Valve-sparing aortic root replacement for valves with paracommissural fenestrations: which valve will fail?

Area of Science:

• Cardiovascular Surgery
• Thoracic Surgery
• Cardiac Surgery

Background:

• Paracommissural fenestrations are common in aortic valves undergoing valve-sparing aortic root replacement (VSARR).
• Morphologic risk factors influencing VSARR outcomes in these patients require definition.

Purpose of the Study:

• To identify specific morphologic risk constellations associated with adverse outcomes in patients undergoing VSARR for aortic valves with paracommissural fenestrations.
• To improve patient selection and surgical planning for VSARR.

Main Methods:

• Prospective data from the German Aortic Root Repair Registry (GEARR) were analyzed.
• Patients with paracommissural cusp fenestrations undergoing VSARR were screened.
• Combined endpoint included residual aortic regurgitation (rAR) post-CPB, mid-term rAR progression, and aortic valve replacement for AR.

Main Results:

• 145 of 762 patients had paracommissural cusp fenestrations; 18% required alternative procedures.
• At 3-year follow-up, 78% freedom from the combined endpoint was observed.
• Patients with a free margin length difference <5 mm had significantly better outcomes (86%) compared to those with ≥5 mm (41%).
• Cusp prolapse combined with a free margin length difference >5 mm showed the worst outcomes (30% freedom from endpoint).

Conclusions:

• Fenestrations in multiple cusps, uneven cusp-free margin lengths, and additional cusp prolapse are associated with inferior outcomes after VSARR.
• These morphologic factors are critical for risk stratification in patients undergoing VSARR for fenestrated aortic valves.