{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T06:05:14Z","timestamp":1790661914237,"version":"4.1.0"},"reference-count":22,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T00:00:00Z","timestamp":1790640000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100000272","name":"National Institute for Health and Care Research","doi-asserted-by":"publisher","award":["K25HL175208"],"award-info":[{"award-number":["K25HL175208"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/501100000272","name":"National Institute for Health and Care Research","doi-asserted-by":"publisher","award":["R01HL173845"],"award-info":[{"award-number":["R01HL173845"]}],"id":[{"id":"10.13039\/501100000272","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100000968","name":"American Heart Association","doi-asserted-by":"publisher","award":["24CDA1272816"],"award-info":[{"award-number":["24CDA1272816"]}],"id":[{"id":"10.13039\/100000968","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Cardiovasc. Med."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Symmetric bicuspidization repair for outlet valve pathologies relies on the surgeon's subjective assessment. Recent computational and ex-vivo work suggests sizing free-edge length to 1.57 times aortic diameter is optimal. This principle was applied clinically at our institution, and this study compares post-implementation outcomes with historical results.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>All patients with attempted bicuspidization from 2011 to 2025 were queried. Primary outcome was freedom from valve-related reoperation or valve replacement. Secondary outcomes were cross-clamp time, number of bypass runs, mean transvalvular gradient, and regurgitation grade. Kaplan\u2013Meier curves were generated for primary outcome with log-rank comparison. Secondary outcomes were compared with Wilcoxon rank-sum test.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      At median age 5.9 years, fourteen patients underwent symmetric bicuspidization (9 historical, 5 simulation-guided). Valve configuration included unicuspid (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20092), bicuspid (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20096), tricuspid (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20094), and quadricuspid (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u20092). Repair indication was predominantly regurgitation (\n                      <jats:italic>n<\/jats:italic>\n                      \u2009=\u200913\/14, 93%). Five (56%) historical patients underwent reoperation compared with zero simulation-guided patients (median follow-up 948 vs. 455 days). Three (33%) historical patients required repeat bypass run, compared to zero simulation-guided. Cross-clamp time was not different between groups (72 vs. 89,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.74). Acute and latest postoperative mean gradients were also not significantly different (acute: 13.5 vs. 9.6,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.14; latest: 12.4 vs. 3.3,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.08), though gradient variability was two to four times lower in the simulation-guided group.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This exploratory study presents promising early outcomes after prespecified, standardized sizing of the free-edge length in symmetric bicuspidization repair. Simulation-guided design can be applied in complex valve repair and may enhance early outcomes.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fcvm.2026.1957668","type":"journal-article","created":{"date-parts":[[2026,9,29]],"date-time":"2026-09-29T05:50:25Z","timestamp":1790661025000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Simulation-guided outlet valve repair: early integration of computationally-derived principles of free-edge length in bicuspidization repair"],"prefix":"10.3389","volume":"13","author":[{"given":"Perry Seo","family":"Choi","sequence":"first","affiliation":[{"name":"Department of Cardiothoracic Surgery, Division of Pediatric Cardiac Surgery, Stanford University","place":["Stanford, CA, United States"]},{"name":"Stanford Maternal and Child Health Research Institute","place":["Stanford, CA, United 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