title: Combined aortic root replacement and mitral valve surgery: The quest to preserve both valves.
abstract: Coexisting aortic root and mitral valve pathology is increasingly recognized among patients undergoing surgery. We characterized the pathology and surgical outcomes of patients with combined aortic root and mitral disease.
  
  
  
  From 1987 to 2016, 118 patients (age 52.40 ± 17.71 years) underwent concomitant aortic root and mitral procedures (excluding aortic stenosis, endocarditis, and reoperations). Aortic root pathologies included degenerative aneurysm (94%) and aortic dissection (6%). The aortic valve was bicuspid in 15% of patients and had normally functioning tricuspid leaflets in 23% of patients. Marfan syndrome was present in 34 patients (29%). Degenerative mitral disease predominated (78%). Mitral procedures were repair (86%) and replacement (14%), and root procedures were valve-preserving root reimplantation (36%), Bentall procedure (47%), and homograft root replacement (17%). In the last 10 years, the combination of valve-preserving root reimplantation and mitral repair has increased to 50%. Kaplan-Meier and competing risk analyses were used to estimate survival and reoperation.
  
  
  
  There were 2 (1.7%) operative deaths with survival of 79% and 71% at 10 and 15 years, respectively, and reoperation rates of 4.7% and 12% after 5 and 10 years, respectively. There were no operative deaths in patients with combined valve-preserving root reimplantation and mitral repair, with survival of 89% and reoperation rate of 7.8% at 10 years. Among patients with Bentall/homograft and mitral operation, survival was 73% and reoperation was 9.8% at 10 years.
  
  
  
  In patients with aortic root and mitral pathology, combined surgical risk is low and valve durability is high. When possible, valve-preserving root reimplantation and mitral repair should be considered to avoid prosthesis degeneration, anticoagulation, and lifestyle limitations.
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Hoda
authors.initials: H
authors.lastname: Javadikasgari
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: roselle@ccf.org.
authors.forename: Eric E
authors.initials: EE
authors.lastname: Roselli
authors.affiliation: Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado, Denver, Colo.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Aftab
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Rakesh M
authors.initials: RM
authors.lastname: Suri
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Milind Y
authors.initials: MY
authors.lastname: Desai
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Mitra
authors.initials: M
authors.lastname: Khosravi
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Frank
authors.initials: F
authors.lastname: Cikach
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Monica
authors.initials: M
authors.lastname: Isabella
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Jay J
authors.initials: JJ
authors.lastname: Idrees
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Sajjad
authors.initials: S
authors.lastname: Raza
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Bassman
authors.initials: B
authors.lastname: Tappuni
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Brian P
authors.initials: BP
authors.lastname: Griffin
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.affiliation: Aorta Center, Valve Center, Departments of Thoracic and Cardiovascular Surgery and Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: A Marc
authors.initials: AM
authors.lastname: Gillinov
mesh_terms: D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001014:Aortic Aneurysm / Q000209:etiology / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001021:Aortic Valve / Q000002:abnormalities* / Q000503:physiopathology / Q000601:surgery; D000082882:Bicuspid Aortic Valve Disease; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D000066491:Clinical Decision-Making; D005260:Female; D006349:Heart Valve Diseases / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D006801:Humans; D008297:Male; D008382:Marfan Syndrome / Q000150:complications; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000150:complications / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D020127:Recovery of Function; D012092:Replantation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: aortic aneurysm; aortic regurgitation; aortic root replacement; mitral regurgitation; mitral valve surgery