To compare the midterm outcomes of the Bentall procedure versus isolated aortic valve replacement (AVR) in patients with bicuspid aortic valve (BAV) complicated with severe stenosis and ascending aortic dilation in order to assess the therapeutic value of these surgical approaches for this complex cardiac condition.

A retrospective cohort study was conducted on 96 eligible patients who underwent surgical treatment in our institute between January 2018 and December 2022. According to surgical approaches, they were divided into an AVR group (65 cases) and a Bentall group (31 cases). Demographic features, comorbidities, preoperative status, and echocardiographic parameters were collected in all patients. Propensity score matching (PSM) was applied in a 1:1 ratio to balance baseline characteristics. Perioperative indicators and follow-up data were compared and analyzed between matched cohorts after control of cofounding factors.

After PSM, 25 matched pairs were screened out and analyzed with comparable baseline data (all P>0.05). The Bentall group demonstrated significantly more superior intraoperative effective orifice area (EOA, 2.69±0.47 vs 2.35±0.47 cm², P=0.013) and EOA index (EOAI, 1.69±0.30 vs 1.47±0.29 cm²/m², P=0.010), and obviously longer cardiopulmonary bypass time [190.00 (147.00, 257.00) vs 101.00 (88.50, 124.50) min, P<0.01] and aortic cross-clamp time [141.00 (120.00, 166.00) vs 66.00 (55.00, 81.50) min, P<0.01] when compared with the AVR group. During a median followup of 28 months, the AVR group had notably larger aortic sinus diameter [32.00 (30.00, 34.00) vs 26.80 (26.00, 28.00) mm, P<0.01] and ascending aortic diameter [38.00 (34.50, 42.00) mm vs 26.00 (26.00, 28.00) mm, P<0.01], with ongoing dilation in the ascending aorta, while the Bentall group maintained stable dimensions. The Bentall group also showed statistically lower peak aortic valve pressure gradients [21.00 (15.50, 27.00) vs 25.00 (19.50, 31.00) mmHg, P=0.049].

Both Bentall procedure and AVR are effective in treatment of BAV complicated with severe stenosis and ascending aortic dilation. But, Bentall procedure offers advantages in hemodynamic optimization and aortic stability.

Currently, endovascular interventional therapy represents the primary clinical approach for vascular lesions. Restenosis caused by mechanical procedures, however, has become increasingly prominent. This study aimed to explore the feasibility and underlying mechanisms of naked plasmid encoding hepatocyte growth factor (HGF) for preventing post-interventional luminal restenosis through a rat animal model and in vitro experiments.

① A rat carotid artery injury model was established by pulling inflated balloon. Eighteen male SD rats (6 to 8 weeks old, weighing 260 to 280 g) were randomly divided into a sham operation group, normal saline group, and HGF group (adentitial injection of HGF naked plasmid) (n=6 for each group). Peak systolic velocity was measured using carotid ultrasound, and the area of the vascular intima and HGF expression were assessed through HE staining and HGF immunofluorescence staining, respectively. The expression levels of phenotypic markers in the carotid media were determined by Western blotting. ② Vascular endothelial cells (ECs) and vascular smooth muscle cells (VSMCs) were obtained from rat carotid arteries through primary culture, and both ECs and VSMCs were transfected with the plasmids haboring HGF. The proliferative and migratory abilities of transfected and untransfected ECs were assessed through CCK-8 assay and cell scratch assay, respectively. After Ang Ⅱ-induced VSMC transformation, the effects of Ang Ⅱ induction alone, Ang Ⅱ induction followed by HGF plasmid transfection, Ang Ⅱ induction followed by exogenous HGF treatment on VSMC migratory ability were detected by cell scratch assay, and the expression levels of phenotypic markers in VSMCs were determined by RT-qPCR and Western blotting.

① Animal experiments showed that, compared with the normal saline group, the peak systolic velocity of the carotid artery in the HGF group was significantly lower on post-injury day 3 and day 7(day 3: 422. 62±16. 99 vs 1050. 58±40. 92 mm/s; day 7: 631. 81±26. 11 vs 1309. 78±73. 13 mm/s; P<0. 001), the increase in carotid artery intimal area was significantly less (day 3: 0. 16±0. 03 vs 0. 83±0. 09 mm²; day 7: 0. 17±0. 03 vs 1. 15±0. 31 mm²; P<0. 001), the green fluorescence intensity of HGF in the carotid artery tissue was significantly higher (P<0. 001), and the protein expression levels of synthetic phenotype markers vimentin, OPN, and PCNA were all significantly lower (P<0. 001), whereas the protein expression level of contractile phenotype marker α-SMA was comparable (P>0. 05). ② Cell experiment results showed that, compared with untransfected ECs, HGF plasmid-transfected ECs exhibited significantly enhanced proliferative activity and migratory ability (P<0. 05). Compared with VSMCs receiving Ang Ⅱ induction alone, both Ang Ⅱ-induced VSMCs subsequently transfected with HGF plasmid and those treated with exogenous HGF demonstrated significantly reduced migratory ability (P<0. 01), significantly decreased mRNA and protein expression levels of the synthetic phenotype marker vimentin (P<0. 05), and significantly elevated mRNA and protein expression levels of the contractile phenotype marker SM-MHC (P<0. 05).

HGF may promote vascular re-endothelialization and inhibit intimal hyperplasia by enhancing the proliferative and migratory abilities of vascular ECs and inhibiting the transition of VSMCs to a synthetic phenotype.

To observe the clinical efficacy of Redo-Bentall surgery in the reoperation of aortic root lesions.

A retrospective analysis was performed on 46 patients who underwent Redo-Bentall surgery for aortic root lesions in our department from June 2010 to April 2022. They were 35 males and 11 females, at a mean age of 43.37±12.79 years, in 4.96±6.76 years since the last operation. General clinical data in perioperative period and during follow-up were collected and analyzed. Kaplan-Meier survival analysis was used to compare the survival rates of each etiological group.

There were 9 cases of central end otitis, 12 cases of Behset's disease, and 25 cases of other causes. After operation, 4 cases (8.70%) experienced cardiac arrest, 4 cases (8.70%) renal failure, 2 cases (4.35%) gastrointestinal bleeding, 2 cases (4.35%) new third-degree atrioventricular block and 2 cases (4.35%) permanent pacemaker placement. In perioperative period, 3 cases (6.52%) died in hospital. During a mean follow-up of 5.03±3.27 years after discharge, 5 cases (11.63%) were lost to follow-up, 1 case died (2.33%), 1 case had lacunar infarction (2.33%), and no severe bleeding or embolism complications was observed in the rest patients. The long-term survival rate was significantly lower in the endocarditis group (62.3%) and the Behcet's disease group (70%) than the other etiological groups (80%, P < 0.05).

The application of Redo-Bentall in the reoperation of aortic root lesions is safe and effective, but the survival rate is quite lower in the patients with infective endocarditis and Behcet's disease.