OBJECTIVES: Aortic valve repair/sparing techniques have been established as effective treatments for aortic regurgitation and/or aortic aneurysms. However, concerns remain regarding long-term durability, reproducibility and patient selection. This study aims to asses long-term clinical and echocardiographic outcomes, with a focus on aortic regurgitation grade and left ventricular ejection fraction evolution, in adults undergoing these procedures. METHODS: Adult patients in the Heart Valve Society Aortic Valve Database, undergoing any aortic valve repair/sparing technique were included. Time-to-event analyses were used for clinical outcomes and mixed-effects models for left ventricular ejection fraction and aortic regurgitation grade evolution. Techniques: isolated valve repair (group 1), ascending aortic replacement + valve repair (group 2), partial-root replacement ± valve repair (group 3) and valve-sparing root replacement ± valve repair (group 4). RESULTS: Survival at 10 years was comparable to survival of the matched-general-population in each group. The 10-year cumulative incidence of reintervention was 19.5% [95% confidence interval (CI) 16.70–22.40%] in group 1 [including only double external annuloplasty in group 1; reintervention was not significantly different between techniques (P = 0.112)]; 13.8% (95% CI 10.10–18.10%) in group 2; 12.7% (95% CI 5.50–22.90%) in group 3; and 8.5% (95% CI 7.00–10.10%) in group 4 (P < 0.001). Severe preoperative aortic regurgitation grade [hazard ratio 1.95 (95% CI 1.19–3.21), P < 0.001] and left ventricular end-diastolic diameter [hazard ratio 1.03 (95% CI 1.00–1.05), P < 0.001] were predictive of reintervention in group 4; patch use was a predictor in all groups. The predicted left ventricular ejection fraction (%) initially increased (P < 0.001) and then stabilized. CONCLUSIONS: This study found that aortic valve repair/sparing techniques provide viable and effective treatment options that should be considered for all eligible patients with aortic regurgitation and/or aortic root/ascending aortic aneurysms, given their potential to restore life expectancy and provide good haemodynamic outcomes with an acceptable hazard of reintervention.

Primary isolated aortic regurgitation (AR) is defined as aortic valve (AV) incompetence in the absence of significant dilation of the aortic root and ascending aorta (AscAo), with diameters <40 mm. According to ESC/EACTS valve guidelines, surgery is recommended for symptomatic patients with severe AR, and selected asymptomatic patients with high-risk features, including left ventricular dysfunction. ¹ Concomitant replacement of the aortic root or ascending aorta should be considered when the diameter exceeds 45 mm, considering factors such as age, body surface area, bicuspid aortic valve (BAV), and intraoperative findings. ¹ However, data specifically addressing patients with AR and intermediate aortic dimensions (<45 mm) remain limited, especially with regard to potential growth of the aortic root and ascending aorta. ^2–4 To evaluate the suitability of isolated Aortic Valve repair (AVr) for primary AR in the context of possible future aortic enlargement. Data were obtained from Heart Valve Society (HVS) Aortic-Valve-Database (recruitment period 1998-2024). Definitions and outcomes are available on the HVS website (https://www.hvs.com). Each participating center obtained local ethical approval to collect and share data with the HVS AV database (Erasmus MC: MEC-2020–0890).

MicroRNA 451 (miR-451) is emerging as a pivotal mediator of cardiac damage in experimental models of diabetic cardiomyopathy. Whether miR-451 plays a detrimental role in the human diabetic myocardium is unknown. The present study investigates miR-451’s role in patients with type 2 diabetes (T2D). We show that miR-451 is upregulated in myocardial specimens from T2D patients compared to controls without diabetes and correlates with cardiometabolic parameters, the myocardial triglyceride content and cardiac expression of lipotoxic genes as well as echocardiographic indices of left ventricular dysfunction. Calcium-binding protein 39 (Cab39)—a known target of miR-451 in mouse hearts—was downregulated in T2D patients vs. controls, and its expression negatively correlated with that of miR-451. In cultured human cardiomyocytes (CMs), Ago2 immunoprecipitation confirmed Cab39 to be a direct target of miR-451. Treatment with a high amount of glucose (25mM) and palmitic acid (PA) mimicked miR-451 upregulation and Cab39 downregulation in human CMs. These changes were associated with increased TGs and markers of lipotoxic injury, such as elevated oxidative stress levels, mitochondrial dysfunction and apoptosis. Targeting miR-451 led to restoration of Cab39 levels while rescuing diabetes-induced lipotoxic injury and metabolic dysfunction. By contrast, miR-451 overexpression recapitulated features of lipotoxic damage. Our findings indicate miR-451 to be a potential target for the prevention of myocardial lipotoxic injury in diabetes.

Clinical decision-making for individuals undergoing valvular and aortic surgery remains challenging, particularly in young patients facing lifelong risk and repeated interventions. As predictive technologies such as artificial intelligence and advanced statistical modelling evolve, the surgical community must ensure that key foundational elements, namely data governance, including data standardization, and regulation, are firmly in place. Without high-quality, standardized, and ethically governed data, predictive models risk offering misleading guidance rather than meaningful personalization. While data governance ensures the scientific robustness of predictive technologies, shared decision-making (SDM) ensures these innovations remain closely aligned with the lived experiences, values, and preferences of individual patients. This perspective emphasizes that advancing decision-making in aortic surgery requires deliberate investment in building data ecosystems and fostering SDM communication practices, ensuring that innovation is both scientifically sound and truly responsive to patient needs.