Comparison between Valve Sparing Aortic Root Replacement and Modified

Bentall

Allan Stewart, MD., Jonathan A. Yang, MD; Mark J. Russo, MD/MPH; Alexander Iribarne, MD; Brendan F. Scully; Rachel Easterwood; Craig R. Smith, MD; Division of

Cardiothoracic Surgery, Columbia University Medical Center, New York, NY

Aortic Insufficiency & Root Aneurysm

• Different treatment options exist• Bentall Procedure1

– Several modifications• Valve-sparing root replacement (VSRR)– Sir Magdi Yacoub, Tirone David

• We have performed both at our Institution since 2005

1. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax. 23(4):338-9.

Methods

• Retrospective study• Peri-Operative and short-term data• VSRR via the re-implantation method

described by David, et al1

• Modified Bentall Procedures – novel composite biologic graft

1. David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg. 1992 April; 103(4):617-21.

Valve-Sparing Root Replacement

BioRootEdwards Perimount Valve ATS 3f Valve

BioRoot

Results

Valve-Sparing Root

ReplacementBioRoot p

Number of patients 111 175 -Mean Age in years (Range) 55 63 <0.0001Pre-Op AI 2+ 75 (67.6%) 145 (82.6%) 0.0044Mean Cardiopulmonary Bypass Time (min) 150.845.6 153.755.5 0.6

Mean Aortic Cross-Clamp Time (min) 112.433.4 108.934.8 0.4

Post-Op AI 2+ 0% 0% -Need for Re-op for AVR 2 (1.8%) 0 (0%) -30-day Mortality 1 (0.9%) 2 (1.1%) 0.8

Pre-Treatment Decisions

Can valve be Repaired?

Remodeling

“Real-time” Repair Algorithm (AI + Aneurysm)

Should it be Repaired?

Ignore

Repair

Replace

BioRoot

Mechanical Conduit

Reimplantation

Should it be Replaced?

Yes

Yes

Yes

No

No

When Should We Repair?• Aortic Leaflet Integrity– Reliable valve-sparing results with: • supple leaflets• normal annular size• Bicuspid and tri-leaflets have good 10-year data

– High Failure Rates with:• Severe AI• Multi-leaflet Prolapse• Multiple Fenestrations

When Should We Replace?• Marked leaflet Asymmetry• Multiple leaflet Fenestrations• “Broken leaflets”

• Bicuspid Patients– Significant Thickening– Prolapse– Calcification– Multiple Fenestrations

• Connective Tissue Patients– Data is unclear – Be cautious in repairing

attenuated & severely prolapsed valves

Conclusions

• Similar operative times• Low rates of post-op AI, repeat AVR and

mortality• Similar short-term outcomes• Reproducible and safe• Need to delineate proper guidelines for

indications• Follow-up needed to assess long-term outcomes