Abstract
Objective
The best method of aortic root repair in older patients remains unknown given a lack
of comparative effectiveness of long-term outcomes data. The objective of this study
was to compare long-term outcomes of different surgical approaches for aortic root
repair in Medicare patients using The Society of Thoracic Surgeons Adult Cardiac Surgery
Database-Centers for Medicare & Medicaid Services–linked data.
Methods
A retrospective cohort study was performed by querying the Society of Thoracic Surgeons
Adult Cardiac Surgery Database for patients aged 65 years or more who underwent elective
aortic root repair with or without aortic valve replacement. Primary long-term end
points were mortality, any stroke, and aortic valve reintervention. Short-term outcomes
and long-term survival were compared among each root repair strategy. Additional risk
factors for mortality after aortic root repair were assessed with a multivariable
Cox proportional hazards model.
Results
A total of 4173 patients aged 65 years or more underwent elective aortic root repair.
Patients were stratified by operative strategy: mechanical Bentall, stented bioprosthetic
Bentall, stentless bioprosthetic Bentall, or valve-sparing root replacement. Mean
follow-up was 5.0 (±4.6) years. Relative to mechanical Bentall, stented bioprosthetic
Bentall (adjusted hazard ratio, 0.80; confidence interval, 0.66-0.97) and stentless
bioprosthetic Bentall (adjusted hazard ratio, 0.70; confidence interval, 0.59-0.84)
were associated with better long-term survival. In addition, stentless bioprosthetic
Bentall (adjusted hazard ratio, 0.64; confidence interval, 0.47-0.80) and valve-sparing
root replacement (adjusted hazard ratio, 0.51; confidence interval, 0.29-0.90) were
associated with lower long-term risk of stroke. Aortic valve reintervention risk was
2-fold higher after valve-sparing root replacement compared with other operative strategies.
Conclusions
In the Medicare population, there was poorer late survival and greater late stroke
risk for patients undergoing mechanical Bentall and a higher rate of reintervention
for valve-sparing root replacement. Bioprosthetic Bentall may be the procedure of
choice in older patients undergoing aortic root repair, particularly in the era of
transcatheter aortic valve replacement.
Graphical abstract
Graphical Abstract
Key Words
Abbreviations and Acronyms:
AHR (adjusted hazard ratio), ARR (aortic root repair), AV (aortic valve), AVR (aortic valve replacement), BB (bioprosthetic Bentall), CI (confidence interval), MB (mechanical Bentall), STS-ACSD (Society of Thoracic Surgeons Adult Cardiac Surgery Database), ViV-TAVR (valve-in-valve transcatheter aortic valve replacement), VSRR (valve-sparing root replacement)To read this article in full you will need to make a payment
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References
- A technique for complete replacement of the ascending aorta.Thorax. 1968; 23: 338-339
- Replacement of the ascending aorta and aortic valve with a composite graft: results in 25 patients.Ann Thorac Surg. 1977; 24: 140-148
- Homograft aortic valve replacement in aortic incompetence and stenosis.Thorax. 1964; 19: 131-150
- Homograft replacement of the aortic valve.Lancet. 1962; 2: 487
- C R Acad Sci Hebd Seances Acad Sci D. 1965; 261: 5733-5734
- Prognostic implications of echocardiographically determined left ventricular mass in the Framingham Heart Study.N Engl J Med. 1990; 322: 1561-1566
- An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.J Thorac Cardiovasc Surg. 1992; 103: 617-622
- Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root.J Thorac Cardiovasc Surg. 1998; 115: 1080-1090
- Outcomes following transcatheter aortic valve replacement for degenerative stentless versus stented bioprostheses.JACC Cardiovasc Interv. 2019; 12: 1256-1263
- 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease.J Am Coll Cardiol. 2010; 55: e27-e129
- Aortic valve and ascending aorta guidelines for management and quality measures.Ann Thorac Surg. 2013; 95: S1-S66
- 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult.Eur Heart J. 2014; 35: 2873-2926
- Long-term survival, valve durability, and reoperation for 4 aortic root procedures combined with ascending aorta replacement.J Thorac Cardiovasc Surg. 2016; 151: 764-74. e4
- The Society of Thoracic Surgeons adult cardiac surgery database: 2018 update on outcomes and quality.Ann Thorac Surg. 2018; 105: 15-23
- The Society of Thoracic Surgeons national database 2016 annual report.Ann Thorac Surg. 2016; 102: 1790-1797
- Updates to the data quality review program: the Society of Thoracic Surgeons adult cardiac national database.Ann Thorac Surg. 1998; 65: 1494-1497
- Successful linking of the Society of Thoracic Surgeons adult cardiac surgery database to centers for Medicare and Medicaid Services Medicare data.Ann Thorac Surg. 2010; 90: 1150-1157
- Contemporary results for proximal aortic replacement in North America.J Am Coll Cardiol. 2012; 60: 1156-1162
- The Society of Thoracic Surgeons 2018 adult cardiac surgery risk models: part 2-statistical methods and results.Ann Thorac Surg. 2018; 105: 1419-1428
- The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2–isolated valve surgery.Ann Thorac Surg. 2009; 88: S23-S42
- A class of K-Sample tests for comparing the cumulative incidence of a competing risk.Ann Stat. 1988; 16: 1141-1154
- A proportional hazards model for the subdistribution of a competing risk.J Am Stat Assoc. 1999; 94: 496-509
Gondara L. Competing risk survival analysis using SAS: when, why and how. Presented at: SAS Global Forum; April 26-29, 2015; Dallas, TX. Paper 1424-2015.
- Aortic valve repair and root preservation by remodeling, reimplantation, and tailoring: technical aspects and early outcome.J Card Surg. 2007; 22: 473-479
- Management of aortic valve disease during aortic surgery.Ann Thorac Surg. 2000; 69: 778-784
- Aortic valve preservation in patients with aortic root aneurysm: results of the reimplantation technique.Ann Thorac Surg. 2007; 83 (discussion S785-90): S732-S735
- Aortic valve-sparing operation in Marfan syndrome: what do we know after a decade?.Ann Thorac Surg. 2007; 83 (discussion S785-90): S764-S768
- Aortic root operations for Marfan syndrome: a comparison of the Bentall and valve-sparing procedures.Ann Thorac Surg. 2008; 85: 2003-2011
- Contemporary outcomes of surgery for aortic root aneurysms: a propensity-matched comparison of valve-sparing and composite valve graft replacement.J Thorac Cardiovasc Surg. 2015; 150: 1120-1129.e1
- Valve-sparing root replacement compared with composite valve graft procedures in patients with aortic root dilation.J Am Coll Cardiol. 2016; 68: 1838-1847
- Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons national database.J Thorac Cardiovasc Surg. 2009; 137: 82-90
- 1-year results in patients undergoing transcatheter aortic valve replacement with failed surgical bioprostheses.JACC Cardiovasc Interv. 2017; 10: 1034-1044
- Transcatheter aortic valve implantation in failed bioprosthetic surgical valves.JAMA. 2014; 312: 162-170
- Transcatheter aortic valve replacement of failed surgically implanted bioprostheses: the STS/ACC registry.J Am Coll Cardiol. 2018; 72: 370-382
- Hemodynamic benefits of the Toronto stentless valve.J Thorac Cardiovasc Surg. 1996; 112: 1431-1446
- Aortic valve replacement with the freestyle stentless bioprosthesis: five-year experience.Circulation. 1999; 100: II17-II23
- Stentless aortic valve reoperations: a surgical challenge.Ann Thorac Surg. 2007; 84: 737-744
- Pseudoaneurysm formation after Medtronic freestyle porcine aortic bioprosthesis implantation: a word of caution.Ann Thorac Surg. 2014; 98: 2061-2067
- Incidence, predictors, and clinical outcomes of coronary obstruction following transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: insights from the VIVID registry.Eur Heart J. 2018; 39: 687-695
- Use of balloon expandable transcatheter valves for valve-in-valve implantation in patients with degenerative stentless aortic bioprostheses: technical considerations and results.J Thorac Cardiovasc Surg. 2014; 148: 917-924
- Valve-in-valve transcatheter aortic valve implantation for failing surgical aortic stentless bioprosthetic valves: a single-center experience.J Thorac Cardiovasc Surg. 2015; 150: 91-98
- Transcatheter aortic valve-in-valve implantation in failed stentless bioprostheses.J Interv Cardiol. 2018; 31: 861-869
- A comparison of valve-in-valve transcatheter aortic valve replacement in failed stentless versus stented surgical bioprosthetic aortic valves.Catheter Cardiovasc Interv. 2019; 93: 1106-1115
- Transcatheter aortic valve implantation for pure severe native aortic valve regurgitation.J Am Coll Cardiol. 2013; 61: 1577-1584
- Long-term results of aortic valve-sparing operations for aortic root aneurysm.J Thorac Cardiovasc Surg. 2006; 132: 347-354
Article info
Publication history
Published online: February 25, 2021
Accepted:
February 12,
2021
Received in revised form:
January 21,
2021
Received:
August 7,
2020
Footnotes
Funding was provided by the Society of Thoracic Surgeons. B.A.Y. is supported by the National Institutes of Health–funded Cardiothoracic Surgery Trials Network 5U01HL088953-05. A.M.V. is supported by the National Institutes of Health Postdoctoral Training in Cardiovascular Clinical Research 5T32HL069749-17.
STS-ACSD Registry analysis approved by Duke University Institutional Review Board with patient consent waived (#Pro00014556, Initial Approval Date: May 12, 2008).
Identification
Copyright
© 2021 by The American Association for Thoracic Surgery
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- Commentary: The root of the matterThe Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 2
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