Midterm outcomes of subcoronary stentless porcine valve versus stented aortic valve replacement

Impact of Aortic Root Enlargement on Patients Undergoing Aortic Valve Replacement

BACKGROUND

Aortic root enlargement (ARE) can be an important adjunct for aortic valve replacement (AVR). This study compared outcomes of AVR with or without ARE.

METHODS

This was an observational study using an institutional database of AVRs from 2010 to 2020 comparing patients who underwent isolated AVR vs AVR with ARE (AVR+ARE). Kaplan-Meier survival estimation and Cox regression were performed.

RESULTS

Of 2371 patients, 2240 (94.5%) underwent isolated AVR and 131 (5.5%) underwent AVR+ARE. Patients who underwent AVR+ARE were more likely to be women and to be younger than those who underwent isolated AVR. Prosthesis size was smaller in patients undergoing AVR+ARE (23 mm [interquartile range {IQR}, 21-25] vs 25 mm [IQR, 23-25], P < .001), but indexed effective orifice area did not differ between the 2 groups. Operative mortality was comparable for AVR (2.3%) and AVR+ARE (3.8%, P = .28). Patients who underwent AVR+ARE had a longer length of stay (7 days [IQR, 6-13] vs 6 days [IQR 5-10], P < .001), were more likely to have acute kidney injury (6.1% vs 2.5%, P = .01), were more likely to require blood product transfusions (40.5% vs 27.6%, P < .001), and were more likely to require prolonged ventilation > 24 hours (16.0% vs 6.8%, P < .001). Rates of stroke, atrial fibrillation, permanent pacemaker, and reoperation were comparable between groups. Kaplan-Meier survival estimates were similar, and on multivariable regression AVR+ARE was not associated with an increased hazard of death as compared with AVR (hazard ratio, 1.09; 95% confidence interval, 0.81-1.46; P = .59).

CONCLUSIONS

ARE can be safely performed with isolated AVR and should be considered for patients with small annuli to avoid prosthesis-patient mismatch.

Outcomes of Root Enlargement Vs Root Replacement for Aortic Stenosis

BACKGROUND

Stentless aortic root replacement (ARR) and aortic root enlargement (ARE) are established strategies to avoid prosthesis-patient mismatch in patients with aortic stenosis (AS) and small annuli. We sought to compare outcomes of these 2 procedures.

METHODS

This was an observational study using an institutional database of aortic valve replacements from 2010 to 2021. The study compared patients who underwent ARE vs ARR for AS. Those with endocarditis or aortic aneurysms were excluded. Postoperative outcomes were compared between groups. Kaplan-Meier survival estimation and multivariable Cox regression for survival were performed. Cumulative incidence functions were generated for all-cause readmissions.

RESULTS

A total of 533 patients underwent either ARE or ARR for AS. Of these, 193 (36.2%) underwent ARE and 340 (63.8%) underwent ARR with a stentless xenograft. There were no significant differences in operative mortality, stroke, length of stay, or new-onset renal failure requiring dialysis. There were also no significant differences in aortic valve reintervention rates (3.1% vs 1.8%; P = .314). Patients in the ARR group had larger valves implanted, larger indexed effective orifice areas, lower rates of prosthesis-patient mismatch, and lower transprosthetic gradients (P < .001). Median follow-up was 5.02 (2.70-7.8) years. Kaplan-Meier survival estimates were comparable, and on multivariable Cox regression, ARR vs ARE was not significantly associated with an increased hazard of death (hazard ratio, 1.00; 95% CI, 0.69-1.45; P = .996). Cumulative incidence estimates for all-cause readmissions were also comparable between groups.

CONCLUSIONS

ARE and stentless xenograft ARR for AS were associated with comparable postoperative complications, aortic valve reinterventions, freedom from readmission, and 5-year survival.

Outcomes of bovine versus porcine surgical aortic valve replacement

INTRODUCTION

There are no guidelines regarding the use of bovine pericardial or porcine valves for aortic valve replacement, and prior studies have yielded conflicting results. The current study sought to compare short- and long-term outcomes in propensity-matched cohorts of patients undergoing isolated aortic valve replacement (AVR) with bovine versus porcine valves.

METHODS

This was a retrospective study utilizing an institutional database of all isolated bioprosthetic surgical aortic valve replacements performed at our center from 2010 to 2020. Patients were stratified according to type of bioprosthetic valve (bovine pericardial or porcine), and 1:1 propensity-score matching was applied. Kaplan-Meier survival estimation and multivariable Cox regression for mortality were performed. Cumulative incidence functions were generated for all-cause readmissions and aortic valve reinterventions.

RESULTS

A total of 1502 patients were identified, 1090 (72.6%) of whom received a bovine prosthesis and 412 (27.4%) of whom received a porcine prosthesis. Propensity-score matching resulted in 412 risk-adjusted pairs. There were no significant differences in clinical or echocardiographic postoperative outcomes in the matched cohorts. Kaplan-Meier survival estimates were comparable, and, on multivariable Cox regression, valve type was not significantly associated with long-term mortality (hazard ratio: 1.02, 95% confidence interval: 0.74, 1.40, p = .924). Additionally, there were no significant differences in competing-risk cumulative incidence estimates for all-cause readmissions (p = .68) or aortic valve reinterventions (p = .25) in the matched cohorts.

CONCLUSION

The use of either bovine or porcine bioprosthetic aortic valves yields comparable postoperative outcomes, long-term survival, freedom from reintervention, and freedom from readmission.

Aortic root enlargement: Just do it

Aortic root enlargement (ARE) can be an important adjunct for aortic valve replacement (AVR) in patients with small annuli, but incremental morbidity of this procedure is not well understood.