VALVE-SPARING ROOT REPLACEMENT VERSUS COMPOSITE VALVE GRAFT PROCEDURES IN THE MANAGEMENT OF AORTIC ROOT DILATION

Abstract

Aortic valve sparing (AVS) procedures theoretically reduce thromboembolism and stroke compared to composite valve grafts (CVG) for aortic root dilation. However, AVS is techinically more challenging, potentially increasing perioperative risk and risk of reoperation when compared with the gold-standard mechanical CVG (mCVG). In the absence of randomized control or large multicentre data, we conducted a meta-analysis comparing perioperative safety outcomes and late all-cause mortality (primary outcome) among AVS vs CVG. MEDLINE and EMBASE were searched for all studies comparing AVS and CVG. A random effects model was used to compare early outcomes (30-day mortality, reintervention for bleeding, myocardial infarction (MI), stroke), and late outcomes (mortality, reintervention, and stroke). Sensitivity (leave one out) analysis was undertaken to determine degree of influence of each study on all outcomes. A total of 32,011 CVG and 6,114 AVS patients were included from nine adjusted/matched and 19 unadjusted observational studies with a mean follow-up of 5.8±3.0 years (range: 1-10). There were some differences in baseline characteristics, CVG patients had greater comorbidities. Results are summarized in Table 1. In the overall analysis, early mortality and reintervention for bleeding favoured AVS, while MI and stroke were equivalent. AVS was associated with lower late mortality in both the overall [Incident Rate Ratio (IRR) = 0.68 (95% confidence interval [95%CI]: 0.54-0.87) p<0.01] and adjusted [IRR = 0.66 (95%CI 0.49, 0.89) p<.01] analyses. Late thromboembolism/stroke was lower in the overall analysis [IRR=0.36 (95%CI 0.22-0.60) p<0.01] but did not reach statistical significance in adjusted studies [IRR=0.30 (95%CI 0.07-1.37) p=0.12] Figure 1. There was no difference in late reintervention after AVS versus CVG in unadjusted [IRR=1.15 (95%CI 0.66-2.01) p=0.62] and adjusted analyses [IRR=0.56 (95%CI 0.25-1.24) p=0.15]. In patients with aortic root dilation, the use of the AVS technique is safe and may be superior to CVG, with lower long term mortality, reduced rates of thromboembolic complications, and equivalent durability.View Large Image Figure ViewerDownload Hi-res image Download (PPT)