Aortic Valve Replacement During Acute Type A Dissection Repair: Mechanical versus Bioprosthetic

P0054 

Abstract Submission 

Brad Rosinski (1), Benjamin Kramer (2), Ashley Lowry (3), Matthew Thompson (4), Rohun Bhagat (1), Marijan koprivanac (5), Patrick Vargo (6), Faisal Bakaeen (1), Eugene Blackstone (1), Lars Svensson (1), Eric Roselli (1)

(1) Cleveland Clinic, Cleveland, OH, (2) Cleveland Clinic, United States, (3) Cleveland Clinic, Department of Quantitative Health Sciences, Cleveland, OH, (4) Cleveland Clinic, Lakewood, OH, (5) N/A, cleveland heights, OH, (6) Cleveland Clinic, Cleveland, Ohio

Bradley Rosinski    -  Contact Me
Cleveland Clinic

Benjamin Kramer    -  Contact Me
Cleveland Clinic

Ashley Lowry    -  Contact Me
Cleveland Clinic, Department of Quantitative Health Sciences

Matthew Thompson    -  Contact Me
Cleveland Clinic

Rohun Bhagat    -  Contact Me
Cleveland Clinic

Marijan Koprivanac    -  Contact Me
N/A

Patrick Vargo    -  Contact Me
Cleveland Clinic

*Faisal Bakaeen    -  Contact Me
Cleveland Clinic

*Eugene Blackstone    -  Contact Me
Cleveland Clinic

*Lars Svensson    -  Contact Me
Cleveland Clinic

*Eric Roselli    -  Contact Me
Cleveland Clinic

Bradley Rosinski    -  Contact Me
Cleveland Clinic

Objectives: Identify factors associated with selection of bioprosthetic or mechanical aortic valve replacement (AVR) at the time of acute type A dissection repair, risk factors for long-term outcomes, and differentiating risk factors of late mortality.

Methods: From 2000 to 2022, 1,311 patients underwent acute type A dissection repair, with 345 (26%) requiring AVR with either a bioprosthetic (N=289, 84%; age 64±14 years) or mechanical (N=56, 16%; age 47±12 years) valve. Multivariable logistic regression identified factors associated with bioprosthetic versus mechanical AVR selection. Risk factors for time-related all-cause mortality were identified by multiphase hazard modeling for each AVR group.

Results: Frequency of mechanical AVR decreased over time while bioprosthetic replacement increased. Factors associated with bioprosthetic valve selection were older age, more recent surgery, total arch replacement, DeBakey type I dissection, concomitant coronary artery bypass grafting (CABG), diabetes, hypertension, and heart failure. Mechanical valve selection was associated with bicuspid aortic valve, Marfan syndrome, aortic root aneurysm, and concomitant root replacement (Figure 1A). Freedom from reoperation after bioprosthetic AVR at 1, 5, and 10 years was 92%, 82%, and 67% respectively; survival was 67%, 47%, and 24% at 5, 10, and 15 years. Freedom from reoperation after mechanical valve AVR at 1, 5, and 10 years was 95%, 81%, and 70%; survival was 83%, 66%, and 60% at 5, 10, and 15 years (Figure 1B). Among those receiving bioprosthetic valves, malperfusion (P<.001) and greater number of surgical components (P<.01) were risk factors for early mortality; older age (P<.001) and preoperative kidney injury (P<.0001) for late mortality. Among those who received mechanical valves, greater number of surgical components (P<.001), concomitant CABG (P<.01), and chronic pulmonary disease (P=.02) were risk factors for late mortality.

Conclusion: Survival is primarily influenced by age, preoperative complications, and preexisting comorbidities. Factors guiding valve selection in the setting of acute type A dissection are distinct. Mechanical valves have been reserved for patients under age 50 years and those with genetic aortopathies; bioprosthetic valve replacement has been favored for all others. This valve choice should be made preoperatively, with consideration for shared decision making, without concern for valve-associated mortality.

Dissection