Intention-to-treat outcome analysis for valve-sparing aortic root replacement: Is there a price to pay for failure?

Abstract

Valve-sparing aortic root replacement (VSRR) provides durable outcomes when successful; however, limited data exist on the incidence or consequences of repeated intraoperative repair attempts or failure. This study evaluated outcomes of aortic root replacement when valve preservation was initially intended, irrespective of the eventual procedural success. We retrospectively reviewed patients who underwent aortic root replacement (VSRR or Bentall) between 2002 and 2023, excluding those with aortic stenosis, previous aortic valve replacement, endocarditis, or partial root replacement. Patients were categorized as single-clamp VSRR (S-VSRR, n = 251), multiple-clamp VSRR (M-VSRR, n = 16), failed VSRR (F-VSRR, n = 10), and primary Bentall (n = 548). VSRR was unsuccessful, or required multiple crossclamp attempts, in 9.4% of cases. Failure occurred in 1.0% of aneurysm and 2.5% of dissection cases (P = .28). Bentall patients were older (58 ± 14 years) than S-VSRR (48.2 ± 14.2 years) and M-VSRR (48 ± 13 years; P < .01). Preoperative severe aortic regurgitation (AR) was most frequent in F-VSRR (70%). Preservation succeeded in 83% with moderate-to-severe AR versus 89% with none-to-mild AR. Leaflet repair was more common in M-VSRR (43.8%) than S-VSRR (19.5%; P = .02). In unadjusted analysis, F-VSRR was associated with more bleeding-related reoperations and longer intensive care unit and hospital stays. At follow-up, 85.6% of S-VSRR and 68.7% of M-VSRR had none-to-mild AR. Mortality and reoperation rates were low across groups. VSRR was technically challenging or unsuccessful in about 10% of cases, especially with advanced AR. Although midterm survival and valve durability were comparable, these patients may experience greater perioperative morbidity, underscoring the need for careful patient selection and intraoperative judgement.