Isolated Aortic Valve Replacement Versus Concomitant Replacement of the Ascending Aorta and Aortic Valve: A Statistical Analysis and Literature Review

TL;DR

This study compares outcomes of isolated aortic valve replacement versus combined aortic valve and ascending aorta replacement surgeries.

Contribution

The study provides institutional data comparing two surgical approaches and evaluates their risks and outcomes.

Findings

Concomitant surgery significantly increases cardiopulmonary bypass and aortic cross-clamp times.

Hospital mortality rates were low and comparable between the two surgical approaches.

Patient demographics and comorbidities differed significantly between the two groups.

Abstract

Introduction: In contemporary practice, a cardiac surgeon is often confronted with critical questions. Should the ascending aorta be replaced concomitantly when the aortic valve is replaced? Does simultaneous surgery significantly increase operative risk? Although the literature offers answers, the decision for simultaneous surgery remains individualized for every patient, taking into account clinical and nonclinical data. Concomitant replacement of the ascending aorta and aortic valve was first introduced in the 1960s, and since then, the debate has continued regarding the most appropriate surgical strategy for managing aneurysmal disease of the ascending aorta and the criteria guiding such interventions. We aim to present and compare our institutional data on isolated aortic valve surgery versus concomitant replacement of the aortic valve and ascending aorta and to compare our findings with the literature.

Methods: We retrospectively analyzed our database of adult patients (≥18 years) who underwent isolated aortic valve replacement (AVR) or concomitant AVR and ascending-aorta replacement from 2007 to 2023 at the Cardiac Surgery Service, University Hospital Center “Mother Teresa,” Tirana. Data were extracted from operating-room registers and medical records. Demographic, pre-, intra-, and postoperative clinical variables were collected. Continuous variables are presented as mean ± standard deviation; categorical variables as percentages. Statistical analysis was performed with IBM SPSS Statistics for Windows, version 26.0.

Results: The study included 491 patients who underwent isolated AVR and 131 patients who had concomitant AVR with ascending-aorta replacement. Sex (p < 0.001) and age (p < 0.001) differed significantly between the groups. Concomitant surgery involved 102 men (77.9%), whereas isolated surgery involved 311 men (63.3%). The mean age for isolated AVR was 62.28 ± 10.76 years; for concomitant surgery, 57.33 ± 11.90 years. New York Heart Association (NYHA) class was also significant, with 457 patients (94.8%) in NYHA II-III in the isolated group and 128 patients (97.7%) in the concomitant group. Arterial hypertension and diabetes mellitus were statistically significant comorbidities; renal insufficiency, smoking, obesity, and COPD were not. Cardiopulmonary bypass (CPB) time (83.85 ± 22.63 min vs. 111.09 ± 23.67 min; P < 0.001) and aortic cross-clamp time (65.22 ± 19.20 min vs. 89.56 ± 20.71 min; P < 0.001) differed significantly. Aortic annulus diameter, body-surface area, and indexed effective orifice area (SEPi) were also significant variables. Although hospital mortality was not statistically different, it was the most clinically relevant outcome in comparison with several international centers, underscoring the good results of our surgical team. Hospital mortality for isolated AVR was 1.6% (eight patients); for concomitant surgery, 2.29% (three patients). This analysis was limited to in-hospital outcomes. No long-term follow-up data, such as reoperation rates, late complications, or survival beyond discharge, were included.

Conclusion: Concomitant replacement of the aortic valve and ascending aorta markedly prolongs CPB and aortic cross-clamp times compared with isolated AVR, yet mortality remained low and comparable with leading international centers. Although concomitant surgery carries a higher operative risk than isolated AVR, our experience demonstrates that it can be performed with satisfactory outcomes.