Long-Term Outcomes of Valve Sparing Aortic Root Replacement in New Zealand

Valve-sparing aortic root replacement (VSARR) has been shown to provide excellent long-term results for patients with aneurysmal aortic roots or aortic dissection and functionally normal aortic valves other than regurgitation (absence of leaflet calcium, no large leaflet free-edge fenestrations). New Zealand has a higher incidence of genetic aortopathies and aortic dissection compared with other countries. This study investigates the long-term outcomes of VSARR in this population.

All patients undergoing VSARR at our institution over a 20-year period (2003-2023) were included. National registries were used for follow-up and survival data. A generalised additive model was used to define experienced surgeons as those who had performed >15 cases. Median follow-up was 6.6 years (interquartile range 4.5-10.6 years; maximum 20.5 years).

In total, 147 patients were included with a mean age of 47 years; 77% were male, and 37% were Māori or Pasifika. Furthermore, 39% had a genetic aortopathy, 45% had preoperative moderate-to-severe aortic regurgitation (AR), and 18% presented with an acute type A aortic dissection (ATAAD). Operations included Valsalva-graft VSARR (73.5%), straight-graft VSARR (21.1%), and Yacoub remodelling (5.4%). Early mortality was 4.8% (3.3% after elective surgery and 11.5% after dissection, p=0.2) and late mortality was 10.7%. Overall survival probability was 95.8% at five years, 90.3% at 10 years, and 65.8% at 20 years and was worsened by older age (hazard ratio [HR] 1.05), Māori/Pasifika status (HR 3.20), and ATAAD (HR 8.64). Progression to moderate or greater AR occurred in 11.9% of patients at a median time of 5.1 years (interquartile range 4.5-10.6 years) after surgery. The incidence was higher in patients who underwent Yacoub-style remodelling procedures compared with David-style reimplantation procedures; however, the difference was not statistically significant (25.0 vs 10.1%; p=0.46). Preoperative severe AR increased the risk of late moderate-to-severe AR (HR 3.20), while experienced surgeons had fewer patients develop progressive AR (HR 0.28). Five patients (3.4%) required a reintervention on the aortic valve during follow-up, with no variable impacting this outcome.

VSARR provides excellent long-term results for young patients with genetic aortopathies in the New Zealand setting. Inexperience of the operating surgeon and presentation with severe AR both result in higher rates of future progression to clinically significant AR, but long-term reintervention and overall survival remain excellent.