Valve-Replacing Aortic Root Replacement: The evolution of Mechanical and Bioprosthetic Surgical Approaches over Four Decades

P0377 

Abstract Submission 

Ahmad Tabatabaeishoorijeh (1), Lynna Nguyen (1), Veronica Glover (1), Ginger Etheridge (1), Susan Green (1), Subhasis Chatterjee (1), Marc Moon (1), Joseph Coselli (1)

(1) Baylor College of Medicine/Texas Heart Institute, Houston, TX

Ahmad Tabatabaeishoorijeh    -  Contact Me
Baylor College of Medicine/Texas Heart Institute

Lynna Nguyen    -  Contact Me
Baylor College of Medicine/Texas Heart Institute

Veronica Glover    -  Contact Me
Baylor College of Medicine/Texas Heart Institute

Ginger Etheridge    -  Contact Me
Baylor College of Medicine/Texas Heart Institute

Susan Green    -  Contact Me
Baylor College of Medicine/Texas Heart Institute

*Subhasis Chatterjee    -  Contact Me
Baylor College of Medicine/Texas Heart Institute

*Marc Moon    -  Contact Me
Baylor College of Medicine/Texas Heart Institute

*Joseph Coselli    -  Contact Me
Baylor College of Medicine/Texas Heart Institute

Ahmad Tabatabaeishoorijeh    -  Contact Me
Baylor College of Medicine/Texas Heart Institute

Objective: The approach to aortic root replacement (ARR) is multifaceted and complex, with valve selection being an integral part of any decision. In cases where traditional mechanical composite valve grafts (CVG), which necessitates a lifelong anticoagulation and potential for related bleeding complications, may not align with patient-specific needs and lifestyle, the selection of a tissue-based prosthesis avoids anticoagulation but at the expense of structural valve degeneration and risk of reoperation. We described our 32-year experience with ARR using mechanical CVGs and bioprosthetic roots and compared outcomes.

Methods: After excluding patients with infection, acute/subacute aortic dissection, and rupture, we retrospectively evaluated data regarding 1149 ARRs performed (1991-2023) in a single practice. Repairs included 581 (51%) using a mechanical CVG, and 568 (49%) using a bioprosthetic root. Bioprosthetic root group included composite CVG-tissue (n=136), homograft (n=98), porcine bioroot (n=333), and Ross procedure (n=1). We evaluated usage trends by decade and compared outcomes of ARRs with mechanical and bioprosthetic valves.

Results: Trends in usage have shifted from our earliest to most recent decade, with the use mechanical CVGs becoming less common over time (from 175/192 [91.1%] in Decade 1 to 100/310 [32.3%] in Decade 4). Compared to patients with a bioprosthetic root, those with mechanical CVG were younger (median age, 46 [Q1-Q3:37-56] vs 60 [49-67] years; P<.001) and had lower rates of prior proximal aortic repair (22.5% vs 56.7%, P=.046), but higher rates of genetic disorder (30.6% vs 14.1%, P<.001) and chronic aortic dissection (16.0% vs 11.6%, P=.03). Patients with a bioprosthetic root had longer cardiopulmonary bypass (175 [145-216] vs 163 [137-200] min; P=.002) and aortic clamp (105 [87-133] vs 94 [81-114] min; P<.001) times. The incidence of redo sternotomy was high but comparable across both groups (mechanical: 34.9% vs bioprosthetic: 38.9%; P=0.163). Operative mortality was similar between groups (mechanical: 8.6% vs bioprosthetic: 11.3%; P=.1); however, patients with a bioprosthetic root had higher rates of renal failure necessitating dialysis at discharge (7.7% vs 3.6%, P=.002) and cardiac failure (20.2% vs 11.9%, P<.001). Unadjusted survival differed by type of valve replacement (mechanical: 66.5%±2.5 vs bioprosthetic: 59.3%±2.8 at 10 years; P=.005). Freedom from repair failure (including late valve dysfunction and other factors) differed between groups (mechanical: 95.6%±1.1 vs bioprosthetic: 89.1%±2.4 at 10 years; P<.001); this was related to operative survivors with bioprosthetic root having higher rates of late valve dysfunction as compared to those with mechanical CVG (n=24/504 [4.8%] vs n=2/531 [0.8%], P=<.001).

Conclusions: Valve selection in ARR remains dependent on patient-specific needs including lifestyle. Descriptively evaluating usage trends can inform the selection process, including awareness regarding longer intra-operative times when using bioprosthetic roots. Operative mortality is similar between groups, although renal and cardiac complication are more pronounced in patients undergoing bioprosthetic ARR. Although late aortic regurgitation is more common in bioprosthetic roots, transcatheter repair is increasingly being used to address these concerns.

Aortic Root