Long-term Outcomes after Aortic Valve-sparing Procedures: Impact of Concomitant Aortic Valve Repair on Long-term Valve Durability

Background: Aortic valve-sparing root surgery (VSRS) has become the preferred surgical procedure for treatment of aortic root aneurysms. Concomitant aortic valve repair (AVRep) is often necessary in cases with residual prolapse. The aim of our study was to analyze the long-term outcome of VSRS with concomitant AVRep.

Methods: A total of 423 patients underwent VSRS at our institution between 1997 and January 2023. 45 patients were excluded due to type A aortic dissection. Of these, 378 patients were electively scheduled for VSRS. Follow-up period ranged from 1 to 18.25 years. Starting in 2016, a structured AVRep protocol was implemented for standardized valve assessment (e.g., geometric and effective height) and repair techniques. Primary endpoints were survival and freedom from aortic valve (AV) re-intervention. Secondary endpoint was freedom from major adverse cardiac and cerebrovascular events (MACCE).

Results: Mean age of the study cohort was 47.7 ± 13.9 years; 72.2% were male and mean EURO-Score was 1.8 ± 1.3. 13.5% of patients had congenital valve disease (CVD), including unicuspid and bicuspid valve disease, and 39.2% had hereditary thoracic aortic disease (HTAD). 80.4% of patients underwent isolated VSRS and 17.5% of patients required concomitant AVRep. 21.9% of isolated VSRS patients underwent a minimally invasive approach via a partial upper mini-sternotomy. In-hospital and 30-day mortality was 0.3%. Overall survival was 96.7, 91.0, and 81.5% at 5, 10, and 15 years. Freedom from MACCE was 98.5% ± 0.9%, 97.2% ± 1.6%, and 90.9% ± 4.9% at 5, 10, and 15 years. The prevalence of HTAD and CVD showed no statistical difference regarding survival, reintervention, and relevant AR. Additional AVRep showed similar results at 5 years regarding long-term survival (96.3 ± 3.6%, p = 0.457). Freedom from aortic valve reintervention at 5 years was significantly lower with concomitant AVRep (75.3 ± 11.1%) compared with no additional AVRep (95.9 ± 1.3%; p = 0.003).

Conclusion: Elective VSRS is a safe procedure with very low in-hospital mortality, high long-term survival, and very low occurrence of MACCE which can be safely performed via a partial-upper sternotomy. Risk for aortic valve reintervention is higher when additional aortic valve repair is performed compared with isolated VSRS. Patients treated with concomitant AVRep during VSRS should be closely monitored to detect recurrent AR and need for reintervention early.

Publication History

Article published online:
11 February 2025