Successful explantation of an EDWARDS INTUITY rapid deployment valve with Yang annular enlargement

Successful explantation of an EDWARDS INTUITY rapid deployment valve with Yang annular enlargement | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Successful explantation of an EDWARDS INTUITY rapid deployment valve with Yang annular enlargement Julian Marsh, Castigliano Bhamidipati, Julie Doberne This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7852144/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted 15 You are reading this latest preprint version Abstract Background: Rapid deployment aortic valves, such as the Edwards Intuity valve, shorten implantation times and facilitate less-invasive approaches. The features that enable the valve’s rapid deployment pose a technical challenge if explant is required, as in the instance of endocarditis or structural valve deterioration (SVD), because the prosthesis often becomes densely embedded in surrounding cardiac structures. Although international reports describe Intuity and Perceval explants, none have been reported from the United States with annular enlargement. Clinical Presentation: A 69 year old woman with a bicuspid aortic valve underwent mini-thoracotomy aortic valve replacement eight years prior with a 23 mm Edwards Intuity valve. Seven years postoperatively she presented with progressive dyspnea and an initial echocardiography showed moderate prosthetic stenosis (valve area 1.3 cm²). After several months of observation, she returned with severe stenosis (mean gradient 60 mmHg, valve area 0.78 cm²). Valve-in-valve transcatheter aortic valve replacement was considered, but surgery was favored given her small valve size and relatively young age. At reoperation, the prosthesis was densely adherent to the aortomitral curtain and left ventricular outflow tract, necessitating transection and careful dissection for safe removal. A Yang Y-incision annular enlargement allowed implantation of a 25-mm Edwards Inspiris Resilia valve. She was discharged on postoperative day 5 and follow-up showed excellent recovery in normal sinus rhythm. Conclusion: Explantation of the Edwards Intuity rapid deployment valve with Yang Y-incision annular enlargement is feasible and safe, offering a surgical option for SVD. Valve explant Rapid deployment valve Annular enlargement Yang technique Figures Figure 1 Figure 2 Background Rapid deployment prosthetic aortic valves, such as the Intuity Valve (Edwards Lifesciences, Irvine, CA) and the Perceval Valve (Corcym, Saluggia, Italy), shorten implantation time and enable less-invasive cardiac surgery [ 1 ]. Since their introduction in the early 2010s, rapid deployment valves have accounted for approximately 10–15% of surgical aortic valve replacements (SAVR) in European practice, whereas uptake in the United States has been more limited [ 2 , 3 ]. Although these valves provide operative advantages, their widespread adoption has been limited by concerns of complications. In comparative studies, patients receiving Intuity valves experienced substantially shorter cross-clamp times (e.g., ~ 52 min vs ~ 74 min) and cardiopulmonary bypass times (~ 83 min vs ~ 102 min) compared to conventional aortic valve replacement (AVR) using traditional bioprosthetic valves [ 4 ]. However, despite these advantages, several limitations of rapid-deployment valves have been reported. Studies have shown an increased risk of postoperative conduction disturbances, particularly a higher rate of permanent pacemaker implantation [ 5 ]. Additional concerns include paravalvular leakage and the technical challenges of prosthesis explantation in the setting of structural valve deterioration (SVD) [ 2 , 5 ]. These limitations are particularly consequential in younger patients, who are more likely to outlive their initial bioprosthetic valve and may require explantation and reoperation. Younger AVR patients for whom vitamin K antagonists are contraindicated will be more likely to outlive the lifespan of their bioprosthetic valves. In such cases, explantation of the degenerated valve and SAVR may be preferred. This approach can be technically challenging because the prosthesis often becomes densely embedded in surrounding cardiac structures, making removal difficult and increasing the risk of damaging the aortic annulus or conduction system [ 6 ]. Although international case reports have described explantation of Perceval and Intuity valves [ 6 , 7 , 8 , 9 ], to our knowledge, there are no published reports describing explantation of a rapidly deployed Intuity valve in the United States. This report describes a patient who presented with SVD after a rapid deployment of an Edwards Intuity valve. They underwent successful explantation of the rapid deployment Edwards Intuity valve and SAVR using an Edwards Inspiris Resilia bioprosthetic valve with annular enlargement. Clinical Summary A 69 year old woman with a history of a bicuspid aortic valve had previously undergone mini-thoracotomy AVR eight years earlier with placement of a 23-mm Edwards Intuity rapid-deployment valve. At the time of implant, her BSA was 1.91 m²; the purported effective orifice area of the Intuity valve was 1.05 cm². Seven years postoperatively, she developed worsening dyspnea that limited her daily activities. An echocardiogram at this time demonstrated a normally functioning left ventricle (ejection fraction 65–70%) and a well-seated prosthesis, but with cusp immobility, an average valve orifice area of 1.3 cm², and findings consistent with moderate prosthetic aortic stenosis. Given her preference, a period of medical management and weight loss was pursued. Several months later, she re-presented with worsening symptoms, when a repeat echocardiography revealed severe prosthetic aortic stenosis, with a mean pressure gradient of 60 mmHg, valve area of 0.78 cm², peak velocity of 5.2 m/s, and a slight decline in preserved ejection fraction to 50–55%. She denied chest pain, edema, or palpitations. Coronary angiography demonstrated normal coronary anatomy. The patient was evaluated by the multidisciplinary valve team and though a valve-in-valve transcatheter aortic valve replacement was thought to be technically feasible, surgery was preferred due to her small prior valve, active lifestyle, and need for long-term durability. Surgery would allow for annular enlargement and a larger valve, facilitating future valve in valve options if needed. After the patient was fully informed of the risks and benefits of the surgery, the patient elected to proceed with valve explant and reoperative SAVR using a 25 mm Edwards Inspiris Resilia bioprosthetic valve. A resternotomy was performed, revealing dense adhesions around the aorta and heart. The patient was placed on standard bicaval cannulation for cardiopulmonary bypass under low to moderate systemic hypothermia. The prior Intuity valve was immobile and densely adherent to the left ventricular outflow tract and aortomitral curtain ( Fig. 1 A ) . Blunt dissection was used to free one side of the prosthesis to support removal of the valve from the annulus. Wire cutters were used to transect the prosthetic ring, which was then rolled inward and dissected off the annulus ( Fig. 1 B ) . Following explant, a defect in the noncoronary sinus extending into the aortomitral curtain was noted but fortunately was in the location of the planned annular enlargement patch. To enlarge the aortic annulus, the Yang Y-incision annular enlargement technique. was performed [ 10 ]. A diamond-shaped bovine pericardial patch was sewn to the mitral annulus from the left to right fibrous trigone and up to the transverse aortotomy using running 4 − 0 Prolene suture. This patch enlarged the annulus, allowing upsizing of the valve. A 25mm Edwards Inspiris valve was then implanted with orientation tailored to the patch position. To relieve tension on the aortotomy closure and re-establish normal sinotubular junction geometry, a 28mm Dacron interposition graft was trimmed and anastomosed to the ascending aorta. The graft was secured proximally to the sinotubular junction and distally to the proximal arch using running 4 − 0 Prolene. The aortic root was de-aired, the cross-clamp removed, and the patient was weaned from bypass in normal sinus rhythm. Cardiopulmonary bypass time was 285 minutes, with an aortic cross-clamp time of 236 minutes. During admission, her postoperative course was notable for intermittent accelerated junctional rhythm up to the time of discharge. She was deemed appropriate for discharge on postoperative day 5 without pacemaker placement. During her 14-day postoperative clinic visit, the patient demonstrated a stable recovery following SAVR. Follow-up transthoracic echocardiogram showed expected post-SAVR gradients and appropriate prosthetic valve positioning. A Zio patch monitor confirmed resolution of her postoperative junctional rhythm, with no evidence of recurrent junctional rhythm or significant arrhythmia. In addition, she denied any episodes of palpitations. The patient was continued on direct oral anticoagulation for three months post-operatively. Discussion As the use of surgical rapid deployment valves increases and extends into younger patients, there will be an increased demand for valve explantion due to SVD [ 11 ]. Removal of these prostheses is technically demanding because their unique subannular skirt and textured cuffs promote dense tissue integration [ 8 ]. Transcatheter aortic valve replacement can serve as an effective treatment for prosthetic valve failure but is often limited by anatomic constraints. However, existing literature indicates that explantation of rapid-deployment valves carries a higher operative risk compared to conventional prostheses, particularly when combined with complex root procedures [ 7 , 8 ]. The Edwards Intuity valve features a balloon-expandable stainless steel frame covered by a textured seal beneath the sewing cuff ( Fig. 2 A, B ) . Over time, this design predisposes the valve to firm adhesions, as further demonstrated by postoperative CT imaging of the footprint and subannular extension ( Fig. 2 C, D ) . In our case, these characteristics mandated painstaking dissection to safely excise the prosthesis while preserving aortic root integrity. Additionally, the application of the Yang Y-incision annular enlargement technique enabled both repair of a defect in the noncoronary sinus extending into the aortomitral curtain and upsizing from a 23-mm to a 25-mm prosthesis. This approach helped restore annular geometry and preserved future options for valve in valve intervention. To our knowledge, we report the first case in the United States of explantation of an Edwards Intuity rapid-deployment valve with subsequent SAVR using the Yang Y-incision annular enlargement technique. The operation was completed without major complications, despite a longer cross-clamp duration than typically reported [ 7 , 8 ]. This prolonged duration likely reflects the meticulous dissection and reconstruction required. In summary, our experience demonstrates that explantation of an Edwards Intuity rapid deployment valve can be performed safely with careful dissection and annular enlargement strategies. This method offers an effective solution for SVD in rapid deployment prostheses, while preserving the potential for future less invasive reinterventions. Abbreviations SVD structural valve deterioration SAVR surgical aortic valve replacement AVR aortic valve replacement Declarations Ethics approval and consent to participate: This case report was reviewed and approved by the Oregon Health & Science University Institutional Review Board (IRB #00028756) on June 6, 2025. Consent for publication : Written informed consent for publication of the clinical details and accompanying images was obtained from the patient. A copy of the consent is available for review by the editor upon request. Availability of data and materials: Not applicable. Competing interests: The authors declare that they have no competing interests. Funding Statement: This study received no external funding. Author Contributions: Julian Marsh drafted the manuscript. Dr. Castigliano Bhamidipati assisted in surgery, contributed to surgical description, and critical revision. Dr. Julie Doberne performed the surgery, supervised the project, provided critical revisions, and is the corresponding author. All authors read and approved of the final manuscript. Acknowledgments: Not applicable. References Bening C, Hamouda K, Oezkur M, Freude B, Hekmat K, Misfeld M, et al. Rapid deployment valve system shortens operative times for aortic valve replacement through anterior minithoracotomy. J Cardiothorac Surg. 2017;12:e27. Di Eusanio M, Berretta P. The sutureless and rapid-deployment aortic valve replacement international registry: lessons learned from more than 4,500 patients. Ann Cardiothorac Surg. 2020;9(4):289–97. Spadaccio C, Nenna A, Pisani A, Laskawski G, Nappi F, Moon MR, et al. Sutureless valves, a wireless option for patients with aortic valve disease: JACC state-of-the-art review. J Am Coll Cardiol. 2024;84(4):382–407. Wahlers TCW, Andreas M, Rahmanian P, Candolfi P, Zemanova B, Giot C, Ferrari E, et al. Outcomes of a rapid deployment aortic valve versus its conventional counterpart: a propensity-matched analysis. Innovations (Phila). 2018;13(3):177–83. Powell RG, Pelletier MP, Chu MWA, Bouchard D, Melvin KN, Adams C. The Perceval sutureless aortic valve: review of outcomes, complications, and future direction. Innovations (Phila). 2017 May–Jun;12(3):155–173. Kim YS, Yoo JS. Easy surgical explantation technique for sutureless Perceval S prosthesis, lasso technique: a case report. J Cardiothorac Surg. 2023;18:64. Sakurai H, Kawamoto N, Kainuma S, Suzuki K, Kakuta T, Hirayama M, et al. Simple surgical explant technique for the EDWARDS INTUITY rapid deployment valve: a case report of prosthetic valve endocarditis. Gen Thorac Cardiovasc Surg Cases. 2025;4:18. Uehara K, Shirakami T, Arai Y. Surgical explantation for a rapid deployment valve: the shave-and-hook technique. Interact Cardiovasc Thorac Surg. 2024;38(5):iv ae072. Di Bacco L, Pfeiffer S, Fischlein TJM, Santarpino G. Rapid explantation of rapid-deployment sutureless valve in case of acute endocarditis: how to remove safely sutureless Perceval S prostheses. Innovations (Phila). 2017;12(6):483–5. Yang B. Aortic annular enlargement with Y-incision/rectangular patch. Ann Cardiothorac Surg. 2024;13(3):285–93. Coti I, Werner P, Kaider A, El-Nashar J, Kocher A, Laufer G, et al. Aortic valve replacement with rapid-deployment bioprostheses: long-term single-center results after 1000 consecutive implantations. J Clin Med. 2025;14(5):1552. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 17 Apr, 2026 Read the published version in Journal of Cardiothoracic Surgery → Version 1 posted Editorial decision: Revision requested 25 Jan, 2026 Reviews received at journal 18 Jan, 2026 Reviews received at journal 18 Jan, 2026 Reviews received at journal 17 Jan, 2026 Reviewers agreed at journal 13 Jan, 2026 Reviews received at journal 11 Jan, 2026 Reviewers agreed at journal 10 Jan, 2026 Reviewers agreed at journal 10 Jan, 2026 Reviewers agreed at journal 08 Jan, 2026 Reviews received at journal 07 Jan, 2026 Reviewers agreed at journal 06 Jan, 2026 Reviewers invited by journal 06 Jan, 2026 Editor assigned by journal 15 Oct, 2025 Submission checks completed at journal 15 Oct, 2025 First submitted to journal 13 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7852144","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":570826600,"identity":"0b4956b4-e979-4cc0-9646-dd1bcc8802ee","order_by":0,"name":"Julian Marsh","email":"","orcid":"","institution":"Oregon Health \u0026 Science University","correspondingAuthor":false,"prefix":"","firstName":"Julian","middleName":"","lastName":"Marsh","suffix":""},{"id":570826601,"identity":"0fa8e90b-d2cc-4180-947c-fba287ca66b8","order_by":1,"name":"Castigliano Bhamidipati","email":"","orcid":"","institution":"Oregon Health \u0026 Science University","correspondingAuthor":false,"prefix":"","firstName":"Castigliano","middleName":"","lastName":"Bhamidipati","suffix":""},{"id":570826608,"identity":"ee9e85f4-c35c-423c-827c-803768550578","order_by":2,"name":"Julie Doberne","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYDCCAzxgSo5BAkwzE6/FmHQtiQ1Ea+E73nvwceUOm/R+6fZnEgwV1okNhLRInjmXbHj2TFruzDlnzCQYzqQT1mJwI8dMsrHtcO6GGzlsEoxth4nSYv6zse1/usGN9GcSjP+I02LG2Nh2IMHgRoKZBGMDEVpAfgE6LNlw5owcY4uEY+nGBLWAQuxjY5udPL9E+sMbH2qsZQlqQQUJpCkfBaNgFIyCUYALAAAWzEEVy+jcZgAAAABJRU5ErkJggg==","orcid":"","institution":"Oregon Health \u0026 Science University","correspondingAuthor":true,"prefix":"","firstName":"Julie","middleName":"","lastName":"Doberne","suffix":""}],"badges":[],"createdAt":"2025-10-13 20:23:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7852144/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7852144/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13019-026-04113-w","type":"published","date":"2026-04-17T15:57:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":100360531,"identity":"d5ee0dca-a27a-4ee9-9529-0b9cc6e857be","added_by":"auto","created_at":"2026-01-16 07:39:18","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":2387116,"visible":true,"origin":"","legend":"","description":"","filename":"IntuityValveExplantCaseStudy101325.docx","url":"https://assets-eu.researchsquare.com/files/rs-7852144/v1/c47fd6d510b495fa72c69307.docx"},{"id":100360767,"identity":"a531fed8-875b-4f8c-8813-996d9f13f367","added_by":"auto","created_at":"2026-01-16 07:42:33","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":5345,"visible":true,"origin":"","legend":"","description":"","filename":"248bb7d5deb343ca9876fa3ccaafde84.json","url":"https://assets-eu.researchsquare.com/files/rs-7852144/v1/3c2759e3e92d5fbbe97edbdd.json"},{"id":100005403,"identity":"18075aff-1957-4d71-9479-ec1738dc9254","added_by":"auto","created_at":"2026-01-12 05:33:53","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":37119,"visible":true,"origin":"","legend":"","description":"","filename":"248bb7d5deb343ca9876fa3ccaafde841enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7852144/v1/3a9faf9a99a5cc4fecc0563e.xml"},{"id":100361584,"identity":"fb57d7d4-d10d-4ecc-83c8-0602e3a80448","added_by":"auto","created_at":"2026-01-16 07:45:20","extension":"jpeg","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":86412,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7852144/v1/75b598bb68554fa3c7f23ef1.jpeg"},{"id":100361447,"identity":"e1ddf0c2-348c-40db-8bc0-7a0da16bd6c7","added_by":"auto","created_at":"2026-01-16 07:45:11","extension":"jpeg","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":469981,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7852144/v1/7d684f6104abfe0ce69612a4.jpeg"},{"id":100005408,"identity":"6f6af38f-6959-46b9-98d9-900d30aa0224","added_by":"auto","created_at":"2026-01-12 05:33:54","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":82271,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7852144/v1/062a4dba3ac28bfb6ff2eb74.png"},{"id":100005404,"identity":"681435d2-08e9-428d-b2b1-b9c0d893ca8e","added_by":"auto","created_at":"2026-01-12 05:33:53","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":128570,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7852144/v1/a136dc5c8e94a2a057f28b6b.png"},{"id":100361214,"identity":"7f28588d-292f-47d1-bdbc-4b4c9490014d","added_by":"auto","created_at":"2026-01-16 07:44:40","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":35558,"visible":true,"origin":"","legend":"","description":"","filename":"248bb7d5deb343ca9876fa3ccaafde841structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7852144/v1/25f87cf738b40fa268974520.xml"},{"id":100005409,"identity":"1847ea7d-8217-4eca-a844-ece9d4dfa637","added_by":"auto","created_at":"2026-01-12 05:33:54","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":42732,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7852144/v1/e3a64a6ac25f9d3f60a7992f.html"},{"id":100005402,"identity":"e0e3a084-48bd-4a03-9030-26d497139d11","added_by":"auto","created_at":"2026-01-12 05:33:53","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1065142,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Severely adherent Edwards Intuity rapid-deployment valve within the aortic annulus. (B) Gross specimen of the explanted Edwards Intuity prosthesis.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7852144/v1/c5ee2a27f42515c19539985e.png"},{"id":100005399,"identity":"2262c582-87ec-4322-8527-222a47391835","added_by":"auto","created_at":"2026-01-12 05:33:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":336317,"visible":true,"origin":"","legend":"\u003cp\u003eFluoroscopy (A, B) and CT (C,D) images demonstrating the Intuity valve footprint.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7852144/v1/136bea2ecf4fd005bb99b5e6.png"},{"id":107351059,"identity":"34e4d8ad-d99b-428d-9275-3809d2ba4089","added_by":"auto","created_at":"2026-04-20 16:08:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2384348,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7852144/v1/6734bca4-a0e7-4766-8bb5-88389cd1ecdb.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Successful explantation of an EDWARDS INTUITY rapid deployment valve with Yang annular enlargement","fulltext":[{"header":"Background","content":"\u003cp\u003eRapid deployment prosthetic aortic valves, such as the Intuity Valve (Edwards Lifesciences, Irvine, CA) and the Perceval Valve (Corcym, Saluggia, Italy), shorten implantation time and enable less-invasive cardiac surgery [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Since their introduction in the early 2010s, rapid deployment valves have accounted for approximately 10\u0026ndash;15% of surgical aortic valve replacements (SAVR) in European practice, whereas uptake in the United States has been more limited [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Although these valves provide operative advantages, their widespread adoption has been limited by concerns of complications.\u003c/p\u003e \u003cp\u003eIn comparative studies, patients receiving Intuity valves experienced substantially shorter cross-clamp times (e.g., ~\u0026thinsp;52 min vs\u0026thinsp;~\u0026thinsp;74 min) and cardiopulmonary bypass times (~\u0026thinsp;83 min vs\u0026thinsp;~\u0026thinsp;102 min) compared to conventional aortic valve replacement (AVR) using traditional bioprosthetic valves [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, despite these advantages, several limitations of rapid-deployment valves have been reported. Studies have shown an increased risk of postoperative conduction disturbances, particularly a higher rate of permanent pacemaker implantation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Additional concerns include paravalvular leakage and the technical challenges of prosthesis explantation in the setting of structural valve deterioration (SVD) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These limitations are particularly consequential in younger patients, who are more likely to outlive their initial bioprosthetic valve and may require explantation and reoperation.\u003c/p\u003e \u003cp\u003eYounger AVR patients for whom vitamin K antagonists are contraindicated will be more likely to outlive the lifespan of their bioprosthetic valves. In such cases, explantation of the degenerated valve and SAVR may be preferred. This approach can be technically challenging because the prosthesis often becomes densely embedded in surrounding cardiac structures, making removal difficult and increasing the risk of damaging the aortic annulus or conduction system [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Although international case reports have described explantation of Perceval and Intuity valves [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], to our knowledge, there are no published reports describing explantation of a rapidly deployed Intuity valve in the United States.\u003c/p\u003e \u003cp\u003eThis report describes a patient who presented with SVD after a rapid deployment of an Edwards Intuity valve. They underwent successful explantation of the rapid deployment Edwards Intuity valve and SAVR using an Edwards Inspiris Resilia bioprosthetic valve with annular enlargement.\u003c/p\u003e"},{"header":"Clinical Summary","content":"\u003cp\u003eA 69 year old woman with a history of a bicuspid aortic valve had previously undergone mini-thoracotomy AVR eight years earlier with placement of a 23-mm Edwards Intuity rapid-deployment valve. At the time of implant, her BSA was 1.91 m\u0026sup2;; the purported effective orifice area of the Intuity valve was 1.05 cm\u0026sup2;. Seven years postoperatively, she developed worsening dyspnea that limited her daily activities. An echocardiogram at this time demonstrated a normally functioning left ventricle (ejection fraction 65\u0026ndash;70%) and a well-seated prosthesis, but with cusp immobility, an average valve orifice area of 1.3 cm\u0026sup2;, and findings consistent with moderate prosthetic aortic stenosis. Given her preference, a period of medical management and weight loss was pursued. Several months later, she re-presented with worsening symptoms, when a repeat echocardiography revealed severe prosthetic aortic stenosis, with a mean pressure gradient of 60 mmHg, valve area of 0.78 cm\u0026sup2;, peak velocity of 5.2 m/s, and a slight decline in preserved ejection fraction to 50\u0026ndash;55%. She denied chest pain, edema, or palpitations. Coronary angiography demonstrated normal coronary anatomy.\u003c/p\u003e \u003cp\u003eThe patient was evaluated by the multidisciplinary valve team and though a valve-in-valve transcatheter aortic valve replacement was thought to be technically feasible, surgery was preferred due to her small prior valve, active lifestyle, and need for long-term durability. Surgery would allow for annular enlargement and a larger valve, facilitating future valve in valve options if needed. After the patient was fully informed of the risks and benefits of the surgery, the patient elected to proceed with valve explant and reoperative SAVR using a 25 mm Edwards Inspiris Resilia bioprosthetic valve.\u003c/p\u003e \u003cp\u003eA resternotomy was performed, revealing dense adhesions around the aorta and heart. The patient was placed on standard bicaval cannulation for cardiopulmonary bypass under low to moderate systemic hypothermia.\u003c/p\u003e \u003cp\u003eThe prior Intuity valve was immobile and densely adherent to the left ventricular outflow tract and aortomitral curtain \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA\u003cb\u003e)\u003c/b\u003e. Blunt dissection was used to free one side of the prosthesis to support removal of the valve from the annulus. Wire cutters were used to transect the prosthetic ring, which was then rolled inward and dissected off the annulus \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB\u003cb\u003e)\u003c/b\u003e. Following explant, a defect in the noncoronary sinus extending into the aortomitral curtain was noted but fortunately was in the location of the planned annular enlargement patch.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo enlarge the aortic annulus, the Yang Y-incision annular enlargement technique.\u003c/p\u003e \u003cp\u003ewas performed [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A diamond-shaped bovine pericardial patch was sewn to the mitral annulus from the left to right fibrous trigone and up to the transverse aortotomy using running 4\u0026thinsp;\u0026minus;\u0026thinsp;0 Prolene suture. This patch enlarged the annulus, allowing upsizing of the valve. A 25mm Edwards Inspiris valve was then implanted with orientation tailored to the patch position. To relieve tension on the aortotomy closure and re-establish normal sinotubular junction geometry, a 28mm Dacron interposition graft was trimmed and anastomosed to the ascending aorta. The graft was secured proximally to the sinotubular junction and distally to the proximal arch using running 4\u0026thinsp;\u0026minus;\u0026thinsp;0 Prolene. The aortic root was de-aired, the cross-clamp removed, and the patient was weaned from bypass in normal sinus rhythm. Cardiopulmonary bypass time was 285 minutes, with an aortic cross-clamp time of 236 minutes.\u003c/p\u003e \u003cp\u003eDuring admission, her postoperative course was notable for intermittent accelerated junctional rhythm up to the time of discharge. She was deemed appropriate for discharge on postoperative day 5 without pacemaker placement. During her 14-day postoperative clinic visit, the patient demonstrated a stable recovery following SAVR. Follow-up transthoracic echocardiogram showed expected post-SAVR gradients and appropriate prosthetic valve positioning. A Zio patch monitor confirmed resolution of her postoperative junctional rhythm, with no evidence of recurrent junctional rhythm or significant arrhythmia. In addition, she denied any episodes of palpitations. The patient was continued on direct oral anticoagulation for three months post-operatively.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs the use of surgical rapid deployment valves increases and extends into younger patients, there will be an increased demand for valve explantion due to SVD [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Removal of these prostheses is technically demanding because their unique subannular skirt and textured cuffs promote dense tissue integration [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Transcatheter aortic valve replacement can serve as an effective treatment for prosthetic valve failure but is often limited by anatomic constraints. However, existing literature indicates that explantation of rapid-deployment valves carries a higher operative risk compared to conventional prostheses, particularly when combined with complex root procedures [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Edwards Intuity valve features a balloon-expandable stainless steel frame covered by a textured seal beneath the sewing cuff \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, B\u003cb\u003e)\u003c/b\u003e. Over time, this design predisposes the valve to firm adhesions, as further demonstrated by postoperative CT imaging of the footprint and subannular extension \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC, D\u003cb\u003e)\u003c/b\u003e. In our case, these characteristics mandated painstaking dissection to safely excise the prosthesis while preserving aortic root integrity. Additionally, the application of the Yang Y-incision annular enlargement technique enabled both repair of a defect in the noncoronary sinus extending into the aortomitral curtain and upsizing from a 23-mm to a 25-mm prosthesis. This approach helped restore annular geometry and preserved future options for valve in valve intervention.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTo our knowledge, we report the first case in the United States of explantation of an Edwards Intuity rapid-deployment valve with subsequent SAVR using the Yang Y-incision annular enlargement technique. The operation was completed without major complications, despite a longer cross-clamp duration than typically reported [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. This prolonged duration likely reflects the meticulous dissection and reconstruction required.\u003c/p\u003e \u003cp\u003eIn summary, our experience demonstrates that explantation of an Edwards Intuity rapid deployment valve can be performed safely with careful dissection and annular enlargement strategies. This method offers an effective solution for SVD in rapid deployment prostheses, while preserving the potential for future less invasive reinterventions.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSVD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003estructural valve deterioration\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSAVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esurgical aortic valve replacement\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eAVR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eaortic valve replacement\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThis case report was reviewed and approved by the Oregon Health \u0026amp; Science University Institutional Review Board (IRB #00028756) on June 6, 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: Written informed consent for publication of the clinical details and accompanying images was obtained from the patient. A copy of the consent is available for review by the editor upon request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Statement:\u0026nbsp;\u003c/strong\u003eThis study received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions:\u0026nbsp;\u003c/strong\u003eJulian Marsh drafted the manuscript. Dr. Castigliano Bhamidipati assisted in surgery, contributed to surgical description, and critical revision. Dr. Julie Doberne performed the surgery, supervised the project, provided critical revisions, and is the corresponding author. All authors read and approved of the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBening C, Hamouda K, Oezkur M, Freude B, Hekmat K, Misfeld M, et al. Rapid deployment valve system shortens operative times for aortic valve replacement through anterior minithoracotomy. J Cardiothorac Surg. 2017;12:e27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Eusanio M, Berretta P. The sutureless and rapid-deployment aortic valve replacement international registry: lessons learned from more than 4,500 patients. Ann Cardiothorac Surg. 2020;9(4):289\u0026ndash;97.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSpadaccio C, Nenna A, Pisani A, Laskawski G, Nappi F, Moon MR, et al. Sutureless valves, a wireless option for patients with aortic valve disease: JACC state-of-the-art review. J Am Coll Cardiol. 2024;84(4):382\u0026ndash;407.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWahlers TCW, Andreas M, Rahmanian P, Candolfi P, Zemanova B, Giot C, Ferrari E, et al. Outcomes of a rapid deployment aortic valve versus its conventional counterpart: a propensity-matched analysis. Innovations (Phila). 2018;13(3):177\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePowell RG, Pelletier MP, Chu MWA, Bouchard D, Melvin KN, Adams C. The Perceval sutureless aortic valve: review of outcomes, complications, and future direction. Innovations (Phila). 2017 May\u0026ndash;Jun;12(3):155\u0026ndash;173.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim YS, Yoo JS. Easy surgical explantation technique for sutureless Perceval S prosthesis, lasso technique: a case report. J Cardiothorac Surg. 2023;18:64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSakurai H, Kawamoto N, Kainuma S, Suzuki K, Kakuta T, Hirayama M, et al. Simple surgical explant technique for the EDWARDS INTUITY rapid deployment valve: a case report of prosthetic valve endocarditis. Gen Thorac Cardiovasc Surg Cases. 2025;4:18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUehara K, Shirakami T, Arai Y. Surgical explantation for a rapid deployment valve: the shave-and-hook technique. Interact Cardiovasc Thorac Surg. 2024;38(5):iv ae072.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDi Bacco L, Pfeiffer S, Fischlein TJM, Santarpino G. Rapid explantation of rapid-deployment sutureless valve in case of acute endocarditis: how to remove safely sutureless Perceval S prostheses. Innovations (Phila). 2017;12(6):483\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang B. Aortic annular enlargement with Y-incision/rectangular patch. Ann Cardiothorac Surg. 2024;13(3):285\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCoti I, Werner P, Kaider A, El-Nashar J, Kocher A, Laufer G, et al. Aortic valve replacement with rapid-deployment bioprostheses: long-term single-center results after 1000 consecutive implantations. J Clin Med. 2025;14(5):1552.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Valve explant, Rapid deployment valve, Annular enlargement, Yang technique","lastPublishedDoi":"10.21203/rs.3.rs-7852144/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7852144/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003cbr\u003e\n \u003c/strong\u003eRapid deployment aortic valves, such as the Edwards Intuity valve, shorten implantation times and facilitate less-invasive approaches. The features that enable the valve’s rapid deployment pose a technical challenge if explant is required, as in the instance of endocarditis or structural valve deterioration (SVD), because the prosthesis often becomes densely embedded in surrounding cardiac structures. Although international reports describe Intuity and Perceval explants, none have been reported from the United States with annular enlargement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Presentation:\u003c/strong\u003e A 69 year old woman with a bicuspid aortic valve underwent mini-thoracotomy aortic valve replacement eight years prior with a 23 mm Edwards Intuity valve. Seven years postoperatively she presented with progressive dyspnea and an initial echocardiography showed moderate prosthetic stenosis (valve area 1.3 cm²). After several months of observation, she returned with severe stenosis (mean gradient 60 mmHg, valve area 0.78 cm²). Valve-in-valve transcatheter aortic valve replacement was considered, but surgery was favored given her small valve size and relatively young age. At reoperation, the prosthesis was densely adherent to the aortomitral curtain and left ventricular outflow tract, necessitating transection and careful dissection for safe removal. A Yang Y-incision annular enlargement allowed implantation of a 25-mm Edwards Inspiris Resilia valve. She was discharged on postoperative day 5 and follow-up showed excellent recovery in normal sinus rhythm.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Explantation of the Edwards Intuity rapid deployment valve with Yang Y-incision annular enlargement is feasible and safe, offering a surgical option for SVD.\u003c/p\u003e","manuscriptTitle":"Successful explantation of an EDWARDS INTUITY rapid deployment valve with Yang annular enlargement","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-12 05:33:49","doi":"10.21203/rs.3.rs-7852144/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-25T07:21:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-18T16:32:37+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-18T15:21:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-17T13:47:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"133153414473150079162806604994793935733","date":"2026-01-13T09:48:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-11T10:37:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295783087154024660617781356694010137186","date":"2026-01-10T17:28:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"250932631289844379577768530215051874155","date":"2026-01-10T07:05:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"213238138027692005299628621659683137659","date":"2026-01-08T17:45:30+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-07T08:48:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"208873736616096793952639393634140942152","date":"2026-01-07T04:08:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-06T17:10:49+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-15T06:32:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-15T06:32:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2025-10-13T20:13:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a29a417e-4ac2-4e0d-b1d9-c62bd66009a1","owner":[],"postedDate":"January 12th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:06:29+00:00","versionOfRecord":{"articleIdentity":"rs-7852144","link":"https://doi.org/10.1186/s13019-026-04113-w","journal":{"identity":"journal-of-cardiothoracic-surgery","isVorOnly":false,"title":"Journal of Cardiothoracic Surgery"},"publishedOn":"2026-04-17 15:57:52","publishedOnDateReadable":"April 17th, 2026"},"versionCreatedAt":"2026-01-12 05:33:49","video":"","vorDoi":"10.1186/s13019-026-04113-w","vorDoiUrl":"https://doi.org/10.1186/s13019-026-04113-w","workflowStages":[]},"version":"v1","identity":"rs-7852144","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7852144","identity":"rs-7852144","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}