitral regurgitation (MR): 19 had isolated MV surgery, 32 had combined MV and aortic root surgery, and 9 had MV surgery after aortic root surgery. Follow-up was complete for a median of 16.1 years. RESULTS: MV pathology was myxomatous degeneration in all patients and of advanced degree in 78.6% with bileaflet prolapse in 65.5%, mitral annulus disjunction in 57.5%, and mitral annulus calcification in 8.2% of patients. The MV was repaired in 47 patients and replaced in 13. Kaplan-Meier estimates of cumulative mortality at 20 years 21.3% for all patients, 6.7% after MV repair, and 57.8% after replacement (P < .001). MV reoperations were performed in 5 patients: 2 after repair and 3 after replacement. The cumulative incidence rate of reoperations on the MV was 3.8% at 10 years and 11.0% at 20 years in the entire cohort. Among 47 patients who had MV repair, moderate MR developed in 11 patients and severe in 2. Both patients with severe MR underwent MV reoperation. The cumulative incidence rate of recurrent moderate or severe MR after MV repair was 20.4% at 10 years, and 36.5% at 20 years. CONCLUSIONS: MV repair was associated with better survival than MV replacement, but recurrent MR after repair occurred in approximately one-third of the patients at 20 years after surgery.

Long-term outcomes following valve-sparing root replacement with concomitant mitral repair.

OBJECTIVES: To examine the late outcomes of valve-sparing root replacement and concomitant mitral valve repair in patients who have been followed prospectively for more than 2 decades. METHODS: From 1992 to 2020, 54 consecutive patients (mean age, 47 ± 16 years; 80% men) underwent valve-sparing root replacement (45 reimplantation and 9 remodeling) with concomitant repair of the mitral valve. Patients were followed prospectively for a median of 9 years (IQR, 3-14 years). RESULTS: No patient experienced perioperative death or stroke. There were 3 late deaths and the 15-year overall survival was 96.0% (95% CI, 74.8%-99.4%), similar to the age- and sex-matched population. Over the follow-up period, 6 patients had reoperation of the aortic valve and 3 on the mitral valve. Of those, 2 had reoperation on both aortic and mitral valves for a total of 7 reoperations in this cohort. The cumulative proportion of reoperation at 10 years of either or both valves were as follows: aortic valve 11.4% (95% CI, 3.9%-33.3%), mitral valve 4.2% (95% CI, 0.6%-28.4%), and both valves 11.4% (95% CI, 3.9%-33.3%). The estimated probability of developing moderate/severe aortic insufficiency at 15 years was 18.5% (95% CI, 9.0%-34.2%). On final echocardiographic follow-up, none of the patients had developed moderate/severe mitral regurgitation. CONCLUSIONS: In this single-center series of concomitant valve-sparing root replacement and mitral valve repair, we observed excellent clinical outcomes with a low risk of death or valve-related complications. Continued surveillance of late valve function is necessary.

Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part II: Surgical Techniques.

Aortic valve disease is common, and valve-preserving operations are preferred whenever possible. Valve-sparing aortic root replacement (VSRR) has become an important tool for managing aortic root pathology in children and adults. The learning curve for this operation is challenging, but with increasing experience and technical modifications, early and late outcomes continue to improve. Durable long term results vary based on underlying anatomy, pathology, and patient selection, as well as surgeon expertise. Part II of this VSRR State-of-the-Art Review article provides technical pearls related to VSRR.

Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part I: Anatomy and Physiology.

Aortic valve disease is common, and valve-preserving operations are preferred whenever possible. Valve-sparing aortic root replacement has become an important tool for managing aortic root pathology in children and adults. The learning curve for this operation is challenging, but with increasing experience and technical modifications, early and late outcomes continue to improve. Durable long-term results vary based on the underlying anatomy, pathology, and patient selection, as well as surgeon expertise. The first installment of this Valve-Sparing Aortic Root Replacement State-of-the-Art Review article addresses patient anatomy and physiology as it relates to candidacy for VSRR.

Outcomes of Reimplantation of the Aortic Valve in Patients With Aortic Cusp Fenestration.

BACKGROUND: Aortic cusp fenestrations are common in patients with aortic root aneurysm, and their management during aortic valve repair remains controversial. We believe that fenestrations in the area of the commissures may rupture after reimplantation of the aortic valve because this operation increases the mechanical stress on the cusps. For this reason we have reinforced the free margin of the aortic cusp with fenestration with fine Gore-Tex sutures (WL Gore). This study examines the outcomes of reimplantation of the aortic valve in patients who had cusp fenestration reinforced with Gore-Tex sutures. METHODS: A review of all patients who had reimplantation of the aortic valve for aortic root aneurysm disclosed 111 patients who had at least 1 cusp fenestration reinforced with a double layer of a fine Gore-Tex suture. The outcomes of these patients were examined and compared with a group of patients without fenestration using propensity score analysis. All patients were followed prospectively with images of the heart. RESULTS: The median follow-up was 8.3 years. Overall the cumulative incidence of aortic valve reintervention at 15 years was 4.8% and the cumulative incidence of aortic insufficiency of moderate or severe degree was 9.2%. Comparison of outcomes of patients with and without fenestrations showed similar results up to 15 years of follow-up. CONCLUSIONS: Reinforcement of the free margins of cusps with fenestrations using Gore-Tex sutures is safe and does not seem to adversely affect the durability of reimplantation of the aortic valve.

Cardiovascular Events After Aortic Root Repair in Patients With Marfan Syndrome.

BACKGROUND: The usefulness of aortic valve sparing operations to treat aortic root aneurysm in patients with Marfan syndrome (MS) remains controversial. OBJECTIVES: The purpose of this study was to evaluate the occurrence of cardiovascular events in patients with MS who have undergone valve-preserving aortic root replacement. METHODS: Patients with MS who had aortic valve sparing operations (reimplantation of the aortic valve or remodeling of the aortic root) from 1988 through 2019 were followed prospectively for a median of 14 years. Pertinent data from clinical, echocardiographic, computed tomography, and magnetic resonance images of the aorta were collected and analyzed. RESULTS: There were 189 patients whose mean age was 36 years, and 67% were men. Ten patients presented with acute type A dissection and 29 had mitral regurgitation. There were 52 patients at risk at 20 years. Mortality rate at 20 years was 21.5% (95% CI: 14.7%-30.8%); advancing age and preoperative aortic dissections were associated with increased risk of death by multivariable analysis. At 20 years, the cumulative incidence of moderate or severe aortic insufficiency was 14.5% (95% CI: 9.5%-22.0%), reoperation on the aortic valve was 7.5% (95% CI: 3.9%-14.7%), and new distal aortic dissections was 19.9% (95% CI: 13.9%-28.5%). Remodeling of aortic root was associated with greater risk of developing aortic insufficiency and aortic valve reoperation than reimplantation of the aortic valve. CONCLUSIONS: Aortic valve sparing operations provide stable aortic valve function and low rates of valve-related complications during the first 2 decades of follow-up but aortic dissections remain problematic in patients with MS.

Reimplantation of the aortic valve in patients with tricuspid aortic valve: the Toronto General Hospital experience.

Background: Aortic valve sparing operations were introduced three decades ago but controversy remains regarding its appropriateness, reproducibility and durability. This article describes the long-term outcomes of patients who had reimplantation of the aortic valve. Methods: All patients who had reimplantation of a tricuspid aortic valve at Toronto General Hospital from 1989 through 2019 were selected for this study. Patients were followed prospectively with periodical clinical assessments and imaging of the heart and aorta. Results: Four hundred and four patients were identified. The median age was 48.0 [interquartile range (IQR), 35.0-59.0] years and 310 (76.7%) were men. There were 150 patients with Marfan syndrome, 20 with Loeys-Dietz syndrome and 33 with acute or chronic aortic dissections. The median follow-up was 11.7 (IQR, 6.8-17.1) years. There were 55 patients alive and without reoperation at 20 years. The cumulative mortality at 20 years was 26.7% [95% confidence interval (CI): 20.6-34.2%], the cumulative incidence of reoperation on the aortic valve was 7.0% (95% CI: 4.0-12.2%) and the development of moderate or severe aortic insufficiency was 11.8% (95% CI: 8.5-16.5%). We could not identify variables associated with reoperation on the aortic valve or with the development of aortic insufficiency. New distal aortic dissections were common in patients with associated genetic syndromes. Conclusions: Reimplantation of the aortic valve in patients with tricuspid aortic valve provides excellent aortic valve function during the first two decades of follow-up. Distal aortic dissections are relatively common in patients with associated genetic syndromes.

Improved Outcomes of Reimplantation vs Remodeling in Marfan Syndrome: A Propensity-Matched Study.

BACKGROUND: Valve-sparing root replacement (VSRR) has excellent outcomes when performed in experienced centers in well-selected patients. It is suggested that reimplantation of the aortic valve may have better durability than remodeling in patients with Marfan syndrome (MFS), although long-term comparative data are limited. METHODS: Between 1988 and 2018, 194 patients with MFS underwent VSRR at our institution. From these, we derived a propensity-matched cohort of 68 patients (44 who underwent reimplantation and 24 who had remodeling). Early outcomes included death and perioperative complications. Late outcomes were survival, probability of aortic insufficiency, and reintervention up to 20 years of follow-up. Median follow-up was 17.8 years (interquartile range, 12.0-20.6 years) for the entire matched cohort. RESULTS: Baseline variables were similar between reimplantation and remodeling patients after matching: age (39 ± 12 vs 40 ± 13 years, P = .75) and male sex (28 [64%] vs 15 [63%], P = 1.0). Similar 20-year survival was observed after reimplantation compared with remodeling (82% vs 72%, P = .20), whereas the probability of developing greater than mild aortic insufficiency at 20 years was increased after remodeling (5.8% vs 13%, P = .013). More patients underwent reoperation on the aortic valve after a remodeling procedure than after reimplantation of the aortic valve (18% vs 0%, P = .018). CONCLUSIONS: VSRR provides excellent long-term survival and freedom from valve-related complications outcomes in patients with MFS. Reimplantation of the aortic valve was associated with a lower risk of aortic valve reoperation and aortic insufficiency than the remodeling procedure after 2 decades of follow-up.

Management of Adults With Anomalous Aortic Origin of the Coronary Arteries: State-of-the-Art Review.

As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has grown in recent years. Existing guidelines provide a framework for management and treatment, but patients with AAOCA present with a wide range of anomalies and symptoms that make general recommendations of limited applicability. In particular, a large spectrum of interventions can be used for treatment, and there is no consensus on the optimal approach to be used. In this paper, a multidisciplinary group of clinical and interventional cardiologists and cardiac surgeons performed a systematic review and critical evaluation of the available evidence on the interventional treatment of AAOCA in adult patients. Using a structured Delphi process, the group agreed on expert recommendations that are intended to complement existing clinical practice guidelines.

Management of Adults With Anomalous Aortic Origin of the Coronary Arteries: State-of-the-Art Review.

As a result of increasing adoption of imaging screening, the number of adult patients with a diagnosis of anomalous aortic origin of the coronary arteries (AAOCA) has grown in recent years. Existing guidelines provide a framework for management and treatment, but patients with AAOCA present with a wide range of anomalies and symptoms that make general recommendations of limited applicability. In particular, a large spectrum of interventions can be used for treatment, and there is no consensus on the optimal approach to be used. In this paper, a multidisciplinary group of clinical and interventional cardiologists and cardiac surgeons performed a systematic review and critical evaluation of the available evidence on the interventional treatment of AAOCA in adult patients. Using a structured Delphi process, the group agreed on expert recommendations that are intended to complement existing clinical practice guidelines.

Post-infarction ventricular septal rupture.

Coronary reperfusion therapies have led to a reduction in the incidence of mechanical complications of acute myocardial infarction (AMI), but the associated mortality of these complications has remained high. Ventricular septal rupture is the most common mechanical complication after myocardial infarction and occurs in approximately 0.21% with ST-segment elevation myocardial infarction and in 0.04% with non-ST-segment elevation myocardial infarction. Surgery is the only definitive treatment but it is associated with high operative mortality and morbidity and, in some centers, alternative treatment with mechanical support of circulation and trans-catheter closure of the defect is being used. We continue to believe that immediate surgery offers the best opportunity for long-term survival. Patients should be taken directly to the operating room or via the heart catheterization laboratory if the coronary artery anatomy is unknown. This should be done as soon as the diagnosis is made, as acute rupture of the interventricular septum is a surgical emergency. The operative technique of infarct exclusion has been our preferred method and when performed in hemodynamically stable patients, the operative mortality is around 10%, although much higher in patients in cardiogenic shock. Patch dehiscence and persistent shunts are uncommon after closure of the defect using this technique. Delaying operative intervention in hemodynamically stable patients frequently leads to cardiogenic shock and multi-organ failure. Transcatheter closure of these acute septal lesions is complex, not necessarily feasible in all patients, and there is no evidence that the results are superior to surgery.

Outcomes of combined aortic and mitral valve replacement with reconstruction of the fibrous skeleton of the heart.

OBJECTIVES: The objectives of this study were to examine operative and long-term results of combined aortic and mitral valve replacement when reconstruction of the fibrous skeleton of the heart is needed because of calcification, abscess, previous operations, or patient-prosthesis mismatch. METHODS: From 1985 to 2020, 182 consecutive patients underwent combined aortic and mitral valve replacement with reconstruction of the intervalvular fibrous skeleton in all cases and also the posterior mitral annulus in 63 patients. Bovine pericardium or Dacron grafts were used for the reconstructions. Median follow-up was 7.5 (interquartile range, 2.1-12.6) years and 98% complete. RESULTS: Patient mean age was 62 years; 69% had 1 or more previous valve operations, and 92% were functional class III or IV. The indications for reconstruction were extensive calcification of the fibrous skeleton in 34%, abscess in 13%, tissue damage secondary to previous operations in 39%, and patient-prosthesis mismatch of the mitral valve in 13%. Bovine pericardium was used in two-thirds of cases and Dacron grafts in one-third. Operative mortality was 13.2% and postoperative complications were common. Survival at 1, 10, and 20 years was 81.8%, 51.1%, and 23.7%, respectively. Fourteen patients required reoperation and 3 transcatheter interventions. The cumulative probability of reinterventions at 1, 10, and 20 years were 3.3%, 5.8%, and 9.1%, respectively. Most patients experienced symptomatic improvement postoperatively. CONCLUSIONS: Reconstructions of the fibrous skeleton of the heart are associated with high operative mortality but the long-term results are satisfactory because most patients would not have survived without surgical intervention.