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Valve-sparing root replacement versus composite valve graft root replacement: Analysis of more than 1500 patients from 2 aortic centers

Read at The American Association for Thoracic Surgery Aortic Symposium Workshop, Boston, Massachusetts, May 13-14, 2022.
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Abstract

Objectives

The long-term outcomes comparing valve-sparing root replacement, composite valve graft with bioprosthesis, and mechanical prosthesis have yet to be explored. We investigated the long-term survival and reintervention rates after 1 of 3 major aortic root replacements in patients with tricuspid aortic valves and patients with bicuspid aortic valves.

Methods

A total of 1507 patients underwent valve-sparing root replacement (n = 700), composite valve graft with bioprosthesis (n = 703), or composite valve graft with mechanical prosthesis (n = 104) between 2004 and 2021 in 2 aortic centers, excluding those with dissection, endocarditis, stenosis, or prior aortic valve surgery. End points included mortality over time and cumulative incidence of aortic valve/proximal aorta reintervention. Multivariable Cox regression compared adjusted 12-year survival. Fine and Gray competing risk regression compared the risk and cumulative incidence of reintervention. Propensity score–matched subgroup analysis balanced the 2 major groups (composite valve graft with bioprosthesis and valve-sparing root replacement), and landmark analysis isolated outcomes beginning 4 years postoperatively.

Results

On multivariable analysis, both composite valve graft with bioprosthesis (hazard ratio, 1.91, P = .001) and composite valve graft with mechanical prosthesis (hazard ratio, 2.62, P = .005) showed increased 12-year mortality risk versus valve-sparing root replacement. After propensity score matching, valve-sparing root replacement displayed improved 12-year survival versus composite valve graft with bioprosthesis (87.9% vs 78.8%, P = .033). Adjusted 12-year reintervention risk in patients receiving composite valve graft with bioprosthesis or composite valve graft with mechanical prosthesis versus valve-sparing root replacement was similar (composite valve graft with bioprosthesis subdistribution hazard ratio, 1.49, P = .170) (composite valve graft with mechanical prosthesis subdistribution hazard ratio, 0.28, P = .110), with a cumulative incidence of 7% in valve-sparing root replacement, 17% in composite valve graft with bioprosthesis, and 2% in composite valve graft with mechanical prosthesis (P = .420). Landmark analysis at 4 years showed an increased incidence of late reintervention in composite valve graft with bioprosthesis versus valve-sparing root replacement (P = .008).

Conclusions

Valve-sparing root replacement, composite valve graft with mechanical prosthesis, and composite valve graft with bioprosthesis demonstrated excellent 12-year survival, with valve-sparing root replacement associated with better survival. All 3 groups have low incidence of reintervention, with valve-sparing root replacement showing decreased late postoperative need for reintervention compared with composite valve graft with bioprosthesis.

Section snippets

Study Design and Patient Selection

The study was approved by the Institutional Review Boards of Columbia University Irving Medical Center and Emory University with the waiver of consent (Columbia, AAAU0575, April 4, 2022; Emory, IRB00001479, August 30, 2021). This is a 2-center retrospective study involving 2747 patients undergoing aortic root replacement between February 4, 2004, and February 18, 2021, at Columbia and Emory University. Exclusion criteria were aortic stenosis (AS), infective endocarditis, aortic dissection,

Patient Characteristics

The baseline characteristics of all patients are listed in Table 2. The median age was 57.0 years (46.0-66.0) with 14.9% being female. Moderate/severe AI was present in 64.7% of patients. Surgery was urgent or emergency in 30.5% of cases, and in 12.1% this was a reoperation. b-CVG patients were older with increased comorbidities (diabetes, hypertension, dyslipidemia, cerebrovascular disease, chronic kidney disease, AI, incidence of urgent/emergency procedure and reoperation) versus VSRR (all P

Discussion

The present study is uniquely equipped to address the knowledge gap: What is the clinical benefit of VSRR over CVG root replacement? Combining cohorts from 2 large aortic centers, our data present 3 critical takeaways: (1) Perioperative morbidity and mortality are similar in VSRR, even after accounting for baseline differences through PSM; (2) with follow-up extended to 12 years, VSRR confers a survival advantage, both when comparing entire populations and matched cohorts; and (3)

Conclusions

Aortic root replacement for proximal aortic aneurysm with no significant abnormal cusp morphology with VSRR, m-CVG, or b-CVG demonstrates excellent 12-year survival, with VSRR associated with better survival. All 3 groups have a low incidence of reintervention, with VSRR showing decreased late postoperative need for reintervention compared with b-CVG. Our data support greater use of VSRR in eligible candidates.

References (26)

  • L.F. Hiratzka et al.

    2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of thoracic Surgeons, and Society for Vascular Medicine

    J Am Coll Cardiol

    (2010)
  • B.G. Leshnower et al.

    Expanding the indications for the David V aortic root replacement: early results

    J Thorac Cardiovasc Surg

    (2012)
  • A.S. Stewart et al.

    Modified Bentall operation with a novel biologic valved conduit

    Ann Thorac Surg

    (2010)

    • Cited by (0)

    Institutional Review Board Approval: AAAU0575; most recent approval date: April 4, 2022, and IRB00001479; most recent approval date: August 30, 2021. Approved with waiver of consent.

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