Long-term Outcomes of Aortic Root Operations in the United States Among Medicare Beneficiaries

Abstract Objectives The best method of aortic root repair (ARR) in older patients remains unknown given a lack of comparative effectiveness long-term outcomes data. Objective of this study was to compare long-term outcomes of different surgical approaches to ARR in Medicare patients using Society of Thoracic Surgeons Adult Cardiac Surgery Database-Centers for Medicare & Medicaid Services (STS ACSD-CMS) linked data. Methods A retrospective cohort study was performed by querying the STS Adult Cardiac Surgery Database for patients 65 years or older, who underwent elective aortic root repair with or without aortic valve replacement. Primary long-term endpoints were mortality, any stroke, and aortic valve re-intervention. Short-term outcomes and long-term survival were compared among each root repair strategy. Additional risk factors for mortality after ARR were assessed with a multivariable Cox Proportional hazards model. Results 4,173 patients age ≥65 years underwent elective aortic root repair. Patients were stratified by operative strategy: mechanical Bentall (MB), stented bioprosthetic Bentall (BB), stentless BB, or valve-sparing root replacement (VSRR). Mean follow-up was 5.0 (± 4.6) years. Relative to MB, stented BB (adjusted hazard ratio [AHR] 0.80, confidence interval [CI] 0.66-0.97) and stentless BB (AHR 0.70, CI 0.59-0.84) were associated with better long-term survival. In addition, stentless BB (AHR 0.64, CI 0.47-0.80), and VSRR (AHR 0.51, CI 0.29-0.90) were associated with lower long-term risk of stroke. Aortic valve re-intervention risk was two-fold higher after VSRR compared to other operative strategies. Conclusions In the Medicare population, there was poorer late survival and greater late stroke risk for patients undergoing MB and a higher rate of re-intervention for VSRR. Bioprosthetic Bentall may be the procedure of choice in older patients undergoing ARR, particularly in the era of transcatheter aortic valve replacement.