Right ventricular function in Marfan patients remains stable despite multiple cardiac interventions

OBJECTIVES

Mitral valve regurgitation and left ventricular dysfunction are cardiovascular symptoms of Marfan syndrome. There is a paucity of information on tricuspid valve regurgitation and right ventricular function. In patients with Marfan syndrome, we looked at long-term changes in right ventricular function, tricuspid valve regurgitation and freedom from tricuspid valve repair.

METHODS

Retrospective-observational single-centre analysis on right ventricular function and tricuspid regurgitation in Marfan patients who underwent surgery with cardioplegic arrest between 1995 and 2020. Patients were followed-up from 1st operation until death, with echocardiographic changes analysed longitudinally. Composite end point was tricuspid annular plane systolic excursion (TAPSE) ≤16 mm, severe tricuspid regurgitation or tricuspid repair.

RESULTS

The study included 135 patients who underwent 193 operations, 58 of those were reoperations in 40 patients. Median age at 1st operation was 35 years [interquartile range (IQR) 26-46], median follow-up was 8.0 years (IQR 3.0-16.0) and median time to 1st reoperation was 7.5 years (IQR 3.4-12.5). The composite end point occurred in 81 observations in 40 patients, mostly as a recurrent event, after median 7.0 years (IQR 1.0-13.0). Ten-year cumulative incidence for composite end point was 22.0% (95% CI 15-31) and 9.0% (95% CI 4.4-16) for new-onset TAPSE ≤16 mm, but no significant change in TAPSE was observed at 10 years. Tricuspid regurgitation was associated with increased risk of annual progression (P < 0.001), but not clinically relevant at 10 years. Actuarial 10-year survival was 91.1%.

CONCLUSIONS

In Marfan patients with a history of cardiac surgery and subsequent reoperations, the right ventricular function remains stable. The incidence of severe tricuspid regurgitation and tricuspid repair remain low.

Challenges in prompt identification and surgical correction of Marfan Syndrome aortic disease in a middle-income country: a case series study

BACKGROUND

Marfan Syndrome is an autosomal dominant disease caused by pathogenetic variants in the FBN1 gene. The progressive dilatation of the aorta and the potential risk of acute aortic syndromes influence the prognosis of these patients. We aim to describe population characteristics, long-term survival, and re-intervention patterns in patients who underwent aortic surgery with a previously confirmed clinical diagnosis of Marfan Syndrome in a middle-income country.

METHODS

A retrospective single-center case series study was conducted. All Marfan Syndrome patients who underwent aortic procedures from 2004 until 2021 were included. Qualitative variables were frequency-presented, while quantitative ones adopted mean ± standard deviation. A subgroup analysis between elective and emergent procedures was conducted. Kaplan-Meier plots depicted cumulative survival and re-intervention-free. Control appointments and government data tracked out-of-hospital mortality.

RESULTS

Fifty patients were identified. The mean age was 38.79 ± 14.41 years, with a male-to-female ratio of 2:1. Common comorbidities included aortic valve regurgitation (66%) and hypertension (50%). Aortic aneurysms were observed in 64% without dissection and 36% with dissection. Surgical procedures comprised elective (52%) and emergent cases (48%). The most common surgery performed was the David procedure (64%), and the Bentall procedure (14%). The in-hospital mortality rate was 4%. Complications included stroke (10%), and acute kidney injury (6%). The average follow-up was 8.88 ± 5.78 years. Survival rates at 5, 10, and 15 years were 89%, 73%, and 68%, respectively. Reintervention rates at 1, 2.5, and 5 years were 10%, 14%, and 17%, respectively. The emergent subgroup was younger (37.58 ± 14.49 years), had the largest number of Stanford A aortic dissections, presented hemodynamic instability (41.67%), and had a higher requirement of reinterventions in the first 5 years of follow-up (p = 0.030).

CONCLUSION

In our study, surveillance programs played a pivotal role in sustaining high survival rates and identifying re-intervention requirements. However, challenges persist, as 48% of the patients required emergent surgery. Despite not affecting survival rates, a greater requirement for reinterventions was observed, emphasizing the necessity of timely diagnosis. Enhanced educational initiatives for healthcare providers and increased patient involvement in follow-up programs are imperative to address these concerns.

Aortic root rotation: morphological analysis of the aortic root with three-dimensional computed tomography

OBJECTIVES

The aortic root (AoR) rotation and its spatial morphology at the base of the heart were postulated but not described in every detail. AoR rotation modalities may play an important role in decision-making during AoR surgery and its outcome. The aim was to provide a detailed spatial anatomy of the AoR rotation and its relation to the vital surrounding structure.

METHODS

The AoR rotation and its relation to the surrounding structure were assessed in 104 patients with tricuspid aortic valve. The interatrial septum was chosen as a reference to describe AoR rotation that marked the midline of the heart base as a landmark for the AoR rotation direction. Intermediate, clockwise and counterclockwise AoR rotations were defined based on the mentioned reference structures.

RESULTS

The AoR rotation was successfully assessed in 104 patients undergoing ascending aorta and or AoR intervention by multidetector row computed tomography. AoR was positioned normally in 53.8% of cases (n = 56) and rotated counterclockwise in 5.8% (n = 6) and clockwise in 40.4% (n = 42) of cases. In clockwise AoR rotation, the right coronary sinus was positioned in proximity to the right atrium and of the tricuspid valve, whereas in a counterclockwise rotation, the noncoronary sinus was placed over the tricuspid valve just over the membranous septum.

CONCLUSIONS

The AoR's rotation can be diagnosed using multidetector row computed tomography. Understanding the anatomy of the aortic valve related to rotational position helps guide surgical decision-making in performing AoR reconstruction.

Multicentre experience with valve-sparing aortic root replacement by means of combined remodelling and external aortic ring annuloplasty in patients with Marfan syndrome

OBJECTIVES

The most recent valve-sparing root replacement technique combines the advantages of the reimplantation (David) and remodelling (Yacoub) techniques. The aortic root is reconstructed according to the remodelling technique, the aortic valve is repaired according to the principle of effective height, and an external ring provides annular support. The purpose of this study was to evaluate operative and mid-term outcomes using this technique in patients with Marfan syndrome.

METHODS

Adult patients with Marfan syndrome who had an indication for aortic root surgery according to European Society of Cardiology guidelines and were operated on using this new root replacement technique were retrospectively evaluated. Follow-up was obtained from standard outpatient visits and included echocardiography.

RESULTS

The study group comprised 22 patients (mean age 36 years, 68% males). Mean follow-up was 7.5 years. There were no mortalities. Two patients required aortic valve replacement because of aortic regurgitation. In both patients, the aortic root was severely dilated (≥65 mm) preoperatively, with grade III aortic valve regurgitation and aortic valve cusps that were very fragile. Aortic regurgitation was grade ≤I on follow-up in 18 of the remaining 20 patients.

CONCLUSIONS

Valve-sparing root replacement using remodelling combined with aortic-ring annuloplasty is safe in patients with Marfan syndrome. The mid-term outcome is promising in patients undergoing elective valve-sparing root replacement at recommended root diameters. However, in patients with extremely dilated aortic roots and already severe aortic regurgitation, the technique should be used cautiously as aortic cusps are fragile and might not be suitable for durable repair.

CLINICAL REGISTRATION NUMBER

UMCG Research registry #11208.

Current review of acute type A aortic dissection in Malaysia

Acute type A aortic dissection (ATAAD) still poses significant challenges and management dilemmas for cardiovascular surgeons worldwide. Despite the continuous improvement in diagnosis and management strategies for ATAAD, clinical outcomes remain poor and the optimal therapy is still debatable especially those with malperfusion syndrome (MPS). This review is based on the current literature and includes the results from the Aortic Registry of National Heart Institute of Malaysia (NHIM) database. It covers different aspects of ATAAD and concentrates on the outcome of surgical repair. The diagnosis is often delayed leading to variable outcomes. High index of suspicion and urgent treatment is required to tackle this dynamic disease which include the variation in presentation and clinical course. Different surgical techniques and perfusion strategies have been described to save patients. Complex techniques such as total arch replacement (TAR) with frozen elephant trunk and valve sparing root surgery may provide long-term benefit in selected patients, but require significant surgical expertise and experience.

Midterm outcomes of aortic root surgery in patients with Marfan syndrome: A prospective, multicenter, comparative study

OBJECTIVE

The objective of this study was to compare midterm outcomes of aortic valve-replacing root replacement (AVR) and aortic valve-sparing root replacement (AVS) operations in patients with Marfan syndrome.

METHODS

Patients who met strict Ghent diagnostic criteria for Marfan syndrome and who underwent either AVR or AVS between March 1, 2005 and December 31, 2010 were enrolled in a 3-year follow-up prospective, multicenter, international registry study; the study was subsequently amended to include 20-year follow-up. Enrollees were followed clinically and echocardiographically.

RESULTS

Of the 316 patients enrolled, 77 underwent AVR and 239 underwent AVS; 214 gave reconsent for 20-year follow-up. The median clinical follow-up time for surviving patients was 64 months (interquartile range, 42-66 months). Survival rates for the AVR and AVS groups were similar at 88.2% ± 4.4% and 95.0% ± 1.5%, respectively (P = .1). Propensity score-adjusted competing risk modeling showed associations between AVS and higher cumulative incidences of major adverse valve-related events, valve-related morbidity, combined structural valve deterioration and nonstructural valve dysfunction, and aortic regurgitation ≥2+ (all P < .01). No differences were found for reintervention (P = .7), bleeding (P = .2), embolism (P = .3), or valve-related mortality (P = .8).

CONCLUSIONS

Five years postoperatively, major adverse valve-related events and valve-related morbidity were more frequent after AVS than after AVR procedures, primarily because of more frequent aortic valve dysfunction. No between-group differences were found in rates of survival, valve-related mortality, reintervention on the aortic valve, or bleeding. We plan to follow this homogenous cohort for 20 years after aortic root replacement.

Current controversies in aortic valve-preserving surgery

The clinical outcome of severe aortic regurgitation (AR) remains suboptimal, but surgery has been shown to have survival benefit over medical therapy. Postoperative survival is inferior in patients with reduced left ventricular function, and therefore early surgical intervention is recommended. Aortic valvuloplasty (AVP) is an attractive option to avoid the major drawbacks of prosthetic valves but has not been widely adopted. The etiology of AR is classified functionally into three groups: normal leaflet motion (type I), cusp prolapse (type II), and restriction (type III). Type I with dilatation of the sinus of Valsalva (type Ib) can be repaired by aortic valve reimplantation or aortic root remodeling with similar valve stability. Type I with dilatation of the aortic annulus (type Ic) can be managed by annuloplasty. Type II can be corrected by plication or resuspension techniques. Pericardial patch is necessary in AVP for type Id (perforation/fenestration) and type III but is associated with risk of recurrence. Bicuspid aortic valve is classified according to commissure angle: symmetrical, asymmetrical, and very asymmetrical. Tricuspidization is recommended for repair of very asymmetrical valves to avoid postoperative stenosis. Recent progress has achieved similar reoperation rates between bicuspid and tricuspid aortic valve repair. For Marfan syndrome, valve-sparing root replacement is advantageous compared to Bentall operation regarding late survival, thromboembolic and hemorrhagic events, and endocarditis. Similar findings have been reported in acute aortic dissection. Both remodeling and reimplantation procedures provide similar favorable outcomes in these settings. Recent advances in AVP are summarized by quantitative assessment of cusp configuration (effective height and geometric height), graft size decision, use of template to cut the graft, and videoscopic assessment of post-repair cusp configuration. Due to these advances, AVP shows superior results to replacement surgery. Further concrete evidence with larger case volumes and longer observation periods are necessary to popularize AVP.

Is valve-sparing aortic root replacement better than total aortic root replacement? An overview of reviews

Background

Total aortic root replacement (TRR) is certainly beneficial for aortic root disease, but does it still have an advantageous prognosis for patients compared to valve-sparing aortic root replacement (VSRR)? An overview of reviews was conducted to assess each of their clinical efficacy/effectiveness.

Review methods

Systematic reviews (SRs)/Meta-analyses comparing the prognosis of TRR and VSRR in aortic root surgery were collected from 4 databases, all searched from the time of database creation to October 2022. Two evaluators independently screened the literature, extracted information and applied the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) tool, Grading of Recommendations, Assessment, Development and Evaluations (GRADE), and Risk of Bias in Systematic Reviews (ROBIS) to evaluate the quality of reporting, methodological quality, risk of bias, and level of evidence of the included studies.

Main results

A total of 9 SRs/Meta-analyses were ultimately included. In terms of the reporting quality of the included studies, PRISMA scores ranged from 14 to 22.5, with issues mainly in reporting bias assessment, risk of study bias, credibility of evidence, protocol and registration, and funding sources. The methodological quality of the included SRs/Meta-analyses was generally low, with key items 2, 7, and 13 having major flaws and non-key items 10, 12, and 16. In terms of risk of bias assessment, the overall assessment of the included 9 studies was high-risk. The quality of the evidence was rated as low to very low quality for the three outcome indicators selected for the GRADE quality of evidence rating: early (within 30 days postoperatively or during hospitalization) mortality, late mortality, and valve reintervention rate.

Conclusions

VSRR has many benefits including reduced early and late mortality after aortic root surgery and reduced rates of valve-related adverse events, but the methodological quality of the relevant studies is low, and there is a lack of high-quality evidence to support this.

Systematic Review Registration

https://www.PROSPERO, identifier: CRD42022381330.

Valve-sparing versus valve-replacing aortic root replacement in patients with aortic root aneurysm

BACKGROUND

Valve-sparing aortic root replacement (VSARR) is an alternative to valve-replacing aortic root replacement (VRARR) with valved-conduits based on recent guidelines for clinical practice. This study investigated outcomes of these two procedures in patients with nonstenotic valves.

METHODS

Between January 7, 2007 and June 30, 2019, 475 patients with aortic root aneurysm without aortic stenosis underwent VSARR (151) or VRARR (324) techniques. Propensity score-matching (PSM) was used to alleviate confounding. Endpoints were 30-day mortality, 8-year survival and reoperation, aortic regurgitation, and valve gradients.

RESULTS

PSM created 69 pairs of patients with a mean age 52 ± 13 years (10.1% Marfan syndrome, 34.8% bicuspid aortic valve). There was no statistically significant difference in major perioperative morbidity or 30-day mortality (0% VSARR vs. 1.4% VRARR; p = 0.316). Overall survival was significantly higher (p = 0.025) in the VSARR group versus the VRARR group (8-year estimates 100% vs. 88.9%, respectively), while freedom from valve reoperation was similar (p = 0.97, 8-year estimates 90.9% vs. 96.7%, respectively). Freedom from > moderate-severe AR was not significantly different (p = 0.08, 8-year estimates 90.0% VSARR group vs. 100% VRARR), but mean valve gradients at last follow-up were better in the VSARR group (5.9 vs. 13.2 mmHg, p < 0.001).

CONCLUSIONS

VSARR is a safe operation in patients with aortic root aneurysm and nonstenotic aortic valves in the hands of experienced surgeons. Freedom from reoperation is similar and the mode of aortic valve failure differs between the two groups.

Aortic regurgitation in Marfan syndrome patients who underwent prophylactic surgery: A single-center experience

BACKGROUND

Marfan syndrome is an inherited connective tissue disease that causes aortic root dilatation and dissection and requires surgical intervention. Apart from emergent surgery for aortic dissection or aortic aneurysmal rupture, prophylactic surgical intervention can also be administered, depending on the severity of aortic root dilatation. The direct relationship between surgical intervention and aortic regurgitation was seldom mentioned in previous studies.

METHODS

A retrospective cohort study was designed to determine the clinical presentations of prophylactic surgery in patients with Marfan syndrome. Between January 2009 and May 2019, 112 patients, adolescents and young adults, treated in the Department of Pediatric Cardiology of Taipei Veterans General Hospital, were enrolled. All patients' sex, body measurements, echocardiography reports, and surgical notes were collected for statistical analysis.

RESULTS

Among the participants, nine patients (8%) underwent the Bentall procedure, and the other 103 did not receive surgical intervention. The operation group had a larger aortic root size (4.89 vs 2.86 cm, p < 0.001), more dilated left ventricle (4.81 vs 4.1 cm, p = 0.002), and higher prevalence of moderate and severe aortic regurgitation (66% vs 1%, p < 0.001) than the nonoperation group.

CONCLUSION

Among adolescents and young adults with Marfan syndrome, echocardiographic presentation of aortic root dilatation, left ventricular dilatation, and significant aortic regurgitation was significantly associated with prophylactic surgical intervention. According to the study, significant aortic regurgitation should also be considered as an important indication for prophylactic surgery.

Pathogenic FBN1 Genetic Variation and Aortic Dissection in Patients With Marfan Syndrome

BACKGROUND

Aortic risk has not been evaluated in patients with Marfan syndrome and documented pathogenic variants in the FBN1 gene.

OBJECTIVES

This study sought to describe aortic risk in a population with Marfan syndrome with pathogenic variants in the FBN1 gene as a function of aortic root diameter.

METHODS

Patients carrying an FBN1 pathogenic variant who visited our reference center at least twice were included, provided they had not undergone aortic surgery or had an aortic dissection before their first visit. Aortic events (aortic surgery or aortic dissection) and deaths were evaluated during the 2 years following each patient visit. The risk was calculated as the number of events divided by the number of years of follow-up.

RESULTS

A total of 954 patients were included (54% women; mean age 23 years). During follow-up (9.1 years), 142 patients underwent prophylactic aortic root surgery, 5 experienced type A aortic dissection, and 12 died (noncardiovascular causes in 3, unknown etiology in 3, post-operative in 6). When aortic root diameter was <50 mm, risk for proven type A dissection (0.4 events/1,000 patient-years) and risk for possible aortic dissection (proven aortic dissection plus death of unknown cause, 0.7 events/1,000 patients-years) remained low in this population that was treated according to guidelines. Three type A aortic dissections occurred in this population during the 8,594 years of follow-up, including 1 in a patient with a tubular aortic diameter of 50 mm, but none in patients with a family history of aortic dissection. The risk for type B aortic dissection in the same population was 0.5 events/1,000 patient-years.

CONCLUSIONS

In patients with FBN1 pathogenic variants who receive beta-blocker therapy and who limit strenuous exercise, aortic risk remains low when maximal aortic diameter is <50 mm. The risk of type B aortic dissection is close to the remaining risk of type A aortic dissection in this population, which underlines the global aortic risk.

Long-term outcome of patients with Marfan syndrome with previous aortic surgery but native aortic roots

OBJECTIVES

The goal of this study was to report the long-term outcomes of patients with Marfan syndrome who had aortic surgery on any aortic segment except for the replacement of the aortic root itself.

METHODS

An observational retrospective single-centre study was conducted with 115 Marfan syndrome patients who underwent 189 major aortic interventions from 1995 until 2018. Patients without aortic root replacement were identified and aortic root growth was analysed over time.

RESULTS

Eleven of 115 patients (9.5%) did not have aortic root replacement during a follow-up of 10.5 [standard deviation (SD) 5.7] years and a mean age at last follow-up of 53.9 (SD 13.4) years. Patients without root replacement did not suffer less frequently from any type of acute aortic dissection (type A 27% vs 25%, P = 0.999; type B 36% vs 25%, P = 0.474). Patients with native aortic roots did not undergo fewer aortic interventions than those with aortic root replacement [12/11, mean 1.09 (SD 0.54) operations/patient vs 177/104, mean 1.7 (SD 1.3); P = 0.128]. Progression of the aortic root dimension was 0.5 (SD 0.3) mm/year in the group of patients with native aortic roots.

CONCLUSIONS

Current data suggest that 10% of patients with Marfan syndrome with previous aortic surgery will be free from aortic root replacement until the sixth decade of life.

Reimplantation versus remodeling in valve-sparing surgery for aortic root aneurysms: a meta-analysis

Background

Valve-sparing aortic root replacement (VSARR), which includes reimplantation and remodeling techniques, has been developed as an important treatment for aortic root aneurysms. We aimed to evaluate the outcomes of reimplantation versus remodeling techniques in valve-sparing surgery for aortic root aneurysms.

Methods

A systematic review and meta-analysis was performed by searching PubMed, Embase and the Cochrane Library until November 2019. Fourteen retrospective cohort studies comparing reimplantation with remodeling techniques for aortic root aneurysms were included and contained at least one of the following outcomes: early mortality, late mortality, aortic valve-related reoperation, and postoperative moderate to severe aortic regurgitation (AR).

Results

The outcomes of 1,672 patients (1,011 underwent reimplantation surgery, and 661 underwent remodeling) were analyzed. Compared with remodeling, the reimplantation technique was associated with a significantly lower risk of late mortality (RR =0.34; 95% CI, 0.17–0.71; P=0.004; I²=37%) and reoperation (RR =0.31; 95% CI, 0.12–0.76; P=0.01; I²=55%). There was no significant difference in early mortality (RR =0.69; 95% CI, 0.31–1.53; P=0.36; I²=0%), postoperative moderate to severe AR (RR =0.64; 95% CI, 0.31–1.32; P=0.22; I²=36%) or postoperative stroke (RR =1.26; 95% CI, 0.58–2.75; P=0.56; I²=0%) between the two groups. No evidence of publication bias was detected.

Conclusions

The current meta-analysis indicate that patients who undergo reimplantation procedures have a significantly lower risk of late mortality and reoperation than those who undergo remodeling procedures. Early mortality, postoperative moderate to severe AR and stroke were comparable between the two techniques.

A Review on the Surgical Management of Subvalvular Aneurysm

The present perspective is a synthesis of published investigations in the setting of subvalvular aortic aneurysms. We identified 75 investigations and reviewed the clinical presentation, diagnostic modalities used, surgical techniques employed, and their outcomes. Clinical presentation, radiographic findings, transthoracic and transesophageal echocardiography, electrocardiogram-gated computerized tomography, and magnetic resonance imaging provided the diagnostic information and were used to define the disease entity before surgery. In this article, we have attempted to address several issues concerning establishment of diagnosis, varied clinical presentation, and their management. We submit that an increased appreciation of this disease entity will contribute to improved surgical management.

Acute type A aortic dissection - a review

Acute type A aortic dissection (ATAAD) is still one of the most challenging diseases that cardiac surgeons encounter. This review is based on the current literature and includes the results from the Nordic Consortium for Acute Type-A Aortic Dissection (NORCAAD) database. It covers different aspects of ATAAD and concentrates on the outcome of surgical repair. The diagnosis is occasionally delayed, and ATAAD is usually lethal if prompt repair is not performed. The dynamic nature of the disease, the variation in presentation and clinical course, and the urgency of treatment require significant attentiveness. Many surgical techniques and perfusion strategies of varying complexity have been described, ranging from simple interposition graft to total arch replacement with frozen elephant trunk and valve-sparing root reconstruction. Although more complex techniques may provide long-term benefit in selected patients, they require significant surgical expertise and experience. Short-term survival is first priority so an expedited operation that fits in with the surgeon's level of expertise is in most cases appropriate.

Bentall's Procedure for Annuloaortic Ectasia and Severe Aortic Regurgitation in a Patient With Repaired Tetralogy of Fallot and Aortic Valvular Reconstruction

A 21-year-old female patient with repaired tetralogy of Fallot and aortic valvular reconstruction with aneurysmal aortic root and severe aortic regurgitation underwent aortic root replacement. Intrinsic aortopathy in tetralogy of Fallot and its surgical importance are highlighted.

Valve-sparing root replacement and composite valve graft replacement in patients with aortic regurgitation: From the Japan Cardiovascular Surgery Database

OBJECTIVES

The advantage of valve-sparing root replacement (VSRR) over aortic root replacement with a composite valve graft (CVG) remains unclear. We compared these 2 procedures with regard to early outcomes with propensity score matching using the Japan Cardiovascular Surgery Database.

METHODS

Of 5303 patients from the Japan Cardiovascular Surgery Database who had undergone aortic root replacement in 2008 to 2017, emergent/urgent or redo cases and those with infective endocarditis or aortic stenosis were excluded (included n = 3841). Two propensity score-matched groups treated with VSRR or CVG replacement (n = 1164 each) were established.

RESULTS

Overall, VSRR was more frequently performed for younger patients with Marfan syndrome with lower operative risk and aortic regurgitation grade compared with CVG replacement. After matching, a weaker but similar trend still existed in baseline characteristics. Although more concomitant procedures were performed in the CVG group, myocardial ischemia and cardiopulmonary bypass time was significantly longer in the VSRR group (median, 193 and 245 minutes) than the CVG group (172 and 223 minutes, both P < .01). The CVG group was associated with a significantly greater incidence of postoperative stroke (2.5% vs 1.1%, P = .01) and prolonged ventilation >72 hours (7.0% vs 4.6%, P = .02). In-hospital mortality rates were significantly greater in the CVG group (1.8%) than the VSRR group (0.8%, P = .02).

CONCLUSIONS

In overall Japanese institutions, VSRR was more frequently performed for patients at low risk and was associated with better morbidity and mortality rates than CVG replacement. After matching, VSRR was also associated with better morbidity and mortality rates despite longer procedure time.