Aortic valve repair versus biological replacement for aortic regurgitation with or without ascending aortic aneurysm: Heart Valve Society Aortic Valve Database Study

Objective To compare the long-term outcomes of aortic valve repair (AVr) (REPAIR group) with biological aortic valve replacement (bAVR group). Methods Adults who underwent REPAIR or bAVR for aortic regurgitation (AR) +/− ascending aortic aneurysm (AscAA), recorded in the Heart Valve Society database until April 2024, were included. Propensity score matching was used to adjust for confounders. Differences in long-term survival, major adverse valve-related events (MAVRE), and other valve-related events were assessed. Results In total, 7318 patients were included (REPAIR n=6773, bAVR n=545). Propensity score matching resulted in 1006 REPAIR patients matched to 530 bAVR patients (median age: 67 years [interquartile range, 59.0-73.0], 22% female). In the matched cohort, early mortality (≤30 days) was comparable between REPAIR and bAVR patients (1.2% vs 2.1%, P = .070). At 7.5 years, overall matched survival was lower in the bAVR group compared to the REPAIR group (73.9% [95% CI, 66.5%-82.1%] vs 85.6% [95% CI, 82.3%-89.3%], P < .001), with a higher proportion of valve-related deaths (bAVR 4.2% vs REPAIR 1.2%, P < .001). At 7.5 years, patients with bAVR had significantly lower freedom from MAVRE ( P < .001) and more infective endocarditis ( P = .006), and severe valve dysfunction ( P < .001) compared to patients with REPAIR. The incidences of aortic valve reintervention ( P = .388) and pacemaker implantation ( P = .671) were comparable. Conclusions Among patients in whom repair was deemed feasible and surgery was performed at mainly expert centers, repair was associated with more favorable long-term outcomes, including improved survival, compared with bAVR in an older propensity-matched cohort. These findings support the consideration of AVr when technically feasible in patients with AR, with or without AscAA.