Comparison of Outcomes of Patients Undergoing Reimplantation versus Bentall Root Procedure

Author:

Svensson Lars G.12ORCID,Rosinski Brad F.1,Tucker Nicholas J.1ORCID,Gillinov A. Marc1,Rajeswaran Jeevanantham3ORCID,Roselli Eric E.12,Johnston Douglas R.12,Desai Milind Y.24,Griffin Brian P.24,Blackstone Eugene H.123ORCID

Affiliation:

1. Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio

2. The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio

3. Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio

4. Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio

Abstract

Abstract Background A bioprosthesis- or mechanical-prosthesis–containing polyester graft (composite graft) is standard surgical management for aortic root aneurysms (Bentall procedure), but particularly in the young patient in whom a bioprosthesis is likely to deteriorate and a mechanical prosthesis mandates life-long anticoagulation, valve-sparing procedures have been devised. One such procedure involves reimplantation of the native aortic valve in the polyester graft. With focus on selecting the optimum procedure for young relatively asymptomatic patients, we compared outcomes of reimplantation of the aortic valve versus the Bentall procedure and identified factors influencing outcomes. Methods From January 2000 to January 2017, 643 adults age ≤ 70 with tricuspid aortic valves underwent elective aortic root replacement with either reimplantation (n = 448/70%) or a composite valve graft (Bentall) procedure (n = 195/30%). Outcomes were compared in 100 propensity-matched pairs. Results Patients with fewer symptoms, less aortic regurgitation (AR), higher left ventricular ejection fraction, and smaller cross-sectional aortic area/height ratio had a higher likelihood of valve repair with reimplantation (all p < 0.02) versus receiving a Bentall procedure. Operative mortality was 0.16% (reimplantation, 1/448, 0.22%; Bentall 0/195, 0%). After reimplantation, 8-year freedom from severe AR was 95% and 10-year freedom from reintervention was 98%. Ten-year survival was 95%. Higher preoperative AR grade (p < 0.0001) but not larger root diameter (p = 0.3) was associated with higher grade of late regurgitation after a reimplantation procedure. Among propensity-matched patients, reimplantation compared with a Bentall was associated with similar 10-year survival (89% vs. 94%), but more late AR (8-year freedom from severe AR: 93% vs. 99.9%) and greater early reduction in, but similar late, left ventricular mass (104 vs. 105 g•m–2 at 8 years). Conclusion Excellent aortic valve reimplantation results versus Bentall lead us to recommend reimplantation more often in patients who present with even moderately severe or severe AR and significantly enlarged aortic roots.

Funder

Marty and Michelle Weinberg and Family Fund

Publisher

Georg Thieme Verlag KG

Subject

Cardiology and Cardiovascular Medicine,Radiology, Nuclear Medicine and imaging,Surgery

Reference24 articles.

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