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Valve-sparing root replacement in patients with bicuspid versus tricuspid aortic valves

Open ArchivePublished:November 24, 2018DOI:https://doi.org/10.1016/j.jtcvs.2018.10.151

      Abstract

      Objectives

      We sought to compare the outcomes of patients undergoing aortic valve-sparing root replacement with bicuspid versus tricuspid aortic valves.

      Methods

      A total of 333 consecutive patients (bicuspid aortic valve, n = 45; tricuspid aortic valve, n = 288) underwent valve-sparing root replacement using the reimplantation technique from 1988 to 2012 at a single institution. The primary analysis was performed on a 1:3 bicuspid aortic valve:tricuspid aortic valve propensity-matched dataset to mitigate known differences between these 2 groups. In the matched, dataset, mean age (bicuspid aortic valve: 40 ± 13 years; tricuspid aortic valve: 41 ± 14) and rates of comorbidities were similar between groups. Patients with bicuspid aortic valves were less likely to have Marfan syndrome (bicuspid aortic valve: 9% vs tricuspid aortic valve: 53%, P < .001). Patients were followed prospectively with aortic root imaging for a median of 8.2 (5.3-12.2) years.

      Results

      Primary cusp repair was required more often in patients with bicuspid aortic valves (bicuspid aortic valve: 79% vs tricuspid aortic valve: 45%, P < .001). A total of 3 operative deaths occurred (bicuspid aortic valve 0% vs tricuspid aortic valve 2%, P = .52). The probability of aortic insufficiency increased significantly over time in both groups (odds ratio, 1.106; 95% confidence interval, 1.033-1.185; P = .004), but there was no significant difference in this increase between the bicuspid aortic valve and tricuspid aortic valve groups (P = .08). Long-term freedom from mortality (P = .20), cumulative incidence of aortic valve reoperation (P = .42), and valve-related events (P = .69) were similar across groups.

      Conclusions

      In well-selected patients with bicuspid aortic valves and favorable cusp morphology, valve-sparing root replacement offers excellent long-term clinical outcomes.

      Key Words

      Abbreviations and Acronyms:

      AI (aortic insufficiency), AVS (aortic valve sparing), BAV (bicuspid aortic valve), TAV (tricuspid aortic valve)
      Figure thumbnail fx1
      Valve-related adverse events over time in patients undergoing AVS surgery.
      In well-selected patients with BAVs, valve-sparing root replacement offers excellent long-term clinical outcomes.
      Whether the outcomes after valve-sparing root replacement in patients with BAVs are similar to those with TAVs remains uncertain. This study reports long-term mortality, aortic valve reoperation, and the development of moderate to severe AI in patients undergoing valve-sparing root replacement with BAV versus TAV.
      See Commentaries on pages 10 and 12.
      Aortic valve-sparing (AVS) operations have proven to be a durable strategy in patients with aortic aneurysms and favorable cusp morphology
      • David T.E.
      • David C.M.
      • Manlhiot C.
      • Colman J.
      • Crean A.M.
      • Bradley T.
      Outcomes of aortic valve-sparing operations in Marfan syndrome.
      • David T.E.
      • Feindel C.M.
      • David C.M.
      • Manlhiot C.
      A quarter of a century of experience with aortic valve-sparing operations.
      and are associated with improved long-term outcomes when compared with valve-replacing root procedures.
      • Ouzounian M.
      • Rao V.
      • Manlhiot C.
      • Abraham N.
      • David C.
      • Feindel C.M.
      • et al.
      Valve-sparing root replacement compared with composite valve graft procedures in patients with aortic root dilation.
      Initially designed for morphologically normal tricuspid aortic valves (TAVs), over the years, AVS techniques have been extended to include patients with cusp prolapse, severe aortic insufficiency (AI), bicuspid aortic valves (BAVs), and acute aortic dissections.
      Whereas the AI associated with aortic root aneurysms and TAV is often due to dilatation of the ventriculoaortic and sinotubular junctions, the mechanism of the AI in patients with BAV and root aneurysms often results from a combination of dilatation and distortion of root geometry along with primary cusp pathology. Although several groups have reported excellent results with AVS in patients with BAV,
      • Schneider U.
      • Feldner S.K.
      • Hofmann C.
      • Schope J.
      • Wagenpfeil S.
      • Giebels C.
      • et al.
      Two decades of experience with root remodeling and valve repair for bicuspid aortic valves.
      • Boodhwani M.
      • de Kerchove L.
      • Glineur D.
      • Rubay J.
      • Vanoverschelde J.L.
      • Noirhomme P.
      • et al.
      Repair of regurgitant bicuspid aortic valves: a systematic approach.
      long-term comparative data are lacking. The purpose of the current study was to compare the outcomes of patients undergoing AVS with BAV versus TAV. We hypothesized there would be no difference in the need for aortic valve replacement or recurrent significant AI for patients with BAV root aneurysms undergoing AVS compared with those with TAV.

      Materials and Methods

      Study Population

      Of the 408 patients who underwent AVS surgery between 1988 and 2012 for aortic root aneurysms at the Peter Munk Cardiac Centre, only patients for whom the reimplantation technique was used (N = 333) were included in this study. A total of 45 patients had BAV, and 288 patients had TAV. Patients who underwent valve-sparing root replacement between 1990 and 2012 represented 25% of all patients undergoing root replacement at our institution. In contrast, among patients with BAV, only 7% of those who underwent root replacement had a valve-sparing approach. Patients were followed prospectively with annual echocardiographic studies during the first decade and every 2 to 3 years thereafter if the aortic valve function had remained stable. For the present report, the follow-up period was closed on September 30, 2015. The median (interquartile range) follow-up duration was 8.2 (5.3-12.2) years with some differences between groups (TAV: 8.4 [5.6-12.6] years vs BAV: 5.6 [3.3-9.6] years; P = .06). The clinical follow-up data were complete in all patients, and specific dates of events were available for all outcomes. A total of 1334 echocardiographic studies were available for analysis (median 4 studies per patient). Echocardiographic studies were available in 98% of patients without terminal events during the most recent 3 years. The Research Ethics Board of the University Health Network approved the study (Research Ethics Board #06-0756) and waived the need for individual patient consent.

      Statistical Analyses

      For the descriptive analysis, clinical characteristics were summarized in terms of means ± standard deviation or medians (interquartile ranges) for continuous variable and frequencies for dichotomous and polytomous variables. Between-group differences in continuous variables were assessed using Wilcoxon rank-sum tests, and differences in dichotomous/polytomous variables were assessed using Fisher exact tests.
      For propensity score matching, logistic regression was used to derive a propensity score for belonging to the BAV versus the TAV group. The variables included in the regression model (a priori selection) were age, sex, New York Heart Association grade, left ventricle grade, and reoperation. Propensity score matching in a 1:3 ratio of BAV:TAV subjects was performed using a greedy algorithm without replacement with a maximum allowable difference in propensity score within pairs of 0.03. Additional controls for cases who were not fully matched using this algorithm were selected using nearest neighbors without replacement.
      For the time-to-event analysis, the primary outcome of interest was mortality, and freedom from mortality was estimated using the Kaplan–Meier survival method. Secondary outcomes of interest included (1) reoperation on the aortic valve; (2) moderate to severe AI (AI >2.5); and (3) valve-related adverse event: a composite of valve-related death, reoperation of the aortic valve, thromboembolism, anticoagulant-related hemorrhage requiring blood transfusion or resulting in stroke or death, and endocarditis. All-cause mortality and cause of death were determined by review of patients' medical records and death certificates. In accordance with the valve-reporting guidelines,
      • Akins C.W.
      • Travis B.
      • Yoganathan A.P.
      Energy loss for evaluating heart valve performance.
      we defined valve-related mortality as any death caused by structural or nonstructural valve deterioration, valve thrombosis, embolism, bleeding event, or endocarditis; death related to reintervention on the operated valve; or sudden, unexplained death.
      Cumulative incidence of valve reoperation was calculated using all-cause death as a competing risk. Cumulative incidence of valve-related events was calculated using nonvalve-related death as the competing risk. Between-group differences were assessed using the log-rank test for freedom from mortality and Gray's test for cumulative incidence estimates. The predicted probability of moderate to severe AI over time was estimated using a logistic regression adjusted for repeated measures using an autoregressive correlation structure. All statistical analyses were performed using SAS v9.4 (SAS Institute Inc, Cary NC) and R (v3.4).

      Results

      Baseline Characteristics

      The baseline characteristics of the final propensity-matched set are shown in Table 1. After 1:3 propensity-matching, the mean age of the set was 41 ± 14 years, and 160 (89%) were male. Most patients undergoing AVS had preserved heart function and were undergoing elective surgery. Patients with BAV were less likely to have Marfan syndrome (BAV: 9% vs TAV: 53%, P < .001) than those with TAV.
      Table 1Baseline characteristics of patients undergoing aortic valve-sparing surgery
      VariableTAVBAVP value
      (N = 135)(N = 45)
      Age, y (range)13541 ± 144540 ± 13.93
      Male, %135121 (90)4539 (87).59
      Urgent or emergency, %1354 (3)451 (2)1.00
      Any previous cardiac surgery, %1358 (6)453 (7)1.00
      Clinical presentation
       Angina (all stable), %1354 (3)452 (4).64
       Heart failure, %1355 (4)450 (0).33
       Shock, %1350 (0)450 (0)1.00
       Syncope, %1352 (1)451 (2)1.00
      New York Heart Association class13545.49
       I, %109 (81)33 (73)
       II, %22 (16)12 (27)
       III, %3 (2)0 (0)
       IV, %1 (1)0 (0)
      Left ventricular ejection fraction13545.33
       >60%, %105 (78)30 (67)
       40%-59%, %21 (16)10 (22)
       20%-39%, %9 (7)5 (11)
       <20%, %0 (0.0)0 (0.0)
      Associated disease
       Marfan syndrome, %13571 (53)454 (9)<.001
       Diabetes, %1351 (1)451 (2).44
       Hypertension, %13542 (31)4513 (29).85
       Hyperlipidemia, %13516 (12)458 (18).32
       Renal failure, %1350 (0)450 (0)
       Smoking history, %13556 (41)4516 (36).60
       Chronic obstructive pulmonary disease, %1352 (1)451 (2)1
       Previous stroke or transient ischemic attack, %1354 (3)453 (7).44
      Preoperative findings
       Aortic root diameter, mm11254 ± 53952 ± 8.24
       Aortic regurgitation (greater than mild), %13583 (61)4535 (78).03
       Mitral regurgitation (greater than mild), %1357 (5)452 (4)1.00
      TAV, Tricuspid aortic valve; BAV, bicuspid aortic valve.

      Operative Details and Perioperative Outcomes

      Among patients with BAV, the majority (82%) had Sievers type 1 valves, and 18% had type 0 valves. Operative details are summarized in Table 2. Primary cusp repair was required more often in patients with BAV (79% vs 45%, P < .001). Specifically, more patients with BAV required cusp plication (BAV: 76% vs TAV: 35%, P < .001), whereas reinforcement of the free margin with polytetrafluoroethylene (Gore-Tex, WL Gore & Associates, Inc, Flagstaff, Ariz) suture was similar between groups (BAV: 25% vs TAV: 28%, P = .84). The most common diameter of the graft used in each group was 34. Among patients with BAV, 33% underwent raphe resection and 13% were noted to have mild calcification of the cusps. No patients with BAV had greater than mild calcification or underwent patch repair of the cusps. A greater proportion of patients with BAV underwent concomitant aortic arch replacement (BAV: 11% vs TAV: 6%, P = .002). Three operative deaths occurred (BAV 0% vs TAV 2%, P = .57). The frequency of all early complications was low and similar between the 2 groups (Table 3).
      Table 2Intraoperative details
      VariableTAVBAVP value
      (N = 135)(N = 35)
      Size of aortic Dacron graft prosthesis13545
       Mean (mm), ± SD31 ± 231 ± 3.93
       Median (IQR) (mm)32 (30-34)32 (30-34)
      Any cusp repaired,
      Repair includes plication or reinforcement with polytetrafluoroethylene (Gore-Tex).
      %
      13259 (45)4233 (79)<.001
      Any cusp plication, %13046 (35)4232 (76)<.001
      No. of cusps shortened by plication13042<.001
       084 (65)10 (24)
       120 (15)16 (38)
       219 (15)16 (38)
       37 (5)
      Any cusp reinforced with polytetrafluoroethylene % (Gore-Tex, WL Gore & Associates, Flagstaff, Ariz)13137 (28)4010 (25).84
      No. of cusps reinforced with Gore-Tex13140.12
       094 (72)30 (75)
       132 (24)6 (15)
       23 (2)4 (10)
       32 (2)0 (0)
      Any neosinus created, %12372 (59)3215 (47).32
      No. of neoaortic sinuses created12332.007
       051 (41)17 (53)
       152 (42)10 (31)
       20 (0)3 (9)
       320 (16)2 (6)
      Aortic arch replacement, %1338 (6)395 (13).002
      Coronary artery bypass grafting, %13510 (7)451 (2).3
      Mitral valve repair, %1357 (5)452 (4)1.00
      Repair of congenital defect13514 (10)452 (4).36
      Cardiopulmonary bypass time (min), ± SD135134 ± 2445139 ± 35.32
      Crossclamp time (min), ± SD135111 ± 2045116 ± 28.28
      Body surface area (m2)1352.1 ± 0.2452.1 ± 0.3.84
      TAV, Tricuspid aortic valve; BAV, bicuspid aortic valve; SD, standard deviation; IQR, interquartile range.
      Repair includes plication or reinforcement with polytetrafluoroethylene (Gore-Tex).
      Table 3Early outcomes
      VariableTAVBAVP value
      (N = 135)(N = 45)
      Mortality, %3 (2)0 (0%).57
      Reoperation for bleeding, %9 (7)3 (7)1.00
      Perioperative myocardial infarction, %0 (0)2 (4).06
      Insertion of intra-aortic balloon pump, %1 (1)0 (0)1.00
      Insertion of permanent pacemaker, %1 (1)1 (2).44
      Postoperative atrial fibrillation, %24 (18)10 (22).51
      Stroke or transient ischemic attack, %1 (1)1 (2).44
      Sternal wound infection, %1 (1)0 (0)1.00
      Sepsis, %1 (1)1 (2).44
      TAV, Tricuspid aortic valve; BAV, bicuspid aortic valve.

      Long-Term Outcomes

      The unadjusted long-term outcomes of interest stratified by valve morphology are reported in Table 4. Table 4 reports the freedom from death and the cumulative incidence rates for the other outcomes of interest at 1, 5, and 10 years. There was no significant difference in freedom from death between the 2 groups (P = .20) (Figure 1).
      Table 4Long-term outcomes
      VariableTAV (n = 135)BAV (n = 45)P value
      Freedom from mortality, %
       1 y99.2% (94.8-99.9)100%.20
       5 y99.2% (94.8-99.9)100%
       10 y94.1% (85.9-97.6)100%
      Cumulative % of AI >2.5
       1 y0.8% (0.3-2.3)2.7% (1.1-6.8).08
       5 y1.2% (0.5-2.9)3.9% (1.5-9.9)
       10 y1.9% (0.8-4.3)6.5% (2.1-18.3)
      Cumulative % of aortic valve reoperation
       1 y00.42
       5 y00
       10 y1.4% (0.0-4.2)4.2% (0.0-11.8)
      Cumulative % of valve-related events
       1 y1.5% (0.0-3.6)2.4% (0.0-6.9).69
       5 y4.7% (1.0-8.3)2.4% (0.0-6.9)
       10 y7.2% (2.1-12.0)20.5% (0.0-38.3)
      Kaplan–Meier estimates for mortality and cumulative incidence estimates for AI greater than 2.5, aortic valve reoperation, and valve-related events. Brackets indicate 95% confidence interval. AI, Aortic insufficiency; BAV, bicuspid aortic valve; TAV, tricuspid aortic valve.
      Figure thumbnail gr1
      Figure 1Freedom from death in patients undergoing AVS surgery. Freedom from death was estimated using the Kaplan–Meier method, and differences were assessed with log-rank tests. There was no significant difference in mortality across the 2 groups (P = .20). TAV, Tricuspid aortic valve; BAV, bicuspid aortic valve.
      During the follow-up periods, 2 patients (BAV: 1, TAV: 1) underwent aortic valve reoperations (Table 4 and Figure 2), and 5 patients (BAV 2, TAV: 3) developed moderate to severe AI (Table 4). There were no differences in the cumulative incidence of aortic valve reoperations (P = .42) or valve-related adverse events (P = .69) (Figure 3) between patients with BAV and TAV. The probability of AI increased significantly over time in both groups (odds ratio, 1.106; 95% confidence interval, 1.033-1.185; P = .004), but there was no significant difference in this increase between patients with BAV and TAV (P = .08). There was no statistically significant difference in the effect of time on postprocedure AI between the BAV and TAV groups (P = .085). Similar results were obtained when the analysis was performed on the entire cohort (N = 333).
      Figure thumbnail gr2
      Figure 2Aortic valve reoperation over time in patients undergoing AVS surgery. The cumulative incidence of patients with aortic valve reoperation was summarized. Gray's test was applied to assess differences between cohorts. There was no significant difference in cumulative incidence rates of aortic valve reoperation in patients with BAV compared with TAV (P = .42). TAV, Tricuspid aortic valve; BAV, bicuspid aortic valve.
      Figure thumbnail gr3
      Figure 3Valve-related adverse events over time in patients undergoing AVS surgery. The cumulative incidence of patients with valve-related adverse events was summarized. Gray's test was applied to assess differences between cohorts. There was no significant difference in cumulative incidence rates of valve-related adverse events in patients with BAV compared with TAV (P = .69). TAV, Tricuspid aortic valve; BAV, bicuspid aortic valve.

      Discussion

      Several groups have demonstrated excellent long-term results with AVS operations,
      • David T.E.
      • Feindel C.M.
      • David C.M.
      • Manlhiot C.
      A quarter of a century of experience with aortic valve-sparing operations.
      • Cameron D.E.
      • Alejo D.E.
      • Patel N.D.
      • Nwakanma L.U.
      • Weiss E.S.
      • Vricella L.A.
      • et al.
      Aortic root replacement in 372 Marfan patients: evolution of operative repair over 30 years.
      • Kvitting J.P.
      • Kari F.A.
      • Fischbein M.P.
      • Liang D.H.
      • Beraud A.S.
      • Stephens E.H.
      • et al.
      David valve-sparing aortic root replacement: equivalent mid-term outcome for different valve types with or without connective tissue disorder.
      which are an attractive option for patients presenting with an aortic root aneurysm with or without AI. In this study, we observed no significant early or long-term differences between patients with BAV undergoing AVS (Video 1) and patients with TAV. Specifically, patients with BAV experienced similar long-term freedom from death, aortic valve reoperation, and moderate or severe AI than those with TAV undergoing AVS.
      Figure thumbnail fx2
      Video 1Valve-sparing root replacement with reimplantation technique in a patient with BAV. Video available at: https://www.jtcvs.org/article/S0022-5223(18)33143-X/fulltext.
      Bicuspid valve disease presents with a wide range of morphologic configurations of the cusps, sinuses, commissures, and associated aortopathy.
      • Sievers H.H.
      • Schmidtke C.
      A classification system for the bicuspid aortic valve from 304 surgical specimens.
      • Fazel S.S.
      • Mallidi H.R.
      • Lee R.S.
      • Sheehan M.P.
      • Liang D.
      • Fleischman D.
      • et al.
      The aortopathy of bicuspid aortic valve disease has distinctive patterns and usually involves the transverse aortic arch.
      Heterogeneity is also observed in the mechanism of BAV AI, which may be due to a restrictive or calcified conjoint cusp, cusp prolapse or fenestrations, a severely dilated annulus, or a combination of these. BAV repair strategies must address each of the pathologic components in an effort to restore functional root geometry and may include free-margin plication, raphe resection or shaving, free margin resuspension, and various techniques of annular downsizing. Adoption of valve-sparing root replacement in the context of BAV has been increasingly undertaken with excellent long-term results.
      • Schneider U.
      • Feldner S.K.
      • Hofmann C.
      • Schope J.
      • Wagenpfeil S.
      • Giebels C.
      • et al.
      Two decades of experience with root remodeling and valve repair for bicuspid aortic valves.
      • Boodhwani M.
      • de Kerchove L.
      • Glineur D.
      • Rubay J.
      • Vanoverschelde J.L.
      • Noirhomme P.
      • et al.
      Repair of regurgitant bicuspid aortic valves: a systematic approach.
      • Kari F.A.
      • Liang D.H.
      • Kvitting J.P.
      • Stephens E.H.
      • Mitchell R.S.
      • Fischbein M.P.
      • et al.
      Tirone David valve-sparing aortic root replacement and cusp repair for bicuspid aortic valve disease.
      Particularly for the young patient, the benefits of valve preservation, with low rates of endocarditis and thrombo-hemorrhagic events are undeniable. However, BAV repair has been accompanied by a considerable rate of recurrent and progressive AI. In a series of 108 consecutive patients undergoing isolated BAV repair without AVS, the need for reoperation was reported to be as high as 51% after 10 years.
      • Ashikhmina E.
      • Sundt III, T.M.
      • Dearani J.A.
      • Connolly H.M.
      • Li Z.
      • Schaff H.V.
      Repair of the bicuspid aortic valve: a viable alternative to replacement with a bioprosthesis.
      Svensson and colleagues
      • Svensson L.G.
      • Al Kindi A.H.
      • Vivacqua A.
      • Pettersson G.B.
      • Gillinov A.M.
      • Mihaljevic T.
      • et al.
      Long-term durability of bicuspid aortic valve repair.
      observed that of 728 patients who underwent BAV repair using a variety of techniques, 25% of patients had moderate AI and 24% had severe AI by 5 years of follow-up.
      Several predictors of failure have been identified in BAV repair. In a study of 357 patients who underwent BAV repair and root remodeling, cusp calcification and cusp reconstruction with a pericardial patch were the strongest predictors of failure.
      • Schneider U.
      • Feldner S.K.
      • Hofmann C.
      • Schope J.
      • Wagenpfeil S.
      • Giebels C.
      • et al.
      Two decades of experience with root remodeling and valve repair for bicuspid aortic valves.
      The number and location of raphes and the extent of their fusion may affect the late success of BAV repair, and valves with larger angles and complete cusp fusion have been linked to favorable outcomes.
      • Aicher D.
      • Kunihara T.
      • Abou Issa O.
      • Brittner B.
      • Graber S.
      • Schafers H.J.
      Valve configuration determines long-term results after repair of the bicuspid aortic valve.
      • Kari F.A.
      • Kvitting J.P.
      • Stephens E.H.
      • Liang D.H.
      • Merk D.R.
      • Fischbein M.P.
      • et al.
      Tirone David procedure for bicuspid aortic valve disease: impact of root geometry and valve type on mid-term outcomes.
      Finally, several groups have suggested that a root replacement procedure rather than subcommissural plication increases the durability of BAV repair, particularly in patients with a dilated annulus.
      • Kari F.A.
      • Liang D.H.
      • Kvitting J.P.
      • Stephens E.H.
      • Mitchell R.S.
      • Fischbein M.P.
      • et al.
      Tirone David valve-sparing aortic root replacement and cusp repair for bicuspid aortic valve disease.
      • Aicher D.
      • Kunihara T.
      • Abou Issa O.
      • Brittner B.
      • Graber S.
      • Schafers H.J.
      Valve configuration determines long-term results after repair of the bicuspid aortic valve.
      • Bavaria J.E.
      • Desai N.
      • Szeto W.Y.
      • Komlo C.
      • Rhode T.
      • Wallen T.
      • et al.
      Valve-sparing root reimplantation and leaflet repair in a bicuspid aortic valve: comparison with the 3-cusp David procedure.
      • de Kerchove L.
      • Boodhwani M.
      • Glineur D.
      • Vandyck M.
      • Vanoverschelde J.L.
      • Noirhomme P.
      • et al.
      Valve sparing-root replacement with the reimplantation technique to increase the durability of bicuspid aortic valve repair.
      Our results add to previous reports that demonstrate the long-term durability of AVS for patients with BAV. The heterogeneity of patients with BAV, the repair techniques used, and the variable length and completeness of follow-up make interpretation of the literature challenging. We have adopted a highly selective policy for choosing which BAVs to repair, avoiding valves that are calcified, have restricted cusp motion, or require patch augmentation or replacement of a cusp. In patients with aortic root aneurysms, we continue to favor reimplantation of the valve to ensure long-term stability of the ventriculoaortic junction.

      Study Limitations

      The main limitations of this study are its retrospective nature and the sample size with relatively few patients with BAV compared with TAV. There is inherent bias in which patients are selected and who are denied a valve-sparing operation, particularly in the context of BAV. Patients with calcified or restrictive leaflets requiring resection or leaflet augmentation were usually deemed ineligible for AVS. We acknowledge that because 2 expert aortic surgeons performed the majority of the root procedures in this highly selected patient population, these data may not be generalizable.

      Conclusions

      Although patients with BAV require more concomitant cusp repair, valve-sparing root replacement offers excellent long-term clinical outcomes in carefully selected patients with both BAV and TAV who require root replacement.

      Webcast

      Conflict of Interest Statement

      Authors have nothing to disclose with regard to commercial support.
      The authors thank Dr Myriam Lafreniere-Roula and Dr Steve Chun-Po Fan for statistical support.

      Supplementary Data

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