Received: 6 January 2022 | Accepted: 22 February 2022
DOI: 10.1111/jocs.16473
ORIGINAL ARTICLE
Valve‐sparing versus valve‐replacing aortic root replacement
in patients with aortic root aneurysm
S. Chris Malaisrie MD1
2 2
Marla Mendelson MD | Jyothy J. Puthumana MD | Patricia Vassallo MD
Jane Kruse BSN1 | Adin‐Cristian Andrei PhD3 | Patrick M. McCarthy MD1
1
Department of Surgery, Division of Cardiac
Surgery, Northwestern University, Chicago,
Illinois, USA
2
Department of Medicine, Division of
Cardiology, Feinberg School of Medicine and
Northwestern Medicine, Northwestern
University, Chicago, Illinois, USA
3
Department of Preventive Medicine, Division
of Biostatistics, Northwestern University,
Chicago, Illinois, USA
Correspondence
S. Chris Malaisrie, MD, Department of
Surgery, Division of Cardiac Surgery,
Northwestern Medicine, Northwestern
University, 676 St Clair Street, Arkes 730,
Chicago, IL 60611, USA.
Email: chris.malaisrie@nm.org
J Card Surg. 2022;37:1947–1956.
| Olga N. Kislitsina MD2 | Lisa Wilsbacher MD2 |
2
|
Abstract
Background: Valve‐sparing aortic root replacement (VSARR) is an alternative to
valve‐replacing aortic root replacement (VRARR) with valved‐conduits based on
recent guidelines for clinical practice. This study investigated outcomes of these two
procedures in patients with nonstenotic valves.
Methods: Between January 7, 2007 and June 30, 2019, 475 patients with aortic root
aneurysm without aortic stenosis underwent VSARR (151) or VRARR (324)
techniques. Propensity score‐matching (PSM) was used to alleviate confounding.
Endpoints were 30‐day mortality, 8‐year survival and reoperation, aortic regurgita-
tion, and valve gradients.
Results: PSM created 69 pairs of patients with a mean age 52 ± 13 years (10.1%
Marfan syndrome, 34.8% bicuspid aortic valve). There was no statistically significant
difference in major perioperative morbidity or 30‐day mortality (0% VSARR vs. 1.4%
VRARR; p = 0.316). Overall survival was significantly higher (p = 0.025) in the VSARR
group versus the VRARR group (8‐year estimates 100% vs. 88.9%, respectively),
while freedom from valve reoperation was similar (p = 0.97, 8‐year estimates 90.9%
vs. 96.7%, respectively). Freedom from > moderate‐severe AR was not significantly
different (p = 0.08, 8‐year estimates 90.0% VSARR group vs. 100% VRARR), but
mean valve gradients at last follow‐up were better in the VSARR group (5.9 vs.
13.2 mmHg, p < 0.001).
Conclusions: VSARR is a safe operation in patients with aortic root aneurysm and
nonstenotic aortic valves in the hands of experienced surgeons. Freedom from
reoperation is similar and the mode of aortic valve failure differs between the two
groups.
KEYWORDS
aortic root replacement, aortic valve repair, aortic valve replacement
wileyonlinelibrary.com/journal/jocs © 2022 Wiley Periodicals LLC. | 1947

1948 | MALAISRIE
1 | INTRODUCTION
The valve‐sparing aortic root replacement (VSARR) operation
replaces the aneurysmal aortic tissue while preserving the native
aortic valve and is commonly performed using either the reimplanta-
tion or the remodeling technique. The VSARR is an alternative
operation to the valve‐replacing aortic root replacement (VRARR)
where both the aortic root and aortic valve are replaced with a
composite valve‐graft (valved‐conduit). Several single center
series1–9 and multicenter registries10,11 have demonstrated low
operative mortality with VSARR even when including emergency
aortic dissections. Some experts have suggested that VSARR should
only be performed only at centers achieving ≤1% operative mortality
and ≥90% freedom from reoperation. 12
Comparative studies have demonstrated that long‐term results
of VSARR are similar to13–17 or better than12,18 VRARR. However,
increased complexity and operating time required for VSARR are
limiting factors to widespread adoption. A recent analysis of the STS
database showed that only 14% of patients with aortic root aneurysm
19
and aortic regurgitation underwent VSARR. Even in experienced
centers, the majority of patients eligible for VSARR do not undergo
VSARR.12
Recommendations for VSARR have recently appeared in Eur-
opean guidelines but not in American guidelines.20,21 While meta‐
analyses of comparative studies have shown a benefit of VSARR in
both Marfan and non‐Marfan patients,22,23 more long‐term data has
24
been called for by another systematic review. The objective of this
study is to compare outcomes of patients undergoing VSARR with
VRARR at our tertiary care center. The hypothesis is that VSARR
patients have superior long‐term survival and valve hemodynamics.
2 | P A T I E NT S A ND ME T HOD S
2.1 | Study population
This study is a single institution, multisurgeon review of 475
consecutive patients undergoing planned VSARR (by 8 surgeons) or
VRARR (by 10 surgeons) between July 1, 2007 and June 30, 2019.
Preoperative, intraoperative, and postoperative data were obtained
from the Cardiovascular Research Database (CARD; approved
by the Institutional Review Board at Northwestern University
STU00012288, including patient consent and conditions for waiver
of consent) and medical record review. Included patients had surgery
for aortic root aneurysm with or without aortic regurgitation and
were grouped by intention to treat. Patients with aortic stenosis,
endocarditis, prior aortic valve surgery, or trauma were excluded.
Sixty‐four patients refused to participate in the registry (18
[10%] VSARR and 46 [6%] VRARR patients) and are excluded.
Registration at clinicaltrial.gov is not applicable to this project.
Patients underwent routine intraoperative and predischarge
echocardiograms, and received surveys at 3, 6, and 12 months after
surgery and annually thereafter to report quality of life surveys,
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ET AL.
medical visits, and tests. Medical records were obtained to verify
operations, echocardiogram reports, or hospitalizations. Echocardio-
graphic assessments of mitral regurgitation were graded as: none or
trivial (0); mild (1+); moderate (2+); moderate to severe (3+); and
severe (4+).25 The Society of Thoracic Surgery definitions were used
to determine complications. Mortality data were aggregated contin-
uously consulting hierarchical sources that included: (1) CARD
registry; (2) reviews of medical records and correspondence with
the treating physician; (3) online death searches and genealogy
resources (ancestry.com).
2.2 | Surgical technique
The choice of procedure was based on surgeon discretion. The basis
for our technique of VSARR (87.4% by SCM) was the T. David 5
Stanford‐modification reimplantation technique26 with annulus sizing
modification using Hegar dilators in 2015,27 assessment of cusp
geometry using valve caliper in 2017,28 and measurement of internal
root (commissure) height in 2018.29 Our technique for VRARR (47%
by SCM) has been described previously.30 Patients who underwent
an attempted VSARR but were converted to VRARR intraoperatively
were included in the VSARR group for analysis.
2.3 | Study outcomes
Overall survival was the primary endpoint. Freedom from reoperation
for valvular dysfunction and hemodynamic outcomes were secondary
endpoints. Hemodynamic outcomes were determined from
echocardiography.
2.4 | Statistical analyses
Variables were summarized using mean ± standard deviation, median
(interquartile range (IQR)) or counts/percentages. VSARR versus
VRARR group comparisons were based on the two‐sample t‐test with
Satterthwaite's approximation, Wilcoxon's rank‐sum test, the χ2 or
Fisher's exact tests (cell counts < 5). To alleviate confounding when
comparing outcomes in the two groups, we used 1−1 propensity
score (PS)‐matching ( Figure S1). A Greedy algorithm was used to
create matched pairs using a caliper of size 0.1 logit‐PS standard
deviation units. Covariate balance was assessed using standardized
means differences (SMDs), absolute values <0.2 being considered
indicative of adequate balance. To estimate the probability of aortic
valve reoperation or freedom from > moderate AR, we used
cumulative incidence functions in the presence of death as a
semicompeting risk, with groups comparisons involving log‐rank type
tests. Overall survival estimates were based on Kaplan−Meier curves
with groups comparisons based on the log‐rank test.
Two‐sided p values < 0.05 were deemed statistically significant,
with no multiplicity adjustments. Statistical analyses were performed

MALAISRIE ET AL.
in R 4.0.0 (R Development Core Team (2020) or SAS 9.4 software
(SAS Institute Inc.).
3 | RESULTS
There were 151 patients who underwent VSARR (47.6% with cusp
repair) and 324 patients underwent VRARR with either a biologic
(89%) or mechanical (11%) valved‐conduit. The spare: replace ratio
increased from academic year 2007−2018 (Figure 1). The average
follow‐up was 4.5 ± 3.6 (median 3.7, IQR 1.1−7.5) years. Echo-
cardiography follow‐up was complete in 66.3% of patients with an
average follow‐up of 4.3 ± 3.2 (median 3.6, IQR 1.3−6.9) years.
Baseline and intraoperative characteristics of VSARR patients
compared to VRARR patients are listed in Table 1 for the total
cohort and for the PS‐matched groups. In the VSARR group, 28
(18.5%) had Marfan syndrome, while 39 (25.8%) had bicuspid aortic
valve, compared to 11 (3.4%) and 104 (32.1%), respectively in the
VRARR group. Severity of AR was greater in VRARR group.
Cardiopulmonary bypass and aortic cross clamp times were longer
in the VSARR group, three patients in the VSARR groups were
converted to an aortic valve replacement intraoperatively. Median
prosthesis size was 27 mm (25.00−29.00) in the VRARR group.
In the original unmatched groups, 30‐day mortality (0% VSARR
vs. 3.7% VRARR, p = 0.017) and major morbidities (stroke, renal
failure, prolonged ventilation, and reoperation for bleeding) were
significantly lower in VSARR group, but not deep sternal wound
infection (not shown in table). After PS‐matching, the difference in
30‐day mortality or postoperative morbidity was no longer statisti-
cally significant (Table 2).
Overall survival at 8 years was 100% in the original VSARR group
and after PS‐matching, it remained significantly higher in the VSARR
F I G U R E 1 Annual volume of aortic root
replacement (ARR) by valve‐sparing (VSARR) and
valve‐replacing (VRARR) groups among patients
with aortic aneurysm and nonstenotic valve. The
utilization of VSARR operation has increased from
less than 20% to almost 50% in patients
undergoing ARR over time. Yearly percent of
number of cases (%) by group is shown at the
bottom of the bar graphs
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| 1949
group (Figure 2, p = 0.025). One death in the VSARR group occurred
at 12 years and autopsy confirmed a noncardiac cause. Freedom from
valve reoperation at 8 years (Figure 3) was similar between groups
(90.9% VSARR vs. 96.7% VRARR; p = 0.97). Subanalysis of the VRARR
group found that patients receiving a bioprosthetic valve were older
(average age 60 ± 12 years) compared to patients who received
mechanical valve (average age 39 ± 8 years). There was no difference
in reoperation at 8 years for recipients of bioprosthetic versus
mechanical valves (97.4% vs. 100%, respectively, p = 0.5) in the
original groups. The 8‐year survival in patients with bioprosthetic
versus mechanical was not statistically different (80.0% vs.
91.1%, p = 0.82).
Hemodynamic evaluation by echocardiography showed lower
mean gradients at last follow‐up (Figure 4A) in the VSARR group (5.9
vs. 13.19 mmHg; p < 0.001). Freedom from moderate‐severe or
greater AR (Figure 4B) was similar (p = 0.08, 8‐year estimates
90.0% VSARR vs. 100% VRARR).
4 | CONCLUSIONS
VSARR is the preferred option for patients with aortic root
aneurysms and nonstenotic aortic valves. Overall survival may be
improved in patients with spared aortic valves compared to those
with replaced aortic valves during aortic root replacement. Freedom
from reoperation was similar between groups. Valve gradients were
superior in the VSARR group but AR progression was less common in
VRARR, suggesting different modes of failure between groups.
The benefits of VSARR in restoring the normal geometric
relationship of the aortic root to preserve physiologic blood flow
patterns have been previously demonstrated mathematically31 and
using finite element analysis.32 Our group has shown that physiologic
 T A B L E 1 Baseline and intraoperative characteristics of patients with aortic aneurysm and nonstenotic aortic valve by valve‐sparing aortic root replacement and valve‐replacing aortic root
1950

replacement in the original and propensity‐matched groups

|

Preoperative characteristics of original groups Preoperative characteristics of PS‐matched groups

Entire cohort Entire cohort
Variable N (N = 475) VRARR (N = 324) VSARR (N = 151) p Value (N = 138) VRARR (N = 69) VSARR (N = 69) p Value

Age 475 (324,151) 54.4 ± 14.93 58.5 ± 13.75 45.8 ± 13.71 <0.001 52.0 ± 13.07 52.2 ± 13.37 51.8 ± 12.84 0.846

Gender (female) 475 (324,151) 88 (18.5) 60 (18.5) 28 (18.5) 0.995 25 (18.1%) 11 (15.9%) 14 (20.3%) 0.507

Body surface area 475 (324,151) 2.1 ± 0.29 2.1 ± 0.31 2.2 ± 0.24 0.092 2.2 ± 0.28 2.2 ± 0.32 2.2 ± 0.23 0.914

NYHA class III IVa 383 (273,110) 47 (12.3) 44 (16.1) 3 (2.7) <0.001 7 (6.0%) 5 (7.9%) 2 (3.8%) 0.348

Marfan syndrome 475 (324,151) 39 (8.2) 11 (3.4) 28 (18.5) <0.001 14 (10.1%) 9 (13.0%) 5 (7.2%) 0.259

Bicuspid aortic valve 475 (324,151) 143 (30.1) 104 (32.1) 39 (25.8) 0.165 48 (34.8%) 24 (34.8%) 24 (34.8%) 1.000

Aortic dissection 475 (324,151) 67 (14.1) 64 (19.8) 3 (2.0) <0.001 4 (2.9%) 2 (2.9%) 2 (2.9%) 1.000

Repeat sternotomy 475 (324,151) 56 (11.8) 45 (13.9) 11 (7.3) 0.038 18 (13.0%) 9 (13.0%) 9 (13.0%) 1.000

Diabetes 473 (322,151) 46 (9.7) 33 (10.2) 13 (8.6) 0.575 12 (8.7%) 5 (7.2%) 7 (10.1%) 0.546

Dyslipidemia 472 (321,151) 204 (43.2) 152 (47.4) 52 (34.4) 0.008 63 (45.7%) 32 (46.4%) 31 (44.9%) 0.864

Hypertension 472 (322,150) 320 (67.8) 241 (74.8) 79 (52.7) <0.001 93 (67.4%) 44 (63.8%) 49 (71.0%) 0.364
a
Coronary artery disease 380 (261,119) 98 (25.8) 78 (29.9) 20 (16.8) 0.007 21 (18.4%) 8 (13.3%) 13 (24.1%) 0.140

Atrial fibrillation history 475 (324,151) 71 (14.9) 57 (17.6) 14 (9.3) 0.018 18 (13.0%) 9 (13.0%) 9 (13.0%) 1.000

Chronic lung disease 468 (317,151) 34 (7.3) 24 (7.6) 10 (6.6) 0.712 12 (8.7%) 5 (7.2%) 7 (10.1%) 0.546

Peripheral vascular disease 471 (320,151) 21 (4.5) 17 (5.3) 4 (2.6) 0.191 5 (3.6%) 3 (4.3%) 2 (2.9%) 0.649

Cerebrovascular disease 469 (319,150) 34 (7.2) 29 (9.1) 5 (3.3) 0.025 7 (5.1%) 5 (7.2%) 2 (2.9%) 0.245
a
Ejection fraction 450 (304,146) 58.00 (55.00, 61.00) 57.00 (51.00, 60.00) 60.00 (55.00, 65.00) <0.001 60.00 (55.00, 63.00) 58.00 (55.00, 60.00) 60.00 (57.00, 65.00) 0.003

Aortic insufficiency 475 (324,151) <0.001 0.992

0, None/trivial 96 (20.2) 33 (10.2) 63 (41.7) 34 (24.6%) 17 (24.6%) 17 (24.6%)

1, Mild 89 (18.7) 55 (17.0) 34 (22.5) 34 (24.6%) 17 (24.6%) 17 (24.6%)

2, Moderate 148 (31.2) 113 (34.9) 35 (23.2) 48 (34.8%) 24 (34.8%) 24 (34.8%)

3, Moderate/severe 30 (6.3) 21 (6.5) 9 (6.0) 5 (3.6%) 2 (2.9%) 3 (4.3%)

4, Severe 112 (23.6) 102 (31.5) 10 (6.6) 17 (12.3%) 9 (13.0%) 8 (11.6%)

Left ventricular end‐systolic 417 (269,148) 36.1 ± 9.31 37.2 ± 10.13 34.2 ± 7.25 0.002 34.4 ± 7.65 34.5 ± 7.95 34.3 ± 7.41 0.908
dimension
MALAISRIE
ET AL.

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 TABLE 1 (Continued)

Preoperative characteristics of original groups Preoperative characteristics of PS‐matched groups

MALAISRIE

Entire cohort Entire cohort

Variable N (N = 475) VRARR (N = 324) VSARR (N = 151) p Value (N = 138) VRARR (N = 69) VSARR (N = 69) p Value
ET AL.

Left ventricular end‐diastolic 417 (269,148) 52.8 ± 9.01 53.6 ± 9.57 51.3 ± 7.70 0.015 51.9 ± 8.07 52.2 ± 8.50 51.5 ± 7.66 0.628
dimension

Perfusion time (minutes) 475 (324,151) 194.00 (149.00, 170.00 (128.50, 206.00 (193.00, <0.001 197.50 (148.00, 148.00 (109.00, 212.00 (198.00, <0.001
230.00 222.00) 236.00) 224.00 197.00) 249.00)

Cross clamp time (minutes) 475 (324,151) 165.00 (125.00, 143.50 (110.00, 183.00 (173.00, <0.001 170.50 (129.00, 130.00 (100.00, 192.00 (174.00, <0.001
192.000 180.50) 208.00) 194.00 153.00) 220.00)

Arch procedure 191 (150,41) 0.006 0.081

Hemi 159 (83.2) 119 (79.3) 40 (97.6) 41 (89.1%) 16 (80.0%) 25 (96.2%)

Total 32 (16.8) 31 (20.7) 1 (2.4) 5 (10.9%) 4 (20.0%) 1 (3.8%)

Coronary artery bypass graft 475 (324,151) 67 (14.1) 59 (18.2) 8 (5.3) <0.001 10 (7.2%) 3 (4.3%) 7 (10.1%) 0.189

Mitral valve surgery 475 (324,151) 30 (6.3) 20 (6.2) 10 (6.6) 0.851 12 (8.7%) 7 (10.1%) 5 (7.2%) 0.546

Tricuspid valve surgery 475 (324,151) 9 (1.9) 9 (2.8) 0 (0.0) 0.039 1 (0.7%) 1 (1.4%) 0 (0.0%) 0.316

Atrial fibrillation ablation 475 (324,151) 48 (10.1) 36 (11.1) 12 (7.9) 0.287 16 (11.6%) 9 (13.0%) 7 (10.1%) 0.595

Congenital defect repair 475 (324,151) 6 (1.3) 3 (0.9) 3 (2.0) 0.335 6 (3.1% 3 (3.1) 3 (3.1) 1.000

Aortic valve surgery type 475 (324,151) <0.001

VSARR—reimplantation 146 (30.7) 0 (0.0) 146 (96.7) 65 (47.1%) 0 (0.0%) 65 (94.2%)

(David)

VSARR—remodeling 2 (0.4) 0 (0.0) 2 (1.3) 3 (2.2%) 0 (0.0%) 3 (4.3%)

(Yacoub)

Aortic valve implant type 327 (3243) 0.547 0.452

Bioprosthestic 292 (89.3) 289 (89.2) 3 (100) 61 (84.7%) 58 (84.1%) 3 (100%)

Mechanical 35 (10.7) 35 (10.8) 0 (0.0) 11 (15.3%) 11 (15.9%) 0 (0.0%)

Aortic valve implant size 327 (3243) 0.790 0.019

19 1 (0.3) 1 (0.3) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0)

21 2 (0.6) 2 (0.6) 0 (0.0) 1 (1.4%) 1 (1.4%) 0 (0.0%)

23 29 (8.9) 28 (8.6) 1 (33.3) 2 (2.8%) 1 (1.4%) 1 (33.3%)

25 69 (21.1) 68 (21.0) 1 (33.3) 16 (22.2%) 15 (21.7%) 1 (33.3%)

27 139 (42.5) 138 (42.6) 1 (33.3) 31 (43.1%) 30 (43.5%) 1 (33.3%)

29 85 (26.0) 85 (26.2) 0 (0.0) 22 (30.6%) 22 (31.9%) 0 (0.0%)

|

(Continues)
1951

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1952 | MALAISRIE ET AL.

blood flow patterns are restored after VSARR using time‐resolved

p Value

0.332
magnetic resonance imaging (4D‐MRI), regardless of valve morphol-
ogy such as bicuspid aortic valve.33 We have also demonstrated that
aortic root blood flow patterns are more physiologic after VSARR
than after VRARR.34 However, patient selection is important and
VSARR (N = 69)

VSARR is not an option for everyone. Our results show that in the

65 (94.2%)
total cohort, patients in the VRARR group were older and sicker with

4 (5.80)
0 (0.0)

more comorbidities such as coronary artery disease and cerebro-

Preoperative characteristics of PS‐matched groups

vascular disease. A longer pump time for no long‐term benefit is not

warranted in many of these patients. Furthermore, there was greater
VRARR (N = 69)

severity of AR in the VRARR group making those valves unsuitable for

66 (95.7%)

repair. Echocardiography‐graded valve hemodynamics have previ-

3 (4.3%)
0 (0.0)

ously shown progression of AR (>mild AR) after VSARR in as many as

7% of patients at 1 year.16 Our study is consistent with other high
volume series, showing 90% freedom from > moderate AR at 10
years.7–9 The stability of the aortic valve repair appears to be
improving in many larger series with greater appreciation of annulus
Abbreviations: NYHA, New York Heart Association; VRARR, valve‐aortic replacing replacement; VSAR, valve‐sparing aortic root replacement.
Entire cohort

131 (94.9%)

repair (via either internal or external annular stabilization) and

(N = 138)

0 (0.0)

7 (5.0)

correction of leaflet prolapse. On the other hand, valve gradients

are less than 10 mmHg after VSARR and are similar to a previous
report documenting long‐term gradients in the single digits after
VSARR.7 Our study contrasts these physiologic gradients after
p Value

<0.001

VSARR with gradients obtained after VRARR. Valve gradients are

consistently lower in VSARR despite large valve prosthesis required
for aneurysm repair in the VRARR group and aortic annular reduction
VSARR (N = 151)

achieved during VSARR. The majority of our VRARR patients

received bioprosthetic valves (89.3% of total cohort). The clinical
147(97.4)
0 (0.0)

benefits of VSARR may stem from the avoidance of a prosthetic valve

4(2.6)

and attendant valve‐related complications. A meta‐analysis of VSARR

series has shown very low linearized occurrence rates of thrombo-
embolism.35 The occurrence of these valve‐related complications
VRARR (N = 324)

contributes to the survival decrement seen 10 years after aortic valve

243 (75.0)

81 (24.9)

replacement (70%−80% survival at 10 years for patients 50−69

2 (0.6)

years).36 However, VSARR series with 20‐years of follow‐up have

Preoperative characteristics of original groups

Note: Values are mean ± SD; n (%); or median (first quartile, third quartile).

reported overall survival rates of 80%−93% at 10 years.6,9,12 Despite

shorter follow‐up than cited reports, our series demonstrates 10‐year
survival after VSARR of 100%, albeit in a younger group of patients
Entire cohort

(45.8 ± 13.71 years, unadjusted VSARR group). Our series is only one
390 (82.1)

85 (17.9)
(N = 475)

of three studies demonstrating a survival benefit for VSARR when

2 (0.6)

compared to VRARR after propensity score‐matching, but is unique

in that the majority of VRARR patients received a biologic valved‐
conduit (89%, unadjusted VRARR group).12,18 Freedom from reopera-
475 (324,151)

tion between the bioprosthetic and mechanical valve patients was

not different in the original and matched populations.
Data not available on entire cohort.

Limitations of this study include the lack of data on valve‐related

N

complications such as thromboembolism, bleeding, and endocarditis.

(Continued)

Our late echo follow‐up in 66% of patients is also a limitation to this

study. Many patients were studied with echocardiography when
symptomatic in accordance with clinical practice guidelines that
Nonelective

recommend repeat echocardiogram when a change in clinical

Surgery type
TABLE 1

Elective

symptoms or signs suggesting valve dysfunction are present and

Variable

31

repeat echocardiogram at 5 and 10 years in the absence of a change

in clinical status.20,37 However, this practice biases echocardiographic
a
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MALAISRIE ET AL. | 1953

TABLE 2 Postoperative outcomes by valve‐sparing and valve‐replacing aortic root replacement in propensity‐score matched groups
Variable Entire cohort (N = 138) VRARR (N = 69) VSARR (N = 69) p Value

30‐day mortality 1 (0.7%) 1 (1.4%) 0 (0.0%) 0.316

Major morbidity

Postoperative stroke > 24 h 2 (1.4%) 1 (1.4%) 1 (1.4%) 1.000

Renal failure 1 (0.7%) 1 (1.4%) 0 (0.0%) 0.316

Prolonged ventilation > 24 h 11 (8.0%) 5 (7.2%) 6 (8.7%) 0.753

Reoperation for bleeding 4 (2.9%) 3 (4.3%) 1 (1.4%) 0.310

Deep sternal wound infection 0 (0.0%) 0 (0.0%) 0 (0.0%)

Postoperative atrial fibrillation 27 (19.6%) 12 (17.4%) 15 (21.7%) 0.520

New permanent pacemaker implant 1 (0.7%) 0 (0.0%) 1 (1.4%) 0.316

Postoperative length of stay 5.00 (5.00, 7.00) 5.00 (4.00, 7.00) 5.00 (5.00, 7.00)

Note: Values are mean ± SD; n (%); or median (first quartile, third quartile).
Abbreviations: VRARR, valve‐replacing aortic root replacement; VSARR, valve‐sparing aortic root replacement.

F I G U R E 2 Estimated overall survival after

aortic root replacement by either valve‐sparing
(VSARR) or valve‐replacing (VRARR) in propensity
score‐matched groups. Overall survival after
VSARR is statistically significant higher when
compared to VRARR (p = 0.025)

findings to patients with high pre‐test probability of valve‐
dysfunction. The heterogeneity of patients in the VRARR group
receiving either a mechanical or bioprosthetic valve is another
limitation. Although we did not study these subgroups, we found that
patients receiving a bioprosthetic valve was older (average age
60 ± 12 years) compared to patients who received a mechanical valve
(average age 39 ± 8 years) consistent with clinical practice guidelines.
Previous studies have shown a survival advantage in younger patients
receiving a mechanical valve but no survival advantage for either
mechanical or bioprosthetic valve in older patients.38 Therefore,
outcome difference between mechanical versus bioprosthetic valves
in the VRARR group may be limited.
In conclusion, VSARR is a safe operation in patients with
aortic root aneurysm and nonstenotic aortic valve
experienced centers. Overall survival may be higher in patients
after VSARR compared to those after VRARR, although freedom
from reoperation is similar. Valve gradients were lower in the
VSARR group but progression of late AR was lower in the VRARR
group, suggesting different modes of failure in the two groups.
Although longer term follow‐up is warranted, the survival benefit
associated with VSARR adds to the accumulating evidence
demonstrating the benefit of a valve‐sparing over valve‐
replacing approach.
A UT H O R C O N T R I B U TI O NS
Concept/design: S. Chris Malaisrie, Jane Kruse, and Adin‐Cristian
Andrei. Data analysis/interpretation: S. Chris Malaisrie, Olga
in N. Kislitsina, Lisa Wilsbacher, Marla Mendelson, Jyothy J.
 15408191, 2022, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocs.16473 by <Shibboleth>-student@ucl.ac.uk, Wiley Online Library on [26/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1954 | MALAISRIE ET AL.

F I G U R E 3 Freedom from reoperation for

aortic valve dysfunction after aortic root
replacement is shown in propensity score‐
matched VSARR and VRARR groups. Reoperation
in the VSARR group was more likely for recurrent
aortic regurgitation and reoperation for the
VRARR groups was more likely for structural
valve degeneration. VRARR, valve‐replacing
aortic root replacement; VSARR, valve‐sparing
aortic root replacement

F I G U R E 4 Echocardiographic hemodynamics after aortic root replacement in propensity score‐matched groups show lower mean pressure
gradients in the VSARR group (A) and a trend toward higher freedom from > moderate AR in the VRARR group (B). AR, aortic regurgitation; AV,
aortic valve; VRARR, valve‐replacing aortic root replacement; VSARR, valve‐sparing aortic root replacement

Puthumana, Patricia Vassallo, Jane Kruse, Adin‐Cristian Andrei, CONFLIC TS OF I NTERES T

and Patrick M. McCarthyarla. Drafting article: S. Chris S. Chris. Malaisrie: Edwards: speaker and consultant; Abbott: speaker;
Malaisrie. Critical revision of article: S. Chris Malaisrie, Olga N. Cryolife: consultant, Terumo: speaker. P. M. McCarthy: Edwards
Kislitsina, Lisa Wilsbacher, Marla Mendelson, Jyothy J. Puthuma- Lifesciences: royalties and speaking fees; Atricure: speaking fees;
na, Patricia Vassallo, Jane Kruse, Adin‐Cristian Andrei, and Patrick Medtronic; speaking fees; Abbott: Co‐PI REPAIR‐MR Trial (unpaid). J.
M. McCarthyarla. Approval of article: S. Chris Malaisrie, Olga N. J. Puthumana: Abbott: Honoraria. The remaining authors declare no
Kislitsina, Lisa Wilsbacher, Marla Mendelson, Jyothy J. Puthuma- conflicts of interest.
na, Patricia Vassallo, Jane Kruse, Adin‐Cristian Andrei, and Patrick
M. McCarthyarla. Statistics: Adin‐Cristian Andrei. Data collection: ORC I D
S. Chris Malaisrie, Olga N. Kislitsina, Lisa Wilsbacher, Marla S. Chris Malaisrie http://orcid.org/0000-0002-0704-0334
Mendelson, Jyothy J. Puthumana, Patricia Vassallo, Jane Kruse, Olga N. Kislitsina http://orcid.org/0000-0003-2673-5219
Adin‐Cristian Andrei, and Patrick M. McCarthyarla. Lisa Wilsbacher http://orcid.org/0000-0002-3676-0680

MALAISRIE ET AL.
REFERENCES
1. Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley‐
Smith R. Late results of a valve‐preserving operation in patients with
aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg.
1998;115(5):1080‐1090.
2. David TE, Feindel CM, David CM, Manlhiot C. A quarter of a century of
experience with aortic valve‐sparing operations. J Thorac Cardiovasc Surg.
2014;148(3):872‐879. Discussion 879−880.
3. De Paulis R, Chirichilli I, Scaffa R, et al. Long‐term results of the valve
reimplantation technique using a graft with sinuses. J Thorac
Cardiovasc Surg. 2016;151(1):112‐119.
4. Schneider U, Feldner SK, Hofmann C, et al. Two decades of
experience with root remodeling and valve repair for bicuspid aortic
valves. J Thorac Cardiovasc Surg. 2017;153(4):S65‐S71.
5. Esaki J, Leshnower BG, Binongo JN, et al. Risk factors for late aortic
valve dysfunction after the David V valve sparing root replacement.
Ann Thorac Surg. 2017;104(5):1479‐1487.
6. Klotz S, Stock S, Sievers HH, et al. Survival and reoperation pattern
after 20 years of experience with aortic valve‐sparing root
replacement in patients with tricuspid and bicuspid valves.
J Thorac Cardiovasc Surg. 2018;155(4):1403‐1411.e1.
7. Martens A, Beckmann E, Kaufeld T, et al. Valve‐sparing aortic root
replacement (David I procedure) in Marfan disease: single‐centre 20‐
year experience in more than 100 patients. Eur J Cardiothorac Surg.
2019;55(3):476‐483.
8. Shrestha ML, Beckmann E, Abd Alhadi F, et al. Elective David I
procedure has excellent long‐term results: 20‐year single‐center
experience. Ann Thorac Surg. 2018;105(3):731‐738.
9. Mastrobuoni S, de Kerchove L, Navarra E, et al. Long‐term
experience with valve‐sparing reimplantation technique for the
treatment of aortic aneurysm and aortic regurgitation. J Thorac
Cardiovasc Surg. 2019;158(1):14‐23.
10. De Paulis R, Scaffa R, Nardella S, et al. Use of the valsalva graft and
long‐term follow‐up. J Thorac Cardiovasc Surg. 2010;140(6) (suppl):
S23‐S27. Discussion S45‐S51.
11. Lansac E, Di Centa I, Sleilaty G, et al. Remodeling root repair with an
external aortic ring annuloplasty. J Thorac Cardiovasc Surg. 2017;
153(5):1033‐1042.
12. Ouzounian M, Rao V, Manlhiot C, et al. Valve‐sparing root
replacement compared with composite valve graft procedures in
patients with aortic root dilation. J Am Coll Cardiol. 2016;68(17):
1838‐1847.
13. Gaudino M, Di Franco A, Ohmes LB, et al. Biological solutions to
aortic root replacement: valve‐sparing versus bioprosthetic con-
duitdouble dagger. Interact Cardiovasc Thorac Surg. 2017;24(6):
855‐861.
14. Esaki J, Leshnower BG, Binongo JN, et al. Clinical outcomes of the
David V valve‐sparing root replacement compared with biopros-
thetic valve‐conduits for aortic root aneurysms. Ann Thorac Surg.
2017;103(6):1824‐1832.
15. Lee H, Cho YH, Sung K, et al. Clinical outcomes of root
reimplantation and Bentall procedure: propensity score matching
analysis. Ann Thorac Surg. 2018;106(2):539‐547.
16. Coselli JS, Volguina IV, LeMaire SA, et al. Early and 1‐year outcomes
of aortic root surgery in patients with Marfan syndrome: a
prospective, multicenter, comparative study. J Thorac Cardiovasc
Surg. 2014;147(6):1758‐1766, 1767 e1‐4.
17. Vallabhajosyula P, Szeto WY, Habertheuer A, et al. Bicuspid
aortic insufficiency with aortic root aneurysm: root reimplanta-
tion versus bentall root replacement. Ann Thorac Surg. 2016;
102(4):1221‐1228.
18. Esaki J, Leshnower BG, Binongo JN, et al. The David V valve‐
sparing root replacement provides improved survival compared
with mechanical valve‐conduits in the treatment of young
15408191, 2022, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocs.16473 by <Shibboleth>-student@ucl.ac.uk, Wiley Online Library on [26/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
| 1955
patients with aortic root pathology. Ann Thorac Surg. 2016;
102(5):1522‐1530.
19. Stamou SC, Williams ML, Gunn TM, Hagberg RC, Lobdell KW,
Kouchoukos NT. Aortic root surgery in the United States: a report
from the Society of Thoracic Surgeons database. J Thorac Cardiovasc
Surg. 2015;149(1):116‐22e.4.
20. Baumgartner H, Falk V, Bax JJ, et al. 2017 ESC/EACTS guidelines for
the management of valvular heart disease. Eur Heart J. 2017;38(36):
2739‐2791.
21. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC
focused update of the 2014 AHA/ACC guideline for the
management of patients with valvular heart disease: a report
of the American College of Cardiology/American Heart Associa-
tion Task Force on Clinical Practice Guidelines. Circulation. 2017;
135(25):e1159‐e1195.
22. Burgstaller JM, Held U, Mosbahi S, et al. A systemic review and
meta‐analysis: long‐term results of the Bentall versus the David
procedure in patients with Marfan syndrome. Eur J Cardiothorac
Surg. 2018;54(3):411‐419.
23. Elbatarny M, Tam DY, Edelman JJ, et al. Valve‐sparing root
replacement vs composite valve grafting in aortic root dilation: a
meta‐analysis. Ann Thorac Surg. 2020;110(1):296‐306.
24. Harky A, Fok M, Froghi S, Bilal H, Bashir M. Valve‐sparing aortic
root repair compared to composite aortic root replacement: a
systematic review and meta‐analysis. J Heart Valve Dis. 2017;
26(6):632‐638.
25. Zoghbi WA, Adams D, Bonow RO, et al. Recommendations for
noninvasive evaluation of native valvular regurgitation: a report from
the American Society of Echocardiography developed in collabora-
tion with the Society for Cardiovascular Magnetic Resonance. J Am
Soc Echocardiogr. 2017;30(4):303‐371.
26. Demers P, Miller DC. Simple modification of "T. David‐V" valve‐
sparing aortic root replacement to create graft pseudosinuses. Ann
Thorac Surg. 2004;78(4):1479‐1481.
27. Svensson LG. Sizing for modified David's reimplantation procedure.
Ann Thorac Surg. 2003;76(5):1751‐1753.
28. Schafers HJ, Bierbach B, Aicher D. A new approach to the
assessment of aortic cusp geometry. J Thorac Cardiovasc Surg.
2006;132(2):436‐438.
29. de Kerchove L, Jashari R, Boodhwani M, et al. Surgical anatomy of
the aortic root: implication for valve‐sparing reimplantation and
aortic valve annuloplasty. J Thorac Cardiovasc Surg. 2015;149(2):
425‐433.
30. Malaisrie SC, Duncan BF, Mehta CK, et al. The addition of hemiarch
replacement to aortic root surgery does not affect safety. J Thorac
Cardiovasc Surg. 2015;150(1):118‐124.e2.
31. Kunzelman KS, Grande KJ, David TE, Cochran RP, Verrier ED. Aortic
root and valve relationships. Impact on surgical repair. J Thorac
Cardiovasc Surg. 1994;107(1):162‐170.
32. Grande‐Allen KJ, Cochran RP, Reinhall PG, Kunzelman KS. Re‐
creation of sinuses is important for sparing the aortic valve: a
finite element study. J Thorac Cardiovasc Surg. 2000;119(4, pt 1):
753‐763.
33. Collins JD, Semaan E, Barker A, et al. Comparison of hemodynamics
after aortic root replacement using valve‐sparing or bioprosthetic
valved conduit. Ann Thorac Surg. 2015;100(5):1556‐1562.
34. Semaan E, Markl M, Malaisrie SC, et al. Haemodynamic outcome at
four‐dimensional flow magnetic resonance imaging following valve‐
sparing aortic root replacement with tricuspid and bicuspid valve
morphology. Eur J Cardiothorac Surg. 2014;45(5):818‐825.
35. Arabkhani B, Mookhoek A, Di Centa I, et al. Reported outcome after
valve‐sparing aortic root replacement for aortic root aneurysm: a
systematic review and meta‐analysis. Ann Thorac Surg. 2015;100(3):
1126‐1131.
 15408191, 2022, 7, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jocs.16473 by <Shibboleth>-student@ucl.ac.uk, Wiley Online Library on [26/03/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1956 | MALAISRIE ET AL.

36. Chiang YP, Chikwe J, Moskowitz AJ, Itagaki S, Adams DH, SUPP ORTING INFO RM ATION
Egorova NN. Survival and long‐term outcomes following biopros- Additional supporting information can be found online in the
thetic vs mechanical aortic valve replacement in patients aged 50 to
Supporting Information section at the end of this article.
69 years. JAMA. 2014;312(13):1323‐1329.
37. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline
for the management of patients with valvular heart disease: a report
of the American College of Cardiology/American Heart Association
How to cite this article: Malaisrie SC, Kislitsina ON,
Joint Committee on Clinical Practice Guidelines. Circulation. 2021;
143(5):e72‐e227. Wilsbacher L, et al. Valve‐sparing versus valve‐replacing
38. Goldstone AB, Chiu P, Baiocchi M, et al. Mechanical or biologic aortic root replacement in patients with aortic root aneurysm.
prostheses for aortic‐valve and mitral‐valve replacement. N Engl J J Card Surg. 2022;37:1947‐1956. doi:10.1111/jocs.16473
Med. 2017;377(19):1847‐1857.