1. 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

2. 1. Remodeling / Reimplantation 2. Biological Composite 3. Mechanical Composite 4. Allograft

3. Free of Complications % Years after Operation Valve-related deaths Reop/endo TE Bleeding Other deaths St Jude Medical Valve Prosthesis Zellner et al. 1999 01261539 100 80 20 60 40 40%

4. Explant for SVD % Age (years) Pericardial Allograft 12 years 203040506070 70 60 50 40 30 20 10

5. Prosthesis by Age 100 80 60 40 20 % ≥8050s60s70s<3030s40s BioprosthesisMechanicalRepairHuman 0 Age (years)

6. Post-op Complications, BAV =728 % DeathStroke RenalFailureLongVent 2.5 1.5 1.0 0.5 0 2.0 MI 0.41% 0.27%

7. % Years Bicuspid Tricuspid Biologic AVR Free of Reoperation

8. Objective Primary endpoints: Primary endpoints: − Complications − Early and late reoperations − Early and late death Secondary endpoints Secondary endpoints Aortic stenosis or insufficiency Aortic stenosis or insufficiency Change in left ventricular mass index Change in left ventricular mass index

9. N 957 Patients Root Procedure + Ascending Aorta Root Procedure + Ascending Aorta 25% Arch Repair with DHCA 1/1995 to End 2010 1/1995 to End 2010 Excluded Excluded − Type A dissection − Active endocarditis − Emergency operations

10. Procedure 27 % Allograft 25 % 16 % 32 % CompositeMechanical CompositeBiologic Valve Preserv 205 Reimplant 56 Remodel 56 Remodel

11. Number of Procedures Bentall (Bio.) Allograft Valve Preserving 1995 Date of Procedure 20 40 50 60 # 0 19971999200120032005200720092011 Bentall (Mech)

12. 1995 Date of Procedure 30 50 70 % 0 19971999200120032005200720092011 Percentage of Procedures Bentall (Mech.) Allograft Valve Preserving Bentall (Biologic) 10 20 40 60

13. Characteristics of Patients

14. Comorbidities 100 80 60 40 20 0 LVF CAD<50% AV Sten. Age(yr) % Valve-Preserving Composite Biologic Composite Mech. Allograft

15. Comorbidities 60 40 20 0 AfibHFHtnCarotid % Valve-Preserving Composite Biologic Composite Mech. Allograft

16. Early Outcomes Mortality 0.73% None Valve Preserving

17. Early Complications Valve-preserving Valve-preserving − More reoperations for bleeding − Valve dysfunction Composite biological Composite biological − More atrial fibrillation − Deep wound infections − Longer ICU and hospital stay

18. 03691215 Years 20 40 60 80 100 Percent in Each Category 0 Competing Events after Procedure Alive with no reoperation Death before reoperation 1 st Operation

19. Survival % Years

20. 03691215 Years 20 40 60 80 100 Survival (%) 0 Survival Bentall (Mech.) Allograft Valve Preserving Bentall (Biologic)

21. AV Regurgitation 3+/4+ % Years Composit e biologic Composit e mech. Allograft Valve-sparing

22. Prevalence of Postoperative Aortic Regurgitation 0246810 Years 0 20 40 60 80 100 Percent in AR Grade 0 Bentall (Mech.) Allograft Valve Preserving Bentall (Biologic)

23. 0246810 Years Bentall (Mech.) Allograft Valve Preserving Bentall (Biologic) Prevalence of Postoperative Aortic Regurgitation 20 40 60 80 100 Percent in AR Grade 3+/4+ 0

24. Aortic Valve Gradients Bentall (Mech.) Allograft Valve Preserving Bentall (Biologic) 0246810 5 10 15 20 Mean Gradient (mmHg) Years

25. LV Mass Index 0246810 110 120 130 140 150 160 Composite Mech. Allograft Valve Preserving Composite Biologic gm -2 Years

26. Left Ventricular Mass Index After the Procedure 0246810 Years Bentall (Mech.) Allograft Valve Preserving Bentall (Biologic) 110 120 130 150 160 LV Mass Index (g/m 2 ) 100 140

27. Left Atrial Diameter 0246810 Years Bentall (Mech.) Allograft Valve Preserving Bentall (Biologic) 4.00 4.25 4.50 4.75 5.00 LA Diameter (cm) 3.75

28. 74 Reoperations, 1.5% Mortality Endocarditis % AR / Aneu / ADS Degeneration

29. Freedom from First Reoperation 03691215 Years 20 40 60 80 100 Free of Reoperation (%) 0

30. 03691215 Years 2 4 6 8 10 Reops (%/year) 0 Hazard

31. Freedom from First Reoperation 03691215 Years 60 70 80 90 100 Free of Reop (%) 50 Bentall (Mech.) Allograft Valve Preserving Bentall (Biologic)

32. Valve Preserving Reoperations Reimplantation Trileaflet Valve Reimplantation Trileaflet Valve Freedom 93% 10 years Remodeling Bicuspid Valve Remodeling Bicuspid Valve Freedom 71% 10 years, p=0.02 5 Reoperations for Distal Disease

33. Conclusions Valve-Preserving procedures Valve-Preserving procedures − Remodeling higher early failure rate − More late aortic regurgitation − Smaller LV mass index over time − Less endocarditis − No warfarin

34. Conclusions Composite biological valve Composite biological valve − Higher death rate over time − More endocarditis

35. Conclusions Composite mechanical valve Composite mechanical valve − Lowest reoperation rate − Sustained benefit in LV mass index − Anticoagulation is the price

36. Conclusions Allografts Allografts − Low early LV mass index − Low risk of endocarditis − High allograft degeneration

37. Implications Reimplantation Excellent for Trileaflet Reimplantation Excellent for Trileaflet Remodeling Fair for BAV Remodeling Fair for BAV Mechanical composite Good AS but Coumadin Mechanical composite Good AS but Coumadin Biological Good for Elderly but Flared graft Biological Good for Elderly but Flared graft − Valve in Valve TAVR Allografts are good for endocarditis Allografts are good for endocarditis