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Original Article
Root remodeling does lead to stable long-term aortic valve function
La remodelación de la raíz no supone estabilidad funcional de la válvula aórtica a largo plazo
Christian Giebels, Karen B. Abeln, Tristan Ehrlich, Hans-Joachim Schäfers
Corresponding author
h-j.schaefers@uks.eu

Corresponding author.
Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Root remodeling was designed to be an alternative to combined valve and root replacement in treating aortic regurgitation &#40;AR&#41; in the presence of root aneurysm&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">1</span></a> The original hypothesis was that AR was due to aortic dilatation&#44; and normalizing root dimensions should lead to normal aortic valve function&#46; While early results were good&#44;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">2</span></a> late results of the original series showed a relevant proportion of patients requiring reoperation for recurrent AR&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">2</span></a> This was assumed to be related to the lack of annular stabilization&#44;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3&#44;4</span></a> questioning the value of the technique&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">After we started to explore the concept of root remodeling as valve-preserving surgery &#40;VPS&#41; 28 years ago&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">5</span></a> we encountered apparent cusp prolapse in the presence of root aneurysm&#59; intuitively we added cusp repair to the root procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">6</span></a> This approach did not compromise valve function&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">7</span></a> it rather became obvious that concomitant cusp repair improved the functional results&#46; In an in-vitro study&#44; we found more physiologic cusp motion with root remodeling compared to valve reimplantation&#44;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">8</span></a> which encouraged us to continue with the concept&#46; We subsequently modified the procedure to accommodate the characteristics of the bicuspid valve &#40;BAV<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">9</span></a>&#41;&#44; and later also the unicuspid aortic valve &#40;UAV<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">10</span></a>&#41;&#46; We found equivalent mid-term valve function with root remodeling and valve reimplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Initial valve assessment relied on visual inspection&#46; The analysis of failed valves stimulated us to analyze aortic valve configuration in more detail&#46; We developed the concept of effective height &#40;eH&#41; as a cusp configuration parameter&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">12&#44;13</span></a> In order to define the amount of cusp tissue&#44; we introduced the measurement of geometric height &#40;gH&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">14</span></a> The measurement of eH facilitated the creation of predictable valve configuration&#44; also in the experience of others&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">15&#44;16</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Lansac propagated the addition of an annuloplasty to improve annular stabilization&#44; which had been considered the Achilles heel of root remodeling&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">17</span></a> The improved results&#44; however&#44; were most likely due to the intraoperative measurement of eH&#44; which was introduced together with the annuloplasty&#46; Stimulated by the efficacy of a suture annuloplasty in isolated BAV repair&#44; we also added an annuloplasty to root remodeling to determine whether it would indeed further improve valve function and stability&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">18</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Over the past 28 years&#44; we have employed root remodeling as a standardized procedure based on geometric principles&#46; The objective of the current analysis was to review the long-term results of root remodeling with a special focus on the effect of an annuloplasty and the influence of the underlying valve morphology&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Patients</span><p id="par0030" class="elsevierStylePara elsevierViewall">We conducted a retrospective analysis of 1285 patients who underwent root remodeling at Saarland University Medical Center between October 1995 and June 2023&#46; The investigation was approved by the Saarland Regional Ethics Committee &#40;CEP 202&#47;19&#44; CEP 203&#47;19&#41;&#44; and individual patient consent was waived for the analysis and publication in anonymized fashion&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Of all patients&#44; 76&#37; were male with a mean age of 53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 years &#40;range 2&#8211;86 years&#59; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The original aortic valve morphology was unicuspid in 34 &#40;3&#37;&#41;&#44; bicuspid in 525 &#40;41&#37;&#41;&#44; and tricuspid in 726 &#40;56&#37;&#41; patients&#46; Fifty-six patients &#40;4&#37;&#41; had confirmed connective tissue disease&#44; in the majority of cases Marfan&#39;s syndrome&#46; Prior to the index procedure&#44; 134 patients &#40;10&#37;&#41; had undergone at least one cardiac operation&#46; The primary indications for surgery were severe and symptomatic aortic regurgitation &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>720&#44; 56&#37;&#41; and aortic root dilatation &#40;sinus &#8805;50<span class="elsevierStyleHsp" style=""></span>mm&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>476&#44; 37&#37;&#41;&#46; Eighty-seven patients underwent remodeling for acute aortic dissection &#40;7&#37;&#59; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Surgical technique</span><p id="par0040" class="elsevierStylePara elsevierViewall">Intraoperative transesophageal echocardiography &#40;TEE&#41; was performed for analysis of root dimensions and cusp pathology&#46; The surgical technique depended on the valve morphology and cusp pathology encountered&#44; including cusp repair and suture annuloplasty as needed&#46; The technique and its modification for bicuspid and unicuspid valves have been described in detail previously&#46;<a class="elsevierStyleCrossRefs" href="#bib0260"><span class="elsevierStyleSup">9&#44;10&#44;19</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Briefly&#44; the operations were performed via a median sternotomy using aortic and right atrial cannulation&#59; in acute dissection&#44; the right axillary artery was used for arterial inflow&#46; Antegrade blood cardioplegia was given directly into the coronary ostia&#46; Cusp size was determined before deciding in favor of valve preservation&#46; In tricuspid valves&#44; a gH &#8805;18<span class="elsevierStyleHsp" style=""></span>mm was the minimum for preservation&#46; In bicuspid valves&#44; a gH of &#8805;20<span class="elsevierStyleHsp" style=""></span>mm of the non-fused cusp&#44; and in unicuspid valves&#44; a gH of &#62;20<span class="elsevierStyleHsp" style=""></span>mm of the left and non-coronary cusps was a prerequisite for repair&#46; A decision for valve replacement was made generally for cusp calcification&#44; active endocarditis&#44; and retraction in bicuspid valves&#46; Tricuspid aortic valves &#40;TAVs&#41; were replaced for cusp retraction&#44; multiple fenestrations or calcification&#44; UAVs for calcification beyond the limits of the right cusp&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">After root mobilization and excision of the sinus wall&#44; a tubular graft was tailored to accommodate the configuration of the aortic root and sutured to the cusp insertion lines&#46; For TAV&#44; three tongues were created&#46; For asymmetric BAV&#44; the commissures of the non-fused cusp were placed at a 160&#176; orientation in the first 119 patients&#46; In all subsequent patients&#44; an orientation of approximately 180&#176; was chosen with two symmetric tongues for symmetric and asymmetric BAV &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>309&#41; as well as for UAV&#46; In very asymmetric BAVs&#44; three tongues were created in analogy to TAVs &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>44&#41;&#46; The length of the tongues was adjusted according to the height of the native commissures&#44; i&#46;e&#46; 1&#8211;1&#46;5<span class="elsevierStyleHsp" style=""></span>cm longer than the native commissural height&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Initially&#44; remodeling was used for patients with an annular diameter of &#60;30<span class="elsevierStyleHsp" style=""></span>mm&#44; and the graft size was chosen 1&#8211;2<span class="elsevierStyleHsp" style=""></span>mm smaller than the basal diameter&#46; Later&#44; all root morphologies were included&#44; and graft size was chosen according to the body surface area of the patient &#40;24<span class="elsevierStyleHsp" style=""></span>mm for &#60;1&#46;8<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; 26<span class="elsevierStyleHsp" style=""></span>mm for 1&#46;9&#8211;2&#46;2<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; and 28<span class="elsevierStyleHsp" style=""></span>mm for 2&#46;3<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> and larger&#41;&#46; In TAVs with a geometric height &#60;20<span class="elsevierStyleHsp" style=""></span>mm&#44; a smaller graft &#40;one size less&#41; was taken&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Valve configuration was visually assessed after completing the root procedure &#40;only visual&#58; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>243&#59; 23&#37;&#41;&#46; Since 2004&#44; eH of each cusp was measured using a caliper &#40;Fehling Instruments&#44; Karlstein am Main&#44; Germany&#59; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1075&#59; 84&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">12</span></a> Cusp prolapse was defined as eH &#60;9<span class="elsevierStyleHsp" style=""></span>mm &#40;in BAV of the non-fused cusp&#41; and corrected by central plication until an eH of 9&#8211;10<span class="elsevierStyleHsp" style=""></span>mm was reached &#40;TAV&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>726&#59; BAV&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>525&#59; UAV&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41;&#46; Fenestrations were accepted if they were not involved in prolapse&#46; Perforations and larger fenestrations with prolapse were closed with a pericardial patch &#40;autologous pericardium&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>26&#59; heterologous pericardium&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41;&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">In unicuspid valves&#44; the left&#47;non-coronary commissure was used as a reference for commissural height&#46; A new commissure was created opposite of this normal commissure for symmetric orientation&#46;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">20</span></a> Using triangular patches&#44; the gaps between preserved left or non-coronary cusp tissue and the new commissure were closed&#46; In seven patients&#44; cusp nadir relocation was performed without the use of a patch&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">21</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">An external annuloplasty was added after 2008 if the annulus measured &#62;26<span class="elsevierStyleHsp" style=""></span>mm&#46; In most instances &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>716&#41;&#44; an expanded polytetrafluoroethylene suture &#40;Gore-TexCV-0&#44; W&#46;L&#46; Gore &#38; Assoc&#46;&#44; Munich&#44; Germany&#41; was used&#46; The suture was tied around a Hegar dilator &#40;&#60;1&#46;8<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#58; 21<span class="elsevierStyleHsp" style=""></span>mm&#44; 1&#46;8&#8211;2&#46;0<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#58; 23<span class="elsevierStyleHsp" style=""></span>mm&#44; &#62;2&#46;0<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#58; 25<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; Of the 726 TAV patients&#44; 404 were treated with an annuloplasty&#44; in BAV 284 of 525&#44; and in UAV 28 of 34&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">All patients underwent intraoperative transesophageal echocardiography&#46; They also underwent transthoracic echocardiography &#40;TTE&#41; before discharge&#44; at three months&#44; at one year and biannually thereafter&#46; Mean and peak systolic gradients were measured&#44; and AR was analyzed by color Doppler and classified as absent&#44; mild&#44; moderate or severe&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Follow-up</span><p id="par0080" class="elsevierStylePara elsevierViewall">All patients were followed prospectively both clinically and echocardiographically &#40;at discharge&#44; 3 months&#44; 1 year and yearly thereafter&#41;&#46; For this study&#44; the echocardiograms from our institution and referring cardiologists were reviewed&#46; Systolic gradients were measured using continuous wave Doppler&#46; AR was determined using color Doppler according to European guidelines&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Median and mean follow-up were six years &#40;range one month to 28 years&#41; and 6&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;5 years&#46; Follow-up was 95&#37; complete &#40;7700 patient-years&#41;&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0090" class="elsevierStylePara elsevierViewall">Non-normally distributed continuous variables are presented as median &#40;interquartile range&#41;&#44; and the Mann&#8211;Whitney <span class="elsevierStyleItalic">U</span> test was used for between-group comparisons&#46; Normally distributed continuous variables are presented as mean<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>SD and were compared using the <span class="elsevierStyleItalic">t</span>-test&#46; Categorical variables are expressed as frequency &#40;&#37;&#41;&#46; Time-dependent data were analyzed using the Kaplan&#8211;Meier method&#46; Differences were assessed using the log-rank test&#46; Survival and freedom from reintervention were calculated at one&#44; five&#44; ten&#44; 15 and 20 years&#46; All statistical tests were 2-sided&#44; and <span class="elsevierStyleItalic">p</span>-values &#60;0&#46;05 were considered statistically significant for all analyses&#46; Statistical analyses were performed using SPSS 28&#46;0 &#40;Version 28&#46;0&#44; IBM&#44; Amrock&#44; NY&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Early</span><p id="par0095" class="elsevierStylePara elsevierViewall">Cusp pathology requiring correction included cusp prolapse &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>972&#59; 82&#37;&#41;&#44; fenestrations &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41;&#44; retraction &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41; and perforations &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;&#46; Cusp repair was performed in 1143 &#40;89&#37;&#41; patients &#40;UAV <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#47;34&#44; BAV <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>510&#47;525&#44; TAV <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>716&#47;726&#41;&#46; A patch was used in 92 patients &#40;7&#37;&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Mean myocardial ischemia time was 85<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>20<span class="elsevierStyleHsp" style=""></span>min with concomitant procedures and 68<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14<span class="elsevierStyleHsp" style=""></span>min without additional procedures &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; There was no myocardial infarction and two patients developed neurological complications&#46; One patient required a permanent pacemaker implantation after ablation for persistent atrial fibrillation&#59; no atrioventricular block was observed in patients with sinus rhythm&#46; There were no early reoperations&#59; re-exploration for bleeding was necessary in 30 patients &#40;2&#46;3&#37;&#41;&#46; Hospital mortality was 1&#46;4&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>18&#47;1285&#41;&#46; Of these&#44; seven were cardiac deaths &#40;cardiac failure&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#59; arrhythmia&#44; <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Aortic regurgitation at discharge</span><p id="par0105" class="elsevierStylePara elsevierViewall">With the introduction of eH measurement&#44; the proportion of patients with a competent valve at discharge was higher &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>675&#59; 65&#37;&#41; compared to only visual assessment &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>73&#59; 30&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;04&#41;&#46; With suture annuloplasty&#44; a higher proportion of patients had no AR at discharge &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>643&#47;716&#59; 91&#37;&#41; than without suture annuloplasty &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>464&#47;569&#59; 80&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; This differed between the aortic valve morphologies &#40;with annuloplasty TAV <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>340&#47;404&#59; 84&#37;&#59; BAV <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>202&#47;284&#59; 71&#37;&#59; UAV <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>14&#47;28&#59; 50&#37;&#59; without annuloplasty TAV <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>239&#47;322&#59; 74&#37;&#59; BAV <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>152&#47;241&#59; 63&#37;&#59; UAV <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>4&#47;6&#59; 67&#37;&#41;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Late survival</span><p id="par0110" class="elsevierStylePara elsevierViewall">Late postoperatively&#44; 141 &#40;12&#37;&#41; patients died between 1&#46;1 months and 23 years&#46; Of these&#44; 62&#37; &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>87&#41; died of a cardiac cause for a cardiac survival of 80&#37; at 20 years &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1198&#41;&#46; It was 80&#37; for TAV &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>640&#41;&#44; 95&#37; for BAV &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>520&#41;&#44; and 100&#37; for UAV &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>34&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#59; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Survival at 15 years was significantly better in patients who underwent elective surgery &#40;76&#37;&#41; compared to acute dissection &#40;58&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; It was superior at 15 years in patients without concomitant CABG procedure &#40;79&#37;&#41; compared to those with CABG &#40;54&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Survival at 10 years was 81&#37; without suture annuloplasty compared to 91&#37; with suture annuloplasty &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Freedom from recurrent AR &#8805;2</span><p id="par0115" class="elsevierStylePara elsevierViewall">Valve function has remained stable in the majority of patients&#46; Over time&#44; however&#44; 104 patients &#40;8&#37;&#41; developed AR &#8805;2&#46; Freedom from AR &#8805;2 was 91&#37; at 10 years &#40;TAV 91&#37;&#59; BAV 92&#37;&#41; and 80&#37; at 15 years &#40;TAV 81&#37;&#59; BAV 78&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;102&#41;&#46; Freedom from AR &#8805;2 in UAVs was 88&#37; at 10 years&#46; At 10 years&#44; there was a trend towards a better freedom from AR &#8805;2 with the addition of a suture annuloplasty &#40;92&#37;&#41; compared to patients without a suture annuloplasty &#40;87&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;07&#41;&#46; At 10 years in patients with TAV&#44; freedom from AR &#8805;2 was 93&#37; with the addition of a suture annuloplasty compared to patients without a suture annuloplasty &#40;88&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;173&#41;&#46; In BAV&#44; freedom from AR &#8805;2 at 10 years was 92&#37; with the addition of a suture annuloplasty compared to patients without a suture annuloplasty &#40;90&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;787&#41;&#46; The limited number of UAV patients did not allow for a reasonable comparison&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Gradients</span><p id="par0120" class="elsevierStylePara elsevierViewall">In patients with TAV&#44; normal systolic gradients &#40;mean 4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>mmHg&#41; remained throughout the follow-up in almost all cases&#46; With BAV&#44; the mean gradient at last follow-up was 7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mmHg&#59; it was 10<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>8<span class="elsevierStyleHsp" style=""></span>mmHg with asymmetric orientation compared to 6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mmHg when symmetric repair was performed &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#41;&#46; With UAV&#44; the mean gradient at last follow-up was 15<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>mmHg&#46; In all valve morphologies&#44; gradients were not higher with compared to without annuloplasty &#40;with annuloplasty&#58; TAV 4<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mmHg&#44; BAV 7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mmHg&#44; UAV 9<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mmHg&#59; without&#58; TAV 6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>mmHg&#44; BAV 8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>mmHg&#44; UAV 18<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Reoperation</span><p id="par0125" class="elsevierStylePara elsevierViewall">Sixty-nine patients required aortic valve reoperation between one month and 21 years postoperatively &#40;median 6 years&#41;&#46; The main indications for reoperation included recurrent AR &#8805;2 &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>40&#41;&#44; active endocarditis &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>11&#41;&#44; and aortic stenosis &#40;BAV <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#44; TAV <span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>3&#41;&#46; Reoperations consisted of valve replacement &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>37&#41;&#44; valve repair &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>21&#41;&#44; root replacement &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>6&#41; and pulmonary autograft replacement &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">Overall freedom from reoperation was 78&#37; at 20 years &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Freedom from reoperation at 15 years was best in TAV &#40;94&#37;&#41; compared to BAV &#40;84&#37;&#41; &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; Freedom from reoperation for UAV at ten years was 64&#37; &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; The introduction of eH measurement had no effect on freedom from reoperation at 15 years &#40;92&#37; with and 87&#37; without&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;275&#41;&#46; It was 92&#37; without and 97&#37; with eH measurement in tricuspid valves &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;043&#41;&#44; and 83&#37; without and 85&#37; with eH measurement in bicuspid valves &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;524&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0135" class="elsevierStylePara elsevierViewall">Freedom from reoperation at 12 years was 95&#37; with the addition of a suture annuloplasty and 91&#37; without &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;949&#59; <a class="elsevierStyleCrossRef" href="#fig0020">Fig&#46; 4</a>&#41;&#46; It was 94&#37; without and 97&#37; with annuloplasty in TAV &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;209&#41;&#44; and 88&#37; and 92&#37; with annuloplasty in BAV &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;488&#41;&#46; In UAV&#44; 5-year freedom from reoperation was 75&#37; without and 85&#37; with an annuloplasty &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;573&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0140" class="elsevierStylePara elsevierViewall">After almost three decades of root remodeling&#44; the basic principle of the operation has remained generally unchanged&#46; Compared to the original description&#44;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">1</span></a> only minor details were modified and then kept constant throughout our practice&#58; the length of the Dacron tongues was not predetermined but adjusted to exceed the height of the native commissures&#46; In order to facilitate the procedure&#44; we have started suturing in the sinus nadir&#46; Our only conceptual modifications have been 1&#46; the addition of cusp repair&#44; 2&#46; the introduction of systematic measurement of effective height to standardize detection and correction of cusp prolapse and 3&#46; the addition of an annuloplasty&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">We were positively impressed by the more physiologic cusp motion and systolic gradients in in-vitro experiments&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">8&#44;22</span></a> There is lesser need for aggressive basal dissection compared to aortic valve reimplantation&#46; This results in shorter ischemic times<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">23</span></a> and fewer instances of atrioventricular block&#44; which is in the range of 5&#37; with reimplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">24</span></a> In this context&#44; the absence of atrioventricular block in our current series is noteworthy&#46; We subsequently modified the original procedure to accommodate the anatomy of a BAV<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">19</span></a> and UAV&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">10</span></a></p><p id="par0150" class="elsevierStylePara elsevierViewall">Based on the analysis of the normal form of an aortic valve&#44; we hypothesized that the height difference between annular plane and cusp margins in diastole &#8211; effective height &#8211; could be used as a configuration parameter for the aortic valve&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">12</span></a> We found a close correlation between eH and patient size&#44;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">13</span></a> with 9&#8211;10<span class="elsevierStyleHsp" style=""></span>mm being ideal for normal-sized adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">13&#44;25</span></a> Normalized eH was associated with better durability in aortic valve repair&#44;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">26</span></a> and we have systematically measured eH with a caliper since 2004&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">Both in the pioneer series of root remodeling and others&#44; a relevant proportion of residual and recurrent AR was observed<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">2&#44;4</span></a> with consecutive need for reoperation&#46; The precise reason for these valve failures was not clear but it was attributed to a lack of annular stabilization&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">3&#44;4</span></a> Consequently&#44; reimplantation of the aortic valve became the preferred form of VPS for many surgeons&#44; based on the excellent results of the pioneer series<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">4</span></a> and the assumedly better annular stabilization&#46; Interestingly&#44; however&#44; we were not as successful as the original pioneer&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">5</span></a> Also in the hands of others&#44; a relevant proportion of patients developed postoperative AR&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">27&#44;28</span></a> In retrospect&#44; these failures were likely due to unrecognized prolapse in the absence of measuring eH&#46; These findings raise the question whether annular stabilization is as important as it has been assumed&#44; or whether patient selection and better control of valve configuration are the more important determinants of postoperative valve function&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Patient selection may lead to exclusion of patients with more pronounced cusp stretching&#46; Very few &#8211; if any &#8211; reports indicate the proportion of patients with root aneurysm that undergo VPS&#46; In the best-known international referral center&#44; probably less than 40&#37; have been treated by VPS&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">29</span></a> We have performed VPS in 90&#37; of all cases&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">30</span></a> probably accepting more cusp deformation than others&#46; This has not yet been associated with an increase in the need for reoperation&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">30</span></a></p><p id="par0165" class="elsevierStylePara elsevierViewall">Patient selection also includes aortic valve morphology&#46; Most series focus on TAV&#44; some include a limited proportion of BAV&#44; and we are not aware of any series including UAV&#46; The natural history of BAV and UAV&#44; however&#44; suggests that they should take a different course from TAV&#46; Indeed&#44; our experience and the current data show that valve morphology has a strong impact on the late results&#46; There is a certain degree of attrition in preserved TAVs over time&#59; it is present in the current series and others with reimplantation&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">31</span></a> BAVs take a different course&#44; with fibrosis and calcification occurring more frequently&#46; In BAVs&#44; the use of pericardial patches or other substitutes for cusp repair has been associated with a higher degree of failure compared to TAVs&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">32</span></a> Both mechanisms have been responsible for the majority of reoperations also in our current series&#46; UAVs will need a cusp substitute in most instances to create a functioning valve design&#44;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">20</span></a> and expectedly&#44; even more attrition of UAVs was observed with root remodeling&#46; Interestingly&#44; in some instances root remodeling allows for UAV repair without patch material&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">21</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">In order to achieve annular stabilization&#44; a ring annuloplasty was proposed by Lansac<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">33</span></a>&#59; its use apparently resulted in drastic improvement of valve competence and durability&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">17</span></a> Interestingly&#44; this was in contrast to our experience&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">34</span></a> Even without any annuloplasty&#44; annular size reduction was observed&#44;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">35</span></a> and valve durability in our hands was markedly better than that of the initial results of Lansac&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">33</span></a> Thus&#44; the described improvement<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">17</span></a> was likely due to introducing the measurement of eH intraoperatively&#44; allowing for better control of valve configuration&#46; We had systematically applied the intraoperative measurement to correct prolapse since 2004&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">We therefore decided to explore the additional value of an annuloplasty while the other operative details remained constant&#44; and also added the concept of annuloplasty to root remodeling&#46; Of the different options&#44;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">36</span></a> we used a suture annuloplasty for ease of application&#46; Early results were promising&#44; and the proportion of competent aortic valves at discharge increased significantly&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">18</span></a> We have&#44; however&#44; not yet seen an improvement in valve durability with the addition of annuloplasty when BAVs were treated by root remodeling&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">37&#44;38</span></a> This is confirmed by the current series&#46; In a TAV anatomy&#44; the addition of an annuloplasty has not yet shown a significant effect on freedom from reoperation&#44; contradicting our expectations and the experience of others&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">39</span></a> As seen in the current analysis&#44; the competence of the aortic valves was improved significantly&#59; up to 14 years&#44; freedom from reoperation is unchanged&#46; A possible explanation for this observation could be the eH-driven and thus aggressive strategy of cusp repair&#46; In doing so&#44; we were even able to treat a relevant number of root aneurysms with prolapse of all three cusps&#46; The avoidance of symmetrical prolapse could perceivably reduce the stress at the level of the ring and thus contribute to annular size reduction&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">35</span></a> It remains to be seen whether a difference in freedom from reoperation may be observed in the second and third postoperative decade&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">In assessing the current long-term experience&#44; it has become increasingly clear that both adequate postoperative valve configuration and the original aortic valve anatomy &#40;i&#46;e&#46; tricuspid&#44; bicuspid or unicuspid&#41; are important&#46; This is confirmed by the current data&#46; While visual assessment of adequate valve form is seemingly easier in BAV than in TAV&#44; valves may still fail due to symmetric prolapse&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">30</span></a> With experience and longer follow-up&#44; a limited but increasing proportion of non-TAVs fails in the second decade due to calcification&#46; The highest probability of failure is to be expected if pericardial patches have been used for cusp repair&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">37&#44;38</span></a> In UAVs&#44; failure occurs even earlier than with BAVs and generally affects the pericardium used for cusp repair&#46; It is noteworthy that remodeling can be utilized to modify UAV anatomy in such a way that no patch material is necessary&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">21</span></a> Further follow-up will be required to judge the long-term value of this approach&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">Cusp pathology was the main reason for failure in most instances after remodeling<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">39</span></a>&#59; persistent&#47;recurrent cusp prolapse or degeneration of patch material used for cusp repair were the main pathologies in some BAV and all UAV&#46; Persistent or recurrent prolapse has been a predictor of failure previously<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">34</span></a>&#59; the majority of cases with postoperative cusp prolapse in our experience had been performed prior to the introduction of intraoperative measurement of eH&#46; In addition&#44; in TAV anatomy&#44; prolapse and secondary retraction were the most frequent mechanisms in the current analysis&#46; Valve calcification &#40;2&#46;5&#37;&#59; most had a BAV&#41; and cusp retraction &#40;0&#46;65&#37;&#41; have been relatively rare&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">39</span></a> In TAVs&#44; the results were comparable when one&#44; two or three cusps were repaired&#44; in both survival and freedom from reoperation&#46; Patients with prolapse repair of three cusps fared somewhat worse only regarding freedom from AR &#8805;2 at 10 years&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">The current series includes different indications&#44; i&#46;e&#46; aneurysm&#44; severe AR&#44; acute aortic dissection&#44; and connective tissue disease&#46; Early mortality was low &#40;1&#46;5&#37;&#41; despite the inclusion of patients with acute aortic dissection<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">40</span></a> as well as morbidity&#46; Only 2&#46;5&#37; required surgical reintervention for hemorrhage&#44; indicating that the procedure is as hemostatic as other procedures<a class="elsevierStyleCrossRefs" href="#bib0235"><span class="elsevierStyleSup">4&#44;41</span></a>&#59; this has been confirmed by a multi-center analysis&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">41</span></a> We did not observe postoperative atrioventricular block requiring pacemaker implantation&#44; most likely due to less basal dissection and the difference in suturing&#46; No relevant difference was observed between patients with aneurysm as the primary indication versus those with AR&#46; The incidence of valve-related complications was very low&#44; with need for reoperation being the most frequent&#44; confirming other studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0400"><span class="elsevierStyleSup">37&#44;42</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">Interestingly&#44; isolated annular dilatation was not identified as a reason for failure&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">39</span></a> While we have observed a few instances of annular dilatation in conjunction with cusp prolapse&#46; The presence of cusp prolapse may have a negative effect on annular stress distribution and its absence contributes to root stabilization&#46; While we have found a clear stabilizing effect of a suture annuloplasty in isolated BAV repair&#44;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">43</span></a> this positive effect was not observed with remodeling for BAV<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">38</span></a> and now for TAV&#46; These findings correlate with a previous study in that even without annuloplasty&#44; a size reduction of the annulus was observed&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">35</span></a> Nevertheless&#44; an annuloplasty improves early valve competence&#59; it may improve late durability of valve repair beyond the first 15 years and is thus probably a useful adjunct&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclusion</span><p id="par0200" class="elsevierStylePara elsevierViewall">Root remodeling is a viable option in valve-preserving root replacement&#44; both for tricuspid and bicuspid valve morphologies&#46; If combined with objective assessment of cusp configuration and aggressive cusp repair&#44; reproducible and durable restoration of aortic valve function can be achieved&#46; It is thus a good and up-to-date option for patients with aortic root aneurysm&#44; independent of the preoperative degree of aortic regurgitation&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Ethical disclosure</span><p id="par0205" class="elsevierStylePara elsevierViewall">Saarland Regional Ethics Committee &#40;CEP 202&#47;19&#44; CEP 203&#47;19&#41; approved the research&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding</span><p id="par0210" class="elsevierStylePara elsevierViewall">The authors received no funding&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflict of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to report&#46;</p></span></span>"
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          "titulo" => "Patients and methods"
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              "titulo" => "Patients"
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              "titulo" => "Surgical technique"
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            2 => array:2 [
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              "titulo" => "Follow-up"
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              "titulo" => "Late survival"
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              "identificador" => "sec0055"
              "titulo" => "Freedom from recurrent AR &#8805;2"
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              "titulo" => "Gradients"
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    "fechaRecibido" => "2023-11-13"
    "fechaAceptado" => "2024-06-10"
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            0 => "Aortic root"
            1 => "Aortic root aneurysm"
            2 => "Valve-preserving root replacement"
            3 => "Aortic cusp repair"
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            0 => "Ra&#237;z a&#243;rtica"
            1 => "Aneurisma de la ra&#237;z a&#243;rtica"
            2 => "Reemplazo de la ra&#237;z con preservaci&#243;n de la v&#225;lvula"
            3 => "Reparaci&#243;n de la c&#250;spide a&#243;rtica"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Background</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Root remodeling is one form of valve-preserving root replacement for aortic regurgitation and root aneurysm&#44; which we have employed consistently for more than 28 years&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Between 10&#47;95 and 7&#47;2023 root remodeling was performed in 1285 patients &#40;76&#37; male&#44; mean age 53<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>14 years&#41;&#46; The aortic valve morphology was unicuspid in 34 &#40;3&#37;&#41;&#44; bicuspid in 525 &#40;41&#37;&#41; and tricuspid in 726 &#40;56&#37;&#41; patients&#46; Fifty-four patients &#40;4&#37;&#41; had Marfan&#39;s syndrome&#46; Measurement of valve configuration &#40;effective height&#41; was performed in 1075 &#40;84&#37;&#41;&#44; and an external suture annuloplasty was added in 705 patients &#40;55&#37;&#41;&#46; Cusp repair was performed in 1143 &#40;89&#37;&#41; patients&#44; most commonly for prolapse &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1000&#59; 82&#37;&#41;&#46; Mean follow-up was 6&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>5&#46;5 years &#40;1 month to 28 years&#41;&#46; Follow-up was 95&#37; complete &#40;8026 patient-years&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Survival was 71&#37; at 20 years&#44; freedom from cardiac death 80&#37;&#46; Freedom from aortic regurgitation &#8805;2 was 77&#37; at 15 years&#46; Freedom from reoperation was 89&#37;&#44; higher in tricuspid &#40;94&#37;&#41; compared to bicuspid &#40;84&#37;&#41; and unicuspid valves &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46; With a suture annuloplasty&#44; freedom from reoperation was 94&#37; at 12 years&#46; The difference with &#40;94&#37;&#41; or without annuloplasty &#40;91&#37;&#41; was not significant &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;949&#41;&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Root remodeling is a viable option in valve-preserving root replacement&#46; Concomitant cusp prolapse is frequent and can be corrected reproducibly by intraoperative measurement of effective height&#46; The long-term stability of the aortic valve depends primarily on the underlying morphology&#46; Up to 15 years postoperatively&#44; the addition of an annuloplasty had a limited positive effect on residual regurgitation&#44; but &#40;as yet&#41; no effect on freedom from reoperation&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antecedentes</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La remodelaci&#243;n de la ra&#237;z es una forma de reemplazo de la ra&#237;z con preservaci&#243;n de la v&#225;lvula&#44; debido a regurgitaci&#243;n a&#243;rtica y aneurisma de la ra&#237;z&#44; que hemos utilizado consistentemente durante m&#225;s de 28 a&#241;os&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Realizamos entre 10&#47;95 y 7&#47;2023 remodelaciones de la ra&#237;z en 1&#46;285 pacientes &#40;76&#37; varones&#44; edad media 53 &#177; 14 a&#241;os&#41;&#46; La morfolog&#237;a de la ra&#237;z a&#243;rtica fue unic&#250;spide en 34 &#40;3&#37;&#41; pacientes&#44; bic&#250;spide en 525 &#40;41&#37;&#41; y tric&#250;spide en 726 &#40;56&#37;&#41;&#46; Cincuenta y cuatro pacientes &#40;4&#37;&#41; ten&#237;an s&#237;ndrome de Marfan&#46; Se realiz&#243; medida de la configuraci&#243;n de la v&#225;lvula &#40;altura efectiva&#41; en 1&#46;075 &#40;84&#37;&#41; pacientes&#44; y se a&#241;adi&#243; anuloplastia externa a la sutura en 705 pacientes &#40;55&#37;&#41;&#46; Se repar&#243; la c&#250;spide en 1&#46;143 &#40;89&#37;&#41; pacientes&#44; debido normalmente a prolapso &#40;n &#61; 1000&#59; 82&#37;&#41;&#46; El seguimiento medio fue de 6&#44;7 &#177; 5&#44;5 a&#241;os &#40;de 1 mes a 28 a&#241;os&#41;&#46; Dicho seguimiento tuvo una compleci&#243;n del 95&#37; &#40;8&#46;026 pacientes-a&#241;os&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">La supervivencia fue del 71&#37; a 20 a&#241;os&#44; con ausencia de muerte cardiaca en un 80&#37;&#46; La ausencia de regurgitaci&#243;n a&#243;rtica &#8805;2 fue del 77&#37; a los 15 a&#241;os&#46; La ausencia de reintervenci&#243;n fue del 89&#37;&#44; siendo m&#225;s alta en las v&#225;lvulas tric&#250;spides &#40;94&#37;&#41; en comparaci&#243;n con las bic&#250;spides &#40;84&#37;&#41; y unic&#250;spides &#40;p &#60; 0&#44;001&#41;&#46; Con anuloplastia de sutura&#44; la ausencia de reintervenci&#243;n fue del 94&#37; a 12 a&#241;os&#46; La diferencia entre la presencia &#40;94&#37;&#41; o ausencia de anuloplastia &#40;91&#37;&#41; no fue significativa &#40;p &#61; 0&#44;949&#41;&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusi&#243;n</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La remodelaci&#243;n de la ra&#237;z es una opci&#243;n viable en t&#233;rminos de reemplazo de la ra&#237;z con preservaci&#243;n de la v&#225;lvula&#46; Es frecuente el prolapso de c&#250;spide concomitante&#44; pudiendo ser corregido reproduciblemente mediante medida intraoperatoria de la altura efectiva&#46; La estabilidad a largo plazo de la v&#225;lvula a&#243;rtica depende principalmente de la morfolog&#237;a subyacente&#46; Hasta un periodo de 15 postoperatorios&#44; la adici&#243;n de anuloplastia tuvo un efecto positivo limitado en la regurgitaci&#243;n residual&#44; pero &#40;hasta la fecha&#41; ning&#250;n efecto en la ausencia de reintervenci&#243;n&#46;</p></span>"
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                  \t\t\t\t">977 &#40;76&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Age&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#44; years</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">BSA&#44; mean</span><span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">SD&#44; m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">1&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>0&#46;4&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Arterial hypertension&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">925 &#40;72&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Coronary artery disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">141 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chronic kidney disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">39 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Chronic obstructive lung disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">39 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Aortic regurgitation&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Aortic root dilatation &#40;&#8805;50<span class="elsevierStyleHsp" style=""></span>mm&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">476 &#40;37&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Acute aortic dissection&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">87 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Combined disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 &#40;0&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">134 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="2" align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">34 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">525 &#40;41&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Tricuspid&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">726 &#40;56&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LVEF &#60;50&#37;&#44; <span class="elsevierStyleItalic">n</span> &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">103 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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ISSN: 11340096
Original language: English
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