Mechanical versus bioprosthetic conduits for the bentall procedure: a 10-year propensity score-matched analysis of early and long-term outcomes

OBJECTIVES The optimal conduit choice for the Bentall procedure—mechanical (MC) or biological (BC)—is confounded by significant baseline selection bias. We aimed to evaluate the impact of conduit choice on early and long-term outcomes after mitigating this bias in a contemporary surgical cohort. METHODS We retrospectively reviewed 442 consecutive patients undergoing elective Bentall procedures between 2015 and 2025 (365 MC vs 77 BC). Propensity score matching (1:1 nearest-neighbor, caliper 0.1) was performed based on 10 baseline covariates (including age, EuroSCORE II, and comorbidities) to generate a balanced cohort of 154 patients (77 per group). Operative outcomes, 30-day morbidity/mortality, long-term overall survival, and reoperation-free survival were compared using paired statistical tests and Kaplan–Meier (Log-rank) analysis. RESULTS PSM successfully balanced baseline covariates, eliminating significant differences in age (mean 64.1 [MC] vs 65.7 [BC] years, p = 0.403) and EuroSCORE II (p = 0.698). The median follow-up was 36.0 months (IQR: 18.0–78.0). In the propensity-matched cohort, no significant differences were found in long-term overall survival (p = 0.574) or reoperation-free survival (p = 0.944) between the mechanical and biological groups. Early mortality was also comparable (p = 0.344). However, the biological group demonstrated a significantly higher rate of early re-exploration for bleeding (24.7% vs 6.5%, p = 0.003), associated with a 3.8-fold increased risk (OR: 4.72, 95% CI: 1.66–13.40). CONCLUSIONS In this 10-year propensity-matched analysis, both mechanical and bioprosthetic conduits demonstrated comparable long-term durability and survival outcomes. Although biological conduits were associated with a higher risk of early re-exploration for bleeding, this did not adversely affect early mortality or long-term reoperation-free survival. These findings suggest that bioprosthetic conduits offer robust mid-term effectiveness, provided that meticulous intraoperative hemostasis is ensured to mitigate early bleeding risks.