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\begin{document}

\title{Long-term Outcomes Following Reoperations for Stentless Aortic Valves.}



\author[1]{Bindu Bittira}%
\author[1]{Mohammed Shurrab}%
\author[1]{Stacey Santi}%
\author[1]{Sarah Grieve}%
\author[1]{Derek J. MacDonald}%
\affil[1]{Health Sciences North}%


\vspace{-1em}



  
  \date{May 28, 2024}


\begingroup
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\selectlanguage{english}
\begin{abstract}
\textbf{Background}: There is limited data on the long-term outcomes in
patients who have undergone a reoperation following a failing stentless
aortic valve. \textbf{Methods}: Between 2006-2016, a retrospective
analysis was performed on 24 patients that underwent open aortic valve
replacement surgery for a failed stentless aortic valve prosthesis at
Health Sciences North, Sudbury, Ontario, Canada. The primary outcome was
low mortality from cardiac related deaths after 5 years.
\textbf{Results}: All patients underwent an insertion of a Medtronic
Freestyle bioprosthesis implanted in the modified subcoronary technique
for their initial operation. The interval from the first operation to
the stentless redo surgery ranged from 6-13 years. Aortic valve
reoperation was performed for structural valve deterioration in 96\% (n=
23) of the cases. Reoperations involved a removal of the stented valve
leaflets and stented valve-in-valve implantation in 20\% (n= 5) of the
cases, with the remaining cases requiring complete removal of the
stentless prosthesis and aortic valve replacement. In those where a
complete removal of the stentless valve was possible (n=19), there was
no disruption of the native aortic root, and a 0\% conversion to a
Bentall procedure. There was no intraoperative mortality. The 30-day and
10-year operative mortality was 4\% and 16\%, respectively.
\textbf{Conclusions}: Redo surgery for failing stentless valves can be
done with relatively low-risk and with acceptable long-term outcomes
without resorting to root replacement techniques.%
\end{abstract}%



\sloppy


\textbf{Title} : Long-term Outcomes Following Reoperations for Stentless
Aortic Valves.

\textbf{Running Head} : Reoperations for Stentless Valves.

\textbf{Authors} : Bindu Bittira MD, MSc\textsuperscript{1}; Mohammed
Shurrab MD\textsuperscript{2}; Stacey Santi\textsuperscript{3}; Sarah
Grieve BA, BEd\textsuperscript{1}; Derek J. MacDonald MD,
RPh\textsuperscript{1}

\textbf{Institutions and Affiliations} :

1. Division of Cardiac Surgery, Department of Surgery, Health Sciences
North, Sudbury, Ontario, Canada.

2. Department of Cardiology, Health Sciences North, Sudbury, Ontario,
Canada.

3. Health Sciences North Research Institute, Sudbury, Ontario, Canada.

\textbf{Key Words} : aortic valve reoperation, survival, aortic valve
replacement, prosthetic valve endocarditis, stentless aortic valve.

\textbf{Word Count} : 3098

\textbf{Address for correspondence} :

Bindu Bittira, MD, MSc.

865 Regent St. South, Suite M-131

Sudbury Outpatient Centre, Health Sciences North

Sudbury, Ontario

P3E3Y9

Telephone: 705-671-5353

Fax: 705-671-5352

Email: bindubittira@sudburyheart.com.

\textbf{AbstractBackground}: There is limited data on the long-term
outcomes in patients who have undergone a reoperation following a
failing stentless aortic valve.\textbf{Methods}: Between 2006-2016, a
retrospective analysis was performed on 24 patients that underwent open
aortic valve replacement surgery for a failed stentless aortic valve
prosthesis at Health Sciences North, Sudbury, Ontario, Canada. The
primary outcome was low mortality from cardiac related deaths after 5
years.\textbf{Results}: All patients underwent an insertion of a
Medtronic Freestyle bioprosthesis implanted in the modified subcoronary
technique for their initial operation. The interval from the first
operation to the stentless redo surgery ranged from 6-13 years. Aortic
valve reoperation was performed for structural valve deterioration in
96\% (n= 23) of the cases. Reoperations involved a removal of the
stented valve leaflets and stented valve-in-valve implantation in 20\%
(n= 5) of the cases, with the remaining cases requiring complete removal
of the stentless prosthesis and aortic valve replacement. In those where
a complete removal of the stentless valve was possible (n=19), there was
no disruption of the native aortic root, and a 0\% conversion to a
Bentall procedure. There was no intraoperative mortality. The 30-day and
10-year operative mortality was 4\% and 16\%,
respectively.\textbf{Conclusions}: Redo surgery for failing stentless
valves can be done with relatively low-risk and with acceptable
long-term outcomes without resorting to root replacement
techniques.\textbf{Introduction}: The Freestyle Stentless Porcine Valve
has been used since 1993\textsuperscript{1} as a third generation
porcine valve. Compared to conventional stented bioprostheses, stentless
valves provided better hemodynamics with a larger effective orifice area
with respect to their valve size.\textsuperscript{2} This allowed for
improved left ventricular function secondary to left ventricular mass
regression\textsuperscript{3-5} and reduced incidences of
patient-prosthesis mismatch. However, despite the advantages,
historically the utilization of stentless valves has been controversial.
The benefits in hemodynamics have been negatively influenced by the
technical difficulty in implanting the valve, with a longer learning
curve and longer ischemic time.\textsuperscript{6} There are multiple
options for implanting a Freestyle valve, including the root inclusion
technique, an isolated complete subcoronary technique, or a full root
replacement.\textsuperscript{7}As the use of the stentless valve gained
popularity, it was reasonable to accept that these valves would
eventually degenerate, leading to stentless valve reoperations. In
addition to the technical difficulty of implantation, reintervention is
also widely regarded as a greater surgical challenge. Over two decades
at our center, Health Sciences North, Sudbury, Ontario, over 300
Medtronic Freestyle stentless valves were inserted. Many patients did
return for reoperations. Prior to the broad introduction of
transcatheter aortic valve replacement (TAVR), all patients returned to
the operating room for reintervention. Subesequent to 2016, with the
introduction of catheter-based aortic valve replacement in our center,
valve-in-valve TAVR soon evolved as another treatment
option.\textsuperscript{8} This option, however, also presented
technical challenges, with the lack of radio-opaque markers to guide
trans-catheter valve implantation. The objective of this study was to
evaluate the short- and long-term outcomes of patients who underwent a
stentless valve reoperation at our center, including their perioperative
outcomes, operative mortality, and long-term survival following aortic
valve reoperation following an initial implantation of a Medtronic
Freestyle stentless valve.\textbf{Material and Methods}:\textbf{Study
Approval and Design}: This study was approved by the Institutional
Review Board at Health Sciences North (Sudbury, Ontario) and was in
compliance with Health Insurance Portability and Accountability Act
regulations. Operative reports and medical records were reviewed by a
single cardiac surgeon (BB) to confirm that these patients all had
received a Medtronic Freestyle stentless valve (Medtronic Inc.,
Minneapolis, MN, USA) for their initial operation and had received a
reoperation for a failed stentless valve. Long-term survival was
obtained through medical record review and supplemented with telephone
calls with 100\% follow-up of all patients. All reoperations for
stentless valves were performed by the same team of cardiac surgeons (BB
and DJM).\textbf{Patient Selection:}From 2006-2016, all consecutive
patients (N=24) who underwent open reoperative aortic valve replacement
(AVR) for a failing stentless valve were enrolled in this
study.\textbf{Operative Technique}: In all cases, surgery was performed
via redo median sternotomy. Prior cannulation of the femoral artery or
subclavian artery was used only when the right ventricle was in close
proximity to the posterior table of the sternum. Cardiopulmonary bypass,
with standard ascending aortic cannulation, the aortic arch or femoral
artery and the right atrium or femoral vein, was used with systemic
hypothermia of 32\textsuperscript{0}C. Myocardial protection was
achieved with intermittent antegrade cold blood cardioplegia. All
concomitant procedures were performed according to standard techniques.
Intraoperatively, the size of the stentless valve inserted in the first
operation often determined whether a valve-in-valve technique would be
feasible. We found that larger stentless valves (size 25 or greater)
often allowed for an adequately sized stented valve to be inserted after
removal of the torn leaflet tissue and the pannus in the left
ventricular outflow tract (LVOT). When the stentless valve was of a
smaller size (size 23 or smaller), meticulous removal of the entire
valve was necessary before an appropriately sized valve was inserted. In
our practice, this decision to proceed with complete removal of the
stentless valve , or perform a valve-in-valve was often made
intraoperatively. Factors such as the amount of calcification of the
stentless casing (particularly in the area of the noncoronary sinus, the
quality of the native tissue, the proximity of the subcoronary suture
line to the ostium of the coronaries, and the annular size of the
stentless bioprosthesis played a role in this decision. Additionally, if
the patient had significant comorbidities and the perceived length of
time required on cardiopulmonary bypass to completely explant the entire
stentless valve was considered too lengthy, we would choose a more
conservative, quicker surgical strategy such as a valve-in-valve
implant. When the stentless was particularly adherent to the native
root, we found that starting the removal in the area of the non-coronary
sinus was the most forgiving strategy. If the wrong tissue plane between
the stentless valve and the native aortic root was entered here, a
pericardial or bovine patch repair of the root could be performed more
easily than in other areas of the disrupted root. Stentless extraction
was typically a lengthy process, requiring great care and patience to
preserve the integrity of the native aortic root, and with strict
adherence to myocardial protection. Fine Penfield dissectors were
employed for much of this process and supported with sharp dissection
when necessary. Great caution was used in the subcoronary areas where
the margin of the stentless bioprosthesis was extremely intimate with
the ostium of the coronary arteries. Removal of the stentless valve in
this area often left a ridge or flap of tissue near the inferior margin
of the main coronary artery. In such instances this area was reinforced
with several 7-0 prolene sutures. When a surgical valve-in-valve
technique was performed, 4-0 Ethibond pledgeted sutures were used, and
the fragile tissue of the remaining porcine annulus was avoided. In
these instances the native aortic annulus was covered by the stentless
sewing cuff and therefore not visible. Sutures were placed just below
the inferior margin of the cuff and exited through the stentless valve
sewing ring ensuring good anchoring of the stented prosthesis that was
being implanted. Maintenance cold blood cardioplegia at 8-12 degrees
Celsius was given selectively into the coronary ostia at twenty-minute
intervals for the duration of the procedure.\textbf{Statistical
Analysis}: Descriptive statistics were computed for the study cohort.
Continuous variables were summarized by reporting the median and ranges.
Categorical variables were reported as N (\%) in frequency
tables.\textbf{Results}: All patients (n=24) received a Freestyle Aortic
Root Bioprosthesis for their initial operation due to disease from
aortic valve pathology. All patients had their initial stentless surgery
performed by the same surgeon at the Sudbury Regional Hospital, Sudbury,
Ontario. All patients had their initial valve inserted with the modified
subcoronary implantation technique. Preoperative status and
comorbidities of the patients are outlined in Table 1. The stentless
valve required reoperation on average after 9.8 years, with aortic
insufficiency as the mode of failure in all cases except one.
Intraoperative examination of the stentless valve and the aortic root
revealed a linear tear at or near the base of one of the leaflets. The
leaflets, although demonstrating remarkably little calcification, were
extremely brittle with minimal traction or manipulation. There were no
serious adverse events which occurred during re-sternotomy. All five
patients who underwent the valve-in-valve technique received a
biological tissue valve. 37.5 \% (N=9) of patients required a
concomitant procedure, predominantly coronary artery bypass grafting.
Surgical variables and characteristics are outlined in Table 2. In
patients where the stentless valve was explanted (N=15), the root was
preserved in 100\% of cases, with no need for a conversion to a Bentall
procedure. Of the 24 patients who underwent this procedure, 10 received
mechanical valves and 14 received a stented aortic prosthesis. In 5 of
these patients, the stentless leaflets were removed, and the new valve
was sutured to the native annulus (valve-in-valve technique). Urgent
surgeries were required in 20.8\% (n= 5) of the cases, mostly due to
hemodynamic compromise or endocarditis. Mean cross-clamp time was 156
minutes. 30- day outcomes revealed no post-operative myocardial
infarctions, or strokes, with only one patient suffering from new onset
renal failure. Hospital length of stay averaged 7.5 days. The single
in-hospital mortality was an immunocompromised patient presenting with
Staphylococcus aureus endocarditis involving the Freestyle valve.
Intraoperatively, the valve was successfully explanted, however the
patient required a concomitant repair of a ventricular septal defect,
reconstruction of the left ventricular outflow tract, and concomitant
coronary artery bypass grafting to the left anterior descending artery.
The patient had a significantly lengthy cardiopulmonary bypass run, with
post-operative coagulopathy and left ventricular dysfunction,
necessitating mediastinal re-exploration twice. The patient subsequently
expired on post-operative day 5 of multi-system organ failure. Follow-up
at 2 months post-operatively and then once annually was performed. All
patients had improved functional status with all in NYHA Functional
Classes I-II. None of the valve-in-valve patients had a measurable
paraprosthetic leak and two of the patients ultimately required
re-interventions on their replaced aortic valves. One patient had a TAVR
procedure performed eightt years later, and one patient underwent a
third sternotomy with a tissue aortic valve replacement. Procedural
outcomes are detailed in Table 3. The 5-year mortality was 4\% (n=1),
who was the in-hospitality mortality identified above. The 10-year
mortality was 16.7\% (n=4). Causes of death included two patients with
acute renal failure and encephalopathy, and one patient with
Staphylococcus aureus endocarditis and acute renal failure. The 10-year
all-cause mortality was 33\% (n=8). Of these 4 deaths, 2 were secondary
to metastatic cancers and 2 were listed as death secondary to
multi-system organ failures.\textbf{Comment}: In this study, we
summarized a retrospective review of a single surgical team's experience
of reoperative surgery for failing, predominantly regurgitant, stentless
valves. The primary findings of the study are as follows. The 30-day
mortality was 4\% (1/24) for all patients, and the long-term cardiac
10-year mortality was 16\% (4/24) for all patients. The primary
operative method involved complete explantation of the stentless
xenograft, without incurring any damage to the root necessitating the
need for a complete root replacement. In their own retrospective series,
Borger and colleagues\textsuperscript{9} reported an operative mortality
of 11\% with 63\% of patients requiring aortic root replacements,
despite specifically attempting to preserve the pre-existing native
aortic root. In a similar study, Boning and
colleagues\textsuperscript{10} reported a 21\% (5/24) 30-day operative
mortality following their stentless reoperations, which was higher than
the 4\% operative mortality in their patients who had a stented aortic
valve reoperation. Our only early mortality was in a patient who had an
active infection of their stentless valve, highlighting the further
complexity in removing not only the stentless valve, but adjacent
structures which were involved in the infectious process. In our hands,
while all attempts were made to completely remove the stentless valve,
if annular dimensions were adequate in an otherwise relatively higher
risk patient, a stented valve was implanted within the stentless casing.
Similar to other centres\textsuperscript{8}, our reoperative approach to
stentless valves has evolved over the years, with the potential role for
valve-in-valve TAVR in this particular setting. However, several
difficulties and potential complications still have to be considered
with this approach: the initial implantation technique of the stentless
valve, the bulky nature of the leaflet tissue, lack of annular
calcification, device malpositioning due to lack of anatomic markers to
guide landing zones and coronary
obstruction.\textsuperscript{11-13}Future studies will need to analyze
the long term impact of valve-in-valve TAVR prior to committing to this
approach for stentless reoperations as a primary approach.

\textbf{Limitations:}

The primary limitation of our study is its retrospective nature and
small sample size. In combination with the small sample size, the very
low event rate of major adverse events including death makes statistical
analysis difficult. However, few studies report longitudinal and
complete follow-up of all patients up to 10 years. While we acknowledge
the limitations of this study, we still feel the results indicate that
redo surgery for a failing stentless valve can still be considered a
reasonable option with good long-term
outcomes.\textbf{Acknowledgements/Disclosures:}None.\textbf{Author
Contributions:}Bindu Bittira: Article concept and design, data analysis
and interpretation, drafting of original article and critical revision,
longitudinal data collection. Derek MacDonald: Article concept and
design, data analysis and interpretation, drafting of original article
and critical revision, longitudinal data collection. Mohammed Shurrab:
Critical revision of article. Stacey Santi: Data analysis and
interpretation, review of article. Sarah Grieve: Data
collection.\textbf{References}:

\begin{enumerate}
\tightlist
\item
  Yun KL, Sintek CF, Fletcher AD, et al. Aortic valve replacement with
  the freestyle stentless bioprosthesis: five-year experience.
  Circulation 1999;100:II17-23.
\item
  Baur LH, Houdas Y, Peels KH, et al. Stentless bioprostheses have ideal
  haemodynamics, even in the small aortic root. Int J Card Imaging
  2000;16:359-64.
\item
  Christ T, Grubitzwch H, Claus B, Heinze G, Dushe S, Konertz W.
  Hemodynamic behavior of stentless aortic valves in long term
  follow-up. Journal of cardiothoracic surgery 2014;9:197. {[}PubMed:
  25527116{]}.
\item
  Bach DS, Kon ND, Dumesnil JG, Sintek CF, Doty DB. Ten-year outcome
  after aortic valve replacement with the freestyle stentless
  bioprosthesis. The Annals of Thoracic surgery 2005;80(2): 480-486;
  discussion 486-487. {[}PubMed: 16039189{]}.
\item
  Bach DS, Kon ND. Long-term clinical outcomes 15 years after aortic
  valve replacement with the freestyle stentless aortic bioprosthesis.
  The Annals of thoracic surgery 2014;97(2):544-551. {[}PubMed:
  24140209{]}.
\item
  Finch J, Roussin I, Pepper J. Failing stentless aortic valves: redo
  aortic root replacement or valve in a valve? European Journal of
  Cardio-Thoracic Surgery 2013;43:495-504.
\item
  Patel PM, Chen EP. Case Report: Challenging surgical management of
  failed freestyle stentless porcine valve:two case reports. Journal of
  Visualized Surgery. 2021; http://dx,diu,irg/10.21037/jovs-20-121.
\item
  Grubitzsch H, Zobel S, Christ T, et al. Redo procedure for degenerated
  stentless aortic zenografts and the role of valve-in-valve
  transcatheter techniques. European Journal of Cardio-Thoracic Surgery.
  2017;51:653-659.
\item
  Borger MA, Prasongsukarn K, Armstrong MS et al. Stentless Aortic Valve
  Reoperations: A Surgical Challenge. Ann Thorac Surg 2007;84:737-44.
\item
  Boning A, Niemann B, Ennker I et al. Are aortic valve reoperations
  after primary replacement with stentless heart valve prostheses more
  demanding than after stented biological prostheses? The Thoracic and
  cardiovascular surgeon. 2014;62(6):475-481.
\item
  Webb, JG, Dvir D. Transcatheter aortic valve replacement for
  bioprosthetic aortic valve failure: the valve-in-valve procedure.
  Circulation 2013;127:2542-550.
\item
  Lange R, Piazza N. Transcatheter aortic valve-in-surgical aortic valve
  implantation: current status and future perspectives. Eur J
  Cardiothoraci Surg 2013;44:403-6.
\item
  Bapat V, Davies W, Attia R, Hancock J, Bolter K, Young C et al. Use of
  balloon expandable transcatheter valves for valve-in-valve
  implantation in patients with degenerative stentless aortic
  bioprosthesis: technical considerations and results. J Thorac
  Cardiovasc Surg. 2014;148:917-24.
\end{enumerate}

Table 1. Population characteristics, preoperative status and
comorbidities of patients who received stentless valve reoperation
(N=24)\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{N (\%)}\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{N (\%)}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Sex\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Sex\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Sex\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Male\\
Female\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
18 (75.0) 6 (25.0)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
18 (75.0) 6 (25.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Smoking status\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Smoking status\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Smoking status\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Smoker\\
Non-smoker\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
7 (29.2) 17 (70.8)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
7 (29.2) 17 (70.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Age/Age at death (years)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
71.5 (median) (range 58-92)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
71.5 (median) (range 58-92)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Age at first operation (years)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
53.5 (median) (range 40-69)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
53.5 (median) (range 40-69)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Age at second operation (years)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
62.5 (median) (range 47-82)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
62.5 (median) (range 47-82)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Time between first and second operation (years)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
9.8 (average) (range 6-13)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
9.8 (average) (range 6-13)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
New York Heart Association (NYHA) Functional Classification Scale\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
New York Heart Association (NYHA) Functional Classification Scale\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
New York Heart Association (NYHA) Functional Classification Scale\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
I\\
II\\
III\\
IV\\
n/a\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
0 (0) 3 (12.5) 14 (58.3) 6 (25.0) 1 (4.2)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
0 (0) 3 (12.5) 14 (58.3) 6 (25.0) 1 (4.2)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
LV Grade (1-4)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
LV Grade (1-4)\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
LV Grade (1-4)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
1\\
2\\
3\\
4\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
18 (75.0) 6 (25.0) n/a n/a\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
18 (75.0) 6 (25.0) n/a n/a\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{No}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{Yes}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Comorbidities\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{N (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{N (\%)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Hypertension\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
6 (25.0)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
18 (75.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Cholesterol\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
13 (54.2)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
11 (45.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Diabetes mellitus\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
22 (91.7)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
2 (8.3)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Cerebrovascular accident (CVA)/Transient ischemic attack (TIA)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
24 (100.0)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
0 (0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Chronic renal failure (CRF)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
22 (91.7)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
2 (8.3)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Coronary artery disease (CAD)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
18 (75.0)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
6 (25.0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Peripheral vascular disease (PVD)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
23 (95.8)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (4.2)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Atrial fibrillation\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
21 (87.5)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
3 (12.5)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
AI\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (4.2)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
23 (95.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
AS\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
22 (91.7)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
2 (8.3)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Endocarditis\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
22 (91.7)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
2 (8.3)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Structural valve deterioration\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (4.2)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
23 (95.8)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table 2 Surgical variables and surgical characteristics of patients who
received stentless valve reoperation (N=24)\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
\begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{No}\strut
\end{minipage} & \begin{minipage}[b]{0.30\columnwidth}\raggedright\strut
\textbf{Yes}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{N (\%)}\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\textbf{N (\%)}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
Surgical variables\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.30\columnwidth}\raggedright\strut
\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Urgent surgery\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
19 (79.2)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
5 (20.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Elective surgery\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
5 (20.8)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
19 (79.2)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Concomitant procedure\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
15 (62.5)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
9 (37.5)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Mechanical valve\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
14 (58.3)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
10 (41.7)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Tissue valve\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
10 (41.7)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
14 (58.3)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Valve-in-valve\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
19 (79.2)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
5 (20.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Intra-op Bentall procedure\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
24 (100.0)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
0 (0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Transfusion\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
4 (16.7)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
20 (83.3)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Ventricular assist device (VAD)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
24 (100.0)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
0 (0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Post-op myocardial infarct (MI)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
24 (100.0)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
0 (0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Stroke\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
24 (100.0)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
0 (0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
New onset renal failure\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
23 (95.8)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
1 (4.2)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Permanent pace maker required\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
24 (100.0)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
0 (0)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Re-operation bleeding\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
22 (91.7)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
2 (8.3)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Second re-op\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
22 (91.7)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
2 (8.3)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Cross-clamp time (min)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
155.7 (average) (range 72-319)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
155.7 (average) (range 72-319)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
Bypass time (min)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
201.04 (average) (range 117-355)\strut
\end{minipage} & \begin{minipage}[t]{0.32\columnwidth}\raggedright\strut
201.04 (average) (range 117-355)\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Table 3. Procedural outcomes in patients who underwent stentless valve
reoperation (N=24)\selectlanguage{english}
\begin{longtable}[]{@{}lll@{}}
\toprule
& \textbf{No} & \textbf{Yes}\tabularnewline
\midrule
\endhead
& \textbf{N (\%)} & \textbf{N (\%)}\tabularnewline
Procedural Outcomes & &\tabularnewline
Intra-op mortality & 24 (100.0) & 0 (0)\tabularnewline
In-hospital mortality & 23 (95.8) & 1 (4.2)\tabularnewline
30-day mortality & 23 (95.8) & 1 (4.2)\tabularnewline
5-year mortality & 23 (95.8) & 1 (4.2)\tabularnewline
10-year mortality & 20 (83.3) & 4 (16.7)\tabularnewline
10-year all-cause mortality & 16 (66.7) & 8 (33.3)\tabularnewline
Hospital length-of-stay (days) & 7.5 (range 2-20) &\tabularnewline
\bottomrule
\end{longtable}

\selectlanguage{english}
\FloatBarrier
\end{document}

