JTCVS open · 2025
Management of the dissected aortic root in young patients: A propensity score-matched analysis of mechanical versus bioprosthetic aortic root replacement.
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Catalano Michael A, Toubat Omar, Gillinov Lauren, Lawrence Kendall M, Zhao Yu, Kelly John J, Goel Nicholas J, Sperry Alexandra, Szeto Wilson Y, Brown Chase R, Desai Nimesh D
Аннотация
OBJECTIVE: Valve selection in acute type A aortic dissection (ATAAD) requiring aortic root replacement is challenging given the clinical acuity, unknown patient preferences, risk of surgical bleeding, and limited life expectancy. We sought to identify long-term outcomes of mechanical versus bioprosthetic aortic root replacement in young patients with ATAAD.
METHODS: Retrospective review of our institution's database of ATAAD was conducted to identify patients aged 65 years and younger who underwent mechanical Bentall (mech-Bentall) or bioprosthetic Bentall (bio-Bentall) for ATAAD from 2002 to 2022. The primary end point was 10-year survival, which was compared in a propensity score-matched cohort and multivariable Cox proportional hazards model. A composite outcome of 10-year freedom from death, stroke, major bleeding, and valvular reintervention was assessed as a secondary end point.
RESULTS: Of 1114 patients who underwent ATAAD repair, there were 79 mech-Bentalls and 67 bio-Bentalls in patients aged 65 years or younger. Patients undergoing mech-Bentall were younger, and they were less likely to undergo an extended arch operation; there was no difference in gender, race, comorbidities, or malperfusion on presentation. In a propensity score-matched analysis, mech-Bentall patients demonstrated a nonsignificant increase in 10-year mortality (P = .058) and demonstrated higher rates of the composite end point (P = .026). In a Cox proportional hazards model, mech-Bentall (hazard ratio, 1.892; P = .023) was independently associated with 10-year composite end point occurrence.
CONCLUSIONS: There is no survival advantage of mech-Bentall in ATAAD in young patients at 10 years, and it is associated with a significantly higher rate of morbid complications. When the aortic valve cannot be spared, bio-Bentall should be considered in ATAAD, even in young patients.
METHODS: Retrospective review of our institution's database of ATAAD was conducted to identify patients aged 65 years and younger who underwent mechanical Bentall (mech-Bentall) or bioprosthetic Bentall (bio-Bentall) for ATAAD from 2002 to 2022. The primary end point was 10-year survival, which was compared in a propensity score-matched cohort and multivariable Cox proportional hazards model. A composite outcome of 10-year freedom from death, stroke, major bleeding, and valvular reintervention was assessed as a secondary end point.
RESULTS: Of 1114 patients who underwent ATAAD repair, there were 79 mech-Bentalls and 67 bio-Bentalls in patients aged 65 years or younger. Patients undergoing mech-Bentall were younger, and they were less likely to undergo an extended arch operation; there was no difference in gender, race, comorbidities, or malperfusion on presentation. In a propensity score-matched analysis, mech-Bentall patients demonstrated a nonsignificant increase in 10-year mortality (P = .058) and demonstrated higher rates of the composite end point (P = .026). In a Cox proportional hazards model, mech-Bentall (hazard ratio, 1.892; P = .023) was independently associated with 10-year composite end point occurrence.
CONCLUSIONS: There is no survival advantage of mech-Bentall in ATAAD in young patients at 10 years, and it is associated with a significantly higher rate of morbid complications. When the aortic valve cannot be spared, bio-Bentall should be considered in ATAAD, even in young patients.