Valve-Sparing Root Replacement in Bicuspid and Tricuspid Aortic Valves: Long-Term Outcomes Into the Second Decade

Valve-sparing aortic root replacement (VSRR) was developed to treat aortic root aneurysms with tricuspid aortic valves (TAVs) and later extended to repair of bicuspid aortic valves (BAVs). We analyzed our long-term outcomes of VSRR in both valve types.

All consecutive patients with BAVs and TAVs undergoing VSRR from 2000 to 2023 in our center were retrospectively investigated. The primary end point was aortic valve reintervention, the secondary end points were mortality and freedom from aortic regurgitation (AR) ≥2/4.

The study included 239 patients (66 BAVs, 173 TAVs). Significant differences were found in age (BAVs, 41.9 [SD, 14.4] years; TAVs, 48.7 [SD, 18.2] years; P = .004), Marfan (BAVs, 7.6%; TAVs, 36.9%; P < .001) and Turner disease (BAVs, 12.1%; TAVs, 0%; P < .001), and the surgical indication (type A dissection: BAVs, 6.1%; TAVs, 15.0%; P = .046; AR ≥2: BAVs, 62.1%; TAVs, 26.6%; P = .003). Perioperative characteristics were comparable, apart from cusp repair (BAVs, 84.8%; TAVs, 24.9%; P < .001). Early and late mortality were 1.3% and 5.4%. After a follow-up of 7.9 (SD, 5.7) years, 16.7% of BAVs and 5.2% of TAVs (P = .004) needed replacement. The peak gradient and the presence of AR ≥2/4 were both significantly more pronounced in BAVs. In multivariable analysis, a BAV (hazard ratio, 3.717; 95% CI, 1.483-9.316; P = .005,) and AR degree at discharge (hazard ratio, 2.745; 95% CI, 1.649-4.569; P < .001) were significant predictors for aortic valve reoperation.

VSRR in TAVs leads to stable long-term outcomes, with only 5% reoperations at 15 years. BAVs demonstrated more disease progression, with ∼17% early reoperation, particularly when valve function at discharge was suboptimal.