Leiden University Medical Center (LUMC), Leiden, The Netherlands.
AVIATOR registry, Heart Valve Society, The Netherlands.
Eur J Cardiothorac Surg. 2023 Feb 3;63(2). doi: 10.1093/ejcts/ezac514.
Our goal was to evaluate the outcome of valve-sparing root replacement (VSRR) and to compare the outcomes to those of patients having composite valve-graft conduit aortic root replacement (CVG-ARR) in a cohort of patients with aortic root aneurysm ± valve insufficiency, without valvular stenosis. Although valve-sparing procedures are preferable in young patients, there is a lack of comparative data in comparable patients.
The VSRR procedures were performed in 2005 patients, and 218 patients underwent a CVG-ARR procedure. Exclusion criteria included aortic dissection, endocarditis and valvular stenosis. Propensity score matching (3:1 ratio) was applied to compare VSRR (reimplantation 33% and remodelling 67%) and CVG-ARR.
We matched 218 patients with CVG-ARR to 654 patients with VSRR (median age, 56.0; median follow-up was 4 years in both groups; interquartile range 1-5 years). Early mortality was 1.1% of those who had VSRR versus 2.3% in those who had CVG-ARR. Survival was 95.4% [95% confidence interval (CI) 94-97%] at 5 years in patients who had VSRR versus 85.4% (95% CI 82-92%) in those who had CVG-ARR; P = 0.002. Freedom from reintervention at 5 years was 96.8% (95% CI 95-98%) with VSRR and 95.4% (95% CI 91-99%) with CVG-ARR (P = 0.98). Additionally, there were more thromboembolic, endocarditis and bleeding events in the patients who had CVG-ARR (P = 0.02).
This multicentre study shows excellent results after valve-sparing root replacement in patients with an ascending aortic aneurysm with or without valve insufficiency. Compared to composite valve-graft aortic root replacement, survival is better and valve-related events are fewer. Consequently, valve-sparing procedures should be considered whenever a durable repair is feasible. We advocate a valve-sparing strategy even in more complex cases when performed in experienced centres.
我们的目标是评估保留瓣膜的主动脉根部替换术（VSRR）的结果，并将其与主动脉根部瘤伴或不伴瓣叶关闭不全的患者中进行复合瓣-移植物管道主动脉根部替换术（CVG-ARR）的患者的结果进行比较。尽管在年轻患者中，保留瓣膜的手术更为可取，但在可比患者中缺乏比较数据。
2005 例患者接受了 VSRR 手术，218 例患者接受了 CVG-ARR 手术。排除标准包括主动脉夹层、心内膜炎和瓣狭窄。采用倾向评分匹配（3:1 比例）比较 VSRR（再植入 33%和重塑 67%）和 CVG-ARR。
我们将 218 例 CVG-ARR 患者与 654 例 VSRR 患者进行了匹配（中位年龄 56.0 岁；中位随访时间均为 4 年，IQR1-5 年）。VSRR 组的早期死亡率为 1.1%，CVG-ARR 组为 2.3%。VSRR 组 5 年生存率为 95.4%（95%CI94-97%），CVG-ARR 组为 85.4%（95%CI82-92%）；P=0.002。VSRR 组 5 年无再干预率为 96.8%（95%CI95-98%），CVG-ARR 组为 95.4%（95%CI91-99%）；P=0.98。此外，CVG-ARR 组血栓栓塞、心内膜炎和出血事件更多（P=0.02）。
这项多中心研究显示，在患有升主动脉瘤伴或不伴瓣叶关闭不全的患者中，进行保留瓣膜的主动脉根部替换术可获得良好的效果。与复合瓣-移植物主动脉根部替换术相比，生存率更高，瓣膜相关事件更少。因此，只要可行持久修复，就应考虑保留瓣膜的手术。我们主张在有经验的中心进行时，即使在更复杂的情况下也应采用保留瓣膜的策略。
