Reimplantation of the aortic valve in patients with tricuspid aortic valve: the Toronto General Hospital experience.

Background: Aortic valve sparing operations were introduced three decades ago but controversy remains regarding its appropriateness, reproducibility and durability. This article describes the long-term outcomes of patients who had reimplantation of the aortic valve. Methods: All patients who had reimplantation of a tricuspid aortic valve at Toronto General Hospital from 1989 through 2019 were selected for this study. Patients were followed prospectively with periodical clinical assessments and imaging of the heart and aorta. Results: Four hundred and four patients were identified. The median age was 48.0 [interquartile range (IQR), 35.0-59.0] years and 310 (76.7%) were men. There were 150 patients with Marfan syndrome, 20 with Loeys-Dietz syndrome and 33 with acute or chronic aortic dissections. The median follow-up was 11.7 (IQR, 6.8-17.1) years. There were 55 patients alive and without reoperation at 20 years. The cumulative mortality at 20 years was 26.7% [95% confidence interval (CI): 20.6-34.2%], the cumulative incidence of reoperation on the aortic valve was 7.0% (95% CI: 4.0-12.2%) and the development of moderate or severe aortic insufficiency was 11.8% (95% CI: 8.5-16.5%). We could not identify variables associated with reoperation on the aortic valve or with the development of aortic insufficiency. New distal aortic dissections were common in patients with associated genetic syndromes. Conclusions: Reimplantation of the aortic valve in patients with tricuspid aortic valve provides excellent aortic valve function during the first two decades of follow-up. Distal aortic dissections are relatively common in patients with associated genetic syndromes.

Encuesta multinacional y transversal sobre las controversias del reemplazo de la raíz aórtica con conservación valvular / Multinational and Cross-Sectional Survey on Valve-Sparing Aortic Replacement Controversies

RESUMEN Introducción : El reemplazo de la raíz aórtica con conservación valvular (valve-sparing aortic root replacement, VSAR) se ha consolidado como un procedimiento eficaz para el tratamiento del aneurisma de la raíz aórtica, el síndrome de Marfan, la válvula bicúspide y la disección aórtica. Sin embargo, es necesario llegar a una opinión unánime sobre los aspectos clave del VSAR. Material y métodos : Se realizó una revisión bibliográfica de los debates y controversias más frecuentes del VSAR. A partir de esta información se elaboró una encuesta en línea que se envió a cirujanos con experiencia comprobada en VSAR para conocer su opinión sobre los factores relacionados con los pacientes, los aspectos técnicos, la ecocardiografía, la investigación, la formación y el futuro del VSAR. Resultados : Veinte cirujanos completaron la encuesta. Según 14 de cada 20 encuestados, la fracción de eyección grave se consideró una contraindicación para el llevar a cabo este procedimiento. El límite del diámetro del anillo aórtico para la remodelación fue heterogéneo entre los participantes. Todos ellos consideraron que el VSAR es un procedimiento seguro para los pacientes con síndrome de Marfan y válvula bicúspide. En el caso de disección de tipo A, 11 de cada 20 prefirieron este procedimiento solo para los pacientes jóvenes. En lo que respecta al tamaño del injerto, la altura del triángulo intervalvar (8/20) y el diámetro sinotubular (7/20) fueron los más frecuentes. Los cirujanos informaron una tasa de fracaso del 7% en la conversión al procedimiento de Bentall, y un cambio de estrategia intraoperatoria del 26%. No se consideró que un abordaje mínimamente invasivo mejorara los resultados. La mayoría de los cirujanos coincidieron en que el VSAR lo deben realizar cirujanos con mucha experiencia. Conclusiones : El VSAR ha sido aceptado como una opción terapéutica para el aneurisma de la raíz aórtica, y, aunque todavía no es posible llegar a un consenso definitivo, se presenta la valiosa experiencia de los cirujanos más destacados en este campo.

ABSTRACT Background : The valve-sparing aortic root replacement (VSAR) has been established as a successful procedure for aortic root aneurysms, Marfan's syndrome, bicuspid valves, and aortic dissections. However, there is a need for a consensus opinion regarding key aspects of VSAR. Methods : A literature review was performed regarding the most frequent debates and controversies in VSAR. An online survey was developed based on this information, and sent to surgeons with known expertise in VSAR regarding their opinion on patient-related factors, technical aspects, echocardiography, research, training, and the future of VSAR. Results : Twenty surgeons completed the survey. The reduction of left ventricular ejection fraction was considered a contra indication to VSAR when severe by 14/20 surveyed. The aortic annulus diameter cutoff point for the remodeling was heterogenous among participants. All of them felt that VSAR is safe for the Marfan´s syndrome population and bicuspid valves. For type A dissections, 11/20 preferred this procedure only in young patients. Regarding to graft sizing, the height of the interleaflet triangle (8/20) and the sino-tubular diameter (7/20) were the more frequent considered parameters. Surgeons reported a 7% of failure rate, leading to conversion to Bentall surgery, and a 26% change of strategy intraoperatively. A minimally invasive approach was not considered to improve results. Most of the surgeons agreed that VSAR should be performed by high-experienced surgeons. Conclusions : The VSAR has been accepted as a treatment option for the aortic root´s aneurysms, and even though there is still not possible to reach a final consensus, a valuable experience from the most relevant surgeons in the field is presented.

Derivation and validation of predictive indices for cardiac readmission after coronary and valvular surgery - A multicenter study.

Objective: To derive and validate models to predict the risk of a cardiac readmission within one year after specific cardiac surgeries using information that is commonly available from hospital electronic medical records. Methods: In this retrospective cohort study, we derived and externally validated clinical models to predict the likelihood of cardiac readmissions within one-year of isolated CABG, AVR, and combined CABG+AVR in Ontario, Canada, using multiple clinical registries and routinely collected administrative databases. For all adult patients who underwent these procedures, multiple Fine and Gray subdistribution hazard models were derived within a competing-risk framework using the cohort from April 2015 to March 2018 and validated in an independent cohort (April 2018 to March 2020). Results: For the model that predicted post-CABG cardiac readmission, the c-statistic was 0.73 in the derivation cohort and 0.70 in the validation cohort at one-year. For the model that predicted post-AVR cardiac readmission, the c-statistic was 0.74 in the derivation and 0.73 in the validation cohort at one-year. For the model that predicted cardiac readmission following CABG+AVR, the c-statistic was 0.70 in the derivation and 0.66 in the validation cohort at one-year. Conclusions: Prediction of one-year cardiac readmission for isolated CABG, AVR, and combined CABG+AVR can be achieved parsimoniously using multidimensional data sources. Model discrimination was better than existing models derived from single and multicenter registries.

Derivation and validation of predictive indices for 30-day mortality after coronary and valvular surgery in Ontario, Canada.

BACKGROUND: Coronary artery bypass grafting (CABG) and surgical aortic valve replacement (AVR) are the 2 most common cardiac surgery procedures in North America. We derived and externally validated clinical models to estimate the likelihood of death within 30 days of CABG, AVR or combined CABG + AVR. METHODS: We obtained data from the CorHealth Ontario Cardiac Registry and several linked population health administrative databases from Ontario, Canada. We derived multiple logistic regression models from all adult patients who underwent CABG, AVR or combined CABG + AVR from April 2017 to March 2019, and validated them in 2 temporally distinct cohorts (April 2015 to March 2017 and April 2019 to March 2020). RESULTS: The derivation cohorts included 13 435 patients who underwent CABG (30-d mortality 1.73%), 1970 patients who underwent AVR (30-d mortality 1.68%) and 1510 patients who underwent combined CABG + AVR (30-d mortality 3.05%). The final models for predicting 30-day mortality included 15 variables for patients undergoing CABG, 5 variables for patients undergoing AVR and 5 variables for patients undergoing combined CABG + AVR. Model discrimination was excellent for the CABG (c-statistic 0.888, optimism-corrected 0.866) AVR (c-statistic 0.850, optimism-corrected 0.762) and CABG + AVR (c-statistic 0.844, optimism-corrected 0.776) models, with similar results in the validation cohorts. INTERPRETATION: Our models, leveraging readily available, multidimensional data sources, computed accurate risk-adjusted 30-day mortality rates for CABG, AVR and combined CABG + AVR, with discrimination comparable to more complex American and European models. The ability to accurately predict perioperative mortality rates for these procedures will be valuable for quality improvement initiatives across institutions.

Valve-in-valve prosthesis-late morphological findings.

Since its implantation in 2002, transcatheter aortic valve implantation (TAVI) has become the preferred intervention for patients with severe aortic stenosis and significant co-morbidities. In 2007, it was adopted as a rescue procedure for failed bioprosthetic valves, now known as the valve-in-valve (VIV) procedure. Unlike other modes of treatment with a multitude of phase 4 post-marketing surveillance (PMS) data, use of these valves have increased rapidly even without long term durability data on this procedure and the near lack of information on the pathology of failed transcatheter aortic valve replacement (TAVR) bioprosthesis and especially after the VIV procedure. We present a case of a late explanted VIV bioprosthesis (ten (10) years post-initial aortic valve replacement and five (5) years post-VIV procedure) in a 65-year-old male with multiple morphologic findings. Further availability of standardized morphologic data from explanted bioprosthetic valves is essential to aid in understanding the pathophysiology of tissue degeneration of the TAVI valve, and ultimately to improve patient outcomes by identifying possible early interventional strategies.

Early outcomes of the Bentall procedure after previous cardiac surgery.

OBJECTIVES: We sought to evaluate the early outcomes of patients undergoing a Bentall procedure after previous cardiac surgery. METHODS: From 1990 to 2014, 473 patients underwent a Bentall procedure after previous cardiac surgery with a composite valve graft at a single institution: composite valve graft with a mechanical prosthesis (n = 256) or composite valve graft with a bioprosthesis (n = 217). Patients were excluded if their index operation was less than 30 days before the reoperation. The primary outcome was 30-day mortality. The secondary outcome was a composite of major morbidity and operative mortality: stroke, renal failure, prolonged mechanical ventilation, deep sternal infection, or reoperation during the same admission. Multivariable logistic regression was used to identify risk factors associated with the primary and secondary outcomes of interest. RESULTS: Median age was 57 (interquartile range, 44-67) years, and 349 patients (74%) were male. Median time between index surgery and reoperation was 13 (interquartile range, 8-21) years. A total of 178 patients (38%) underwent urgent or emergency intervention, 61 patients (13%) had active endocarditis/abscess, 87 patients (19%) had left ventricular ejection fraction less than 40%, and 262 patients (55%) had undergone more than 1 previous operation. Previous operations (not mutually exclusive) included coronary artery bypass grafting (n = 58, 12%), aortic valve/root replacement (n = 376, 80%) or repair (n = 36, 8%), and other surgical interventions (n = 245, 52%). Ninety-six patients (20%) had undergone coronary reimplantation during the previous operation, which consisted of a Bentall procedure in 81 patients, a Ross operation in 8 patients, a valve-sparing root replacement in 4 patients, and an arterial switch in 3 patients. At the time of the reoperative Bentall, both coronary arteries were reimplanted directly in 357 patients (77%), whereas 79 patients (17%) received at least 1 interposition graft. In 26 patients (5%), at least 1 of the native coronary arteries was oversewn and a vein graft bypass was performed. Thirty-day mortality occurred in 37 patients (7.8%), and 152 patients (32%) had major morbidity and operative mortality. On multivariable analysis, risk factors associated with increased 30-day mortality included older age and coronary reimplantation by a technique other than direct anastomosis. Indirect coronary reimplantation was also associated with a higher incidence of major morbidity and operative mortality, as were more than 1 previous cardiac operation and preoperative New York Heart Association functional class III/IV or greater. CONCLUSIONS: In the largest reported cohort of aortic root replacement after previous cardiac surgery, the reoperative Bentall procedure was associated with a significant operative risk. The need for complex coronary reimplantation techniques was an important factor associated with adverse perioperative events.

A progress report on reimplantation of the aortic valve.

OBJECTIVE: To examine the late outcomes of reimplantation of the aortic valve (RAV) in patients followed prospectively since surgery. METHODS: All 465 patients who had RAV from 1989 to 2018 were followed prospectively with periodic clinical and echocardiographic assessments. Mean follow-up was 10 ± 6 years and 98% complete. RESULTS: Patients' mean age was 47 ± 5.1 years, and 78% were men. The aortic root aneurysm was associated with Marfan syndrome in 164 patients, Loeys-Dietz syndrome in 13, bicuspid aortic valve (BAV) in 67, and type A aortic dissection in 33. Aortic insufficiency (AI) was greater than mild in 298 patients. Concomitant procedures were performed in 105 patients. There were 5 operative and 51 late deaths. At 20 years, 69.1% of patients were alive and free from aortic valve reoperation, and the cumulative probability of aortic valve reoperation with death as a competing risk was 6.0%, and the cumulative probability of developing moderate or severe AI was 10.2%. Only time per 1-year interval was associated with the development of postoperative AI by multivariable analysis (hazard ratio, 1.06; 95% confidence interval, >1.02-1.10; P = .006). Gradients across preserved BAV increased in 5 patients, and 1 required reoperation for aortic stenosis. Distal aortic dissections occurred in 22 patients, primarily in those with associated genetic syndromes. CONCLUSIONS: RAV provides excellent long-term results, but there is a progressive rate of AI over time, and patients with BAV may develop aortic stenosis. Patients with genetic syndromes have a risk of distal aortic dissections. Continued surveillance after RAV is necessary.

Severely calcified bicuspid aortic valve stenosis after valve-sparing root replacement: A word of caution.

A 58-year-old man was admitted for reoperation for severe aortic stenosis in a previously preserved bicuspid aortic valve (BAV). He had undergone valve-sparing root replacement (VSSR) for dilated aortic root 6 years ago. Transesophageal echocardiography following VSSR showed good valve function with no aortic incompetence. However, the BAV became stenotic causing shortness of breath. At reoperation, the preserved BAV was noted to be fibrotic and calcified and had a fixed rigid small orifice. It was replaced with a biological valve plus root enlargement. Macroscopic finding showed thickening of the cusps and nodular calcification. Microscopic examination revealed severe nodular calcification.

Valve-sparing root replacement in patients with bicuspid versus tricuspid aortic valves.

OBJECTIVES: We sought to compare the outcomes of patients undergoing aortic valve-sparing root replacement with bicuspid versus tricuspid aortic valves. METHODS: A total of 333 consecutive patients (bicuspid aortic valve, n = 45; tricuspid aortic valve, n = 288) underwent valve-sparing root replacement using the reimplantation technique from 1988 to 2012 at a single institution. The primary analysis was performed on a 1:3 bicuspid aortic valve:tricuspid aortic valve propensity-matched dataset to mitigate known differences between these 2 groups. In the matched, dataset, mean age (bicuspid aortic valve: 40 ± 13 years; tricuspid aortic valve: 41 ± 14) and rates of comorbidities were similar between groups. Patients with bicuspid aortic valves were less likely to have Marfan syndrome (bicuspid aortic valve: 9% vs tricuspid aortic valve: 53%, P < .001). Patients were followed prospectively with aortic root imaging for a median of 8.2 (5.3-12.2) years. RESULTS: Primary cusp repair was required more often in patients with bicuspid aortic valves (bicuspid aortic valve: 79% vs tricuspid aortic valve: 45%, P < .001). A total of 3 operative deaths occurred (bicuspid aortic valve 0% vs tricuspid aortic valve 2%, P = .52). The probability of aortic insufficiency increased significantly over time in both groups (odds ratio, 1.106; 95% confidence interval, 1.033-1.185; P = .004), but there was no significant difference in this increase between the bicuspid aortic valve and tricuspid aortic valve groups (P = .08). Long-term freedom from mortality (P = .20), cumulative incidence of aortic valve reoperation (P = .42), and valve-related events (P = .69) were similar across groups. CONCLUSIONS: In well-selected patients with bicuspid aortic valves and favorable cusp morphology, valve-sparing root replacement offers excellent long-term clinical outcomes.

Evolving Surgical Approaches to Bicuspid Aortic Valve Associated Aortopathy.

Bicuspid aortic valve (BAV) is the most common congenital cardiac pathology which results from the fusion of two adjacent aortic valve cusps. It is associated with dilatation of the aorta, known as bicuspid valve-associated aortopathy or bicuspid aortopathy. Bicuspid aortopathy is progressive and is linked with adverse clinical events. Hence, frequent monitoring and early intervention with prophylactic surgical resection of the proximal aorta is often recommended. Over the past two decades resection strategies and surgical interventions have mainly been directed by surgeon and institution preferences. These practices have ranged from conservative to aggressive approaches based on aortic size and growth criteria. This strategy, however, may not best reflect the risks of important aortic events. A new set of guidelines was proposed for the treatment of bicuspid aortopathy. Herein, we will highlight the most recent findings pertinent to bicuspid aortopathy and its management in the context of a case presentation.

The aortic root does not dilate over time after replacement of the aortic valve and ascending aorta in patients with bicuspid or tricuspid aortic valves.

OBJECTIVE: Whether the aortopathy associated with bicuspid aortic valve (BAV) disease occurs secondary to genetic or hemodynamic factors remains controversial. In this article we describe the natural history of the aortic root in patients with bicuspid versus tricuspid aortic valves (TAVs) after replacement of the aortic valve and ascending aorta. METHODS: From 1990 to 2010, 406 patients (269 BAV, 137 TAV) underwent aortic valve and ascending aorta replacement at a single institution. Patients with aortic dissection, endocarditis, previous aortic surgery, or Marfan syndrome were excluded. All available follow-up imaging was reviewed. RESULTS: Mean imaging follow-up was 5.5 (±5.3) years. Of all patients, 66.5% had at least 1 aortic root measurement after the index operation. Baseline aortic diameter was comparable between groups. In patients with BAV, aortic root diameter increased at a clinically negligible rate over time (0.654 mm per year; 95% confidence interval, 0.291-1.016; P < .001), similar to patients with TAV (P = .92). Mean clinical follow-up was 8.1 (±5.4) years. During follow-up, 18 patients underwent reoperation, 89% for a degenerated bioprosthetic aortic valve. Only 1 patient underwent reoperation for a primary indication of aortic aneurysmal disease, 22 years after the index operation. There were no differences in cumulative incidence rates of aortic reoperation (P = .14) between patients with BAV and TAV. CONCLUSIONS: Mid-term imaging after aortic valve and ascending aorta replacement indicates that if the aortic root is not dilated at the time of surgery, the risk of enlargement over time is minimal, negating the need for prophylactic root replacement in patients with BAV or TAV.

Surgical Enlargement of the Aortic Root Does Not Increase the Operative Risk of Aortic Valve Replacement.

BACKGROUND: Surgical aortic root enlargement (ARE) during aortic valve replacement (AVR) allows for larger prosthesis implantation and may be an important adjunct to surgical AVR in the transcatheter valve-in-valve era. The incremental operative risk of adding ARE to AVR has not been established. We aimed to evaluate the early outcomes of patients undergoing AVR with or without ARE. METHODS: From January 1990 to August 2014, 7039 patients underwent AVR (AVR+ARE, n=1854; AVR, n=5185) at a single institution. Patients with aortic dissection and active endocarditis were excluded. Mean age was 65±14 years and 63% were male. Logistic regression and propensity score matching were used to adjust for unbalanced variables in group comparisons. RESULTS: Patients undergoing AVR+ARE were more likely to be female (46% versus 34%, P<0.001) and had higher rates of previous cardiac surgery (18% versus 12%, P<0.001), chronic obstructive pulmonary disease (5% versus 3%, P=0.004), urgent/emergent status (6% versus 4%, P=0.01), and worse New York Heart Association status (P<0.001). Most patients received bioprosthetic valves (AVR+ARE: 73.4% versus AVR: 73.3%, P=0.98) and also underwent concomitant cardiac procedures (AVR+ARE: 68% versus AVR: 67%, P=0.31). Mean prosthesis size implanted was slightly smaller in patients requiring AVR+ARE versus AVR (23.4±2.1 versus 24.1±2.3, P<0.001). In-hospital mortality was higher after AVR+ARE (4.3% versus 3.0%, P=0.008), although when the cohort was restricted to patients undergoing isolated aortic valve replacement with or without root enlargement, mortality was not statistically different (AVR+ARE: 1.7% versus AVR: 1.1%, P=0.29). After adjustment for baseline characteristics, AVR+ARE was not associated with an increased risk of in-hospital mortality when compared with AVR (odds ratio, 1.03; 95% confidence interval, 0.75-1.41; P=0.85). Furthermore, AVR+ARE was not associated with an increased risk of postoperative adverse events. Results were similar if propensity matching was used instead of multivariable adjustments for baseline characteristics. CONCLUSIONS: In the largest analysis to date, ARE was not associated with increased risk of mortality or adverse events. Surgical ARE is a safe adjunct to AVR in the modern era.

Trainee Perceptions of the Canadian Cardiac Surgery Workforce: A Survey of Canadian Cardiac Surgery Trainees.

Management of cardiac surgery health human resources (HHR) has been challenging, with recent graduates struggling to secure employment and a shortage of cardiac surgeons predicted as early as 2020. The length of cardiac surgery training prevents HHR supply from adapting in a timely fashion to changes in demand, resulting in a critical need for active workforce management. This study details the results of the 2015 Canadian Society of Cardiac Surgeons (CSCS) workforce survey undertaken as part of the CSCS strategy for active workforce management. The 38-question survey was administered electronically to all 96 trainees identified as being registered in a Canadian cardiac surgery residency program for the 2015-2016 academic year. Eighty-four of 96 (88%) trainees responded. The majority of participants were satisfied with their training experience. However, 29% stated that their clinical and operative exposure needed improvement, and 57% of graduating trainees did not believe that they would be competent to practice independently at the conclusion of their training. Although 51% of participants believe the job market is improving, 94% of senior trainees found it competitive or extremely difficult to secure an attending staff position. Participants highlighted a need for improved career counselling and formal mentorship. Although the job market is perceived to be improving, a mismatch in the cardiac surgery workforce supply and demand remains because current trainees continue to experience difficulty securing employment after the completion of residency training. Trainees have identified improved career counselling and mentorship as potential strategies to aid graduates in securing employment.

Reimplantation of the aortic valve at 20 years.

OBJECTIVE: To provide additional information on clinical and echocardiographic outcomes after reimplantation of the aortic valve (RAV) in patients with aortic root aneurysm. METHODS: All 333 patients who underwent RAV at our hospital between 1989 and 2012 were followed prospectively with periodical clinical assessment and echocardiography. The mean duration of clinical follow-up was 10.3 ± 6.8 years, and follow-up was completed within 2 years before this report. RESULTS: The study cohort had a mean patient age was 46 ± 5 years and was 78% male. The aortic root aneurysm was associated with Marfan syndrome in 124 patients, with bicuspid aortic valve in 45, with type A aortic dissection in 28, and with moderate to severe aortic regurgitation (AR) in 144. In addition to the RAV, 113 patients underwent another cardiac procedure owing to associated pathology. There were 4 early deaths (<90 days) and 35 late deaths. Survival at 15 and 20 years was 77.9 ± 2.9% and 72.4 ± 3.8%, respectively. Eleven patients developed moderate or severe AR during the follow-up; using interval censoring, 96.2 ± 1.0% were free from this event at 15 to 20 years. Six patients underwent reoperation on the aortic valve at 2 days to 23 years after RAV, including 1 patient for endocarditis and 5 patients for AR; freedom from reoperation at 15 to 20 years was 96.9 ± 1.3%. Seventeen patients sustained stroke or transient ischemic attacks; 92.5 ± 2.8% were free from thromboembolism at 15 and 20 years. Three patients developed infective endocarditis: 1 in the aortic valve and 2 in the mitral valve. CONCLUSIONS: RAV continues to provide excellent clinical results and stable aortic valve function during the second decade of observation.

Valve-Sparing Root Replacement Compared With Composite Valve Graft Procedures in Patients With Aortic Root Dilation.

BACKGROUND: Although aortic valve-sparing (AVS) operations are established alternatives to composite valve graft (CVG) procedures for patients with aortic root aneurysms, comparative long-term outcomes are lacking. OBJECTIVES: This study sought to compare the results of patients undergoing AVS procedures with those undergoing CVG operations. METHODS: From 1990 to 2010, a total of 616 patients age <70 years and without aortic stenosis underwent elective aortic root surgery (AVS, n = 253; CVG with a bioprosthesis [bio-CVG], n = 180; CVG with a mechanical prosthesis [m-CVG], n = 183). A propensity score was used as a covariate to adjust for unbalanced variables in group comparisons. Mean age was 46 ± 14 years, 83.3% were male, and mean follow-up was 9.8 ± 5.3 years. RESULTS: Patients undergoing AVS had higher rates of Marfan syndrome and lower rates of bicuspid aortic valve than those undergoing bio-CVG or m-CVG procedures. In-hospital mortality (0.3%) and stroke rate (1.3%) were similar among groups. After adjusting for clinical covariates, both bio-CVG and m-CVG procedures were associated with increased long-term major adverse valve-related events compared with patients undergoing AVS (hazard ratio [HR]: 3.4, p = 0.005; and HR: 5.2, p < 0.001, respectively). They were also associated with increased cardiac mortality (HR: 7.0, p = 0.001; and HR: 6.4, p = 0.003). Furthermore, bio-CVG procedures were associated with increased risk of reoperations (HR: 6.9; p = 0.003), and m-CVG procedures were associated with increased risk of anticoagulant-related hemorrhage (HR: 5.6; p = 0.008) compared with AVS procedures. CONCLUSIONS: This comparative study showed that AVS procedures were associated with reduced cardiac mortality and valve-related complications when compared with bio-CVG and m-CVG. AVS is the treatment of choice for young patients with aortic root aneurysm and normal or near-normal aortic cusps.