Valve-sparing aortic root replacement for valves with paracommissural fenestrations: which valve will fail?

OBJECTIVES: To define morphologic risk constellations during valve-sparing aortic root replacement (VSARR) for aortic valves with paracommissural fenestrations. METHODS: Patients from the multicentre prospective intention-to-treat VSARR-registry German Aortic Root Repair Registry (GEARR) were screened for paracommissural cusp fenestrations. We studied a combined end-point of residual aortic regurgitation (rAR) on post-cardiopulmonary bypass (CPB) transesophageal echocardiography (TEE), mid-term progress of rAR (transthoracic echocardiography) and aortic valve replacement for AR. RESULTS: Of a total of 762 registry patients (operated 2016-2024), 145 were identified with ≥1 paracommissural cusp fenestration. Eighteen patients (12%) were not treated as planned but underwent composite valved graft (CVG) implantation. Mean follow-up time was 3 years. Upon post-CPB TEE, rAR grade 1 or 2 were present in 44 (33%) and 3 (2%) patients. 50% of patients with fenestrations in more than one cusp showed early progression of rAR. At 3 years, freedom from the combined end-point was 78% (99% CI 74-79%) for the complete study cohort. Patients with a maximum free margin length difference of <5 mm, reflecting balanced root anatomy with respect to sinus and cusp sizes, had a significantly better outcome than those with ≥5 mm: at 3 years, freedom from the combined end-point was 86% (99% CI 80-91%) vs 41% (99% CI 38-46%, P = 0.011). Outcome was worst for patients with cusp prolapse and a free margin length difference of >5 mm (30% vs 70%, P = 0.018). CONCLUSIONS: Fenestrations in more than one cusp, inhomogeneities of cusp-free margin lengths, and additional prolapse are associated with inferior outcome after VSARR for valves with paracommissural fenestrations. CLINICAL TRIAL REGISTRATION NUMBER: DRKS00007872.