Valve-sparing versus bio-Bentall aortic root replacement in patients aged 60-75 years: Survival, Reintervention and Aortic Regurgitation.

Background: Valve-sparing root replacement(VSRR) with the David technique is an established therapy for aortic root pathology in young patients. The aim of this study was to evaluate short and long-term outcomes between VSRR and aortic root replacement(ARR) with a biological-valved conduit in sexagenarians.

Methods: A multicenter retrospective review from 2002-2022 identified 299-sexagenarians undergoing aortic root surgery, among whom 82(27.4%) underwent VSRR and 217(72.6%) bio-Bentall. Inverse probability of treatment weighting(IPTW) was applied to balance clinical variables. Median follow-up was 15-years[12-18 years]. Endpoints of the study were in-hospital mortality, long-term survival, freedom from reintervention and recurrence of at-least-moderate AR.

Results: There were no major differences in baseline characteristics. The incidence of bicuspid valves(VSRR 4.9% vs ARR 19%), severe AR(42% vs 51%), type-A aortic dissection(1.2% vs 6.9%), and reoperation(4% vs 23%) were higher in ARR. Following IPTW, there was no difference in in-hospital mortality(VSRR 1.2% vs ARR 4.6%,p=0.3). The incidence of neurologic complications(p=0.003), and permanent pacemaker(PPM) implantation(p=0.022) were significantly higher in the bio-Bentall group. After IPTW, 10-year survival did not differ between VSRR(87%) and ARR(80%)(p=0.176). However, cardiac-survival was significantly higher in VSRR patients(98% vs 92%,p=0.018), with deaths mainly due to infective endocarditis and end-stage heart failure(HF). Regarding reoperation/recurrence of at-least-moderate AR, no difference was reported among groups at 10-years, with only 1-patient undergoing reintervention following bio-Bentall(p=0.117).

Conclusions: David and bio-Bentall procedures have low in-hospital mortality and good long-term survival in sexagenarians. VSRR is associated with improved long-term cardiac-survival, lower rates of infective endocarditis, PPM-implantation and HF-episodes, with similar rates of reintervention/recurrence of moderate AR.