Conversion to Prosthetic Replacement after Scheduled Valve-Sparing Aortic Root Replacement: What Is the Role of Complex Mechanisms of Aortic Regurgitation?

All articles of this category Objective: To study patient- and valve-related characteristics of conversion cases (mechanical or biological aortic valve replacement, AVR) after initially planned valve-sparing aortic root replacement (V-SARR) with a special focus on complex (defined as at least two contributing lesions) versus isolated mechanisms of aortic regurgitation (AR) according to El Khoury’s classification. Methods: Patients scheduled for any type of V-SARR (Reimplantation, Remodeling, all David V-SARR techniques) including any combined aortic valve cusp repair were identified ( n = 398, single center, 2003–2015). N = 169 patients fulfilled the criteria of either intraoperative conversion to AVR without attempted V-SARR (Group A) , conversion immediately after attempted V-SARR and transesophageal echocardiographic (TEE) evaluation of the aortic valve (Group B) , or reoperation within the first three years after V-SARR with need of prosthetic AVR (Group C) . Variables studied included type of valve, localization of restriction, localization of prolapse or billowing, and the presence of complex versus isolated mechanisms of aortic regurgitation (AR). Results: There were 126 patients in Group A (60 ± 13 years) with a median preoperative AR grade of 3.0 (average 2.5). The predominant El Khoury AR mechanisms in the group were Type I ( n = 81 patients, 64%). With n = 31 patients (25%), complex AR mechanisms were overrepresented. Localized calcium spots were documented in n = 56 patients (44%). Bicuspid aortic valve (BAV) was present in n = 51 (40%). Group B was comprised by n = 24 patients (62 ± 10 years, 83% male) with a median preoperative AR grade of 3.0 (average 2.75). N = 4 (16%) patients had complex AR mechanisms. BAV was present in n = 5 patients (20%). Group C was comprised by 19 patients (39 ± 18 years, 89% male) with a median preoperative AR grade of 2.0 (average 2.4). Complex AR mechanisms were found in 3 patients (16%). BAV was present in 9 patients (47%). Conclusion: The presence of a BAV, high preoperative AR grade and of complex AR mechanisms contributed to conversion before V-SARR was attempted. Multi-center prospective research is needed to clarify if these patients are actually better treated by AVR or if a more aggressive strategy of V-SARR attempts is to be implemented.