# Root Remodeling versus Root Reimplantation in Patients with Bicuspid Aortic Valve and Root Aneurysm

## TL;DR

This study compares two surgical techniques for treating bicuspid aortic valve and root aneurysm, finding similar safety but recommending one method for better long-term results.

## Contribution

The study provides a direct comparison of root remodeling and reimplantation outcomes in bicuspid aortic valve patients with root aneurysm.

## Key findings

- Root reimplantation had lower rates of late aortic valve regurgitation and reoperations compared to remodeling.
- Both techniques showed similar midterm survival and safety.
- Reimplantation required longer surgical time but led to better valve durability.

## Abstract

Valve-sparing root replacements are increasingly being performed in patients with bicuspid aortic valve (BAV) and root aneurysm. This study aims to compare the outcomes of patients who underwent root remodeling versus root reimplantation.

From 2000 to 2022, 206 adults with BAV and root aneurysm (mean age: 47 ± 12 years, 183 [89%] male) underwent root remodeling (
n
 = 32) or reimplantation (
n
 = 174) at Cleveland Clinic. Compared with remodeling, patients in the reimplantation group had more aortic regurgitation (severe 61/174 [35%] vs. 3/32 [9.4%]) and smaller aortic roots (sinus diameter: 4.3 ± 0.56 vs. 4.6 ± 0.47 cm). Operative mortality and morbidity, durability, and time-related mortality were compared.

Patients in both groups underwent additional aortic valve repair (reimplantation vs. remodeling group: figure-of-8 hitch-up stitch 10/174 [5.7%] vs. 14/32 [44%],
p
 < 0.001; cusp plication 91/174 [52%] vs. 11/32 [34%],
p
 = 0.06). Compared with the remodeling group, aortic clamp time was longer in the reimplantation group (median 136 vs. 76 minutes,
p
 < 0.001). Two in-hospital reoperations occurred after remodeling from valve dysfunction. One operative death occurred in each group. At 5 years, severe aortic regurgitation was 16% after remodeling versus 5.0% after reimplantation (
p
 = 0.06), mean gradient 11 versus 10 mm Hg (
p
 = 0.12), aortic valve reoperation 23% versus 6.0% (
p
 = 0.14), and survival 97% versus 95%, respectively (
p
 = 0.71).

Both root remodeling and reimplantation can be safely performed in patients with BAV and root aneurysms with similar midterm outcomes. Although root remodeling is a shorter surgery, less late aortic valve regurgitation and fewer valve reoperations lead us to recommend root reimplantation.