Incidence, Cause, and Outcome of Reinterventions after Aortic Root Replacement

Propensity score matching analysis of valve-sparing versus aortic root replacement in type A aortic dissection patients

This study compared long-term survival and reintervention rates between Valve-Sparing Root Replacement (VSRR, n = 244) and Aortic Root Replacement (ARR, n = 499) in 743 patients undergoing Type A acute aortic dissection (AAD), given the lack of prospective comparative data. Multivariable analysis is identifying advanced age, high Body Mass Index (BMI), Marfan syndrome, severe aortic regurgitation, bicuspid aortic valve, increased aortic root diameter, and reduced aortic cross-clamp time (ACC) as significant factors associated with ARR. After Propensity Score Matching (PSM), VSRR is showing significantly higher 5-year survival rates than ARR (80.2% vs. 64.1%, P = 0.001), validated by Inverse Probability of Treatment Weighting (IPTW) analysis. Reintervention rates are being found comparable, with endocarditis more prevalent in ARR and aortic regurgitation in VSRR. Subgroup analysis indicated that patients aged less than 60 years and those with a BMI greater than 24 in the VSRR group exhibited significantly improved survival probabilities compared to the ARR group. These findings support the wider utilization of valve-sparing root replacement (VSRR) in appropriately selected patients, highlighting its potential advantages for suitable candidates.

Reoperation after aortic root replacement and its impact on long-term survival

Objective

Reoperation after aortic root replacement (ARR) is associated with increased operative risk and complexity. This study evaluated clinical outcomes and reoperation rates in patients undergoing ARR.

Methods

From 2004 to 2021, 2700 adult patients underwent an ARR in a 2-institution database. Among 2542 surviving patients, 705 patients who had a history of previous cardiac surgery as well as 11 patients who underwent transcatheter aortic valve replacement after index ARR were excluded. Among the finalized cohort of 1826 patients, 88 (4.8%) underwent a reoperation (REDO) on the aortic valve or proximal aorta (root/ascending) a mean of 3.1 years after index ARR whereas 1738 (95%) did not undergo reoperation (no-REDO). A subgroup analysis was performed among those undergoing reoperation by indication including valve dysfunction (48%), endocarditis/graft infection (33%), and aortic aneurysm/dissection/rupture (12%). Reoperative indication was unknown in 6 patients (7%).

Results

The REDO group was younger at time of index ARR (52 vs 58 years, P < .0001) and had more bicuspid aortic valves (56% vs 37%, P = .0003). Most patients underwent modified Bentall ARR (61%), whereas 38% underwent a valve-sparing root replacement. Index root operations were similar between groups. At time of reoperation, 53% underwent aortic valve replacement and 35% underwent redo root replacement. Long-term survival was similar between REDO and no-REDO groups (80% vs 85%, P = .26) and reoperation was not a risk factor for late mortality (hazard ratio, 1.31; P = .26); however, REDO ARR was a risk factor for late mortality (hazard ratio, 2.41; P = .02).

Conclusions

The incidence of aortic valve and/or proximal aorta reoperation after index ARR is relatively low at 4.8%; however, root reoperation is a risk factor for late mortality.

Homograft Aortic Root Replacement for Destructive Prosthetic Valve Endocarditis: Results in the Current Era

Background: Destructive aortic prosthetic valve endocarditis portends a high morbidity and mortality, and requires complex high-risk surgery. Homograft root replacement is the most radical and biocompatible operation and, thus, the preferred option. Methods: A retrospective analysis was conducted on 61 consecutive patients who underwent a cardiac reoperation comprising homograft aortic root replacement since 2010. The probabilities of survival were calculated with the Kaplan-Meier method, whereas multivariable regression served to outline the predictors of adverse events. The endpoints were operative/late death, perioperative low cardiac output and renal failure, and reoperations. Results: The operative (cumulative hospital and 30-day) mortality was 13%. The baseline aspartate transaminase (AST) and associated mitral procedures were predictive of operative death (p = 0.048, OR [95% CIs] = 1.03 [1-1.06]) and perioperative low cardiac output, respectively (p = 0.04, OR [95% CIs] = 21.3 [2.7-168.9] for valve replacement). The latter occurred in 12 (20%) patients, despite a normal ejection fraction. Survival estimates (±SE) at 3 months, 6 months, 1 year, and 3 years after surgery were 86.3 ± 4.7%, 82.0 ± 4.9%, 75.2 ± 5.6, and 70.0 ± 6.3%, respectively. Survival was significantly lower in the case of AST ≥ 40 IU/L (p = 0.04) and aortic cross-clamp time ≥ 180 min (p = 0.01), but not when excluding operative survivors. Five patients required early (two out of the five, within 3 months) or late (three out of the five) reoperation. Conclusions: Homograft aortic root replacement for destructive prosthetic valve endocarditis can currently be performed with a near 90% operative survival and reasonable 3-year mortality and reoperation rate. AST might serve to additionally stratify the operative risk.

Transcatheter valve-in-valve interventions after aortic root replacement: A systematic review

Structural valve deterioration after aortic root replacement (ARR) surgery may be treated by transcatheter valve-in-valve (ViV-TAVI) intervention. However, several technical challenges and outcomes are not well described. The aim of the present review was to analyze the outcomes of ViV-TAVI in deteriorated ARR. This review included studies reporting any form of transcatheter valvular intervention in patients with a previous ARR. All forms of ARR were considered, as long as the entire root was replaced. Pubmed, ScienceDirect, SciELO, DOAJ, and Cochrane library databases were searched until September 2023. Overall, 86 patients were included from 31 articles that met our inclusion criteria out of 741 potentially eligible studies. In the entire population, the mean time from ARR to reintervention was 11.0 years (range: 0.33-22). The most frequently performed techniques/grafts for ARR was homograft (67.4%) and the main indication for intervention was aortic regurgitation (69.7%). Twenty-three articles reported no postoperative complications. Six (7.0%) patients required permanent pacemaker implantation (PPI) after the ViV-TAVI procedure, and 4 (4.7%) patients had a second ViV-TAVI implant. There were three device migrations (3.5%) and 1 stroke (1.2%). Patients with previous ARR present a high surgical risk. ViV-TAVI can be considered in selected patients, despite unique technical challenges that need to be carefully addressed according to the characteristics of the previous surgery and on computed tomography analysis.

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

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.

Valve Sparing vs Composite Valve Graft Root Replacement: Propensity Score-Matched Analysis

BACKGROUND

Both valve-sparing root replacement and composite valve graft (CVG) are acceptable options in aortic root replacement. We compare outcomes of these 2 approaches and durability of the aortic valve.

METHODS

A consecutive 1635 patients without acute dissection underwent primary aortic root replacement from 1997 to 2022; 473 (29%) underwent valve-sparing root replacement, and 1162 (71%) received CVG. Propensity score matching was used to reduce baseline differences.

RESULTS

The CVG group was older (59 ± 14 years vs 49 ± 14 years; P < .001) with more comorbidities, such as hypertension (88.4% vs 66.4%; P < .001), diabetes (7% vs 1.7%; P < .001), ischemic heart disease (5.1% vs 1.3%; P = .001), pulmonary disease (6.6% vs 1.3%; P < .001), renal impairment (8.6% vs 1.3%; P < .001), class III-IV heart failure (35% vs 9.2%; P < .001), bicuspid aortic valves (44.8% vs 24.1%; P < .001), and severe aortic insufficiency (50.2% vs 13.2%; P < .001). Operative mortality was 0.4% (0% in valve sparing); incidence of major postoperative complications was 2.9% (3.6% vs 1.1%; P = .009). Ten-year survival was 93.1% (91.2% vs 97.7%; hazard ratio [HR], 1.7; 95% CI, 0.9-3.3; P = .120). Mean follow-up was 65 ± 60 months; aortic valve reoperations were similar (5.8% vs 5.7%; HR, 0.8; 95% CI, 0.4-1.4; P = .401). Recurrent moderate-severe aortic insufficiency was less prevalent in CVG (6.1% vs 11.1%; HR, 0.14; 95% CI, 0.07-0.27; P < .001). Propensity score matching identified 225 pairs. There was no difference in 10-year survival or reoperations. Recurrent moderate-severe aortic insufficiency was higher with valve sparing.

CONCLUSIONS

Both valve-sparing operations and CVG provide excellent early and late outcomes out to 10 years. Valve sparing is associated with a higher risk for development of aortic insufficiency but no difference in reoperations.

Selective Sinus Replacement for Aortic Root Aneurysm: Durable Approach in Selected Patients

BACKGROUND

Selective sinus replacement (SSR) allows a tailored repair approach in patients with sinus of Valsalva or asymmetric aortic root aneurysm. SSR avoids the need for coronary reimplantation for nondiseased sinuses and shortens operative time, although potential for late growth of retained sinuses exists. This study describes selection of patients and assesses operative outcomes and late root dimensions after SSR.

METHODS

From 2006 to 2020, 60 patients underwent SSR at a single referral institution. Mixed effect models were used to assess trajectory of postoperative growth of remaining sinuses, adjusting for age of the patient, valve morphology, and baseline root diameter.

RESULTS

Median age of the patients was 57 (interquartile range [IQR], 48-65) years. Twenty-four (40%) had a bicuspid aortic valve. Most patients (n = 55 [92%]) underwent single sinus replacement (n = 46 noncoronary, n = 9 right), whereas 5 (8%) underwent repair of both the right and noncoronary sinuses. Concomitant aortic valve replacement was performed in 15 patients (25%); aortic valve repair with internal ring annuloplasty or cusp plication was performed in 37 (62%). There was no operative death, stroke, renal failure, or respiratory failure. Median preoperative root diameter was 53 mm (IQR, 51-56 mm) vs 42 mm (IQR, 39-45 mm) at median imaging follow-up of 34 (IQR, 13-49) months. Rate of midterm root growth was 0.2 mm/y, and there were no late root reinterventions.

CONCLUSIONS

For patients with sinus of Valsalva or asymmetric root aneurysm, SSR is associated with excellent operative outcomes, and midterm follow-up suggests that the technique is durable. Longer term follow-up is needed to confirm continued stability of the aortic root.

Bentall Operation: Early Surgical Results, Seven-Year Outcomes, and Risk Factors Analysis

Aim: To analyze early and mid-term outcomes of the Bentall operation. Methods: Two hundred and seventeen patients (mean age 65.6 ± 15.9 years, males/females 172/45) underwent Bentall operation in a 7-year period (January 2015−December 2021), on average, 30 Bentall operations occurred per year, using biological (n = 104) or mechanical (n = 113) valved conduits for the treatment of ascending aorta−aortic root aneurysms. Associate procedures were performed in 58 patients (26.7%); coronary artery bypass grafting (CABG) in 35 (16%). Mean follow-up was 55.2 ± 24 (median 60.2) months. Cox model analysis was used to assess risk factors, Kaplan−Meier and log-rank tests were used to assess different survival rates. Results: Operative mortality was 1.38%. At 7 years, survival, freedom from cardiac death, and event-free survival were 93% ± 2%, 99% ± 1%, and 81% ± 5%. NYHA class (p < 0.0001), trans-aortic valve mean (p < 0.0001) and maximum (p < 0.000) gradients, left ventricular hypertrophy (p < 0.05), and pulmonary arterial pressure (p = 0.002) significantly improved vs. preoperative values. Concomitant CABG during Bentall operation independently affected late outcomes (HR 1.9−2.3; p-values < 0.05). Late survival was affected by concomitant CABG (84% ± 8% vs. 95% ± 2%, p = 0.04), preoperative myocardial infarction (91% ± 9% vs. 97% ± 2%, p = 0.02), and biological vs. mechanical prostheses valved conduits (91% ± 9% vs. 95% ± 3%, p = 0.02). Event-free survival also was affected by concomitant CABG (62% ± 14% vs. 85% ± 5%, p = 0.005) and biological prostheses (78% ± 8% vs. 84% ± 6%, p = 0.06). Freedom from endocarditis−redo operation was 83% ± 9% for biological prostheses vs. 89% ± 6% for mechanical prostheses (p = 0.49). Conclusions: Low rates of operative mortality and late complications make Bentall operation the gold standard for the treatment of ascending aorta−aortic root aneurysms. Coronary ischemic disease affects late outcomes. Biological prostheses should be preferred for the elderly.

Computed tomography follow-up after elective proximal aortic surgery: Less is more?

STUDY OBJECTIVE

The added value of computed tomography (CT) follow-up after elective proximal aortic surgery is unclear. We evaluated the benefit of CT follow-up by assessing the incidence of aorta-related complications and reinterventions detected during routine CT follow-up.

METHODS

Data on 314 patients undergoing first time elective proximal aortic surgery between 2000 and 2015 were collected. The primary study end points were aorta-related complications and reinterventions, detected during routine CT follow-up. Secondary study endpoints included all aorta-related complications and reinterventions, irrespective of the mode of detection and survival.

RESULTS

Median CT follow-up time was 6.8 (IQR 4.1-9.8) years, during which a total of 1303 routine follow-up CT-scans (median 4, IQR 3-5) were performed. During CT follow-up, aorta-related complications were detected in 18 (5.7%) patients, of which 6 (1.6%) underwent reintervention. In total, 28 aorta-related complications were observed in 23 (7.3%) patients, of which 9 led to reintervention. In order to detect 1 aorta-related complication leading to reintervention, 218 routine follow-up CT-scans were required. The unadjusted and EuroSCORE II adjusted hazard ratios of not undergoing CT follow-up on mortality were 1.260 (95% CI 0.705-2.251) and 0.830 (95% CI 0.430-1.605), respectively.

CONCLUSIONS

Following first time elective proximal aortic surgery, aorta-related complications are uncommon, are not always detected during CT follow-up and, if detected, often do not result in reintervention. Therefore, a more conservative CT follow-up protocol could be considered in selected patients to reduce lifetime radiation burden and health care costs.

Incidental finding of rare and huge asymptomatic pseudoaneurysm after Bentall procedure: A challenging case report

We report the case of a 62-year-old male who underwent urgent cardiac surgery due to the incidental finding of a huge and asymptomatic coronary button pseudoaneurysm at an 18-month outpatients clinic follow-up requiring a very complex preoperative planning.

Valve Sparing Root Replacement versus Bio-Bentall: Inverse Propensity Weighting of 796 Patients

BACKGROUND

This large cohort, single center study aims to compare the 10-year survival and freedom from aortic valve reintervention between valve sparing root replacement (VSRR) and bioprosthetic Bentall (bio-Bentall).

METHODS

All patients undergoing elective VSRR or bio-Bentall for aortic root aneurysm between March 2005 through October 2019 were retrospectively reviewed (n=796 [VSRR = 360]). Inverse probability of treatment weighting (IPTW) balanced clinical variables between groups. Mean follow-up was 58.0 +/- 45.4 (range 0-167) months.

RESULTS

After IPTW adjustment, 10-year survival did not differ between groups (VSRR: 87.0% vs bio-Bentall: 92.7%, p=0.780). Cumulative incidence of aortic valve reintervention was 5.9% for VSRR (95% CI, 2.9%-10.4%) and 10.6% for bio-Bentall (95% CI, 6.2%-16.4%, p=0.798). Fine and Gray computing risk regression model identified age at surgery (sHR 0.97, 95% CI, 0.95-0.99, p=0.015), body surface area (sHR 6.21, 95% CI, 1.97-19.59, p=0.002) and bicuspid aortic valve (sHR 2.15, 95% CI, 1.04-4.44, p =0.038) as independently associated with aortic valve reintervention. For patients ≤50-year-old, cumulative incidence of aortic valve reintervention was 16.2% for VSRR (95% CI, 7.0%-28.8%) and 17.8% for bio-Bentall (95% CI, 6.9%-32.8%)(p=0.363).

CONCLUSIONS

VSRR and bio-Bentall show similar excellent survival and freedom from aortic reintervention rates up to 10 years; however, a durable valve solution for young patients with bicuspid aortic valve remains a challenge.