Background: For severe mitral valve (MV) degenerative disease, repair is recommended. Prediction of repair complexity and referral to centers of excellence can increase rates of successful repair. This study sought to demonstrate that TEE is a feasible imaging modality to predict the surgical MV complexity score previously developed by Anyanwu et al. Methods: Two hundred TEE examinations of patients who underwent MV repair (2009 – 2011) were retrospectively reviewed and scored by two cardiac anesthesiologists. TEE scores were compared to surgical complexity scores of same subset of patients. Kappa values were reported for the agreement of TEE and surgical scores. McNemar’s tests were used to test the homogeneity of the marginal probabilities of different scoring categories. Results: TEE scores were slightly lower (2[1,3]) than surgical scores (3[1,4]). Agreement was 66% between the scoring methods, with a moderate kappa (0.46). Using surgical scores as the gold standard, 70%, 71% and 46% of simple, intermediate and complex surgical scores, respectively, were correctly scored by TEE. P1, P2, P3, and A2 prolapse were easiest to identify with TEE and had the highest agreement with surgical scoring (P1 agreement 79% with kappa 0.55, P2 96% (kappa 0.8), P3 77% (kappa 0.51), A2 88% (kappa 0.6)). The lowest agreement between the two scores occurred with A1 prolapse (kappa 0.05) and posteromedial commissure prolapse (kappa 0.14) (Figure 3). In the presence of significant disagreement, TEE scores were more likely to be of higher complexity than surgical. McNemar’s test was significant for prolapse of P1 (p=0.005), A1 (p=0.025), A2 (p=0.041), and the posteromedial commissure (p<.0001).

Alternatives to traditional aortic valve replacement now form part of the valve surgeon's armamentarium. Sutureless valves offer decreased bypass and crossclamp times, excellent maneuverability, and promising outcomes. We present a case of a sutureless aortic valve replacement for a late failed David procedure, complicated by post-operative development of severe paravalvular regurgitation. We attempted off-label balloon post-dilation to improve expansion of the valve, however paravalvular regurgitation persisted. The patient underwent subsequent aortic valve replacement using a mechanical valve and experienced no further paravalvular leak.

Rupture of a congenital left ventricular diverticulum (CLVD), a rare anatomical anomaly, is a catastrophic event, with potential fatal consequences. Repair techniques documented in the literature include primary closure and single patch closure. We describe a case of a 57-year-old woman with symptomatic anterolateral CLVD. Our approach involves a linear incision through the epicardial surface of the diverticulum with exclusion of the cavity, and restoration of normal ventricular geometry via a two patch technique.

Background: Aortic root abscess surgery has significant mortality but can be performed safely by trainees supervised by senior surgeons. Methods: Between 2007 and 2017, 54 consecutive patients (mean 64 years old) with active aortic endocarditis complicated with periannular abscess underwent aortic root replacement with homograft. Twenty-eight cases (52%) in which postgraduate year 5-8 residents or junior attending surgeons performed under senior attending supervision were compared to 26 cases the senior attending performed. Mean follow-up was 2.2 years. Results: Forty-three patients (80%) had previous aortic valve replacement and 26 (48%) were in New York Heart Association class III or IV status. Forty-two patients (78%) had concomitant procedure including 20 (37%) aorto-mitral curtain reconstruction and 6 (11%) hemi aortic arch replacement under circulatory arrest. Median cross clamp time was 218 minutes. There was no operative mortality. One patient (2%) had re-exploration for bleeding and 3 (6%) had stroke. Median hospital stay was 10 days. Preoperative characteristics and short and mid-term results were all comparable between mentee cases vs senior attending cases. Survival at 6 years were 67.3% (95% CI 38.0 – 85.0%) in mentee cases and 75.6% (95% CI 47.1 – 90.1%) in senior attending cases (adjusted hazard ratio 1.48, 95% CI 0.33- 6.73, P=0.61). During follow up, 2 patients (3.7%) required reoperation on the aorta valve for structural valve deterioration and 1 (1.8%) had recurrent endocarditis. Conclusions: Homograft aortic root replacement can be performed safely by trainees with an experienced surgeon showing favorable outcomes, midterm survival, and freedom from recurrent endocarditis.