Personalized external aortic root support and valve sparing root replacement in syndromic aortic root aneurysm: a propensity score-matched analysis.

Objectives
Valve-sparing root replacement (VSRR) is an established treatment of aortic root aneurysms. In Personalized external aortic root support (PEARS), a bespoke mesh is used to stabilize the ascending aorta. Differences in indication and surgical technique make a randomized comparison between PEARS and VSRR conceptually challenging. This study aims to perform a propensity score (PS) matched comparison of PEARS and VSRR in patients with syndromic aortic aneurysm.

Methods
This study employed the PEARS 200 database and the AVIATOR registry, both containing prospectively and retrospectively collected data. Patients with connective tissue disease (Marfan syndrome, Loeys-Dietz and ACTA2 mutations) operated electively for aortic root aneurysm <60mm with at most mild (1/4) aortic regurgitation (AR) were included. Using a PS analysis, 83 patients in each cohort were matched. Survival, freedom from reintervention and from AR ≥2/4 were estimated using a Kaplan-Meier analysis. Continuous variables were compared using Student's t-test, categorical variables with Chi-square or Fisher's Exact test.

Results
The 159 included PEARS patients had a median follow-up of 25 months while the 142 VSRR patients had a median follow-up of 55 months. Before matching, patients undergoing VSRR were older, more likely to have mild AR or a history of cardiac surgery, had a higher EuroSCORE II and larger aortic root (Table 1). Among 83 matched PEARS patients, 3 suffered coronary injury (2 repaired without consequence, 1 perioperative death) and there were 2 myocardial infarctions. In the VSRR group, there were no early deaths and 1 patient required percutaneous coronary intervention. Survival for the matched cohorts at 5 years was similar, 98% for PEARS (n=16 at risk) vs. 99% for VSRR (n=38 at risk)(P=0.76). Freedom from reintervention at 5 years was also similar at 100% for PEARS vs. 99% for VSRR (P=0.22). Freedom from AR ≥2/4 at 5 years in the matched cohorts was 97% for PEARS (n=13 at risk) vs. 90% for VSRR (n=29 at risk)(P=0.20). Nevertheless, the rate of AR ≥1/4 postoperatively and at last follow-up was higher in the VSRR group. We observed no type A dissections. While not significant, there were more type B dissections and ascending aortic reinterventions after VSRR (Table 1).

Conclusions
VSRR and PEARS both seem to offer very good mid-term survival, freedom from reintervention and preservation of valve function in syndromic root aneurysm. PEARS is associated with a higher rate of perioperative coronary complications, potentially related to the learning curve of this emerging procedure. VSRR, on the other hand, is associated with a higher rate of early reoperation for bleeding. Depending on the disease stage of the individual patient, both treatments may be complementary. Main limitations of this study are related to its retrospective nature and different length of follow-up in both cohorts.

Lucas Van Hoof (1), Tom Treasure (2), John Pepper (3), Ismail El-Hamamsy (4), Emmanuel Lansac (5), Filip Rega (1), Peter Verbrugghe (1), (1) Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium, (2) Clinical Operational Research Unit, University College London, London, UK, (3) Royal Brompton Hospital Department of Surgery, London, UK, (4) Mount Sinai Hospital, New York, NY, USA, (5) Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France

Lucas Van Hoof

Abstract Presenter

General Surgery Resident - PhD Student Cardiac Surgery at KU Leuven and University Hospitals Leuven, Leuven, Belgium. I am currently studying the early mechanobiological adaptation of the pulmonary autograft after the Ross procedure, both in an ovine model of and in an imaging study in patients. Furthermore, we are evaluating the potential role of the personalized external aortic root support technique in the Ross procedure.

Specialties: Adult Cardiac, Aorta, Aortic Valve, Anatomy and Conditions, Great Vessels, Aorta, Aortic root, Valve, Aortic Valve, Treatment/Procedure/Operation/Surgery, Valve, Aortic valve