Long-term Survival, Valve Durability, and Reoperation

for Four Aortic Root + Ascending Procedures

Lars G. Svensson, Saila T. Pillai,

Jeevanantham Rajeswaran, Milind Desai, Brian Griffin,

Richard Grimm, Donald F. Hammer, Maran Thamilarasan,

Eric E. Roselli, Gösta B. Pettersson, A. Marc Gillinov,

Jose L. Navia, Nicholas G. Smedira, Joseph F. Sabik III,

Bruce W. Lytle, Eugene H. Blackstone

1. Remodeling / Reimplantation

2. Biological Composite

3. Mechanical Composite 4. Allograft

Free of Complications

%

Years after Operation

Valve-related deathsReop/endo

TEBleeding

Other deaths

St Jude Medical Valve Prosthesis

Zellner et al. 1999

0 126 153 9

100

80

20

60

40 40%

Explant for SVD

%

Age (years)

Pericardial

Allograft

12 years

20 30 40 50 60 70

70

60

50

40

30

20

10

Prosthesis by Age

100

80

60

40

20

%

≥8050s 60s 70s<30 30s 40s

BioprosthesisMechanicalRepairHuman

0

Age (years)

Post-op Complications, BAV =728

%

Death Stroke Renal Failure

LongVent

2.5

1.5

1.0

0.5

0

2.0

MI

0.41%0.27%

20

40

60

80

100

0 2 4 6 8 10 12

%

Years

Bicuspid

Tricuspid

Biologic AVR

Free of Reoperation

Objective• Primary endpoints:

− Complications− Early and late reoperations− Early and late death

• Secondary endpoints• Aortic stenosis or insufficiency• Change in left ventricular mass

index

N 957 Patients• Root Procedure + Ascending Aorta

25% Arch Repair with DHCA• 1/1995 to End 2010

• Excluded− Type A dissection−Active endocarditis−Emergency operations

Procedure

27%

Allograft

25%

16%

32%

CompositeMechanical

CompositeBiologic

Valve Preserv205 Reimplant 56 Remodel

Number of Procedures

Bentall (Bio.)

Allograft

Valve Preserving

1995

Date of Procedure

20

40

50

60

#

01997 1999 2001 2003 2005 2007 2009 2011

Bentall (Mech)

Characteristics of Patients

Comorbidities100

80

60

40

20

0LVFCAD

<50%AV Sten. Age

(yr)

%

Valve-PreservingComposite BiologicComposite Mech.Allograft

Comorbidities

60

40

20

0AfibHFHtn Carotid

%

Valve-PreservingComposite BiologicComposite Mech.Allograft

Early Outcomes

Mortality 0.73%

None Valve Preserving

Early Complications

• Valve-preserving −More reoperations for bleeding −Valve dysfunction

• Composite biological−More atrial fibrillation−Deep wound infections− Longer ICU and hospital stay

0 3 6 9 12 15

Years

20

40

60

80

100

Per

cen

t in

Eac

h C

ateg

ory

0

Competing Events after Procedure

Alive with no reoperation

Death before reoperation

1st Operation

Survival

%

Years

20

40

60

80

100

0 3 6 9 12 15

0 3 6 9 12 15

Years

20

40

60

80

100

Su

rviv

al (

%)

0

Survival

Bentall (Mech.)

AllograftValve

Preserving

Bentall (Biologic)

Prevalence of Postoperative Aortic Regurgitation

0 2 4 6 8 10

Years

0

20

40

60

80

100

Per

cen

t in

AR

Gra

de

0

Bentall (Mech.)

Allograft

Valve Preserving

Bentall (Biologic)

Aortic Valve Gradients

Bentall (Mech.)

Allograft

Valve Preserving

Bentall (Biologic)

0 2 4 6 8 105

10

15

20

Mea

n G

rad

ien

t (m

mH

g)

Years

LV Mass Index

0 2 4 6 8 10

110

120

130

140

150

160

Composite Mech.

Allograft

Valve Preserving

Composite Biologic

g•m

-2

Years

Left Atrial Diameter

0 2 4 6 8 10

Years

Bentall (Mech.)Allograft

Valve Preserving

Bentall (Biologic)

4.00

4.25

4.50

4.75

5.00

LA

Dia

met

er (

cm)

3.75

74 Reoperations, 1.5% Mortality

Endocarditis

%

AR / Aneu / ADS

Degeneration

Freedom from First Reoperation

0 3 6 9 12 15

Years

20

40

60

80

100

Fre

e o

f R

eop

erat

ion

(%

)

0

0 3 6 9 12 15

Years

2

4

6

8

10

Reo

ps

(%/y

ear)

0

Hazard

Freedom from First Reoperation

0 3 6 9 12 15

Years

60

70

80

90

100

Fre

e o

f R

eop

(%

)

50

Bentall (Mech.)

Allograft

Valve Preserving

Bentall (Biologic)

Valve Preserving Reoperations

• Reimplantation Trileaflet Valve

Freedom 93% 10 years

• Remodeling Bicuspid Valve

Freedom 71% 10 years, p=0.02

5 Reoperations for Distal Disease

Conclusions

• Valve-Preserving procedures

−Remodeling higher early failure rate−More late aortic regurgitation−Smaller LV mass index over time− Less endocarditis−No warfarin

Conclusions

• Composite biological valve

−Higher death rate over time−More endocarditis

Conclusions

• Composite mechanical valve

− Lowest reoperation rate−Sustained benefit in LV mass index−Anticoagulation is the price

Conclusions

• Allografts

− Low early LV mass index− Low risk of endocarditis−High allograft degeneration

Implications• Reimplantation Excellent for Trileaflet

• Remodeling Fair for BAV

• Mechanical composite Good AS but Coumadin

• Biological Good for Elderly but Flared graft−Valve in Valve TAVR

• Allografts are good for endocarditis