ADULT CARDIAC
Valve-Sparing Root Replacement in
Elderly Patients With Annuloaortic Ectasia
Koki Yokawa, MD, Yuki Ikeno, MD, Yojiro Koda, MD, Soichiro Henmi, MD,
Takashi Matsueda, MD, Hiroaki Takahashi, MD, Hidekazu Nakai, MD,
Katsuhiro Yamanaka, MD, PhD, Yasuko Gotake, MD, Hiroshi Tanaka, MD, PhD, and
Yutaka Okita, MD, PhD
Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
Background. We report early and midterm outcomes of
elderly patients who underwent valve-sparing root
replacement (VSRR) compared with younger patients
and those with Bentall procedure.
Methods. From October 1999 to October 2017, 73
patients greater than or equal to 65 years of age who
underwent VSRR procedure were assigned as group S.
Two hundred thirty-two VSRR patients who were
between 15 and 64 years of age were assigned as group Y.
Forty-five patients greater than or equal to 65 years of age
who underwent Bentall procedure were assigned as
group R. Preoperative grades of aortic regurgitation were
3.4 of 4 in group S, 3.1 of 4 in group Y, and 3.3 of 4 in
group R (p [ 0.07).
Results. Hospital mortality was found in 1 (1.4%)
patient in group S, 3 (6.7%) in group R, and 2 (0.9%) in
group Y. Postoperative survival at 5 years was 88.5% in
A better understanding of the pathophysiology of
annuloaortic ectasia (AAE) has led to the wider
application of the valve-sparing root replacement (VSRR)
technique for AAE patients with complicated valve le-
sions [1], depressed left ventricular function, or other
marginal indications [2]. Although biologic composite
prosthetic valve implantations have been used to treat
elderly populations, the incidence of the prosthesis-
related complications is not negligible. On the other
hand, the advantages of the VSRR have been demon-
strated especially in the younger population. Very few
studies have discussed regarding the application of the
VSRR for elderly patients [3]. The purpose of this study
was to evaluate the midterm clinical outcome after VSRR
for patients over 65 years of age and to assess the function
of the aortic valve by echocardiography compared with
those who underwent aortic root replacement with a
prosthetic valve and with younger patients.
Our basic strategy for AAE is as follows. VSRR with the
David-type reimplantation technique is performed as
possible. On the other hand, the most important criterion
Accepted for publication Oct 29, 2018.
Address correspondence to Dr Okita, Department of Surgery, Division of
Cardiovascular Surgery, Kobe University, 7-5-2 Kusunoki-cho, Chuo-ku,
Kobe, Japan 650-0017; email: yokita@med.kobe-u.ac.jp.
Ó 2019 by The Society of Thoracic Surgeons
Published by Elsevier Inc.
group S, 98.7% in group Y, and 82.4% in group R (p <
0.01). Freedom from more than mild aortic regurgitation
at 5 years was 81.0% in group S and 85.4% in group Y.
Follow-up echocardiography disclosed an effective aortic
valve orifice area of 1.76 cm2 in group R, 2.40 cm2 in group
Y, and 2.41 cm2 in group S (p < 0.01), and peak pressure
gradient across the aortic valve was 17.7 mm Hg in group
R, 13.6 mm Hg in group Y, and 10.8 mm Hg in group S
(p < 0.01).
Conclusions. Similar early and late outcomes were
achieved in elder VSRR patients compared with younger
patients. A better postoperative valve performance was
demonstrated in VSRR patients than patients undergoing
valve-replacement.
(Ann Thorac Surg 2019;107:1342–7)
Ó 2019 by The Society of Thoracic Surgeons
to indicate Bentall procedure is the aortic cusp compe-
tency. Moreover, patients’ preoperative comorbidities
and concurrent procedures are also considered as sig-
nificant factors that the heart team considers when
making a decision. For example, in patients with
congestive heart failure or low left ventricular function,
we adopted the Bentall procedure to avoid longer aortic
cross-clamp time.
Patients and Methods
From October 1999 to October 2017, 305 patients with
AAE underwent aortic root replacement with the reim-
plantation (David) technique. The mean age at operation
was 51.2
16.6 years (range, 15 to 86 years). Seventy-
three patients were greater than or equal to 65 years of
age at the time of surgery (assigned as repair group
[group S]). The mean age was 71.5
5.3 years (Table 1).
The etiology of the valve lesions was degenerative in 54
patients, bicuspid aortic valve (BAV) in 4, acute aortic
dissection (AD) in 3, chronic AD in 7, and aortitis in 1.
Marfan syndrome was found in 1 patient. Two hundred
thirty-two patients who were between 15 and 65 years of
age were assigned as group Y. The mean age of group Y
was 44.8
13.4 years. The etiology of the valve lesions
was degenerative in 55 patients, BAV in 61, acute AD in 7,
0003-4975/$36.00
https://doi.org/10.1016/j.athoracsur.2018.10.075
Ann Thorac Surg YOKAWA ET AL 1343
2019;107:1342–7 VALVE-SPARING ROOT REPLACEMENT IN THE ELDERLY

ADULT CARDIAC
Table 1. Patients and Methods
VSRR (Group S: VSRR (Group Y: Bentall (Group R:
65 Years of Age) <65 Years of Age) 65 Years of Age)

Characteristics n ¼ 73 n ¼ 232 n ¼ 45 p Value

Age, years 71.5
5.3 44.8
13.4 73.3
5.2 <0.01

Male 62 (84.9) 177 (76.3) 26 (57.8) <0.01
Acute type A dissection 3 (4.1) 7 (3.0) 4 (8.9) 0.25
Aortitis 1 (1.4) 10 (4.3) 3 (6.7) 0.286
Reoperative root replacement 3 (4.1) 12 (5.2) 15 (33.3) <0.01
Marfan syndrome 1 (1.4) 60 (25.9) 2 (4.4) <0.01
BAV 4 (5.5) 61 (26.3) 3 (6.8) <0.01
NYHA functional class III 7 (9.6) 6 (2.6) 7 (15.6) <0.01
EF 40% 8 (11.0) 24 (10.3) 9 (20.0) 0.22

Values are mean
SD or n (%).

BAV ¼ bicuspid aortic valve; EF ¼ ejection fraction; NYHA ¼ New York Heart Association; VSRR ¼ valve-sparing root replacement.

chronic AD in 27, Marfan syndrome in 60, and aortitis in
10. The basic surgical procedure was the David-type
aortic root reimplantation technique. From November
2002, we solely used Gelweave Anteflow Valsalva graft
(Terumo, Tokyo, Japan) and the size of the graft was 22
mm in 1 patient, 24 mm in 24 patients, 26 mm in 122
patients, 28 mm in 112 patients, 30 mm in 39 patients, and
32 mm in 6 patients.
During the same period, a Bentall operation or aortic
root replacement with a stentless porcine prosthesis was
performed in 120 patients with AAE. Twenty-four
patients who received Bentall operation for active infec-
tive endocarditis or prosthetic valve endocarditis were
excluded. Forty-five of 108 patients were greater than or
equal to 65 years of age (assigned as replacement group
[group R]). The mean age of group R at the time of
operation was 73.3
5.2 years, with a maximum age of 87
years. The etiology was degenerative AR in 12 patients,
aortic stenosis with root aneurysm in 3, BAV in 3, reo-
perative root replacement in 15, and chronic AD in 6. Six
patients had stentless porcine root prosthesis. The labeled
size of the prosthetic valve was 19 mm in 2 patients, 21
mm in 11 patients, 23 mm in 27 patients, 25 in 3 patients,
27 mm in 1 patient, and 29 mm in 1 patient. A bio-
prosthetic valve was used in all patients. Preoperative
grades of aortic regurgitation (AR) were 3.4
0.8 of 4
in group S, 3.1
1.1 of 4 in group Y, and 3.3
0.8 of 4 in
group R (p ¼ 0.07). Preoperative echocardiography data in
detail are shown in Table 2. In groups S and Y, various
cusp repair techniques including plication of the nodule
of Arantius (n ¼ 37 and 126 for groups S and group Y,
respectively), reinforcement of the free margin of the cusp

Table 2. Preoperative Echocardiographic Data

VSRR (Group S: VSRR (Group Y: Bentall (Group R:
65 Years of Age) <65 Years of Age) 65 Years of Age)

Characteristics n ¼ 73 n ¼ 232 n ¼ 45 p Value

LVDd, mm 57.2
9.8 57.4
10.1 56.6
9.7 0.89

EF, % 56.7
9.6 57.5
10.3 54.3
10.5 0.19
AVJ diameter, mm 24.5
2.7 26.0
3.2 23.5
3.4 <0.01
Valsalva diameter, mm 48.0
7.7 46.8
10.4 40.8
9.1 <0.01
AR grade 0.01
None to trivial 3 (4.1) 29 (12.5) 1 (2.2) .
Mild 4 (5.5) 32 (13.8) 6 (13.3) .
Moderate 28 (38.4) 53 (22.8) 15 (33.3) .
Severe 38 (52.1) 118 (50.9) 22 (48.9) .
Peak PG, mm Hg 15.0
8.1 15.3
7.7 31.6
25.1 0.04
Cusp prolapse 30 (41.1) 99 (42.7) 5 (11.4) <0.01
Cusp calcification 9 (12.3) 19 (8.2) 11 (25.0) 0.01
Cusp fenestration 14 (19.2) 48 (20.7) 5 (11.4) 0.32

Values are mean
SD or n (%).

AR ¼ aortic regurgitation; AVJ ¼ aortoventricular junction; EF ¼ ejection fraction; LVDd ¼ left ventricular diastolic diameter;
PG ¼ pressure gradient; VSRR ¼ valve-sparing root replacement.
 1344 YOKAWA ET AL Ann Thorac Surg
VALVE-SPARING ROOT REPLACEMENT IN THE ELDERLY 2019;107:1342–7
ADULT CARDIAC

Table 3. Surgical Characteristics

VSRR (Group S: VSRR (Group Y: Bentall (Group R:
65 Years of Age) <65 Years of Age) 65 Years of Age)

Characteristics n ¼ 73 n ¼ 232 n ¼ 45 p Value

Central plication 37 (50.7) 126 (54.3) . 0.59

Reinforcement 12 (17.8) 66 (28.5) . 0.06
Patch repair 7 (9.6) 17 (7.3) . 0.54
Decalcification 5 (6.9) 2 (0.9) . <0.01
Commissure plasty 3 (4.1) 15 (6.5) . 0.44
CPB time, minutes 232
61 227
58 222
87 0.69
ACC time, minutes 170
37 176
38 147
46 <0.01
Total arch replacement 6 (8.2) 31 (13.4) 7 (15.6) 0.39
Hemiarch replacement 17 (23.3) 17 (7.3) 7 (15.6) <0.01
Circulatory arrest 14.9
22.4 11.3
19.0 11.5
18.4 0.55
time, minutes
Cerebral perfusion 22.9
44.9 19.7
35.1 22.5
43.8 0.86
time, minutes
Mitral valve repair 7 (9.6) 17 (7.3) 6 (13.3) 0.43
CABG 5 (6.9) 10 (4.3) 10 (22.2) <0.01

Values are n (%) or mean
SD.

ACC ¼ aortic cross-clamp; CPB ¼ cardiopulmonary bypass; CABG ¼ coronary artery bypass grafting; VSRR ¼ valve-sparing root
replacement.

using CV7 Gore-Tex (Flagstaff, AZ) suture (n ¼ 12 and compared with group S and group Y (p ¼ 0.08). Late
66), decalcification of the cusps (n ¼ 5 and 2), commissure deaths in group S were recognized in 2 patients, and the
reinforcement using a pericardial strip (n ¼ 3 and 15), and causes which were stroke and chronic obstructive pul-
pericardial patching of the cusps (n ¼ 7 and 17). monary disease. Three patients in group Y died due to
Concomitant procedures and cardiopulmonary bypass rupture of a residual aneurysm, the second operation of
data are shown in Table 3. Postoperative echocardiogra- the thoracoabdominal aortic aneurysm, and cerebral
phy was performed at discharge and every 6 months hemorrhage. Late deaths occurred in 7 patients in group
thereafter. The mean postoperative follow-up period was R, and the cause was sepsis in 2 patients, pneumonia in 3,
5.4
2.3 years in group S, 6.8
3.6 years in group Y, and and unknown in 2. Postoperative survival at 5 years was
6.7
4.5 years in group R. 88.5%
4.2% in group S, 98.7%
0.8% in group Y, and
This study was approved by the internal review board 82.4%
6.1% in group R (p < 0.01) (Fig 1). Most recent
at Kobe University, and individual consent from patients
was waived. This study received no funding.
Continuous data are presented as mean
SD or me-
dian (range) for nonparametric data. The date of the first
diagnosis of recurrent AR moderate or more was recor-
ded for time-to-event calculation. Univariate comparisons
between groups for failure time data were performed
using the log-rank test. Statistical analyses were per-
formed using SPSS software version 17.0 (SPSS Inc,
Chicago, IL). Statistical significance was considered for p
value less than or equal to 0.05.

Results
In group S, hospital mortality was found in 1 (1.4%) pa-
tient who underwent reimplantation owing to massive
necrosis of the gastrointestinal tract secondary to mal-
perfusion syndrome of the superior mesenteric artery due
to acute AD. Two patients in group Y (0.9%) died of brain
hemorrhage and heart failure. In group R, 3 patients
(6.7%) died due to cerebral bleeding, continued sepsis, Fig 1. Survival after surgery and comparison with age and sex
and reoperation for prosthetic valve endocarditis. There adjusted Japanese healthy population. (VSRR ¼ valve-sparing root
was a tendency of worse early survival in group R replacement.)
Ann Thorac Surg YOKAWA ET AL 1345
2019;107:1342–7 VALVE-SPARING ROOT REPLACEMENT IN THE ELDERLY

ADULT CARDIAC
Table 4. Postoperative Echocardiographic Data
VSRR (Group S: VSRR (Group Y: Bentall (Group R:
65 Years of Age) <65 Years of Age) 65 Years of Age)

Characteristics n ¼ 73 n ¼ 232 n ¼ 45 p Value

AR grade 0.22
None to trivial 50 (58.5) 187 (80.6) .
Mild 21 (2.8) 42 (18.1) .
Moderate 2 (2.7) 2 (0.9) .
Severe 0 1 (0.4) .
Redo surgery for AR 3 (3.9) 19 (8.3) . 0.11
At discharge
AVA, cm2 2.40
0.61 2.38
0.69 1.87
0.42 <0.01
pPG, mm Hg 11.4
5.5 13.6
8.6 18.3
7.2 <0.01
Follow-up
AVA, cm2 2.40
0.58 2.40
0.81 1.76
0.62 <0.01
pPG, mm Hg 10.8
5.9 13.6
9.2 17.7
10.8 <0.01

Values are n (%) or mean
SD.

AR ¼ aortic regurgitation; AVA ¼ aortic valve area; pPG ¼ peak pressure gradient; VSRR ¼ valve-sparing root replacement.

postoperative echocardiography was performed at 5.8

4.3 years (Table 4). Moderate or severe AR was noticed in
5 patients in group S and 40 patients in group Y (p ¼ 0.06).
Freedom from more than mild AR at 5 years was 81.1%

5.6% in group S and 85.4%
2.6% in group Y (Fig 2). Redo
aortic valve replacement due to AR was required in 3
patients in group S and 19 patients in group Y (p ¼ 0.41).
Freedom from reoperation at 5 years was 94.0%
2.0% in
group S, 93.0%
1.8% in group Y, and 97.5%
2.5% in
group R (Fig 3). Echocardiography recorded at discharge
disclosed effective aortic valve orifice areas of 1.87
0.42
cm2 in group R, 2.38
0.69 cm2 in group Y, and 2.40

0.61 cm2 in group S (p < 0.01), and peak pressure gradi-
ents across the aortic valve were 18.3
7.2 mm Hg in
group R, 13.6
8.6 mm Hg in group Y, and 11.4
5.5 mm
Hg in group S (p < 0.01). Follow-up echocardiography
disclosed effective aortic valve orifice areas of 1.76
0.62
cm2 in group R, 2.40
0.81 cm2 in group Y, and 2.41

0.58 cm2 in group S (p < 0.01), and peak pressure gradi-
ents across the aortic valve were 17.7
10.8 mm Hg in
group R, 13.6
9.2 mm Hg in group Y, and 10.8
5.9 mm
Hg in group S (p < 0.01) (Fig 4).
Comment
Historically, composite valve replacement with Dacron
graft (Bentall) has been the default procedure for the sur-
gical management of AAE [4]. In the last 2 decades, aortic
valve repair has been performed more widely, driven in
part by improvements in the echocardiographic

Fig 2. Freedom from aortic valve reoperation (AVR). (VSRR ¼ valve- Fig 3. Freedom from more than mild aortic regurgitation (AR).
sparing root replacement.) (VSRR ¼ valve-sparing root replacement.)
 1346 YOKAWA ET AL
VALVE-SPARING ROOT REPLACEMENT IN THE ELDERLY
ADULT CARDIAC
Fig 4. Comparison of aortic valve
performance. (EOA ¼ effective valve
orifice area; Group R ¼ Bentall pa-
tients; Group S ¼ valve-sparing root
replacement (VSRR) in elderly pa-
tients; PG ¼ pressure gradient; Post
OP ¼ postoperative data at
discharge.)
delineation of cusp anatomy and the quantification of
anatomical abnormalities, and consequent to an increasing
facility with VSRR among cardiac surgeons [5–8]. VSRR
has become the first-choice operation for younger patients
with AAE [9]. A survey of the Japanese Association for
Thoracic Surgery recognized that 339 patients underwent
VSRR among 1,584 patients who had aortic root replace-
ment in 2014 [10]. As the proportion of elderly people has
rapidly increased in Japan, the age of patients with AR has
significantly increased. The Bentall procedure is the gold
standard for the elderly population because aortic valve
lesions become more complex with age. For example, cusp
calcification or cusp thickening due to longstanding
hemodynamic stress and tissue degeneration as well as the
diameter of the aorta increase as age advances [11, 12]. The
durability of a bioprosthetic valve in the aortic position
improves as patients’ age progresses, and valve-in-valve
procedures for the treatment of structural valve deterio-
ration of bioprostheses have also been developed. Recent
guidelines recommend using a bioprosthetic valve in the
aortic position for elderly patients with aortic stenosis, and
the threshold has also been lowered for the age of bio-
prosthesis usage [13, 14].
A meta-analysis of 17 studies regarding the VSRR
procedure reported that the mean age at surgery ranged
from 33 to 61 years [15]. In 2014, Arimura and colleagues
[16] surveyed 250 Japanese institutes and disclosed that
236 patients underwent VSRR and 463 underwent the
Bentall procedure. Of the VSRR patients, 174 (73%)
patients were treated using the root reimplantation
technique and 65 (27%) had root remodeling. The mean
ages at surgery were 54
20 years and 56
20 years,
respectively. Only 30 (12.7%) patients were over 64 years
of age. There is no age limitation to mitral valve repair for
patients with degenerative mitral valve regurgitation
because mitral valve repair provides excellent long-term
durability and superior hemodynamics compared with
valve replacement [13]. The impetus to develop and
promote valvuloplasty strategies for isolated AR in the
absence of calcific stenosis was the belief that aortic valve
Ann Thorac Surg
2019;107:1342–7
repair would offer significant advantages to patients in a
manner analogous to mitral valve repair by avoiding
prosthesis-related complications such as prosthesis-
patient mismatch, endocarditis, thromboembolism, and
early structural valve degeneration [17, 18]. We believe
that the aortic valve repair technique provides better
hemodynamic outcomes compared with valve replace-
ment in patients with AR.
Preoperative characteristics showed that patients who
underwent the Bentall operation (group R) were signifi-
cantly sicker because of higher age, advanced heart fail-
ure, more incidence of endocarditis, and severer AR.
Although the result was limited in selected patients, early
mortality in group S was slightly better than group R
despite a longer cross-clamp time and a longer cardio-
pulmonary bypass time. In our experience, postoperative
low-cardiac-output syndrome has been rarely seen even
in patients with depressed left ventricular function who
had VSRR.
Very few articles have discussed postoperative aortic
valve hemodynamics. Esaki and colleagues [19]
compared clinical outcomes in patients who underwent
VSRR with those who underwent the Bentall procedure
with a mechanical prosthesis and concluded that an
improved midterm survival was found among patients
undergoing VSRR, with similar operative mortality and
morbidity. They also reported that VSRR and bio-
Bentall resulted in equivalent operative mortality and
morbidity, with similar midterm survival and valve
durability [20]. Gaudino and colleagues [21] stated that
both VSRR and bio-Bentall operations provided excel-
lent outcomes, but the use of a biologic composite
conduit was associated with a higher risk of reoperation
at midterm follow-up. Svensson and colleagues [3]
found that VSRR and allograft procedures have the
lowest valve gradients and best ventricular remodeling,
but they have late AR. They concluded that VSRR for
young patients was recommended when possible
despite the early risk of reoperation, and bioprostheses
are preferable for the elderly. However, they did not
Ann Thorac Surg
2019;107:1342–7
report detailed hemodynamics with regard to aortic
valve function. Our results indicate that the post-
operative aortic valve orifice area in patients who had
VSRR was larger than that in patients who underwent
the Bentall operation, and also that there was a smaller
pressure gradient of the aortic valve in VSRR patients
than that in Bentall patients. In terms of preventing
prosthesis-patient mismatch [22], VSRR may have some
advantage toward Bentall procedure.
The incidence of residual AR, as well as redo surgery
for AR in elderly patients with VSRR, was similar to that
in young patients with VSRR. David and colleagues [1]
found by multivariate analyses that age, type A AD,
impaired ventricular function, and preoperative AR were
associated with increased mortality; however, preopera-
tive AR and cusp repair had no adverse effect on valve
function. Our previous report [23] disclosed that risk
factors for VSRR failure (redo surgery due to AR or AR
more than moderate) did not include patients’ age.
Similarly, de Kerchove and colleagues [24] reported by
multivariate analyses that predictors of recurrent AR
greater than or equal to 2 were the preoperative left
ventricular end-diastolic diameter and an AR greater than
1 on discharge echocardiography.
Limitations of this study are the following. First, this
was a retrospective observational study. Second, surgery
was performed by only 1 surgeon in a single institute.
Third, the number of patients was relatively small. Last,
there was a significant selection bias between group S
and group R. Ideally, a comparison based on propensity-
matched analysis may be more preferable. However,
even if our results were obtained from selected patients,
the results would provide a new insight toward our
clinical decision. Further analysis is needed.
Conclusion
The application of VSRR is justified in elderly patients.
Similar early and late outcomes were achieved compared
with younger patients. A better postoperative valve per-
formance in early and late follow-up periods was
demonstrated in VSRR patients compared with patients
undergoing valve-replacing root replacement.
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