COVID 19- Perspective of an Italian Center.

Italy has been hard hit by severe acute respiratory syndrome coronavirus 2 infection with more than 240,000 cases and 35,000 deaths. During the acute phase of the pandemic, the Italian government decided on the lockdown which lasted about 2 months. During this period, all surgical activities were limited to nondeferable procedures only. The sudden closure posed problems with the management of the heart surgery waiting which at that time included 135 patients. Among these were selected cases with the worst clinical characteristics that were progressively operated on. Compared with a similar period in 2019, the cardiac surgery activity of the "Lancisi Cardiovascular Center" in Ancona has been reduced by 65%. With pandemic mitigation, heart surgery activity has gradually resumed but many open questions remain. Above all, there is the problem of living with a low but persistent level of presence of the virus with the need to organize the activity to ensure patients and staff safety and an optimal level of performance.

Risk Factors and Impact on Clinical Outcome of Multidrug-Resistant Acinetobacter Baumannii Acquisition in Cardiac Surgery Patients.

OBJECTIVES: Acinetobacter baumannii recently has emerged as an important nosocomial pathogen. The aim of this study was to assess the impact on mortality of multidrug-resistant A. baumannii (MDR-AB) infection/colonization in patients undergoing cardiac surgery and to investigate microbiologic characteristics, epidemiologic spread of this pathogen, and the relative containment measures. DESIGN: Single-center, retrospective cohort study of prospectively collected data. SETTING: Cardiac surgery tertiary-care center. PARTICIPANTS: Patients with positive MDR-AB cultures from September 1, 2009 to December 31, 2011. INTERVENTIONS: Bivariate and multivariate analyses were performed to individualize the risk factors for MDR-AB-infections in cardiac surgery patients. To evaluate the MDR-AB attributable mortality, a retrospective matched cohort study was performed. Incidence density ratio (IDR) was calculated to compare the MDR-AB infection/colonization before and after the introduction of preventive measures adopted following the first cases. MEASUREMENTS AND MAIN RESULTS: MDR-AB acquisition occurred in 14 patients (0,6%) of 2385 patients. At the multivariate analyses, preoperative use of inotropic drugs (OR 18.2, 95% CI 4.6-71.9) and logistic EuroSCORE (OR 1.09, 95% CI 1.06-1.13) were found as independent risk factors. Patients with MDR-AB had 57% cumulative in-hospital mortality; no statistical differences in mortality were observed in the matched group. IDR revealed a significantly decreased incidence of infection/colonization (0.3 per 1,000 days of stay compared with 0.03/1,000 days of stay, p = 0.0001) after the containment measures became effective. CONCLUSIONS: Sicker patients are more susceptible to be infected by A. baumannii, but mortality is not significantly higher compared with other patients with similar characteristics. Adequate measures are fundamental to control the spread of the infection.

Surgical repair and replacement for native mitral valve infective endocarditis.

AIMS: The clinical benefits of mitral valve repair over replacement in the setting of mitral infective endocarditis are not clearly established. METHODS: Data of patients who underwent cardiac surgery for infective endocarditis over a 20-year period (2001-2021) at two cardiac centres were reviewed. Among them, 282 patients underwent native mitral valve surgery and were included in the study. Nearest-neighbour propensity-score matching was performed to account for differences in patients' profile between the repair and replacement subgroups. RESULTS: Mitral valve replacement was performed in 186 patients, while in 96 cases patients underwent mitral valve repair. Propensity match analysis provided 89 well matched pairs. Mean age was 60 ±â€Š15 years; 75% of the patients were male. Mitral valve replacement was more commonly performed in patients with involvement of both mitral leaflets, commissure(s) and mitral annulus. Patients with lesion(s) limited to P2 segment formed the majority of the cases undergoing mitral valve repair. There was no difference in terms of microbiological findings. In-hospital mortality was 7% with no difference between the repair and the replacement cohorts. Survival probabilities at 1, 5 and 10 years were 88%, 72% and 68%, respectively after mitral repair, and 88%, 78% and 63%, respectively after mitral replacement (log-rank P  = 0.94). CONCLUSIONS: Mitral valve repair was more commonly performed in patients with isolated single leaflet involvement and provided good early and 10-year outcomes. Patients with annular disruption, lesion(s) on both leaflets and commissure(s) were successfully served on early and mid-term course by mitral valve replacement.

Enhanced recovery after minimally invasive heart valve surgery: Early and midterm outcomes.

BACKGROUND: Although the use of protocols for "enhanced recovery after surgery" (ERAS) have been associated with improved results in different surgical specialties, only a few data are available for ERAS in cardiac surgery. This study aimed to compare 30-day outcomes of patients undergoing ultra-fast-track minimally invasive valve surgery (UFT-MIVS) versus conventional MIVS (c-MIVS). METHODS: The key features of UFT-MIVS approach involves: 1) less invasive valve surgery techniques, 2) normothermic cardiopulmonary bypass management, 3) UFT-anesthesia with table extubation, 4) immediate rehabilitation therapy and patient-family contact. Five-hundred and seventy-six consecutive patients who underwent aortic or mitral MIVS were analyzed (2016-2020). Treatment selection bias (UFT-MIVS vs. c-MIVS) was addressed by the use of propensity score (PS) matching. After PS-matching 2 well-balanced groups of 152 patients each were created. RESULTS: In the matched cohort, the overall 30-day mortality and stroke rates were 0.3% and 0.7%, respectively, with no difference between groups. UFT-MIVS resulted in lower rates of respiratory insufficiency and agitation/delirium compared with c-MIVS. Patients receiving UFT-MIVS were associated with significantly shorter intensive care unit length of stay and hospital stay. CONCLUSIONS: Our study confirms that MIVS is associated with excellent results in terms of early mortality and major postoperative complications rates. The implementation of UFT-MIVS protocol showed to be safe and was associated with improved clinical outcomes in regard to respiratory insufficiency, delirium and lengths of stay.

Results and insights after 413 TAVI procedures performed by cardiac surgeons on their own.

OBJECTIVES: Current evidence on transcatheter aortic valve implantation (TAVI) has been generated exclusively by cardiology studies and no operative data from cardiac surgeons are available. Here, we describe the development of our TAVI programme and report the results of transfemoral (TF) TAVI done by cardiac surgeons on their own. METHODS: This study included all the TAVI procedures on native valve performed at Cardiac Surgery Unit, Ospedali Riuniti di Ancona, during the period October 2018 to July 2022. Relevant prospectively collected preoperative, intraprocedural and postoperative data were retrieved from the Institutional database. RESULTS: A total of 413 patients were included in the study. Mean patients' age was 82 years and among them 44% (180/413) were male. STS score was 3.1% (2.2-4.4). Eighty patients underwent transapical TAVI and 333 patients had a TF approach. We progressively moved from transapical TAVI towards TF procedures that are now routinely performed on conscious sedation and using a fully percutaneous approach. After TF TAVI, 30-day mortality rate was 1%, cerebral stroke occurred in 2% of the cases, permanent pacemaker implantation was necessary in 23% of the patients and in 6% of the cases there was a moderate/severe degree of aortic regurgitation. There was no association between operators performing TAVI and 30-day mortality. CONCLUSIONS: The acquisition of catheter-based skills and an adequate training allowed cardiac surgeons to perform on their own awake and fully percutaneous TF TAVI with similar results when compared with major randomized clinical trials and registries' experiences.

Minimally invasive approach: is this the future of aortic surgery?

Median sternotomy incision has shown to be a safe and efficacious approach in patients who require thoracic aortic interventions and still represents the gold-standard access. Nevertheless, over the last decade, less invasive techniques have gained wider clinical application in cardiac surgery becoming the first-choice approach to treat heart valve diseases, in experienced centers. The popularization of less invasive techniques coupled with an increased patient demand for less invasive therapies has motivated aortic surgeons to apply minimally invasive approaches to more challenging procedures, such as aortic root replacement and arch repair. However, technical demands and the paucity of available clinical data have still limited the widespread adoption of minimally invasive thoracic aortic interventions. This review aimed to assess and comment on the surgical techniques and the current evidence on mini thoracic aortic surgery. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-021-01258-2.

Catheter-based cerebral protection system in open cardiac surgery: An example of true hybrid surgery.

Postoperative stroke after cardiac surgery is an ominous complication. Clinical manifestations range from cognitive disturbances and altered states of consciousness to focal neurological deficits. Stroke is also a well-documented risk of catheter-based cardiac interventions. Recently, the growth of transcatheter procedures has led to the increasing development of devices that are designed to minimize neurological events during valve implantation.  In this video tutorial we demonstrate how to transfer a catheter-based cerebral protection technology into an open cardiac surgical intervention. The operation shown in this tutorial was an aortic valve replacement and the cerebral protection device implanted was the  Sentinel Cerebral Protection System (Boston Scientific, Marlborough, MA, USA).

[One-year outcomes of surgical aortic valve replacement: a single, high-volume center experience]. / Risultati ad un anno dopo chirurgia sostitutiva della valvola aortica: esperienza di un centro ad alto volume.

BACKGROUND: The introduction of transcatheter aortic valve replacement (AVR) mandates attention to outcomes after surgical AVR (SAVR). The aim of this study was to assess 1-year outcomes in a contemporary large cohort of patients undergoing AVR. METHODS: Data from 520 patients who underwent isolated SAVR between October 2016 and April 2019 were prospectively collected. RESULTS: The mean age of the study population was 72.8 ± 10.1 years and the average EuroSCORE II was 1.8 ± 1.5%. SAVR was performed using minimally invasive approaches (MI-AVR) in 306 patients (58.9%). However, the rate of MI-AVR considerably increased over the observational period from 47.9% to 86.7% (p<0.001). MI-AVR patients received rapid deployment valves in 40% of cases, minimally invasive extracorporeal circulation system in 34.4% and ultra fast track anesthetic management with table extubation in 38.2%. Overall 30-day mortality was 0.4% (n=2). The rates of postoperative stroke and atrioventricular block requiring pacemaker implantation were 0.6% (n=3) and 3.8% (n=20), respectively. At 1 year, the estimated survival, stroke and rehospitalization rates were 97.3%, 1% and 4.5%, respectively. Overall, the estimated incidence of the composite endpoint - death, stroke and rehospitalization - was 7%. CONCLUSIONS: Contemporary SAVR in a high-volume center yields excellent clinical outcomes with very low mortality and morbidity. In this setting, the extensive use of minimally invasive approaches combined with the modern techniques and technologies demonstrated to improve clinical outcomes and increase patient and family satisfaction.

Conduction disorders after aortic valve replacement: what is the real impact of sutureless and rapid deployment valves?

BACKGROUND: Although sutureless and rapid deployment aortic valve replacement (SURD-AVR) has been associated with an increased rate of permanent pacemaker (PPM) implantation compared to conventional AVR (c-AVR), the predictors of new conduction abnormalities remain to be clarified. This study aimed to identify risk factors for conduction disorders in patients undergoing AVR surgery. METHODS: Data from 243 patients receiving minimally invasive AVR were prospectively collected. SURD-AVR was performed in 103 (42.4%) patients and c-AVR in 140 (57.6%). The primary endpoint was the occurrence of new-onset conduction disorders, defined as first degree atrioventricular (AV) block, advanced AV block requiring PPM implantation, left anterior fascicular block (LAFB), left bundle branch block (LBBB) and right bundle branch block (RBBB). RESULTS: The unadjusted comparison revealed that SURD-AVR was associated with a higher rate of advanced AV block requiring PPM when compared with c-AVR (10.5% vs. 2.1%, P=0.01). After adjusting for other measured covariates (OR: 1.6, P=0.58) and for the estimated propensity of SURD-AVR (OR: 5.1, P=0.1), no significant relationship between type of AVR and PPM implantation emerged. On multivariable analysis, preoperative first-degree AV block (OR: 6.9, P=0.04) and RBBB (OR: 6.9, P=0.03) were independent risk factors for PPM. Subgroup analysis of patients with normal preoperative conduction revealed similar incidence of PPM between SURD-AVR and c-AVR (1.3% vs. 1.9%, P=0.6). When compared with c-AVR, SURD-AVR was associated with a greater incidence of postoperative new onset LBBB (18.1% vs. 3.2%, P<0.001). This finding was confirmed after adjusting for the estimated propensity of SURD-AVR (OR: 6.3, P=0.009). CONCLUSIONS: Our study revealed that the risk of PPM implantation in patients receiving surgical AVR is heavily influenced by the presence of pre-existing conduction disturbances rather than the type of valve prosthesis. Conversely, SURD-AVR emerged as an independent predictor for LBBB and was associated with an increased risk of PPM in patients presenting with RBBB.

Surgery for Bentall endocarditis: short- and midterm outcomes from a multicentre registry.

OBJECTIVES: Endocarditis after the Bentall procedure is a severe disease often complicated by a pseudoaneurysm or mediastinitis. Reoperation is challenging but conservative therapy is not effective. The aim of this study was to assess short- and midterm outcomes of patients reoperated on for Bentall-related endocarditis. METHODS: Seventy-three patients with Bentall procedure-related endocarditis were recorded in the Italian registry. The mean age was 57 ± 14 years and 92% were men; preoperative comorbidities included hypertension (45%), diabetes (12%) and renal failure (11%). The logistic EuroSCORE was 25%; the EuroSCORE II was 8%. RESULTS: Preoperatively, 12% of the patients were in septic shock; left ventricular-aortic discontinuity was present in 63% and mitral valve involvement occurred in 12%. The most common pathogens were Staphylococcus aureus (22%) and Streptococci (14%). Reoperations after a median interval of 30 months (1-221 months) included a repeat Bentall with a bioconduit (41%), a composite mechanical (33%) or biological valved conduit (19%) and a homograft (6%). In 1 patient, a heart transplant was required (1%); in 12%, a mitral valve procedure was needed. The hospital mortality rate was 15%. The postoperative course was complicated by renal failure (19%), major bleeding (14%), pulmonary failure (14%), sepsis (11%) and multiorgan failure (8%). At multivariate analysis, urgent surgery was a risk factor for early death [hazard ratio 20.5 (1.9-219)]. Survival at 5 and 8 years was 75 ± 6% and 71 ± 7%, with 3 cases of endocarditis relapse. CONCLUSIONS: Surgery is effective in treating endocarditis following the Bentall procedure although it is associated with high perioperative mortality and morbidity rates. Endocarditis relapse seems to be uncommon.

Endoscopic vein-graft harvesting in coronary artery bypass surgery: Tips and tricks.

Despite increased use of arterial grafts, the greater saphenous vein remains the most commonly used conduit in coronary artery bypass grafting. The use of less invasive techniques for vessel harvesting has gained interest in recent years, and, many studies have reported that endoscopic vein-graft harvesting reduces postoperative pain, the incidence of wound complications, and the length of hospital stay, as well as eliminating the need for a large longitudinal incision. Over the past decade, our cardiac surgery department has gained considerable experience (>1000 cases) with this endoscopic approach.  In this video tutorial, we demonstrate our endoscopic techniques for saphenous vein-graft harvesting using two widely used devices: the VirtuoSaph Endoscopic Vein Harvesting System from Terumo (Tokyo, Japan), an open tunnel system, and the VasoView System from Maquet Cardiovascular (Rastatt, Germany), a closed tunnel system.

[Surgical treatment of aortic valve disease: early results of a 360° minimally invasive approach]. / Trattamento chirurgico della valvulopatia aortica: esperienza iniziale di un approccio mini-invasivo a 360°.

BACKGROUND: Over the years, with the introduction of minimally invasive techniques and technologies aimed at reducing surgical trauma, aortic valve surgery has considerably developed and improved. Our approach includes: reduced incisions (upper "J" ministernomy or anterior right minithoracotomy), "ultra fast-track" anesthesia protocols, sutureless and rapid deployment valve prostheses and miniaturized circuits of extracorporeal circulation. The aim of this study was to evaluate the clinical outcomes associated with this multidisciplinary approach. METHODS: Between October 2016 and November 2018, 429 patients underwent isolated aortic valve replacement at the Cardiac Surgery Unit of the "Ospedali Riuniti" of Ancona, Italy. Overall, 91 patients (21.2%) were operated according to our minimally invasive approach. A severe aortic valve stenosis was the indication for surgery in 90.1% of patients, aortic valve insufficiency in the remaining 18.7%. RESULTS: There were neither in-hospital deaths nor major or minor neurological events. Atrial fibrillation was the main postoperative complications (n=26, 28.6%). Four patients (4.4%) underwent permanent pacemaker implantation due to third-degree atrioventricular block, and a surgical bleeding revision was performed in 3.3%. No episodes of respiratory failure were reported. The median length of hospital stay was 6 days (5-8 days). CONCLUSIONS: Our initial experience with a 360° minimally invasive approach for the treatment of patients undergoing aortic valve replacement shows encouraging clinical outcomes; this approach may lead to an improved perception of surgery both by patients and their families. However, further clinical studies are needed to evaluate the long-term results.

Mini Bentall operation: technical considerations.

Bentall operation via median sternotomy has been largely shown to be safe and long-term efficacious and currently represents the "gold standard" intervention in patients presenting with aortic valve and root disease. However, over the last years, minimally invasive techniques have gained wider clinical application in cardiac surgery. In particular, minimally invasive aortic valve replacement through ministernotomy has shown excellent outcomes and becomes the first choice approach in numerous experienced centers. Based on these favorable results, ministernotomy approach has also been proposed for complex cardiac procedures such as aortic root replacement and arch surgery. Herein, we present our technique for minimally invasive Bentall operation using a ministernotomy approach.

Ultra fast track surgery: a rapid deployment aortic valve replacement through a J-ministernotomy.

Aortic valve surgery has been undergone continuous development over the last years, involving less invasive techniques and the use of new technologies to reduce the traumatic impact of the intervention and extend the operability toward increasingly high-risk patients. Minimally invasive aortic valve replacement (AVR) has gradually been recognized as a less traumatic technique compared to median sternotomy, becoming first choice approach in numerous experienced centers. Herein we present our multidisciplinary minimally invasive approach for AVR, involving: (I) reduced chest incision; (II) rapid deployment AVR; (III) minimally invasive extracorporeal circulation system; and (IV) ultra fast track (UFT) anaesthetic management.

Prosthetic valve endocarditis: predictors of early outcome of surgical therapy. A multicentric study.

OBJECTIVES: Prosthetic valve endocarditis (PVE) is an uncommon yet dreadful complication in patients with prosthetic valves that requires a distinct analysis from native valve endocarditis. The present study aims to investigate independent risk factors for early surgical outcomes in patients with PVE. METHODS: A retrospective cohort study was conducted in 8 Italian Cardiac Surgery Units from January 2000 to December 2013 by enrolling all PVE patients undergoing surgical treatment. RESULTS: A total of 209 consecutive patients were included in the study. During the study period, the global rate of surgical procedures for PVE among all operations for isolated or associated valvular disease was 0.45%. Despite its rarity this percentage increased significantly during the second time frame (2007-2013) in comparison with the previous one (2000-2006): 0.58% vs 0.31% (P < 0.001). Intraoperative and in-hospital mortality rates were 4.3% and 21.5%, respectively. Logistic regression analysis identified the following factors associated with in-hospital mortality: female gender [odds ratio (OR) = 4.62; P < 0.001], shock status (OR = 3.29; P = 0.02), previous surgical procedures within 3 months from the treatment (OR = 3.57; P = 0.009), multivalvular involvement (OR = 8.04; P = 0.003), abscess (OR = 2.48; P = 0.03) and urgent surgery (OR = 6.63; P < 0.001). CONCLUSIONS: Despite its rarity, PVE showed a significant increase over time. Up to now, in-hospital mortality after surgical treatment still remains high (>20%). Critical clinical presentation and extension of anatomical lesions are strong preoperative predictors for poor early outcome.

Prevention of atrial fibrillation and inflammatory response after on-pump coronary artery bypass using different statin dosages: a randomized, controlled trial.

BACKGROUND: This randomized controlled trial aimed to evaluate the effects of seven-day preoperative treatment with two different dosages of atorvastatin on the incidence of postoperative atrial fibrillation (POAF) and release of inflammatory markers such as high-sensitive C-reactive protein (hsCRP) and interleukin-6 in patients undergoing elective first-time on-pump coronary artery bypass grafting (CABG). METHODS: The cohort study comprised 212 consecutive patients, already taking statins, who underwent elective first-time CABG with cardiopulmonary bypass without history of atrial fibrillation (AF). Patients were randomly divided into two groups: those who received atorvastatin 40 mg (TOR40 group, 111 patients) and those who received 80 mg (TOR80 group, 101 patients) once a day for 7 days before the planned operation. The primary endpoint was the incidence of AF. The secondary endpoints were the postoperative variations of inflammatory markers, hospital length of stay, and the incidence of major adverse cardiac and clinical events. RESULTS: A total of 26 patients (23.6 %) pretreated with atorvastatin 40 mg and 16 (15.8 %) patients pretreated with atorvastatin 80 mg had postoperative AF but the difference did not reach the statistical significance (p = 0.157). Median values of interleukin-6 and hsCRP at 12 and 24 h did not have differences between the two groups. No statistically significant differences in the other secondary endpoints were detected. CONCLUSIONS: According to our result, 7-day preoperative treatment with a high dose of atorvastatin is associated with a trend to a decrease in the incidence of POAF compared with treatment at a lower dose, although it does not impact on the level of inflammatory markers. CLINICAL TRIAL REGISTRATION: European Clinical Trials Database (EudraCT: 2006-005757-30).

'Early' and 'late' timing for renal replacement therapy in acute kidney injury after cardiac surgery: a prospective, interventional, controlled, single-centre trial.

OBJECTIVES: Acute kidney injury after cardiac surgery (CS-AKI) is strongly associated with in-hospital mortality and morbidity. We aimed to investigate whether 'early' or 'late' initiation of renal replacement therapy (RRT) in patients with CS-AKI is associated with a survival benefit or more favourable outcomes. METHODS: All patients who had undergone cardiac surgery at 'Ospedali Riuniti' of Ancona from July 2011 to February 2013 were prospectively enrolled and divided into two treatment groups: the 'early' approach was used during the first 10 months, and the 'late' approach during the next 10 months. 'Early' RRT was started after 6 h of urine output less than 0.5 ml/kg/h, whereas in the 'late' group, therapy started on the basis of persistent (>12 h) oliguria. A total of 1658 patients were enrolled in the trial. The primary outcome was operative mortality, and the secondary outcomes were length of intensive care unit and hospital stay. RESULTS: The total number of patients treated with RRT was 59 (3.6%): 46 (5.5%) in the 'early' group and 13 (1.6%) in the 'late' group (P < 0.0001). Although RRT was significantly less utilized in the 'late' group, no significant difference in the primary and secondary outcomes was found, but a trend towards a better outcome in the 'late' group was observed. Furthermore, we found a significant difference in mortality between the two approaches in the subgroups of patients with preoperative renal dysfunction and in patients suffering from CS-AKI with a clear advantage of the late strategy. CONCLUSIONS: Our results do not support the use of early RRT in CS-AKI. CLINICAL TRIAL REGISTRATION: This trial is registered in the clinicaltrial.gov registry: NCT01961999.

Cannulation of the brachiocephalic trunk during surgery of the thoracic aorta: a simplified technique for antegrade cerebral perfusion.

Here we present our simplified technique of cannulation of the brachiocephalic trunk for cardiopulmonary bypass and antegrade cerebral perfusion institution.

Aortic valve-sparing surgery for aortic root aneurysm.

BACKGROUND: Replacement of the aortic valve and ascending aorta with a composite graft is the most common surgical treatment for aortic root aneurysms with or without aortic regurgitation (AR). In the early 90's reconstructive procedures of the aortic root have been described with encouraging results. This paper presents our experience with this technique. METHODS: Between January 2001 and May 2003, 28 patients (25 males, 3 females, mean age 60 years) with aortic root aneurysm were treated with reimplantation of the aortic valve. Twenty-two patients had AR > 2+, 5 had Marfan syndrome, 5 had an aortic arch aneurysm, 4 had type A aortic dissection, 2 patients had associated coronary artery disease, and one had mitral valve insufficiency. The only contraindication was primitive disease of the aortic leaflets. RESULTS: There was one perioperative death (type A aortic dissection) and 1 patient was discharged with mild to moderate AR requiring aortic valve replacement. The cardiopulmonary bypass and aortic cross-clamping times were 230 and 184 min respectively. No neurological events were recorded. During follow-up (mean 16.7 months, range 3-32 months) 1 patient died and one had mild AR. Freedom from reoperation and from AR at 24 months was 94 and 89% respectively. At multivariate analyses we did not find any correlation between Marfan syndrome, type A aortic dissection, grade of preoperative AR, and recurrence of AR. CONCLUSIONS: In our experience, valve-sparing surgery was feasible with a low mortality and morbidity and with good early results. It should be applied to all patients requiring aortic root surgery for aortic root aneurysm, a diseased aortic valve being the only contraindication.