Thinking below the surface in valve-sparing aortic root repair: iceberg or smooth waters?

Abstract

Aortic root dilation with associated progressive aortic insufficiency (AI) may eventually lead to left ventricular (LV) dilation and systolic dysfunction [1]. Aortic valve replacement in patients with AI and LV dilation promotes long-term ventricular remodelling [2]. Valve-sparing root replacement (VSRR) performed in the setting of significant AI has been previously shown to result in improved LV remodelling and function [3]; however, the impact of LV dilation on the valve durability and long-term survival following VSRR have not been previously explored. In this issue of the European Journal of Cardio-Thoracic Surgery, Dr. Patrick et al. [4] compare long-term outcomes in VSRR patients with and without preoperative LV dilation, defined as an indexed LV internal diameter during systole of ≥2.0 cm/m2. Utilizing a single-institutional aortic surgery database with excellent follow-up (785 person years of echocardiographic follow-up), the cohort included 295 patients, of whom 17.8% (N = 52) had baseline LV dilation. There was no significant increase in hazard of long-term AI or reintervention after VSRR in patients with LV dilation. Although LV dilation patients had progressive improvement in indexed LV internal diameter during systole after surgery, mortality at 7 years was significantly higher compared to VSRR patients without LV dilation (hazard ratio 5.56).