Valve-sparing aortic root replacement versus composite valve graft with bioprosthesis in patients under age 50

Objective Although the unique risks of a prosthetic aortic valve to young patients are well established after aortic valve surgery, studies are lacking regarding aortic root replacement. We investigated long-term outcomes after valve-sparing root replacement (VSRR) versus composite valve graft with bioprosthesis (b-CVG) in patients under 50 years old. Methods A total of 543 patients under 50 underwent VSRR (n=335) or b-CVG (n=208) between 2004-2021 from two aortic centers, excluding those with dissection or endocarditis. Endpoints included mortality over time, reoperative aortic valve replacement (AVR), and development of > moderate AI or AS. Fine and Gray competing risk regression compared risk of reintervention. Propensity score matching (PSM) balanced patient comorbidities, and landmark analysis isolated outcomes beginning four years postoperatively. Results B-CVG had decreased 12-year survival (88.6% vs VSRR 92.9%, p=0.036) and increased AV reintervention (37.6% vs 12.0%, p=0.018). After PSM, survival was similar (b-CVG 93.4% vs VSRR 93.0%, p=0.72). However, Fine and Gray multivariable risk regression and PSM both showed b-CVG was independently associated with >4 years postop AV reintervention [Fine and Gray, sHR 4.3 (95% CI 1.8-10.2), p=0.001; PSM b-CVG 35.7% vs VSRR 14.3%, p=0.024]. PSM rates of >moderate AI/AS at 10 years were greater than double in b-CVG (37.1% vs 15.9%, p=0.571). Conclusions B-CVG in young patients is associated with early valvular degeneration, with increasing rates of reop AVR occurring even within 10 years. In contrast, VSRR is durable with excellent survival. In eligible young patients, every effort should be made to retain the native aortic valve.