Fifteen articles met eligibility criteria, covering a total of 3,044 patients (1,991 in the reimplantation group and 2,018 in the remodeling group). All studies were nonrandomized and observational.

For overall survival, the median follow-up was 5 years (interquartile range: IQR = 2.2–8.6 years). Patients who underwent VSARR with remodeling demonstrated a higher risk of all-cause mortality (hazard ratio [HR] = 1.54; 95% confidence interval [CI] = 1.16–2.03; p = 0.002, log-rank test p < 0.001). This mortality risk was significantly elevated (HR > 1) in the postoperative period up to 4 years, after which the risk became non-significant. At the 4-year benchmark, survival was lower in patients undergoing VSARR with remodeling (HR = 2.15; 95% CI = 1.43–3.24; p < 0.001), with no survival differences observed beyond 4 years (HR = 1.04; 95% CI = 0.72–1.50; p = 0.822).

The median follow-up in the reintervention rate analysis was 3.4 years (IQR = 0.9–7.3 years). The risk of requiring reintervention on the aortic valve and/or root was higher in patients who underwent VSARR with remodeling (HR = 1.49; 95% CI = 1.07–2.07; p = 0.019, log-rank test p < 0.001). No statistically significant differences were identified in age, female sex, connective tissue disorders, bicuspid aortic valve, aortic dissection, coronary artery bypass, total arch replacement, or annular stabilization, indicating that these variables did not influence the results in the pooled analysis.

Authors conclude that VSARR with reimplantation is associated with improved overall survival and a reduced risk of reintervention compared to VSARR with remodeling. For overall survival, a favorable temporal effect was noted with the reimplantation technique up to 4 years of follow-up, though not beyond.

COMMENTARY:

This meta-analysis provides valuable data for the literature, mostly from single-center studies, many of which failed to detect significant differences between techniques.

These findings likely reflect the prevalence of observational series (mostly single-center) that carry a high risk of bias, along with pathology heterogeneity represented, including sporadic aneurysms, type A dissections, bicuspid aortic valves, and genetic aortopathies.

The reimplantation technique was associated with improved overall survival and a lower risk of reintervention over time. However, after 4 years, this benefit was not clearly evident. Furthermore, no modulating factors were identified in these observed effects.

The long-term stability of the remodeling technique compared to reimplantation may be compromised due to the lack of aortic ring stabilization, particularly when no additional subvalvular stabilization suture or concomitant annuloplasty rings are used. David et al. emphasized that restoring the normal geometry of the aortic cusps is critical for the long-term success of VSARR. Cusp coaptation should occur a few millimeters above the nadir of the aortic annulus, and the coaptation length should be at least 4 mm in the central portion.

The primary advantage of the remodeling technique is argued to be the restoration of aortic sinuses for more physiologic aortic valve function. However, while aortic root remodeling is a physiologically superior procedure compared to aortic valve reimplantation, it does not address aortic annulus dilation, a significant issue in younger patients. Progressive annular dilation post-remodeling has been the main cause of procedural failure, particularly in patients with Marfan syndrome.

When annular dilation is present, or when the annulus is at risk of future dilation, the remodeling procedure is now commonly combined with annuloplasty, which can be performed using an external ring, a Dacron band, or a heavy Gore-Tex suture.

A recent substudy from the Aortic Valve Insufficiency and Ascending Aorta Aneurysm International Registry (AVIATOR) indicated that VSARR is a safe and durable procedure for patients with hereditary aortic disorders. However, root remodeling alone was associated with late annular dilation. In AVIATOR, grade 2 or higher aortic insufficiency rates were high in both groups and comparable between reimplantation and remodeling with annuloplasty, prompting consideration of valved conduit replacement (De Bono-Bentall procedure) in cases with suboptimal outcomes. The comparison between valve-sparing root replacement vs. valved conduits has already been discussed in previous blog entries.

In this meta-analysis, only 3 studies clearly described the type of reimplantation technique (whether David I or David V or a combination), limiting the ability to evaluate this as a confounding or modulating variable. Additionally, it would have been beneficial if studies had described annular and aortic root sizes to analyze the extent to which these factors modulate our findings.

In concluding this discussion, it is important to note that in technically demanding surgeries such as those described by David and Yacoub, surgeon experience creates a significant confounding factor. Therefore, surgeons should avoid generalizing results with both strategies and should prioritize individualized decisions for each patient and operating surgeon.

The surgical treatment of the aortic root presents contrasting alternatives with ongoing questions. When should the aortic valve be replaced or preserved? Is remodeling or reimplantation better? Should annuloplasty be routinely added to remodeling, and if so, which is preferable? Scientific evidence, to which this meta-analysis now contributes, gradually helps answer these questions. Nevertheless, while this debate continues, the cardiac surgeon must decide on the best therapeutic option for each patient with a dilated aortic root.

REFERENCE:

Sá MP, Jacquemyn X, Awad AK, Brown JA, Chu D, Serna-Gallegos D, et al. Valve-Sparing Aortic Root Replacement With Reimplantation vs Remodeling: A Meta-analysis. Ann Thorac Surg. 2024 Mar;117(3):501-507. doi: 10.1016/j.athoracsur.2023.08.018.