Comparison of different surgical techniques in 112 consecutive patients with aortic root operations: when should the valve be spared?

BACKGROUND AND AIM OF THE STUDY: The benefit of valve-sparing aortic root replacement compared to conventional aortic root replacement surgery remains unclear.

METHODS

Between February 2009 and November 2010, a total of 112 patients underwent aortic root surgery at the Department of Cardiovascular and Thoracic Surgery, Heinrich-Heine-University, Dusseldorf, Germany. The valve-sparing technique was used when leaflets were grossly normal. In cases where the valve could not be saved, a prosthetic or biological substitute was used for the aortic root, according to existing guidelines. The patients were allocated to three groups: (i) valve-sparing aortic root replacement group using the David technique (VSR-David; n = 47); (ii) valve-replacing aortic root surgery with a prosthetic conduit using the Bentall-Kuchucus technique (VRR-Prosthetic; n = 31); and (iii) valve-replacing aortic root surgery with a biological stentless valve with the full root technique (VRR-Bio; n = 34).

RESULTS

Intraoperative data revealed that, in the VSR-David group, the cardiopulmonary bypass and cross-clamp times were significantly longer (207 +/- 68 min and 140 +/- 38 min respectively; both p = 0.001). The VRR-Prosthetic patients were at highest risk (mean EuroSCORE 15.9%) compared to the VSR-David and VRR-Bio groups (10.8% and 10.4%, respectively). Postoperative analysis showed that patients in the VRR-Bio group had the lowest number of perioperative heart failures (p = 0.004). The perioperative 30-day mortality was significantly higher in the VRR-Prosthetic group (22.6%; p = 0.004). Transaortic flow velocities were significantly lower in the VSR-David group, followed by the VRR-Bio group and VRR-Prosthetic group (1.66 +/- 0.54, 1.98 +/- 0.45, and 2.29 +/- 0.39 m/s, respectively; p = 0.012). The univariate and multivariate analyses of perioperative risk factors showed that only open distal anastomosis was strongly associated with negative results, but not the valve-sparing technique.

CONCLUSION

Aortic valve-sparing root replacement must be considered as an excellent alternative for young patients requiring aortic root replacement when a biological valve is clinically indicated. For patients aged >65 years, or with a decreased life expectancy, the full root technique with a stentless valve should be used, given its technical simplicity and excellent postoperative results.