Key result
Valve-sparing root replacement shows no significant difference in neurological events vs mechanical replacement in Marfan syndrome.
Why the study?
Does valve-sparing root replacement reduce thromboembolic and bleeding events without excessively increasing reintervention risk compared to mechanical aortic root replacement in Marfan syndrome patients?
Cohort (n=59)
No
Does valve-sparing root replacement reduce thromboembolic and bleeding events without excessively increasing reintervention risk compared to mechanical aortic root replacement in Marfan syndrome patients?
Absolute Event Rate: 0% vs 1.46%
p-value: p=0.11
Valve-sparing root replacement using the reimplantation technique in Marfan syndrome patients offers a lower risk of thromboembolic or bleeding events compared to mechanical root replacement, with a low perioperative risk of reintervention.
May support valve-sparing preference in Marfan syndrome to limit neurological events; leaves open reintervention trade-offs pending randomized data.
OBJECTIVES: Valve-sparing root replacement (VSRR) is thought to reduce the rate of thromboembolic and bleeding events compared with aortic root replacement using a mechanical aortic root replacement (MRR) with a composite graft by avoiding oral anticoagulation. But as VSRR carries a certain risk for subsequent reinterventions, decision-making in the individual patient can be challenging. METHODS: Of 100 Marfan syndrome (MFS) patients who underwent 169 aortic surgeries and were followed at our institution since 1995, 59 consecutive patients without a history of dissection or prior aortic surgery underwent elective VSRR or MRR and were retrospectively analysed. RESULTS: VSRR was performed in 29 (David n = 24, Yacoub n = 5) and MRR in 30 patients. The mean age was 33 ± 15 years. The mean follow-up after VSRR was 6.5 ± 4 years (180 patient-years) compared with 8.8 ± 9 years (274 patient-years) after MRR. Reoperation rates after root remodelling (Yacoub) were significantly higher than after the reimplantation (David) procedure (60 vs 4.2%, P = 0.01). The need for reinterventions after the reimplantation procedure (0.8% per patient-year) was not significantly higher than after MRR (P = 0.44) but follow-up after VSRR was significantly shorter (P = 0.03). There was neither significant morbidity nor mortality associated with root reoperations. There were no neurological events after VSRR compared with four stroke/intracranial bleeding events in the MRR group (log-rank, P = 0.11), translating into an event rate of 1.46% per patient-year following MRR. CONCLUSION: The calculated annual failure rate after VSRR using the reimplantation technique was lower than the annual risk for thromboembolic or bleeding events. Since the perioperative risk of reinterventions following VSRR is low, patients might benefit from VSRR even if redo surgery may become necessary during follow-up.
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Schoenhoff et al. (2015) conducted a cohort in Marfan syndrome (n=59). Valve-sparing root replacement (VSRR) vs. Mechanical aortic root replacement (MRR) was evaluated on neurological events (stroke/intracranial bleeding) (p=0.11). Valve-sparing root replacement in Marfan syndrome was associated with no neurological events compared to 1.46% per patient-year after mechanical root replacement (P=0.11).
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