David valve-sparing aortic root replacement: equivalent mid-term outcome for different valve types with or without connective tissue disorder

Abstract

Objective: Although implicitly accepted by many that the durability of valve-sparing aortic root replacement in patients with bicuspid aortic valve disease and connective tissue disorders will be inferior, this hypothesis has not been rigorously investigated.

Methods: From 1993 to 2009, 233 patients (27% bicuspid aortic valve, 40% Marfan syndrome) underwent Tirone David valve-sparing aortic root replacement. Follow-up averaged 4.7 ± 3.3 years (1102 patient-years). Freedom from adverse outcomes was determined using log-rank calculations.

Results: Survival at 5 and 10 years was 98.7% ± 0.7% and 93.5% ± 5.1%, respectively. Freedom from reoperation (all causes) on the aortic root was 92.2% ± 3.6% at 10 years; 3 reoperations were aortic valve replacement owing to structural valve deterioration. Freedom from structural valve deterioration at 10 years was 96.1% ± 2.1%. No significant differences were found in survival (P = .805, P = .793, respectively), reoperation (P = .179, P = .973, respectively), structural valve deterioration (P = .639, P = .982, respectively), or any other functional or clinical endpoints when patients were stratified by valve type (tricuspid aortic valve vs bicuspid aortic valve) or associated connective tissue disorder. At the latest echocardiographic follow-up (95% complete), 202 patients (94.8%) had none or trace aortic regurgitation, 10 (4.7%) mild, 0 had moderate to severe, and 1 (0.5%) had severe aortic regurgitation. Freedom from greater than 2+ aortic regurgitation at 10 years was 95.3% ± 2.5%. Six patients sustained acute type B aortic dissection (freedom at 10 years, 90.4% ± 5.0%).

Conclusions: Tirone David reimplantation valve-sparing aortic root replacement in carefully selected young patients was associated with excellent clinical and echocardiographic outcome in patients with either a tricuspid aortic valve or bicuspid aortic valve. No demonstrable adverse influence was found for Marfan syndrome or connective tissue disorder on durability, clinical outcome, or echocardiographic results.

Figure 1:

[A] Distribution of patients undergoing valve-sparing aortic root replacement according to type of aortic valve. [B] Age distribution of tricuspid and bicuspid aortic valve patients. [C] Distribution of patients (number, %) with a bicuspid aortic valve according to Sievers’ classification. [D] Distribution of arch replacement during the study period according to valve type. TAV= tricuspid aortic valve; BAV= bicuspid aortic valve.

Figure 2:

[A] Kaplan-Meier survival curve for the 233 patients undergoing valve-sparing aortic root replacement. [B] Kaplan-Meier survival curve of the 233 patients undergoing valve-sparing aortic root replacement compared to the general U.S. population matched for age, gender and race. [C] Kaplan-Meier survival curves comparing the tricuspid and bicuspid aortic valve subsets. [D] Kaplan-Meier survival curves comparing patients with a confirmed diagnosis of MFS or other connective tissue disorders (CTD) versus the remainder of the patients. Vertical bars represent ± 1 SE.

Figure 3:

[A] Freedom from reoperation on the aortic root after valve-sparing aortic root replacement. [B] Freedom from reoperation on the aortic root comparing the tricuspid and bicuspid aortic valve (TAV and BAV) subsets. [C] Freedom from reoperation on the aortic root after valve-sparing aortic root replacement comparing patients with confirmed MFS or another connective tissue disorder (CTD) and the rest of the patient cohort. Vertical bars represent ± 1 SE.

Figure E1:

[A] Freedom from structural valve deterioration (SVD) after valve-sparing aortic root replacement (V-SARR). [B] Freedom from SVD comparing the tricuspid and bicuspid aortic valve (TAV and BAV) subsets. [C] Freedom from SVD comparing patients with a confirmed diagnosis of MFS or other connective tissue disorder (CTD) and the remainder of the patients. Vertical bars represent ± 1 SE.

Figure E2:

[A] Freedom from Stanford type B aortic dissection for all patients. [B] Freedom from Stanford type B aortic dissection comparing patients with a confirmed diagnosis of MFS or other connective tissue disorder (CTD) with the remainder of the patients. [C] Freedom from more than 2+ aortic regurgitation (AR). Vertical bars represent ± 1 SE

Figure E3:

[A] Freedom from structural valve deterioration comparing patients with 4+ aortic regurgitation preoperatively versus the remainder of the patients. [B] Freedom from reoperation on the aortic root comparing patients with 4+ aortic regurgitation preoperatively versus the remainder of the patients.