Comparative analysis of stentless aortic root and composite valve grafts for aortic root replacement: a retrospective single-centre study

Aim: The efficacy of composite valve graft (CVG) versus stentless aortic root replacement (SARR) in patients with aortic valve and root pathologies remains a subject of debate. This study aims to analyze the in-hospital outcomes and long-term survival of these two surgical approaches. Methods: A retrospective analysis was conducted on 594 patients who underwent ARR between July 2003 and December 2023. Of these, 346 received a stentless aortic root and 248 CVG (100 biological and 148 mechanical). Propensity score matching (PSM) was utilized to create well-balanced cohorts based on preoperative demographics and intraoperative characteristics. Univariable and multivariable regression analyses were performed to evaluate in-hospital mortality and long-term survival rates. Kaplan-Meier curves were constructed to visualize survival outcomes. Results: After PSM, 212 patients in each group were well-balanced in terms of baseline characteristics. The analysis of in-hospital outcomes revealed no significant differences between the SARR and CVG groups for key outcomes except neurological complications that were consistently higher in the CVG group, with a significant difference observed in both unmatched (8.4% vs. 4.9%, P = 0.014) and matched cohorts (8.5% vs. 4.3%, P = 0.022). Long-term survival analysis in the matched cohorts demonstrated a statistically significant survival advantage for the SARR group, with a 20-year survival rate of 54% compared to 47% for the CVG group (log-rank P value of 0.047). Further analysis by specific graft type within the matched groups suggested that xenografts might offer a significant survival advantage (log-rank P value of 0.009). Conclusions: While SARR and CVG provided similar in-hospital outcomes, SARR, particularly xenografts, demonstrated a significant long-term survival advantage. Xenografts may be a preferable option for patients, especially those with longer life expectancies, due to their durability and reduced need for anticoagulation.