title: Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valve-preserving aortic root repair.
abstract: OBJECTIVE
  Technical controversies exist in valve-preserving aortic root replacement. We sought to determine predictors of long-term stability of the aortic valve.
  
  
  METHODS
  A total of 430 patients (aged 57 ± 15 years, 323 male) underwent valve-preserving aortic root surgery (remodeling in 401, reimplantation in 29) between 1995 and 2009 and were followed echocardiographically. Factors influencing late recurrence of aortic valve regurgitation grade II or greater (n = 45) or need for reoperation on the aortic valve (n = 25) were analyzed.
  
  
  RESULTS
  Early mortality was 2.8% (1.9% for elective cases), and actuarial survival at 10 years was 83.5% ± 2.4%. Ten-year freedom from aortic valve regurgitation grade II or greater was 85.0% ± 2.5%. Preoperative aortoventricular junction diameter greater than 28 mm and postoperative effective height of the aortic cusp less than 9 mm were identified as significant predictors for late aortic valve regurgitation grade II or greater in multivariate analysis (both P < .001). Ten-year freedom from reoperation on the aortic valve was 89.3% ± 2.5%. Preoperative aortoventricular junction diameter greater than 28 mm (P < .001), use of pericardial patch (P = .022), and effective height of the aortic cusp less than 9 mm (P = .049) were identified as significant predictors for reoperation in multivariate analysis. Operative technique (remodeling, reimplantation), Marfan syndrome, bicuspid valve anatomy, concomitant central cusp plication, size of prosthesis used, and acute dissection were not associated with an increased risk of late aortic valve regurgitation grade II or greater or reoperation. In patients with preoperative aortoventricular junction diameter greater than 28 mm (n = 94), the addition of central cusp plication significantly improved freedom from aortic valve regurgitation grade II or greater (P = .006) regardless of root procedures (remodeling, P = .011; reimplantation, P = .053).
  
  
  CONCLUSIONS
  Long-term stability of valve-preserving aortic root replacement was influenced not by the technique of root repair but by the preoperative aortic root geometry and postoperative cusp configuration.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, University Hospital of Saarland, Homburg, Germany.
authors.forename: Takashi
authors.initials: T
authors.lastname: Kunihara
authors.forename: Diana
authors.initials: D
authors.lastname: Aicher
authors.forename: Svetlana
authors.initials: S
authors.lastname: Rodionycheva
authors.forename: Heinrich-Volker
authors.initials: HV
authors.lastname: Groesdonk
authors.forename: Frank
authors.initials: F
authors.lastname: Langer
authors.forename: Fumihiro
authors.initials: F
authors.lastname: Sata
authors.forename: Hans-Joachim
authors.initials: HJ
authors.lastname: Schäfers
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000209:etiology / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D002908:Chronic Disease; D005260:Female; D005858:Germany; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D016016:Proportional Hazards Models; D012086:Reoperation; D012092:Replantation / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014463:Ultrasonography