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

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.

Surgical management of the aortic root in acute type A aortic dissection: A comparative analysis

BACKGROUND

This study aimed to assess the early- and mid-term outcomes of aortic root repair and replacement, and to provide evidence to improve root management in acute type A aortic dissection (AAAD).

METHODS

This study enrolled 455 patients who underwent AAAD root repair (n = 307) or replacement (n = 148) between January 2016 and December 2017. Inverse probability of treatment weighting (IPTW) method was used to control for treatment selection bias. The primary outcomes were in-hospital mortality, mid-term survival, and proximal aortic reintervention.

RESULTS

The success rate of root repair was 99.7%. The in-hospital mortality in the conservative root repair (CRR) and aggressive root replacement (ARR) were 8.1% and 10.8%. The median follow-up time was 67.76 months (IQR, 67-72 months). After adjusting for baseline factors, there was no significant differences in mid-term survival (p = .750) or the proximal aortic reintervention rate (p = .550) between the two groups. According to Cox analysis, age, hypertension, severe aortic regurgitation, CPB time, and concomitant CABG were all factors associated with mid-term mortality. Regarding reintervention, multivariate analysis identified renal insufficiency, bicuspid aortic valve, root diameter ≥ 45 mm, and severe aortic regurgitation as risk factors, while CRR did not increase the risk of reintervention. The subgroup analysis revealed heterogeneity in the effects of surgical treatment across diverse populations based on a variety of risk factors.

CONCLUSIONS

For patients with AAAD, both CRR and ARR are appropriate operations with promising early and mid-term outcomes. The effects of treatment show heterogeneity across diverse populations based on various risk factors.

Reoperative aortic root replacement following previous cardiac surgery or type A aortic dissection repair

OBJECTIVE

Reoperative aortic root replacement (ARR) is a technically challenging procedure. This study assesses the influence of reoperation on outcomes following ARR, particularly after prior acute type A aortic dissection repair.

METHODS

Of the 1823 patients in this study, 1592 (87.3%) underwent primary ARR, and 231 (12.7%) underwent reoperative ARR. Within the reoperative ARR group, 69 patients (29.9%) had previous acute type A aortic dissection repair, and 162 patients (70.1%) underwent reoperative ARR for other indications.

RESULTS

Reoperative ARR patients exhibited higher rates of ischemic heart disease (13.9% vs 3%; P < .001), diabetes (10% vs 5.3%; P = .009), chronic pulmonary disease (9.1% vs 5%; P = .018), renal impairment (17.7% vs 5.3%; P < .001), and had lower ejection fraction (45.5% ± 8.1% vs 47.6% ± 7.9%; P < .001) compared with primary ARR. The overall operative mortality was 0.4%, with no significant difference between groups (0.9% vs 0.3%; P = .485). At multivariable analysis, previous operation was the most powerful predictor for major adverse events (odds ratio, 3.20; 95% CI, 2.12-4.79; P < .001). Reoperative ARR had a lower 10-year survival compared with primary ARR (67.4% vs 85.9%; log-rank P < .001). Multivariable analysis further confirmed that reoperation was significantly associated with 10-year mortality (hazard ratio, 1.76; 95% CI, 1.01-3.06; P = .044). Among the reoperative ARR group, operative mortality after previous acute type A aortic dissection repair was similar to that for other etiologies (0% vs 1.2%; P = .880).

CONCLUSIONS

Patients undergoing reoperative ARR have more comorbidities and extensive aortic disease compared with those undergoing primary surgery. They face a 3.5-fold increased risk of major adverse events but no difference in operative mortality compared with primary ARR.

Aortic valve degeneration after valve-sparing root replacement in patients with bicuspid aortopathy or connective tissue disorder

OBJECTIVE

We sought to evaluate outcomes of valve-sparing root replacement (VSRR) in patients with bicuspid aortopathy (BAV) versus other connective tissue disorder (CTD).

METHODS

This was a single-center cohort study of consecutive patients undergoing VSRR via reimplantation from 2000 to 2023 with BAV or CTD. Operative outcomes, Kaplan-Meier survival estimates, and cumulative risk of reoperation and recurrent aortic insufficiency (AI) with the competing risk of death were assessed.

RESULTS

Of 516 patients who underwent VSRR, 109 (51.9%) had BAV and 101 (48.1%) had CTD. Patients with BAV were older (46.9 ± 10.4 vs 38.4 ± 14 years, P < .001) and more likely male (89.0% vs 56.4%, P < .001) and hypertensive (66.1% vs 28.7%, P < .001). Preoperative AI was similar (P = .57) between groups (30.3% mild, 18.3% moderate, 11.1% severe). Most patients had no/trivial immediate postoperative residual AI (96.3% vs 93.1%). Operative mortality was zero; postoperative adverse events were minimal. Mean clinical follow-up was 5.2 ± 4.4 years; 10-year survival was 95.6% versus 95.7% (P = .70). Echocardiographic follow-up was 3.9 ± 4.1 years; incidence of >2+ AI (9.7% vs 10.1%, P = 1.0) was similar between groups, whereas the incidence of moderate or greater aortic stenosis was greater with BAV (7.5% vs 0%, P = .02). Reoperation was low in both groups (3.7% vs 5.9%, P = .65). Competing risk analysis found no difference in reoperation hazard between BAV and CTD groups (hazard ratio, 0.36; 95% confidence interval, 0.07-1.81, P = .21).

CONCLUSIONS

Patients with BAV and CTD have excellent operative outcomes, no mortality, and minimal residual AI after VSRR. Although the incidence of recurrent AI was similar, patients with BAV are at risk for AS.

Aortic Valve-Sparing Operations

Aortic valve-sparing operations were developed >3 decades ago and have become part of the surgical armamentarium to treat patients with aortic root and ascending aortic aneurysms. Although remodeling of the aortic root is physiologically sounder than reimplantation of the aortic valve, most surgeons seem to prefer the latter. This review summarizes the views of one of the pioneers of aortic valve-sparing operation and includes their development, the various modifications that occurred over the years, comparative outcomes with aortic root replacement with valved conduits, outcomes from several recently reported series, and the future directions. The author argues that comparisons between aortic valve-sparing operations and aortic root replacement with valved conduits based on retrospective studies are inappropriate because these 2 types of surgery are performed in patients with different aortic valve pathology. Late outcomes after aortic valve-sparing operations have not been consistent among various reports and raise the question of surgical expertise and patients' selection. Aortic valve-sparing operations are the best treatment for young patients with aortic root aneurysm and normal aortic cusps. Further studies are needed to define their role in the management of patients with diseased aortic cusps.