title: Long-term survival, valve durability, and reoperation for 4 aortic root procedures combined with ascending aorta replacement.
abstract: OBJECTIVE
  To evaluate long-term results of aortic root procedures combined with ascending aorta replacement for aneurysms, using 4 surgical strategies.
  
  
  METHODS
  From January 1995 to January 2011, 957 patients underwent 1 of 4 aortic root procedures: valve preservation (remodeling or modified reimplantation, n = 261); composite biologic graft (n = 297); composite mechanical graft (n = 156); or allograft root (n = 243).
  
  
  RESULTS
  Seven deaths occurred (0.73%), none after valve-preserving procedures, and 13 strokes (1.4%). Composite grafts exhibited higher gradients than allografts or valve preservation, but the latter 2 exhibited more aortic regurgitation (2.7% biologic and 0% mechanical composite grafts vs 24% valve-preserving and 19% allografts at 10 years). Within 2 to 5 years, valve preservation exhibited the least left ventricular hypertrophy, allograft replacement the greatest; however, valve preservation had the highest early risk of reoperation, allograft replacement the lowest. Patients receiving allografts had the highest risk of late reoperation (P < .05), and those receiving composite mechanical grafts and valve preservation had the lowest. Composite bioprosthesis patients had the highest risk of late death (57% at 15 years vs 14%-26% for the remaining procedures, P < .0001), because they were substantially older and had more comorbidities (P < .0001).
  
  
  CONCLUSIONS
  These 4 aortic root procedures, combined with ascending aorta replacement, provide excellent survival and good durability. Valve-preserving and allograft procedures have the lowest gradients and best ventricular remodeling, but they have more late regurgitation, and likely, less risk of valve-related complications, such as bleeding, hemorrhage, and endocarditis. Despite the early risk of reoperation, we recommend valve-preserving procedures for young patients when possible. Composite bioprostheses are preferable for the elderly.
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: svenssl@ccf.org.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Saila T
authors.initials: ST
authors.lastname: Pillai
authors.affiliation: Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Jeevanantham
authors.initials: J
authors.lastname: Rajeswaran
authors.affiliation: Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Milind Y
authors.initials: MY
authors.lastname: Desai
authors.affiliation: Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Brian
authors.initials: B
authors.lastname: Griffin
authors.affiliation: Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Richard
authors.initials: R
authors.lastname: Grimm
authors.affiliation: Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Donald F
authors.initials: DF
authors.lastname: Hammer
authors.affiliation: Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Maran
authors.initials: M
authors.lastname: Thamilarasan
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Gösta B
authors.initials: GB
authors.lastname: Pettersson
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: A Marc
authors.initials: AM
authors.lastname: Gillinov
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Jose L
authors.initials: JL
authors.lastname: Navia
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Nicholas G
authors.initials: NG
authors.lastname: Smedira
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Joseph F
authors.initials: JF
authors.lastname: Sabik
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Bruce W
authors.initials: BW
authors.lastname: Lytle
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Eugene H
authors.initials: EH
authors.lastname: Blackstone
mesh_terms: D000367:Age Factors; D064591:Allografts; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001021:Aortic Valve / Q000503:physiopathology / Q000637:transplantation*; D001705:Bioprosthesis; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D018579:Patient Selection; D011183:Postoperative Complications / Q000401:mortality / Q000601:surgery; D011474:Prosthesis Design; D012042:Registries; D012086:Reoperation; D012092:Replantation; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: aorta; aortic valve; root; root sparing; valve preservation