Valve-sparing root replacement (VSRR) is an appealing strategy in aortic root surgery, particularly in younger patients with longer life expectancy. Avoiding a prosthetic valve eliminates prosthesis-related drawbacks, including lifelong anticoagulation with mechanical valves, structural valve degeneration in bioprostheses, and prosthetic valve endocarditis. When technical execution is optimal, durable native valve function can be achieved. However, its role in the setting of resternotomy remains controversial because of increased technical complexity, including dense adhesions, prior coronary grafts, previously mobilized coronary buttons, and the frequent need for associated procedures, all of which may increase perioperative morbidity.

Reoperative aortic root surgery is increasingly encountered in contemporary practice. Nonetheless, valve preservation during resternotomy remains uncommon. As reported in North American series, reoperative sternotomy has been associated with increased operative mortality in aortic root replacement (ARR), rising from 6.2% to 10.8%, although institutional experience may attenuate part of this excess risk. In routine clinical practice, VSRR in the reoperative setting represents a minority strategy; among more than 55000 ARR procedures performed in the United States between 2011 and 2020, only 622 (1.1%) were redo VSRR.

The authors included all consecutive VSRR procedures performed between 2005 and 2020 at Columbia University Irving Medical Center and Emory University. Reoperation was defined as any prior sternotomy. Time-dependent outcomes were compared after balancing covariates using inverse probability of treatment weighting (IPTW). Long-term survival was assessed with Cox regression, and aortic valve reintervention was analyzed using a Fine–Gray competing risk model, accounting for death as a competing event.

Among 778 valve-sparing procedures, 69 were performed in the setting of resternotomy. Reoperative patients were significantly younger (p < .001) and less frequently presented with moderate or severe aortic insufficiency (p = .02), suggesting a more restrictive selection toward anatomically repairable valves. Intraoperatively, cardiopulmonary bypass and crossclamp times were significantly longer in the redo cohort (p < .001). In the early postoperative period, reoperation was associated with a higher incidence of acute kidney injury (p = .01) and prolonged mechanical ventilation (p < .001). No statistically significant differences were observed in operative mortality or in adjusted long-term outcomes.

The authors conclude that although technically demanding, reoperative VSRR can be performed with low operative mortality in carefully selected patients, with acceptable 10-year survival and reintervention rates comparable to those observed in primary sternotomy.

Several limitations merit consideration. First, patient selection was highly restrictive; the highest-risk patients were unlikely to be offered a valve-sparing strategy and are therefore underrepresented. Second, the redo cohort was relatively small (69 patients), limiting statistical power and precision. Finally, the median follow-up for reintervention was 4.49 years (83% complete), requiring cautious interpretation of 10-year estimates, particularly for infrequent events.

COMMENTARY:

This study provides relevant insights into a recurring dilemma in aortic surgery: should a valve-sparing strategy be pursued during reoperation? The data support a nuanced answer. VSRR in the redo setting is feasible, with low operative mortality and acceptable long-term outcomes, but only in highly selected patients treated in experienced centers. These results arise from a carefully curated cohort and should therefore be interpreted with caution.

Even after adjustment for preoperative comorbidities, the reoperative cohort exhibited higher rates of renal and respiratory complications and longer ICU stays (p = .01). This has practical implications. Preoperative discussions should acknowledge that the potential long-term benefit of avoiding a prosthetic valve may be accompanied by a more demanding early postoperative course. In this context, meticulous preoperative optimization becomes even more relevant, including assessment of renal reserve, correction of anemia, evaluation of pulmonary function, and global frailty.

Importantly, durability appears to depend more on intrinsic valve quality than on reoperative status itself. In the Fine–Gray model, bicuspid aortic valve morphology was associated with higher rates of reintervention (p = .02), whereas redo status was not (p = .77). This reinforces a key principle: in reoperative cases, valve preservation should be avoided when leaflet tissue is rigid, calcified, or geometrically unfavorable. Conversely, in younger patients with good tissue quality, including selected post-Ross patients, valve preservation may provide meaningful cumulative lifetime benefit, provided that an optimal postoperative echocardiographic result is achieved.

The study also raises unresolved questions. Most notably, what would the outcomes be in the same clinical scenario if a composite graft (biological or mechanical) were chosen instead of VSRR? This analysis cannot address that issue, as no alternative redo ARR group was included. Furthermore, the study does not define a universally exportable candidate profile for lower-volume centers. An implicit but important message emerges: reoperative VSRR is likely best reserved for teams with established experience and well-developed institutional pathways. In daily practice, a balanced approach seems reasonable. Valve preservation during reoperative root surgery should remain an option, but only when patient risk profile, anatomical characteristics, and surgical expertise align to achieve an excellent repair, accepting that early morbidity may be higher in exchange for potential long-term benefit.

REFERENCE:

Chung MM, Rajesh K, He C, Zhao Y, Hohri Y, Jimenez V, et al. Valve-sparing aortic root replacement in resternotomy settings. J Thorac Cardiovasc Surg. 2025 Nov;170(5):1363-1370.e6. doi: 10.1016/j.jtcvs.2024.12.030.