Personalized external aortic root support: The Dutch experience

Patients with connective tissue disease and aortic root aneurysm are at risk of dissection and progression of the dilatation. Standard treatment of aortic root aneurysm is either a total root replacement or valve-sparing root replacement. Both procedures have drawbacks, such as the need for anticoagulation and long-term exposure to the chance of reoperation or endocarditis. The ExoVasc personalized external aortic root support (PEARS) is a perivascular stent that has been introduced to reduce these risks while aiming for a similar beneficial outcome on late aortic complications. We sought to report the safety and efficacy of PEARS in the first 90 patients with connective tissue disease and aortic root aneurysm in the Netherlands.

From January 2018 to February 2023, in 2 affiliated centers 90 patients underwent surgery with the intention of either an isolated PEARS procedure, or PEARS as a concomitant procedure or a Ross-PEARS procedure. Isolated PEARS was generally performed off-pump under sustained induced hypotension. Patient characteristics, preoperative and postoperative echocardiography, and computed tomography or magnetic resonance imaging findings were assessed.

Median age was 37 (±15 standard deviation) years, and 62 (69%) patients were male. Among all patients, 37% had Marfan syndrome, 8% Loeys-Dietz syndrome, and 32% had a bicuspid aortic valve. Sixty (67%) patients were planned for isolated PEARS, 21 (23%) underwent Ross-PEARS, and 9 (10%) patients underwent PEARS as a concomitant procedure. Mean aortic root diameter at the level of the sinus of Valsalva was 44.6 ± 7.0 mm before surgery and 38.6 ± 5.6 mm at the follow-up (P < .001). Two patients in the isolated PEARS group were converted to conventional surgery, resulting in a procedural success rate of 96.6%. One Ross PEARS patient had to be reoperated on the first postoperative day because of compression of the RCA by the PEARS prosthesis. Median follow-up duration was 6 months (interquartile range, 3-18; range, 0-45). No death, endocarditis, or dissection occurred during follow-up. One patient had a transient ischemic attack 1 year after surgery (mitral valve plasty and PEARS as concomitant procedure). Three patients were reoperated in the follow-up period. At follow-up aortic root and ascending aortic diameters were all significantly reduced.

The PEARS procedure can be performed with acceptable operative risk and no dissections were observed during follow-up. PEARS has been adapted as a valid alternative treatment strategy in our centers. Complications related to coronary artery origin are an important issue.