Minimal-access isolated aortic valve surgery is a reproducible, safe, and effective procedure with similar outcomes and operating times compared with conventional sternotomy.

TAVI yields good results in patients with depressed LVEF. Age, preoperative creatinine and preoperative pacemaker are independently associated with mortality. The TA access is associated with mortality only after 3 years of follow-up, thus probably reflecting a worse general clinical status of these patients.

Aortic valve repair is the gold standard for aortic valve diseases and it is mandatory, every time it is possible, to spare the valve, especially in adults. In non-repairable aortic valves, the most common treatment is replacement with valve prostheses. Despite the risk of reoperation, bioprosthesis are often implanted in non-elderly adults. The durability of the bioprostheses in youngers is lower than in the elderlies. Immune reaction, shear stress and calcium metabolism can play a fundamental role in degeneration.The alternative to prosthetic aortic valve replacement is the Ross procedure, which apparently is the best option for this patient, but its complexity combined with the need for intervention on both aortic and pulmonary valves have limited the use of this technique over time. A more recent alternative is aortic valve neocuspidization, as outlined by Ozaki, which consists in aortic valve reconstruction using glutaraldehyde treated autologous pericardium. Seen the recent positive outcomes reported with this technique, we decided to submit the patient, an obese 57 years old female affected by severe rheumatic aortic valve stenosis and moderate mitral valve stenosis, to this procedure. Our idea was to reduce the risk of prosthesis-patient mismatch (PPM) that this patient faced, seen that she had a small aortic annulus, but a high body mass index. Results have been great: aortic valve gradients were low at discharge and at follow up. Learning from this case, we can assert that this kind of surgery can be safely performed achieving superior hemodynamic results and quality of life. Thus, we did not perform many cases of Ozaki neocuspidization, we always looked for the "perfect patient": young, without big comorbidities, thin. The case we describe obliged us to face with a problem that today's surgeons find out more and more in their clinical practice: obesity in young adults. It is a matter of fact that when a prosthetic valve is implanted the risk of PPM is always behind the corner for the valve structure itself and the big amount of prosthetic material it is composed by. Performing echocardiography and angio CT scan in patients who underwent aortic valve neocuspidization the effective orifice of the valve and the transvalvular gradients where always lower than in those patients who underwent replacement with a prosthesis. This fact has been the starting point for the thought that, maybe, Ozaki technique is the best solution for obese patients and this case proved us right.

Although aortic valve replacement remains the gold standard treatment for aortic valve diseases like stenosis (AS) or insufficiency, new surgical methods have been developed with a focus in the reconstruction of the aortic valve rather than replacing it. The Ozaki procedure involves a tailored replacement of each individual valvular leaflet with glutaraldehyde-treated autologous pericardium and aims to reproduce the normal anatomy of the aortic valve. Cases of patients with unicuspid aortic valve treated with the Ozaki procedure are uncommon in the litrature and become even more rare when it comes to concomitant diseases like AS and ascending aorta aneurysm. We present the case of a 21-year-old, fit and asymptomatic male, with unicuspid aortic valve with severe stenosis and ascending aorta dilatation, surgically treated with tricuspidization of the aortic valve with glutaraldehyde-treated autologous pericardium and replacement of the ascending aorta with a straight synthetic graft. Postoperative studies showed a fully functional, neo-tailored tricuspid aortic valve with trivial regurgitation. The patient had an uncomplicated recovery, stayed in the intensive care unit for 2 days and was discharged on the 7th postoperative day.