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Long Term Outcomes of Aortic Root Operations for Marfan Syndrome: A Comparison of Bentall versus Aortic Valve-Sparing Procedures Joel Price, MD, J. Trent.

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Presentation on theme: "Long Term Outcomes of Aortic Root Operations for Marfan Syndrome: A Comparison of Bentall versus Aortic Valve-Sparing Procedures Joel Price, MD, J. Trent."— Presentation transcript:

1 Long Term Outcomes of Aortic Root Operations for Marfan Syndrome: A Comparison of Bentall versus Aortic Valve-Sparing Procedures Joel Price, MD, J. Trent Magruder, MD, Allen Young, MPH, Joshua C. Grimm, MD, Nishant D. Patel, MD, Diane Alejo, Luca A. Vricella, MD, and Duke E. Cameron, MD From the Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Maryland 2015 AATS Annual meeting

2 No disclosures

3 Background Marfan Syndrome: –autosomal dominant condition FBN1 gene, incidence of 1 in 3000-5000 –Aortic root dilation most common feature, part of diagnostic criteria –Dismal natural history, aortic dissection and death Prophylactic aortic root replacement in Marfan syndrome improves survival

4 Background Mechanical Composite Valve-GraftAortic Valve Sparring Root Replacement

5 Background Optimal procedure unknown –Bentall versus valve-sparing root replacement (VSRR) Little published data on long-term comparative outcomes

6 Johns Hopkins experience

7 Objectives To compare long-term clinical and valve-related outcomes of Marfan patients undergoing aortic root replacement with mechanical valve-graft or VSRR

8 Methods Adult MFS patients undergoing mechanical composite valve-graft replacement or VSRR procedures 1997 – 2014 Comprehensive follow-up from records and telephone interview Outcomes: Survival, thromboembolism/ hemorrhage, AV endocarditis, aortic valve/root reoperation Statistics: T-tests/chi2/rank-sum tests, Time-to-event analysis, Cox proportional hazards modeling with propensity score adjustment

9 Results

10 Baseline characteristics BentallVSRRp N = 1656798- Median age (IQR)37 (31-50)36 (29-41)0.03 Male sex (%)40 (61.5)66 (72.5)0.17 Median sinus diameter (cm) (IQR) 5.5 (5.0-6.0)5.0 (4.9-5.3)0.003 Bicuspid valve (%) 5 (7.4)2 (2.1)0.20 Aortic dissection (%) 17 (25.4)4 (4.1)<0.001 3+/4+ AI (%) 33 (49.3)14 (14.4)<0.001 Urgent/emergent operation (%) 16 (24.6)3 (3.3)<0.001

11 Baseline characteristics BentallVSRRp N = 1656798- Median age (IQR)37 (31-50)36 (29-41)0.03 Male sex (%)40 (61.5)66 (72.5)0.17 Median sinus diameter (cm) (IQR) 5.5 (5.0-6.0)5.0 (4.9-5.3)0.003 Bicuspid valve (%) 5 (7.4)2 (2.1)0.20 Aortic dissection (%) 17 (25.4)4 (4.1)<0.001 3+/4+ AI (%) 33 (49.3)14 (14.4)<0.001 Urgent/emergent operation (%) 16 (24.6)3 (3.3)<0.001

12 Baseline characteristics BentallVSRRp N = 1656798- Median age (IQR)37 (31-50)36 (29-41)0.03 Male sex (%)40 (61.5)66 (72.5)0.17 Median sinus diameter (cm) (IQR) 5.5 (5.0-6.0)5.0 (4.9-5.3)0.003 Bicuspid valve (%) 5 (7.4)2 (2.1)0.20 Aortic dissection (%) 17 (25.4)4 (4.1)<0.001 3+/4+ AI (%) 33 (49.3)14 (14.4)<0.001 Urgent/emergent operation (%) 16 (24.6)3 (3.3)<0.001

13 Baseline characteristics BentallVSRRp N = 1656798- Median age (IQR)37 (31-50)36 (29-41)0.03 Male sex (%)40 (61.5)66 (72.5)0.17 Median sinus diameter (cm) (IQR) 5.5 (5.0-6.0)5.0 (4.9-5.3)0.003 Bicuspid valve (%) 5 (7.4)2 (2.1)0.20 Aortic dissection (%) 17 (25.4)4 (4.1)<0.001 3+/4+ AI (%) 33 (49.3)14 (14.4)<0.001 Urgent/emergent operation (%) 16 (24.6)3 (3.3)<0.001

14 Baseline characteristics BentallVSRRp N = 1656798- Median age (IQR)37 (31-50)36 (29-41)0.03 Male sex (%)40 (61.5)66 (72.5)0.17 Median sinus diameter (cm) (IQR) 5.5 (5.0-6.0)5.0 (4.9-5.3)0.003 Bicuspid valve (%) 5 (7.4)2 (2.1)0.20 Aortic dissection (%) 17 (25.4)4 (4.1)<0.001 3+/4+ AI (%) 33 (49.3)14 (14.4)<0.001 Urgent/emergent operation (%) 16 (24.6)3 (3.3)<0.001

15 Baseline characteristics BentallVSRRp N = 1656798- Median age (IQR)37 (31-50)36 (29-41)0.03 Male sex (%)40 (61.5)66 (72.5)0.17 Median sinus diameter (cm) (IQR) 5.5 (5.0-6.0)5.0 (4.9-5.3)0.003 Bicuspid valve (%) 5 (7.4)2 (2.1)0.20 Aortic dissection (%) 17 (25.4)4 (4.1)<0.001 3+/4+ AI (%) 33 (49.3)14 (14.4)<0.001 Urgent/emergent operation (%) 16 (24.6)3 (3.3)<0.001

16 Operative data BentallVSRRp Reimplantation- 69 (70.4) - Remodeling- 29 (29.6) - CPB time 158.8143.60.08 Cross-clamp time 111.6104.20.25 Concomitant procedures PFO/ASD closure 18 (26.9)43 (44.3)0.03 MV repair 2 (3.0)7 (7.2)0.31 MV replacement 4 (6.0)00.03 CABG 6 (9.0)2 (2.1)0.06

17 Operative data BentallVSRRp Reimplantation- 69 (70.4) - Remodeling- 29 (29.6) - CPB time 158.8143.60.08 Cross-clamp time 111.6104.20.25 Concomitant procedures PFO/ASD closure 18 (26.9)43 (44.3)0.03 MV repair 2 (3.0)7 (7.2)0.31 MV replacement 4 (6.0)00.03 CABG 6 (9.0)2 (2.1)0.06

18 Operative data BentallVSRRp Reimplantation- 69 (70.4) - Remodeling- 29 (29.6) - CPB time 158.8143.60.08 Cross-clamp time 111.6104.20.25 Concomitant procedures PFO/ASD closure 18 (26.9)43 (44.3)0.03 MV repair 2 (3.0)7 (7.2)0.31 MV replacement 4 (6.0)00.03 CABG 6 (9.0)2 (2.1)0.06

19 Short-term outcomes BentallVSRRp In-hospital death 001.00 Pneumothorax 6 (9.0)7 (7.1)0.77 Hemothorax 2 (3.0)1 (1.0)0.57 Reoperation for bleeding 1 (1.5)2 (2.0)1.00 Atrial fibrillation 14 (20.9)19 (19.4)0.85

20 Long-term outcomes

21 Survival by procedure type

22 Freedom from thromboembolic events

23 Freedom from hemorrhagic events

24 Freedom from composite outcome

25 Freedom from aortic valve endocarditis

26 Freedom from aortic valve/root reoperation

27 Sub-group analysis Reimplantation vs Remodelling

28 Freedom from aortic valve/root reoperation

29 Freedom from moderate/severe AI

30 Limitations Retrospective study; method of repair chosen at time of operation Relatively small sample size

31 Conclusions VSRR has a significantly decreased risk of composite thromboembolic/hemorrhagic events as compared to Bentall procedures Survival and freedom from endocarditis were similar in both procedure types VSRR has similar durability compared to Bentall procedures Reimplantation VSRR should continue to play an important role in the treatment of well-selected patients with MFS

32 2015 AATS Annual meeting Thank you

33 Results – late events Bentall (n=67) VSRR (n=98) Log rank p Ten-year survival 90.5%96.3%0.10 Deaths 63 Linearized event rate (%/yr) 1.23%0.41% Ten-year freedom from thromboembolism/hemorhage 77.6%96.7%< 0.001 Thromboembolic/hemorrhagic events 154 Linearized event rate (%/yr) 3.50%0.55% Ten-year freedom from AV/root reoperation 92.0%92.9%0.52 AV/root reoperations 44 Linearized event rate (%/yr) 0.86%0.56% Ten-year freedom from endocarditis 91.7%98.9%0.14 Endocarditis events 31 Linearized event rate (%/yr) 0.17%0.04%

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