Midterm outcomes after aortic valve reimplantation with a Straight versus Valsalva graft

OBJECTIVES: To compare midterm hemodynamic performance and durability of valve-sparing aortic root reimplantation (VSRR) using a Straight graft versus Valsalva graft. METHODS: From January 1, 2000, to December 1, 2023, 1495 adults without endocarditis underwent VSRR at Cleveland Clinic, of whom 838 (56%) received a Straight graft and 657 (44%) a Valsalva graft. Mean aortic valve gradient, aortic regurgitation grade, aortic valve reoperation, and survival were compared in 365 propensity-matched patient pairs (730 patients). RESULTS: After matching (Straight graft vs Valsalva), operative mortality was 0.56% versus 0.28% (P = .56). At 5 years, mean aortic valve gradients were 6.6 versus 6.3 mm Hg (P = .46) and prevalence of moderate or severe aortic regurgitation 12% versus 9.1% (P = .38). Straight grafts were associated with higher freedom from aortic valve reoperation overall (96% vs 94%, P = .045) and for structural valve deterioration (98% vs 95%, P[constant phase] = .019), at a rate of 0.27%/year versus 0.83%/year at 5 years. Concomitant aortic valve repair was more prevalent in patients receiving a Valsalva graft (37% vs 44%, P = .059), which carried a higher risk of reoperation (P[log-rank] = .0023; after adjusting for the confounding effect of concomitant aortic valve repair, P for risk of reoperation was .082). CONCLUSIONS: Despite its increasing use in patients with more complexity and greater risk, VSRR demonstrates excellent midterm durability and hemodynamic performance, regardless of graft type. Greater risk of reoperation with Valsalva grafts likely reflects case mix and technical complexity.