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CC BY 4.0 · Aorta (Stamford) 2025; 13(01): 001-008
DOI: 10.1055/s-0045-1809688
Original Research Article

Root Remodeling versus Root Reimplantation in Patients with Bicuspid Aortic Valve and Root Aneurysm

Fei Xiang
1   The Aorta Center, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
2   Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
3   Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
,
Lin Chen
1   The Aorta Center, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
2   Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
,
Eric E. Roselli
1   The Aorta Center, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
2   Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
,
Brian Griffin
1   The Aorta Center, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
3   Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
,
Milind Desai
1   The Aorta Center, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
3   Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
,
Jeevanantham Rajeswaran
4   Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
,
Austin Firth
5   Cardiovascular Outcomes Registries and Research, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
,
Eugene H. Blackstone
1   The Aorta Center, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
2   Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
4   Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
,
Lars G. Svensson 
1   The Aorta Center, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
2   Department of Thoracic and Cardiovascular Surgery, Miller Family Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
› Author Affiliations
Funding This study was supported in part by the Marty and Michelle Weinberg and Family Fund, and the Delos M. Cosgrove, MD, Chair for Heart Disease Research Fund (L.G.S.).
› Further Information
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Abstract

Background

Valve-sparing root replacements are increasingly being performed in patients with bicuspid aortic valve (BAV) and root aneurysm. This study aims to compare the outcomes of patients who underwent root remodeling versus root reimplantation.

Methods

From 2000 to 2022, 206 adults with BAV and root aneurysm (mean age: 47 ± 12 years, 183 [89%] male) underwent root remodeling (n = 32) or reimplantation (n = 174) at Cleveland Clinic. Compared with remodeling, patients in the reimplantation group had more aortic regurgitation (severe 61/174 [35%] vs. 3/32 [9.4%]) and smaller aortic roots (sinus diameter: 4.3 ± 0.56 vs. 4.6 ± 0.47 cm). Operative mortality and morbidity, durability, and time-related mortality were compared.

Results

Patients in both groups underwent additional aortic valve repair (reimplantation vs. remodeling group: figure-of-8 hitch-up stitch 10/174 [5.7%] vs. 14/32 [44%], p < 0.001; cusp plication 91/174 [52%] vs. 11/32 [34%], p = 0.06). Compared with the remodeling group, aortic clamp time was longer in the reimplantation group (median 136 vs. 76 minutes, p < 0.001). Two in-hospital reoperations occurred after remodeling from valve dysfunction. One operative death occurred in each group. At 5 years, severe aortic regurgitation was 16% after remodeling versus 5.0% after reimplantation (p = 0.06), mean gradient 11 versus 10 mm Hg (p = 0.12), aortic valve reoperation 23% versus 6.0% (p = 0.14), and survival 97% versus 95%, respectively (p = 0.71).

Conclusion

Both root remodeling and reimplantation can be safely performed in patients with BAV and root aneurysms with similar midterm outcomes. Although root remodeling is a shorter surgery, less late aortic valve regurgitation and fewer valve reoperations lead us to recommend root reimplantation.

Keywords

aortopathy - valve-sparing root replacement - durability - survival

Supplementary Material



Publication History

Received: 10 November 2023

Accepted: 01 September 2024

Article published online:
12 June 2025

© 2025. 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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