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Shraer N, Youssefi P, Zacek P, Debauchez M, Leprince P, Raisky O, Lansac E. Bicuspid valve repair outcomes are improved with reduction and stabilization of sinotubular junction and annulus with external annuloplasty. J Thorac Cardiovasc Surg 2024; 168:60-73.e6. [PMID: 36535821 DOI: 10.1016/j.jtcvs.2022.11.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 10/26/2022] [Accepted: 11/11/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE We investigated long-term outcomes of bicuspid aortic valve (BAV) repair, with external annuloplasty, according to aorta phenotype. METHODS Between 2003 and 2020, all patients with BAV operated on for aortic insufficiency (AI) and/or aneurysm were included. Repairs included isolated AI repair with subvalvular with or without sinotubular junction (STJ) (single or double) annuloplasty, supracoronary aorta replacement (with or without hemiroot remodeling), and root remodeling with external subvalvular ring annuloplasty. RESULTS Among 343 patients operated, reparability rate was 81.3% (n = 279; age 46 ± 13.3 years). At 10 years (median follow-up: 3.42 years; interquartile range, 1.1, 5.8), survival was 93.9% (n = 8 deaths, similar to general population), cumulative incidence of reoperation was 6.2% (n = 10), AI grade >2 was 5.8% (n = 9), and grade >1 was 23.0% (n = 30). BAV repair stabilizing both the annulus and STJ with annuloplasty, compared with nonstabilized STJ repair (single annuloplasty), had lower incidence of reoperation (2.6% vs 22.5%, P = .0018) and AI grade >2 (1.2% vs 23.6%, P < .001) at 9 years. Initial commissural angle <160° was not a risk factor for reoperation, compared with angle ≥160° if symmetrical repair was achieved (2.7% and 4.1%, respectively, at 6 years, P = .85). Multivariable model showed that absence of STJ stabilization (odds ratio, 6.7; 95% confidence interval, 2.1-20, P = .001) increased recurrent AI, but not initial commissural angle <160° (odds ratio, 1.01; 95% confidence interval, 0.39-2.63, P = .98). Commissures adjusted symmetrically led to lower transvalvular gradient, compared with nonsymmetrical repair (8.7 mm Hg vs 10.2 mm Hg, P = .029). CONCLUSIONS BAV repair, tailored to aorta phenotype, is associated with excellent durable outcomes if both annulus and STJ are reduced and stabilized with external ring annuloplasty. Commissural angle <160° is not associated with reoperation if symmetrical repair is achieved.
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Affiliation(s)
- Nathanael Shraer
- Department of Pediatric Cardiac Surgery, Necker APHP Hospital, Paris, France.
| | - Pouya Youssefi
- Department of Cardiac Surgery, Royal Brompton & Harefield Hospital, London, United Kingdom
| | - Pavel Zacek
- Department of Cardiac Surgery, Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Mathieu Debauchez
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière APHP Hospital, Paris, France
| | - Pascal Leprince
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière APHP Hospital, Paris, France
| | - Olivier Raisky
- Department of Pediatric Cardiac Surgery, Necker APHP Hospital, Paris, France
| | - Emmanuel Lansac
- Department of Cardiovascular and Thoracic Surgery, Pitié-Salpêtrière APHP Hospital, Paris, France
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2
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Rankin JS, Deja MA. Commentary: Achieving "symmetrical" annular geometry during bicuspid aortic valve repair. J Thorac Cardiovasc Surg 2024; 168:74-75. [PMID: 36610885 DOI: 10.1016/j.jtcvs.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Affiliation(s)
- J Scott Rankin
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa.
| | - Marek A Deja
- Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland
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3
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Desai ND, Kelly JJ, Iyengar A, Zhao Y, Cannon BJ, Grimm JC, Patrick WL, Ibrahim M, Freas M, Siki M, Szeto WY, Bavaria JE. Midterm Results of an Algorithmic 3-Pronged Approach to Bicuspid Aortic Valve Repair. Ann Thorac Surg 2024; 117:950-957. [PMID: 37517532 DOI: 10.1016/j.athoracsur.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/27/2023] [Accepted: 07/08/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND This study evaluated midterm outcomes of a 3-pronged algorithm for bicuspid aortic valve (BAV) repair. Valve-sparing root reimplantation (VSRR) was performed for patients with aortic root dilatation. In those without a root aneurysm, external subannular ring (ESAR) was performed for annuli ≥28 mm and subcommissural annuloplasty (SCA) for annuli <28 mm. METHODS This was a retrospective review of prospectively collected data of 242 patients undergoing primary BAV repair from April 29, 2004, to March 1, 2023, at a single institution. Primary end points were mortality, structural valve degeneration (SVD), which was defined as a composite of more than moderate aortic insufficiency or severe aortic stenosis, and reintervention. RESULTS The algorithm was used to treat 201 patients; of these, 130 underwent VSRR, 35 had ESAR, and 36 underwent SCA. Most were men with mean age of 43.8 years (SD, 12.0 years), which was similar between groups. Preoperative aortic insufficiency more than moderate was more common for ESAR compared with VSRR and SCA (74.3% vs 37.7% vs 44.4%, P < .001). At 30 days, mortality was 0.8% (n = 1) for VSRR and 0% for ESAR and SCA. At 6 years, overall Kaplan-Meier survival was 98.9% (95% CI, 97.3%-100%), with no differences between groups (P = .5). The cumulative incidence of SVD was 4.7% (95% CI, 0.1%-9.2%) for VSRR, 6.4% (95% CI, 0%-14.6%) for ESAR, and 0% for SCA (P = .4). Similarly, the cumulative incidence of reintervention with all-cause mortality as a competing risk was 2.2% (95% CI, 0.4%-6.9%), 6.1% (95% CI, 1%-17.9%), and 0% for VSRR, ESAR, and SCA, respectively (P = .506). CONCLUSIONS A 3-pronged algorithmic approach to BAV repair results in excellent survival and freedom from reoperation at 6 years.
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Affiliation(s)
- Nimesh D Desai
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania.
| | - John J Kelly
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Amit Iyengar
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yu Zhao
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brittany J Cannon
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua C Grimm
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - William L Patrick
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
| | - Michael Ibrahim
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melanie Freas
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary Siki
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Leonard Davis Institute of Health Economics, Philadelphia, Pennsylvania
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4
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Stephens EH, Dearani JA, Pochettino A, Vricella LA, Sundt TM, David TE, Bavaria JE, Cameron DE. Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part I: Anatomy and Physiology. Ann Thorac Surg 2024:S0003-4975(24)00115-2. [PMID: 38360340 DOI: 10.1016/j.athoracsur.2023.12.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/03/2023] [Accepted: 12/09/2023] [Indexed: 02/17/2024]
Abstract
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.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | | | - Luca A Vricella
- Division of Pediatric Cardiovascular Surgery, Department of Surgery, Advocate Children's Heart Institute, Chicago, Illinois
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Tirone E David
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Duke E Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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5
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Stephens EH, Dearani JA, Pochettino A, Vricella LA, Sundt TM, David TE, Bavaria JE, Cameron DE. Valve-Sparing Aortic Root Replacement State-of-the-Art Review, Part II: Surgical Techniques. Ann Thorac Surg 2024:S0003-4975(24)00116-4. [PMID: 38360342 DOI: 10.1016/j.athoracsur.2023.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 12/03/2023] [Accepted: 12/19/2023] [Indexed: 02/17/2024]
Abstract
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.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
| | | | - Luca A Vricella
- Division of Pediatric Cardiovascular Surgery, Department of Surgery, Advocate Children's Heart Institute, Chicago, Illinois
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Tirone E David
- Division of Cardiovascular Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Duke E Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Ma K, Carlestål E, Franco-Cereceda A, Olsson C. Reoperation or Aortic Regurgitation Progression after Reimplantation of the Aortic Valve (David's Procedure) Using the Valsalva Graft. AORTA (STAMFORD, CONN.) 2023; 11:97-106. [PMID: 37619566 PMCID: PMC10449566 DOI: 10.1055/s-0043-1768968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 04/07/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND This study aimed to assess predictors of a composite endpoint (reoperation for aortic valve [AV] failure or aortic regurgitation [AR] grade ≥ 2) after reimplantation of the aortic valve (RAV) using the Valsalva graft. METHODS From 2012 to 2021, 112 patients underwent RAV in a single center. Clinical and echocardiographic data were collected retrospectively. Cox regression analysis was used to identify predictors of the composite endpoint. Kaplan-Meier methods were used for time-to-event analysis. RESULTS Median (interquartile range) age was 52 years (44, 62). Nineteen patients (17%) were operated for acute Type A aortic dissection, and the remainder for aortic root aneurysm, 60 mm or larger in 12/112 (11%). Thirty-day mortality was 1/112 (1%). During follow-up, four patients (3.6%) were reoperated for AV failure, and another nine patients (8.1%) developed AR grade ≥ 2. Overall estimated freedom from reoperation or AR grade ≥ 2 was 87% (95% confidence interval: 76-93%) at 5 years. Significantly lower estimated 5-year freedom from the composite endpoint was found in cases with simultaneous aortic valve repair (AVr; 77 vs. 90%, p = 0.007) and nearly significant for large (≥ 6 cm) aortic root diameter (82 vs. 87%, p = 0.055). In Cox's analysis, aortic root diameter and simultaneous AVr were independent predictors for the composite endpoint. CONCLUSION Outcomes (survival, reoperation, freedom from AR grade ≥ 2) with RAV were good up to 11-year follow-up. Larger aortic root diameter and simultaneous AVr were identified as predictors for reoperation or AR grade ≥ 2. Long-term follow-up remains necessary to confirm adequate AV function.
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Affiliation(s)
- Kristina Ma
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
| | - Emelie Carlestål
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Anders Franco-Cereceda
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Christian Olsson
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
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7
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Hui DS. Commentary: The not-so-basic bicuspid. JTCVS Tech 2021; 9:48. [PMID: 34647058 PMCID: PMC8501253 DOI: 10.1016/j.xjtc.2021.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 07/31/2021] [Accepted: 08/03/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Dawn S. Hui
- Department of Cardiothoracic Surgery, Joe R. and Teresa Lozano Long School of Medicine, UT Health San Antonio, San Antonio, Tex
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8
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Romagnoni C, Contino M, Jaworek M, Rosa R, Salurso E, Perico F, Gelpi G, Vismara R, Fiore GB, Mangini A, Antona C. Commissural repositioning in bicuspid aortic valve repair: an in vitro acute model to explore and explain different results. Eur J Cardiothorac Surg 2021; 61:647-654. [PMID: 34363669 DOI: 10.1093/ejcts/ezab359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 06/10/2021] [Accepted: 06/17/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Commissural orientation <160° is a recognized risk factor for bicuspid aortic valve repair failure. Based on this observation, repairing this subtype of aortic valve by reorienting the 2 commissures at 180° has recently been proposed. METHODS Nine porcine hearts with aortic annulus diameters of 25 mm were selected. A pathological model of a Sievers 1 bicuspid aortic valve was obtained by suturing the coaptation line between the left and right leaflets. Each heart underwent reimplantation procedures both in the native (120°) and the reoriented (180°) configuration. After the operation, each sample was tested on a pulse duplicator at rest (heart rate 60 beats per min) and with mild exercise (heart rate 90 beats per min) conditions. RESULTS No statistically significant difference was noted in mean and peak transvalvular aortic gradients between the 2 configurations at rest (18.6 ± 5 vs 17.5 ± 4 for the mean aortic gradient; 42.8 ± 12.7 vs 36.3 ± 5.8 for the peak aortic gradient) but the group with the 120°-oriented commissures had significantly higher mean transaortic gradients compared to the group with the 180°-oriented commissures at initial exercise stress conditions (30.1 ± 9.1 vs 24.9 ± 3.8; p value 0.002). CONCLUSIONS The 180° commissural reorientation of the asymmetrical bicuspid aortic valve does not improve the transvalvular aortic gradient in an acute model at rest conditions, but it could do so under stress situations. Even if it is surgically more complex and time-consuming, this approach could be a good strategy to improve long-term results, particularly in young patients.
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Affiliation(s)
- Claudia Romagnoni
- Cardiovascular Surgery Department, ASST Fatebenefratelli Sacco, Milano, Italy.,ForcardioLab-Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milano, Italy
| | - Monica Contino
- Cardiovascular Surgery Department, ASST Fatebenefratelli Sacco, Milano, Italy.,ForcardioLab-Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milano, Italy
| | - Michal Jaworek
- ForcardioLab-Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milano, Italy.,Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Rubina Rosa
- Cardiovascular Surgery Department, ASST Fatebenefratelli Sacco, Milano, Italy.,ForcardioLab-Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milano, Italy
| | - Eleonora Salurso
- ForcardioLab-Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milano, Italy.,Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Francesca Perico
- ForcardioLab-Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milano, Italy.,Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Guido Gelpi
- Cardiovascular Surgery Department, ASST Fatebenefratelli Sacco, Milano, Italy.,ForcardioLab-Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milano, Italy.,Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Riccardo Vismara
- ForcardioLab-Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milano, Italy.,Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Gianfranco Beniamino Fiore
- ForcardioLab-Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milano, Italy.,Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milano, Italy
| | - Andrea Mangini
- Cardiovascular Surgery Department, ASST Fatebenefratelli Sacco, Milano, Italy.,ForcardioLab-Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milano, Italy
| | - Carlo Antona
- Cardiovascular Surgery Department, ASST Fatebenefratelli Sacco, Milano, Italy.,ForcardioLab-Fondazione per la Ricerca in Cardiochirurgia ONLUS, Milano, Italy.,Università degli Studi di Milano, Milano, Italy
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9
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A progress report on reimplantation of the aortic valve. J Thorac Cardiovasc Surg 2021; 161:890-899.e1. [DOI: 10.1016/j.jtcvs.2020.07.121] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/07/2020] [Accepted: 07/30/2020] [Indexed: 02/07/2023]
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10
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Zhu Y, Woo YJ. Cusp repair techniques in bicuspid and tricuspid aortic valves. JTCVS Tech 2021; 7:109-116. [PMID: 34318219 PMCID: PMC8311607 DOI: 10.1016/j.xjtc.2021.01.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 12/21/2022] Open
Affiliation(s)
- Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif.,Department of Bioengineering, Stanford University, Stanford, Calif
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif.,Department of Bioengineering, Stanford University, Stanford, Calif
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11
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Surgical Treatment of Bicuspid Aortic Valve With Dilated Aortic Root. Ann Thorac Surg 2020; 112:746. [PMID: 33279554 DOI: 10.1016/j.athoracsur.2020.09.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/09/2020] [Indexed: 11/21/2022]
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12
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David TE. Commentary: Are the results of reimplantation of the aortic valve the same for bicuspid and tricuspid valves? J Thorac Cardiovasc Surg 2020; 163:64-65. [DOI: 10.1016/j.jtcvs.2020.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/03/2020] [Indexed: 12/29/2022]
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13
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Mehaffey JH, Hawkins RB. Commentary: Bicuspid aortic valve geometry-A tale of two valves. J Thorac Cardiovasc Surg 2019; 160:59-60. [PMID: 31420148 DOI: 10.1016/j.jtcvs.2019.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/04/2019] [Indexed: 11/19/2022]
Affiliation(s)
- J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va.
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Va
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14
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De Paulis R. Commentary: Should we attempt to refine an already imperfect nature? J Thorac Cardiovasc Surg 2019; 160:58-59. [PMID: 31399232 DOI: 10.1016/j.jtcvs.2019.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 07/01/2019] [Indexed: 11/25/2022]
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