Limiting coronary malperfusion in bioprosthetic aortic root replacement

Coronary malperfusion requiring concomitant coronary revascularization is a known complication of aortic root replacement. We predict that coronary malperfusion is rare in porcine xenograft root replacements. The primary aim of this study is to evaluate the incidence of coronary malperfusion following Freestyle aortic root replacement, with a focus on techniques to limit this complication.

Nine hundred sixty-nine patients underwent aortic root replacement with a stentless bioprosthetic valve at our institution from 2012 to 2023. This study analyzed 310 patients who also had concomitant coronary artery intervention (coronary artery bypass grafting or Cabrol procedure). The defined primary outcome was the incidence of coronary malperfusion post-aortic root replacement. Coronary insufficiency was defined as a dysfunctional ventricle requiring unplanned coronary intervention.

The incidence of coronary malperfusion because of coronary insufficiency that required revascularization post-Freestyle aortic root replacement was 1.3% (13/969), compared with 2.6% in our earlier series. Of the patients who underwent coronary intervention, 3.7% (11/299) had revascularization because of coronary artery dissection from type A dissections. Six percent (18/299) of patients required a Cabrol procedure because of calcification or stenosis. We found a significant difference in length of stay and rate of reoperation during index hospitalization for patients with coronary insufficiency.

We demonstrate a low incidence of coronary malperfusion and related complications following stentless bioprosthetic aortic root replacement. Furthermore, we demonstrate a decrease in these adverse outcomes because of improvements in technique, including not oversizing the root and extensive coronary button mobilization. Bioprosthetic aortic root replacement, when performed using a particular series of techniques, is safe and effective.