At the Root of the Repair Debate: Outcomes After Elective Aortic Root Replacements for Aortic Insufficiency With Aneurysm.
BACKGROUND
There is growing interest in aortic valve-sparing and valve repair operations, but the ideal operation and timing of intervention in these generally younger patients undergoing operations for aortic insufficiency (AI) and dilated ascending aorta remains controversial.


METHODS
Root replacements at a single institution from 2002 to 2014 were reviewed. Inclusion criteria were age younger than 70 and presence of moderate or greater aortic insufficiency (AI), with or without aortic aneurysm. Of 1,425 root replacements, 220 patients were considered in the final analysis.


RESULTS
Moderate AI was present in 87 patients and severe AI in 133 patients. The 30-day mortality was 0% in moderate AI patients and 2% (n = 3) in severe AI patients (p = 0.3). Freedom from reoperation was 95% at 10 years. Severe preoperative AI was associated with worse long-term survival compared with moderate AI (hazard ratio, 2.6; p = 0.04). Patients undergoing root replacement with moderate AI had similar survival compared with the age- and gender-matched United States population (log-rank p = 0.93), whereas patients with severe AI had significantly worse survival (log-rank p = 0.02). Other multivariable predictors of decreased long-term survival were age (hazard ratio, 1.1; p = 0.01) and preoperative renal failure (hazard ratio, 6.9; p < 0.01).


CONCLUSIONS
Elective root replacement operations in patients younger than 70 are associated with low rates of mortality and reoperation, which should be considered the benchmark operation for aortic valve-sparing or repair operations in similar patients. Worse survival was associated with severe AI and older age, suggesting earlier intervention may be an appropriate therapeutic strategy in selected patients.
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Fenton H
FH
McCarthy
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Joseph E
JE
Bavaria
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Katherine M
KM
McDermott
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Patrick
P
Moeller
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Danielle
D
Spragan
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Ashley
A
Hoedt
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Taylor
T
Dibble
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Danielle
D
Savino
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Matthew L
ML
Williams
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Prashanth
P
Vallabhajosyula
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania.
Wilson Y
WY
Szeto
Division of Cardiovascular Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania. Electronic address: nimesh.desai@uphs.upenn.edu.
Nimesh D
ND
Desai
D000328:Adult; D017545:Aortic Aneurysm, Thoracic / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods* / Q000401:mortality; D002423:Cause of Death; D016208:Databases, Factual; D017558:Elective Surgical Procedures / Q000379:methods* / Q000401:mortality; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000379:methods* / Q000401:mortality; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D012189:Retrospective Studies; D018570:Risk Assessment; D016019:Survival Analysis; D016896:Treatment Outcome