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CC BY 4.0 · Aorta (Stamford) 2022; 10(02): 57-68
DOI: 10.1055/s-0042-1744135
Original Research Article

Comparison of Outcomes of Patients Undergoing Reimplantation versus Bentall Root Procedure

Lars G. Svensson 
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
,
Brad F. Rosinski
1   Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
,
Nicholas J. Tucker 
1   Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
,
A. Marc Gillinov
1   Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
,
Jeevanantham Rajeswaran 
3   Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
,
Eric E. Roselli
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
,
Douglas R. Johnston
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
,
Milind Y. Desai
2   The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
4   Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
,
Brian P. Griffin
2   The Aorta Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
4   Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
,
Eugene H. Blackstone 
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
› Author Affiliations Funding This study was funded in part by the Marty and Michelle Weinberg and Family Fund, The Friends of the Cleveland Clinic Foundation, the Delos M. Cosgrove, MD, Chair for Heart Disease Research, the Dana A. Hamel Family Foundation, the Gus P. Karos Registry Fund, the David Whitmire Hearst, Jr. Foundation, the Judith Dion Pyle Endowed Chair in Heart Valve Research, the Stephens Family Endowed Chair in Cardiothoracic Surgery, the Haslam Family Endowed Chair in Cardiovascular Medicine, the John and Rosemary Brown Endowed Chair in Cardiovascular Medicine, and the Drs. Sidney and Becca Fleischer Heart and Vascular Education Chair.
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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.

Keywords

aortic valve - aortic root - bioprosthesis - surgery

Supplementary Material



Publication History

Received: 18 September 2020

Accepted: 09 September 2021

Article published online:
07 August 2022

© 2022. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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