Optimal strategy for aortic root replacement in patients of advanced age: Valve-sparing root replacement or Bio-Bentall?

Abstract

Valve-sparing root replacement (VSRR) is being performed into the eighth decade of life. This study evaluated clinical outcomes in patients aged ≥65 years undergoing VSRR or Bio-Bentall. From 2004 to 2021, 801 patients ≥65 years of age underwent root replacement at 2 academic medical centers. Nonelective cases, patients with moderate or greater aortic stenosis, previous aortic valve replacement, and mechanical Bentall procedures were excluded. In total, 330 patients underwent either VSRR (n = 94, 28%) or Bio-Bentall (n = 236, 72%). The median age of the cohort was 71 (67, 75) years. The VSRR group had less incidence of cerebrovascular disease (3.2% vs 11%, P = .02), bicuspid aortic valves (5.3% vs 16%, P = .01), moderate-to-severe aortic insufficiency (60% vs 76%, P = .002) and previous cardiac surgery (2.1% vs 8.9%, P = .03). Patients who underwent VSRR underwent more partial/total arch replacement (17% vs 5.5%, P = .0009) but had similar cardiopulmonary bypass and crossclamp times. Patients who underwent VSRR had less prolonged ventilation (7.5% vs 18%, P = .01) and shorter lengths of stay (7 vs 9 days, P = .001). Overall, in-hospital mortality was 3% and was similar between VSRR (2.1%) and Bio-Bentall (3.0%) groups (P = .73). Eight patients (2.4%) required reoperation on the aortic valve or proximal aorta during follow-up and was similar between groups. Patients who underwent VSRR had better long-term survival than patients who underwent Bio-Bentall (12-year: 70% vs 59%, P = .03). In patients ≥65 years of age, elective root replacement with either a VSRR or a Bio-Bentall can be performed with excellent short- and long-term outcomes. In the absence of significant valvular structural degeneration, VSRR is an appropriate strategy for this age group in patients with few comorbidities.