Enrico Ferrari, is a graduate of Turin Medical School (MD) in Italy and received Cardiovascular surgery training at University of Padova (Italy), Catharina Hospital of Eindhoven (The Nederland), and at University of Lausanne (Switzerland). He received special training in minimally invasive cardiac surgery and transcatheter heart valve procedures at University Hospital of Lausanne, Switzerland, where he became Associate Professor in 2010. Since 2015, he works as team leader at Cardiocentro Ticino Foundation in Lugano, Switzerland, and continues the academic career at Cardiovascular Research Unit of Lausanne. He is a member of the STS/AATS joint workforce on New Technology (2011-2018) and STS workforce on International Relationship 2011-2018. He is Associate Editor of the Interactive Cardiovascular and Thoracic Surgery Journal (ICVTS), member of the Editorial Board of the Archive of Sciences Journal, and member of the Editorial Board of the Multimedia manual of Cardio-Thoracic Surgery (MMCTS).


The aim of this brief report is to show technical details and feasibility of balloon-expandable stent-valve implantation in aortic position during conventional redo open-heart surgery in overweight patients with small-sized mechanical aortic prosthesis and patient-prosthesis mismatch.

Methods and results
Two consecutive symptomatic overweight patients (BMI of 31 and 38) with small mechanical aortic prosthesis (a 4 year-old 21mm Hancock II valve and a 29 year-old 23mm Duromedic valve), increased gradients (59/31mmHg and 74/44mmHg) and reduced indexed effective orifice area (0.50cm2/m2 and 0.43cm2/m2) were treated successfully with surgical implantation of two 26mm balloon-expandable SapienTM 3 valves during redo procedures. Under full sternotomy, cardiopulmonary bypass and cardioplegic arrest the stent-valves were implanted under direct view through the aortotomy and after mechanical valves removal. In one patient, a concomitant regurgitant mitral valve was replaced with a standard bioprosthesis. Aortic cross clamp times were 162 and 126 minutes; cardiopulmonary bypass times were 178 and 180 minutes; total surgical times were 360 and 318 minutes. At discharge, the echocardiographic control showed transvalvular peak and mean gradients of 13/9mmHg and 23/13mmHg, and indexed effective orifice areas of 0.64cm2/m2 and 1.08cm2/m2. The 3-month echocardiographic control showed transvalvular peak and mean gradients of 18/9mmHg and 19/11mmHg, and indexed effective orifice areas of 0.78cm2/m2 and 0.84cm2/m2, with improved symptoms.

Balloon-expandable stent-valve implantation during redo open-heart surgery is feasible and safe and prevents patient-prosthesis mismatch in overweight and obese patients. Moreover, in case of stent-valve degeneration this approach allows for additional valve-in-valve procedures with big-size stent-valves and prevents high-risk re-redo surgery