Aortic valve-sparing root replacement and composite root replacement: A Danish multicenter nationwide study

Background Aortic valve-sparing root replacement is recommended over composite root replacement for aortic root aneurysms, especially in younger patients, but long-term outcomes in low-volume nationwide settings remain unclear. Objectives To compare long-term survival, stroke, and reoperation rates between the two procedures in a low-volume national setting. Methods Patients were identified from the Western Danish Heart Registry and the Danish Heart Registry. Cases were validated by review of operative descriptions. Primary outcome was long-term survival from all-cause mortality; secondary outcomes included stroke, reoperation, recurrent aortic regurgitation and aortic stenosis. Groups were balanced using propensity score matching. Echocardiographic data were provided for the matched cohort. Results We identified 760 patients treated with composite root replacement and 179 patients with aortic valve-sparing root replacement between January 2010 and April 2022. Mean follow-up was 6.5 years. Composite root replacement patients were younger (50.7 years (SD 14.1) vs. 55.2 (SD 13.5), p<0.001), but more comorbid with a median EuroSCOREII of 5.5 (IQR: 3.3-11.7) vs. 3.4 (IQR: 2.6-5.0) (p<0.001). After matching 157 patients per group, aortic valve-sparing root replacement showed improved 10-year survival (91.2%, 95%CI 82.3-95.8 vs. 80.4%, 95%CI 70.0-87.5, log-rank p=0.026), with lower 10-year stroke risk (4.9%, 95%CI 1.8-13.0 vs. 18.9%, 95%CI 11.7-29.9, log-rank p=0.007). Risk of reoperation was non-significant (log-rank p=0.12), which was consistent in the crude population when accounting for competing risk of death (log-rank p=0.09). Conclusion In this nationwide study, aortic valve-sparing root replacement was associated better long-term survival and lower stroke risk, supporting its role as a durable surgical option for selected patients.