Results
We identified 49 patients who underwent a valve-sparing root replacement
during our study period. Twenty-four patients had a history of the Ross
procedure, 17 patients had a history of connective tissue disease, and
eight patients had a history of congenital heart defect. Group 1 was
comprised of seven patients who underwent the aortic root remodeling
technique, Group 2 was comprised of 32 patients who underwent the aortic
root reimplantation technique, and Group 3 was comprised of ten patients
who underwent an aortic root remodeling technique with a rigid aortic
annuloplasty ring. All seven patients in Group 1 had undergone a prior
Ross procedure. Group 2 and Group 3 were patients with a history of
connective tissue disease, prior conotruncal heart surgery, congenital
heart disease, or a prior Ross procedure. Mean follow-up was
significantly different between groups (p < 0.001). Group 1
and Group 2 patients had 7- and 14-year follow-up respectively and Group
3 had 1-year follow-up. The traditional aortic root remodeling technique
has been largely abandoned in our institution and replaced with the
aortic root remodeling technique with rigid annuloplasty ring since
2018. Aortic root reimplantation has been largely replaced as well, but
is still used for selected patients based on surgeon preference and
patient anatomy. Patient demographics were similar among groups with a
median age of 19 years (range 8-32) and 87% male sex (table 1). There
were no significant differences between the cardiopulmonary bypass and
aortic cross-clamp times between groups 1 and 2; however,
cardiopulmonary bypass times and aortic cross-clamp times were
significantly higher in group 3 (p < 0.001). Group 1 and 3
were more likely to have a history of the Ross procedure (p = 0.003),
and group 2 was more likely to have a history of connective tissue
disease (p = 0.21). Group 1 was more likely to require subsequent aortic
valve replacement, with all Group 1 patients requiring aortic valve
replacement over the study period (p < 0.001). Group 3 did not
have any required valve reinterventions during the study period. Group 3
was also more likely to have undergone aortic valve leaflet plication as
part of their procedure (p = 0.004). There were no significant
differences between aortic annulus measurements preoperatively (p =
0.741), but there was a significant difference in postoperative aortic
annulus measurement (p = 0.01) Preoperative AI grades were similar
between groups and were 2, 1.7, and 2.4 respectively (p = 0.2). However,
immediate postoperative AI grades were significantly different between
groups: 2.2, 1.2, and 1.2 respectively (p = 0.3). The most recent AI
grades in patients from group 2 and 3 who did not require subsequent
aortic valve replacement were similar (p = 0.9). Survival was good in
all groups with one early mortality due to hemorrhage and one late
mortality from malignancy.
Thirteen patients required aortic valve replacement after their
valve-sparing root replacement during the study period. According to
procedure type, all seven patients (100%) in Group 1 required valve
replacement, six patients (19%) in Group 2 required aortic valve
replacement, and no patient required valve replacement in Group 3 (p
< 0.001). Average time to aortic valve replacement after
valve-sparing aortic root replacement between Group 1 and Group 2 was
4.7 and 3.4 years, respectively (p =0 .6). History of connective tissue
disease, prior Ross procedure, concomitant procedures, and prior
sternotomy were not associated with increased risk for reintervention.
Patients who required subsequent valve reintervention had significantly
longer follow-up (p < 0.001), larger postoperative aortic
annulus measurements (p = 0.012), and longer cardiopulmonary bypass (p =
0.01) and aortic cross clamp times (p = 0.003). There was no significant
difference in preoperative AI grades; however, patients requiring future
aortic valve replacement had significantly higher immediate
postoperative AI grades (p < 0.001). Six of seven patients
with greater than mild aortic insufficiency on immediate postoperative
echocardiogram required subsequent aortic valve replacement (p
< 0.001). Postoperative mitral regurgitation was also higher
in patients who eventually required aortic valve replacement (p = 0.05)