Adult: Aortic Valve
Reintervention after valve-sparing aortic root replacement: A comprehensive analysis of 781 David V procedures

Read at the 103rd Annual Meeting of The American Association for Thoracic Surgery, Los Angeles, California, May 6-9, 2023.
https://doi.org/10.1016/j.jtcvs.2023.04.013Get rights and content

Abstract

Objective

Studies of reintervention after valve-sparing aortic root replacement (VSRR) are limited by sample size and failure to evaluate all types of reinterventions, including distal aorta and transcatheter interventions. In this report, reintervention after VSRR using a large patient cohort was comprehensively analyzed.

Methods

In a series involving 2 academic aortic centers, 781 consecutive patients from 2005 to 2020 undergoing David V VSRR for aortic aneurysm (91%) or dissection (9%) were included. Median age was 50 years, and 23% had a bicuspid aortic valve (AV). Median follow-up was 7.0 years. Open or transcatheter reintervention on the AV, proximal, or distal thoracic aorta was identified. Cumulative incidence was calculated, and subdistribution hazard models identified factors associated with reintervention. Time-dependent incidence of reintervention was plotted using risk-hazard functions.

Results

Sixty-eight reinterventions (57 open, 11 transcatheter) were performed. Reinterventions were divided by indication into degenerative AV (n = 26, including 1 transcatheter aortic valve replacement), endocarditis (n = 11), proximal aorta (n = 8), and distal aorta (n = 23, including 10 thoracic endovascular aortic repairs). Risk of reintervention for endocarditis peaked 1 to 3 years after VSRR, whereas other indications had stable, low rates of occurrence throughout the follow-up period. The cumulative incidence of reintervention was 12.5% whereas the cumulative incidence of AV reintervention was 7.0% at 10 years and was associated with residual postoperative aortic insufficiency. In-hospital mortality after reintervention was 3%.

Conclusions

Reintervention rates after VSRR are relatively low in long-term follow-up and can be performed with acceptable operative risk. The majority of reinterventions are performed for indications other than AV degeneration, with the timing of reintervention varying by the specific clinical indication.

Section snippets

Patient Selection and Outcome Measures

The study was approved by the institutional review board of Columbia University Irving Medical Center with the waiver of consent (abbreviated title: Common Root Study; number: AAAU0575; most recent approval date: April 4, 2022). This 2-center retrospective study involved 2727 patients undergoing aortic root replacement between February 23, 2005, and November 11, 2020, at Columbia and Emory University. Of those, 781 underwent VSRR using the reimplantation technique for an aortic root aneurysm or

Patient Characteristics

A total of 781 patients underwent VSRR between 2005 and 2020. Baseline characteristics are summarized in Table 1. Median age at time of VSRR was 50 years (IQR, 39-61) and 16.6% (n = 130) were female. Surgical indications for VSRR included aortic aneurysm (n = 711, 91.0%) and acute type A dissection (n = 70, 9.0%). BAV was present in 23.0% (n = 180) of patients, and 46.9% (n = 366) had moderate or severe AI preoperatively. AV repair was performed in 59.3% of patients (50.2% of tricuspid aortic

Discussion

VSRR has become an established treatment for patients with aortic root pathology. The indications over time have expanded to include more complex patients, such as patients with type A dissection,9,13 BAV,2,5,11,12,19 and complex cusp pathology.10 Even with broader indications, centers have continued to report very low rates of operative mortality and perioperative morbidity along with excellent long-term survival and freedom from reoperation.6,20 By preserving native aortic valve function, the

Conclusions

In conclusion, the rate of reintervention after VSRR remains relatively low, and reintervention procedures can be performed safely. Reintervention after VSRR is often performed for indications other than aortic valve failure alone, and timing and operative complexity vary based on specific clinical indication.

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