Optimal strategy for aortic root replacement in patients of advanced age: Valve-sparing root replacement or Bio-Bentall?

OBJECTIVE Valve-sparing root replacement (VSRR) is being performed into the 8th decade of life. This study evaluated clinical outcomes in patients aged ≥65 years undergoing VSRR or Bio-Bentall. METHODS From 2004-2021, 801 patients ≥65 years of age underwent root replacement at two academic medical centers. Non-elective cases, patients with ≥moderate AS, prior aortic valve replacement, and mechanical Bentalls were excluded. 330 patients underwent either VSRR (n=94, 28%) or Bio-Bentall (n=236, 72%). RESULTS The median age of the cohort was 71 (67, 75) years. The VSRR group had less cerebrovascular disease (3.2% vs 11%, p=0.02), bicuspid aortic valves (5.3% vs 16%, p=0.01), moderate-severe AI (60% vs 76%, p=0.002), and prior cardiac surgery (2.1% vs 8.9%, p=0.03). VSRR patients underwent more partial/total arch replacement (17% vs 5.5%, p=0.0009) but had similar cardiopulmonary bypass and cross-clamp times. VSRR patients had less prolonged ventilation (7.5% vs 18%, p=0.01) and shorter lengths of stay (7 vs 9 days, p=0.001). Overall, in-hospital mortality was 3% and was similar between VSRR (2.1%) and Bio-Bentall (3.0%) groups (p=0.73). Eight patients (2.4%) required reoperation on the aortic valve or proximal aorta during follow-up and was similar between groups. VSRR patients had better long-term survival than Bio-Bentall patients (12-year:70% vs 59%, p=0.03). CONCLUSION In patients ≥65 years of age, elective root replacement with either a VSRR or a Bio-Bentall can be performed with excellent short- and long-term outcomes. In the absence of significant valvular structural degeneration, VSRR is an appropriate strategy for this age group in patients with few comorbidities.