Valve Sparing Aortic Root Replacement: long-term variables significantly associated with mortality and morbidity.

Abstract

In aortic root surgery, Valve Sparing Aortic Root Replacement (VSARR) is an attractive alternative by mitigating the risks inherent to prosthetic valves, however little is known about the variables that impact its durability. We review our mid to long-term outcomes following VSARR and describe factors that impact survival and valve reintervention and insufficiency. A retrospective review of 284 consecutive patients undergoing VSARR between November 1999 and January 2022 at Austin Health, Melbourne, Australia, was undertaken, with median follow-up of 6.43±4.83 years, but up to 22.0 years. Freedom from mortality, aortic re-intervention and insufficiency was analysed using Kaplan Meier methods, Cox Proportional Hazard Models and Fine-Gray analysis. The median age at intervention was 60.0 years (IQR 48.0-67.0), of which 68 (23.9%) had bicuspid aortic valve (BAV) disease, 27 (9.5%) Marfan's disease, 119 (41.9%) severe aortic root dilation (>50mm), and 155 (54.6%) severe aortic insufficiency at the time of intervention. The 30-day mortality was 1.8%, with freedom from mortality of 96.0% (95%CI 92.6-97.8%) at 5 years and 88.2% (95%CI 81.4-92.6%) at 10 years. Freedom from aortic re-intervention was 92.2% (95%CI 87.7-95.2%) at 5 years and 79.8% (95%CI 71.8-85.8%) at 10 years. Factors associated with re-intervention were concomitant leaflet repair (HR 8.13, 95%CI 1.07-61.7) and bicuspid valvulopathy (HR 2.23, 95%CI 1.07-4.68), with re-intervention in the BAV being more likely due to Aortic Stenosis and in TAV to Aortic Insufficiency (chi-squared p=0.05). The freedom from aortic insufficiency was 89.1% (95%CI 83.5-92.9%), 84.9% (95%CI 77.8-89.9%) and 80.7% (95%CI 71.0-87.4%) at 5- and 10- years respectively. VSARR has excellent long-term outcomes, with low mortality and re-intervention rates. Concomitant Leaflet repair and Bicuspid Valve Disease are the only long-term factors associated with re-intervention.