Bentall Procedure or Aortic Annular Enlargement for Small Aortic Annuli
Y. Wang1, A. Makkinejad2, K. Monaghan3, M. Titsworth4, S. Bhirud3, C. Ghita3, R. Ahmad5, H. Patel6, K. M.. Kim7, S. Fukuhara8, G. Ailawadi9, B. Yang10 1University of Michigan, Ann Arbor, Michigan 2University of Florida, Gainesville, Florida 3Michigan Medicine, Ann Arbor, Michigan 4University of Michigan, Belleville, Michigan 5Michigan State University, College of Human Medicine, Grand Rapids, Michigan 6University of Michigan Medical Center, Ann Arbor, Michigan 7UT Health Austin, Austin, Texas 8University of Michigan, Michigan Medicine, Frankel Cardiovascular Cen, Ann Arbor, Michigan 9The University of Michigan Cardiovascular Center, Ann Arbor, Michigan 10University of Michigan / Michigan Medicine, Ann Arbor, Michigan
University of Michigan Ann Arbor, Michigan, United States
Disclosure(s):
Yoyo Wang, n/a: No financial relationships to disclose
Purpose: The optimal treatment strategy for patients with small aortic annulus who needs aortic valve replacement remains unclear. The objective of our study was to compare the differences in outcomes between AVR with annulus enlargement (AVR + AAE) and the Bentall procedure. Methods: From January 2011 to September 2022 at our institution, 333 patients with a small native annulus (≤23 mm) underwent aortic valve replacement with either AVR+AAE (n=286) or the Bentall procedure (n=47) for either aortic stenosis, aortic insufficiency, or aortic root aneurysm. Patients with endocarditis or acute type A aortic dissection were excluded. Overall survival across the AVR+AAE and Bentall groups were compared using Kaplan-Meier analysis and Cox proportional hazards regression adjusting for procedure type, age, sex, prior cardiac surgery, coronary artery disease, chronic lung disease, dialysis, and diabetes. Results: Compared to the Bentall group, patients undergoing AVR+AAE were older (64 years old vs 60 years old, p=0.03) and had higher rates of diabetes (32% [94/286] vs 15% [7/47], p=0.02). Patients in the Bentall group had higher rates of bicuspid aortic valve (36% [17/47] vs 16% [46/286], p=0.002) and prior cardiac surgery (74% [35/47] vs 26% [74/286], p< 0.001) as well as longer cardiopulmonary bypass time (229 mins vs 174 mins, p< 0.001) and cross clamp time (187 mins vs 142 mins, p< 0.001). The AVR+AAE had smaller native annulus size when compared to the Bentall group (21mm v 23mm, p=0.02) and had a signijcantly larger implanted valve size (25mm v 23mm, p=0.01). Postoperatively, the Bentall group had longer intensive care unit (ICU) stay (95 hours vs 70 hours, p=0.04) and ventilator dependence (7.9 hours vs 5.4 hours, p=0.002). Kaplan- Meier analysis demonstrated better mid-term survival in the AVR+AAE group than the Bentall group (P=0.001) [5-year survival:93.2% (95% CI: 87.9%-96.2%) vs 61.3% (95% CI: 31.1%-81.4%)] (Figure). The independent risk factors associated with worse survival were the Bentall procedure (HR: 3.07, 95% CI: 1.18-8.03, p=0.022) and patients with chronic lung disease (HR: 3.47, 95% CI: 1.56-7.69, p=0.002). Conclusion: Among patients with a small native aortic annulus, AVR+AAE should be considered a preferred management strategy over aortic root replacement with a Bentall procedure with better perioperative morbidity and long-term survival.
Identify the source of the funding for this research project: No funding was provided for this study.
