Malak Elbatarny1, Derrick Y Tam2, J James Edelman2, Rodolfo V Rocha2, Michael W A Chu3, Mark D Peterson4, Ismail El-Hamamsy5, Jehangir J Appoo6, Jan O Friedrich7, Munir Boodhwani8, Bobby Yanagawa4, Maral Ouzounian9. 1. Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada; Queen's University School of Medicine, Kingston, Ontario, Canada. 2. Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada. 3. Division of Cardiac Surgery, Department of Surgery, London Health Sciences Center and University of Western Ontario, London, Ontario, Canada. 4. Division of Cardiac Surgery, Department of Surgery, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada. 5. Division of Cardiac Surgery, Department of Surgery, Montreal Heart Institute and Université de Montréal, Montreal, Quebec, Canada. 6. Division of Cardiac Surgery, Department of Surgery, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada. 7. Department of Critical Care Medicine, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada. 8. Division of Cardiac Surgery, Department of Surgery, Ottawa Heart Institute and University of Ottawa, Ottawa, Ontario, Canada. 9. Division of Cardiac Surgery, Department of Surgery, Toronto General Hospital and University of Toronto, Toronto, Ontario, Canada. Electronic address: maral.ouzounian@uhn.ca.
Abstract
BACKGROUND: Aortic valve-sparing operations theoretically have fewer stroke and bleeding complications but may increase late reoperation risk versus composite valve grafts. METHODS: We meta-analyzed all studies comparing aortic valve-sparing (reimplantation and remodelling) and composite valve-grafting (bioprosthetic and mechanical) procedures. Early outcomes were all-cause mortality, reoperation for bleeding, myocardial infarction, and thromboembolism/stroke. Long-term outcomes included all-cause mortality, reintervention, bleeding, and thromboembolism/stroke. Studies exclusively investigating dissection or pediatric populations were excluded. RESULTS: A total of 3794 patients who underwent composite valve grafting and 2424 who underwent aortic valve-sparing procedures were included from 9 adjusted and 17 unadjusted observational studies. Mean follow-up was 5.8 ± 3.0 years. Aortic valve sparing was not associated with any difference in early mortality, bleeding, myocardial infarction, or thromboembolic complications. Late mortality was significantly lower after valve sparing (incident risk ratio, 0.68; 95% confidence interval [CI], 0.54-0.87; P < .01). Late thromboembolism/stroke (incident rate ratio, 0.36; 95% CI, 0.22-0.60; P < .01) and bleeding (incident rate ratio, 0.21; 95% CI, 0.11-0.42; P < .01) risks were lower after valve sparing. Procedure type did not affect late reintervention. CONCLUSIONS: Aortic valve sparing appears to be safe and associated with reduced late mortality, thromboembolism/stroke, and bleeding compared with composite valve grafting. Late durability is equivalent. Aortic valve sparing should be considered in patients with favorable aortic valve morphology.
BACKGROUND: Aortic valve-sparing operations theoretically have fewer stroke and bleeding complications but may increase late reoperation risk versus composite valve grafts. METHODS: We meta-analyzed all studies comparing aortic valve-sparing (reimplantation and remodelling) and composite valve-grafting (bioprosthetic and mechanical) procedures. Early outcomes were all-cause mortality, reoperation for bleeding, myocardial infarction, and thromboembolism/stroke. Long-term outcomes included all-cause mortality, reintervention, bleeding, and thromboembolism/stroke. Studies exclusively investigating dissection or pediatric populations were excluded. RESULTS: A total of 3794 patients who underwent composite valve grafting and 2424 who underwent aortic valve-sparing procedures were included from 9 adjusted and 17 unadjusted observational studies. Mean follow-up was 5.8 ± 3.0 years. Aortic valve sparing was not associated with any difference in early mortality, bleeding, myocardial infarction, or thromboembolic complications. Late mortality was significantly lower after valve sparing (incident risk ratio, 0.68; 95% confidence interval [CI], 0.54-0.87; P < .01). Late thromboembolism/stroke (incident rate ratio, 0.36; 95% CI, 0.22-0.60; P < .01) and bleeding (incident rate ratio, 0.21; 95% CI, 0.11-0.42; P < .01) risks were lower after valve sparing. Procedure type did not affect late reintervention. CONCLUSIONS: Aortic valve sparing appears to be safe and associated with reduced late mortality, thromboembolism/stroke, and bleeding compared with composite valve grafting. Late durability is equivalent. Aortic valve sparing should be considered in patients with favorable aortic valve morphology.