Is aortic valve repair or replacement with a bioprosthetic valve the best option for a patient with severe aortic regurgitation?

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is best to repair or replace the aortic valve with a bioprosthesis in young patients with severe aortic regurgitation as the patients do not like to take warfarin for the rest of life. Altogether 74 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The results of the reported studies provided interesting results. All the studies identified are retrospective. Three papers reported the results about the Ross operation for aortic valve (AV) disease. Freedom from autograft reoperation at 10 years was from 81 to 84%, at 15 years 92% and at 18 years 51%. Freedom from aortic insufficiency (AI) (moderate to severe) at 15 years was 89.7%. Four papers reported that freedom from AV reoperation after AV repair at 5 years was from 86 to 94% and at 8 years was from 83 to 93%. Freedom from recurrent AI (>2+) at 5 years was from 85 to 94%. One study showed that reoperation-free survival after AV repair for rheumatic valve disease at 160 months was 85%. Two papers compared AV repair with aortic valve replacement (AVR) with a bioprosthetic valve and found that freedom from AV reoperation at 5 years was from 90 to 91% for the repair group and 94 to 98% for AVR. Freedom from AI (moderate or severe) at 5 years was 79% for the repair group and 94% for AVR. Aortic valve repair yielded good early and mid-term results. It is a viable alternative to replacement with a bioprosthesis, especially for young patients who did not like to take warfarin. The Ross operation appeared to be a good choice for selected patients with AV disease.

INTRODUCTION

A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].

THREE-PART QUESTION

In [young patients with severe aortic regurgitation] is [aortic valve repair or replacement with a bioprosthetic valve] the best operation in order to optimize [event free survival]?

CLINICAL SCENARIO

A young patient is referred with dyspnoea. Echocardiography shows severe aortic regurgitation. The patient does not like to take warfarin for life. You tell him that there are two options of surgical treatment: aortic valve repair or aortic valve replacement with a bioprosthetic valve.

SEARCH STRATEGY

An English language literature review was performed on Medline using the Ovid interface from 1980 to April 2013 [aortic valve repair. mp OR aortic valve replacement. mp OR bioprosthetic valve. mp] AND [aortic valve regurgitation, mp].

All reference lists of articles found were reviewed for further relevant articles.

SEARCH OUTCOME

Using the reported search, 74 papers were identified, of which 10 papers provided the best evidence to answer the question. These papers are summarized in Table 1.

Table 1:

Best evidence papers

Author, date, journal and country Study type (level of evidence)	Patient group	Outcomes	Key results	Comments
Casselman et al. (1999), Eur J Cardiothorac Surg, USA [2] Cohort study (level 2b)	94 patients with BAV and regurgitation from leaflet prolapse underwent aortic valve repair Mean age was 38 ± 10 years (range 16–67 years) In 66 of 94 (70%) cases, the repair employed triangular resection of the prolapsing leaflet. The remainder 28 of 94 (30%) underwent mid-leaflet plication of the prolapsing leaflet Isolated aortic valve repair was performed in 80 of 94 (85%) patients. Concomitant procedures were done in 14 of 94 (14.8%) patients	Mean follow-up Re-exploration for bleeding Early deaths Late deaths Episodes of thromboembolism or endocarditis Aortic valve reoperations during follow-up Freedom from aortic valve reoperation at 1, 5 and 7 years after aortic valve repair Aortic regurgitation (≥2+) at late follow-up	5.1 ± 2.4 years 5 of 94 (5%) patients None None None 12 of 94 (13%) patients (3 re-repairs and 9 AVR) 95, 87 and 84%, respectively 22 of 60 (37%) patients who underwent triangular resection and 10 of 26 (38%) patients who underwent plication (P = 0.7)	A limitation was that this study was a single-institution, single-surgeon study Late aortic regurgitation did not progress with time (P = 0.3) In this study, another consideration was the technique for eliminating the prolapsing area, triangular resection vs central plication The authors changed their technique in favour of plication of the central area BAV repair for prolapsing leaflet is a safe procedure with good intermediate term results. Any residual aortic regurgitation jeopardizes repair durability. Initial repair is more difficult in dilatated, poor functioning ventricles
Davierwala et al. (2003), J Heart Valve Dis, Canada [3] Cohort study (level 2b)	151 patients with BAV disease and AI underwent surgery Mean age was 39.3 ± 12.1 years for the repair group and 40.4 ± 12.4 years for the replacement group 44 patients who underwent aortic valve repair were matched for age and left ventricular function to 44 patients who had AVR with biological valves 40 of 44 (91%) patients in the repair group and 15 of 44 (34%) patients in the replacement group had single cusp prolapse. 11 patients in the repair group and 12 patients in the AVR group had asymptomatic ascending aortic aneurysm	Mean follow-up Operative deaths Late deaths AI (trace or no) before leaving hospital AI (mild) before leaving hospital Mean peak systolic gradient across the aortic valve at discharge Thromboembolic or haemorrhagic events Aortic valve reoperation Freedom from AV reoperation at 1 year Freedom from AV reoperation at 5 years Freedom from AI at 1 year Freedom from AI at 5 years Peak systolic gradient across the aortic valve at last follow-up	2.6 ± 2.1 years for the repair group and 3.5 ± 2.1 years for the replacement group None None 35 of 44 (79.5%) patients in the repair group and 38 of 44 (86%) patients in the AVR group 9 of 44 (20.5%) in the repair group and 6 of 44 (14%) in the AVR group (P = 0.04) 16.2 ± 7.6 mmHg for repair and 13.2 ± 7.2 mmHg for AVR group (P = 0.08) None in either group 4 of 44 (9%) patients in the repair group and 2 of 44 (4.5%) patients in the AVR group 95 ± 4% in the repair group and 100% in the replacement group (P = 0.1) 91 ± 5% in the repair group and 94 ± 6% in the replacement group (P = 0.1) 85 ± 7% in the repair group and 100% in the AVR group (P = 0.024) 79 ± 8% in the repair group and 94 ± 6% in the AVR group (P = 0.024) 11.7 ± 6.8 mmHg in the repair group and 13.3 ± 9.6 mmHg in the AVR group (P = 0.4)	Small sample size Short duration of follow-up Retrospective study It might be concluded that most patients could undergo a valve repair for AVR with biological valves for incompetent BAV with no mortality and only low morbidity. But the study promoted scepticism about repairing incompetent BAV because of a higher recurrence or progression of AI in those patients compared with those who underwent AVR with biological valves
Talwar et al. (2005), Ann Thorac Surg, India [4] Cohort study (level 2b)	61 patients with rheumatic aortic valve disease underwent aortic valve repair, 41 (67%) patients were male Mean age was 23.7 ± 9.3 years The aortic valve disease was graded as moderate (n = 3) or severe (n = 58) Pure AR was present in 48 of 61 (78.7%) patients, pure AS was present in 6 of 61 (9.7%) patients and mixed AS and AR was present in 7 (11.3%) patients 39 (63.9%) patients were in New York Heart Association Class III Associated procedures included mitral valve repair (n = 36) and tricuspid valve repair with mitral valve repair (n = 5)	Mean follow-up Early mortality Thromboembolic events or haemolysis Endocarditis Aortic regurgitation (no or trivial or mild at closing interval) AR (moderate or severe at closing interval) Freedom from significant AR or AS (at 160 months) Late deaths Reoperations due to valve dysfunction (AVR) Freedom of reoperation (at 160 months) Late deaths Actuarial survival (at 160 months) Event- free survival in operative survivors (at 160 months)	93.8 ± 46.4 months 4.9% (3 of 61 patients) None 1 of 61 patient (0.2 events per 100 patient-years) 79.4% (46 of 58 survivors) 20.6% (12 of 58 survivors) 52.5 ± 16.9% None 4 of 58 (6.9%) 85.4 ± 6.7% None 95 ± 2.8% 48.5 ± 15.9%	Patients were highly selected. Aortic valves were considered suitable for repair if there was minimal calcification of aortic valve leaflets, some degree of mobility of cusps and at least 2–3 mm of leaflet coaptation Only patients with a successful aortic valve repair were included for longer term follow-up More than half of patients had combined aortic and mitral valve repair
de Kerchove et al. (2009), Ann Thorac Surg, Belgium [5] Cohort study (level 2b)	218 patients underwent the Ross operation, [148 of 218 (68%) patients had root replacement and 70 of 218 (32%) had the inclusion technique] Mean age was 40 ± 10 years 31% of patients had AR, 34% of patients had AS and 35% of patients had mixed aortic lesion, 60.5% of patients had congenital aortic valve disease	Mean follow-up Early mortality Late mortality Overall survival at 10 years Freedom from autograft reoperation at 10 years Freedom from RVOT reintervention at 10 years Freedom from autograft valve replacement at 10 years Freedom from proximal aorta dilatation >40, ≥45 and ≥50 mm Freedom from autograft regurgitation (moderate or greater) Freedom from autograft failure at 10 years	94 ± 44 months 3 of 218 (1.5%) patients 5 of 218 (2.3%) patients 94 ± 4% (root group) and 97 ± 3% (inclusion group) 81 ± 10% (root group) and 84 ± 13% (inclusion group) 100% in both groups 95 ± 5% 57 ± 12%, 67 ± 12%, 81 ± 11%, respectively (in root group) and 80 ± 15%, 87 ± 12%, 95 ± 5%, respectively (in inclusion group) 73 ± 14% in root group and 76 ± 10% in inclusion group 75 ± 11% in root group and 83 ± 13% in inclusion group	A limitation was the origin diversity of the echocardiographic data with the variability that it induced in measures Another limitation was the missing data on annulus dimension Another limitation was the absence of randomization between both techniques The main cause of reoperation was autograft dilatation in the root group and valve prolapse in the inclusion group. The root technique, follow-up length and preoperative aortic valve regurgitation were predictors of proximal aorta dilatation
Ashikhmina et al. (2010), J Thorac Cardiovasc Surg, USA [6] Cohort study (level 2b)	108 patients underwent BAV repair for aortic regurgitation with or without concomitant supracoronary tube graft replacement of the ascending aorta for aortic dilatation The cohort of patients with the repair was matched with 81 patients who underwent AVR with a bioprosthesis (matching by year of operation, age and sex) The mean age was 41 years The primary indication for operation was moderately severe or severe AR in 90 (83%) patients, and severe mitral regurgitation was associated with at least moderate AR in 9 (8%) patients Isolated BAV repair was performed in 61 (56%) patients AV repair was combined with graft replacement in 15 patients and with reduction annuloplasty in 8 patients for dilatation of the ascending aorta; 11 patients had concomitant mitral valve repair	Mean follow-up Early deaths Late deaths Survival rates at 1, 5 and 10 years AVR after aortic valve repair Freedom from valve replacement at 1, 5 and 10 years after repair Survival at 10 years for the group with aortic valve repair matched with the group with AVR Freedom from reoperation at 5 and 10 years for the group with aortic valve repair matched with the group with AVR	5.1 years None 7 of 108 (6%) 99, 96 and 87%, respectively, which are similar to those of an age- and sex-matched general population 19 of 108 (17.5%) patients [failure of the repair was the primary indication for reoperation in 14 of 19 patients] 96, 89 and 49%, respectively 72 vs 79%, respectively (P = 0.13) 90 vs 98% and 72 vs 64%, respectively (P < 0.12)	The present study focused on outcomes of a homogeneous group of patients with regurgitation of a BAV In that study, the comparability of risk of reoperation for patients undergoing BAV repair vs AVR with a bioprosthesis was important. The cumulative risk of reoperation for patients with a bioprosthesis appears to increase sharply after 8 years All patients in the study had preserved left ventricular ejection fraction (>45%), so no conclusion can be made about the feasibility of BAV repair in patients with impaired myocardial performance The end point of that study was reoperation but not the grade of AR, so the incidence of severe AR (e.g. repair failure) could be underestimated
Boodhwani et al. (2010), J Thorac Cardiovasc Surg, Belgium [7] Cohort study (level 2b)	122 consecutive patients with bicuspid aortic valves underwent non-emergency valve repair for isolated aortic insufficiency (43%), aortic root dilatation (14%) or both (43%) Mean age was 44 ± 11 years Preoperative echo identified aortic dilatation (n = 75), cusp prolapse (n = 96) and cusp restriction (n = 45) Raphé repair (n = 98) was performed by shaving (21%) or resection with primary closure (60%) or pericardial patch (18%) Functional aortic annuloplasty was performed using subcommissural annuloplasty (n = 51), ascending aortic replacement (n = 17) or aortic root replacement (n = 54) using a reimplantation (76%) or remodelling technique (24%)	Mean follow-up Clinical follow-up In-hospital mortality Stroke Early AV reoperations Late AV reoperations Freedom from AV reoperation at 5 and 8 years Freedom from AV replacement at 5 and 8 years Freedom from bleeding and thromboembolic complications at 8 years AI (grade 0) at discharge AI (grade I) at discharge AI (grade II) at discharge Freedom from recurrent AI (>2+) at 5 years Overall survival at 8 years	61 ± 38 months 100% None 1 (0.8%) patients 5 of 122 (4%) patients 7 of 122 (5.7%) patients 94 ± 2%, 83 ± 5%, respectively 96 ± 2%, 90 ± 5%, respectively 96 ± 2% 50% (59 of 122) 43% (51 of 122) 7% (9 of 122) 94 ± 3% 97 ± 3%	A study limitation was that it was a single-centre experience using an approach and surgical techniques that had evolved over the past decade BAV repair yielded good early and mid-term results Repair of bicuspid valves for aortic insufficiency was a feasible and attractive alternative to mechanical valve replacement in young patients Follow-up echo was not always obtained at Saint-Luc Hospital and thus a number of quantitative parameters and descriptive features of recurrent AI were not available
David et al. (2010), J Thorac Cardiovasc Surg, Canada [8] Cohort study (level 2b)	212 patients underwent the Ross operation Mean age was 34 ± 9 years 82% of patients had congenital aortic valve disease 77 (36.3%) patients had aortic insufficiency, 28 (13.2%) patients had mixed aortic lesion and 107 (50.4%) patients had aortic stenosis	Mean follow-up Operative deaths Late deaths Survival at 15 years Freedom from thromboembolic complications at 15 years Freedom from infective endocarditis of the pulmonary homograft at 15 years Late major haemorrhagic event Freedom from reoperation on the pulmonary autograft at 15 years Freedom from any reoperation or transcatheter valve implantation at 15 years Freedom from moderate or severe AI (>3+) at 15 years Freedom from AI (>2+) at 15 years Freedom from moderate or severe pulmonary insufficiency, peak gradient of ≥40 mmHg or both at 15 years Event-free survival at 15 years	10.1 ± 4.2 years 1 of 212 patients 4 of 212 patients 96.6 ± 1.5% 98.4 ± 0.8% 97.5 ± 1.4% None 92.1 ± 2.3% 85.2 ± 3.5% 89.7 ± 3.3% 63.2 ± 8.6% 70.8 ± 6.8% 81 ± 3.7%	A limitation is that the results were from a single institution. Survival at 15 years was similar to that seen in general population matched for age and sex The best results were in female patients, those with aortic stenosis and those with an aortic annulus of <27 mm in diameter The Ross operation provided suboptimal results in male patients with AI The technique of implantation did not have a demonstrable effect on the fate of operation Patients with a dilatated aortic annulus at the time of surgical intervention did not resolve the problem, so a dilatated aortic annulus might be a marker for premature degeneration of the pulmonary autograft cusps
Badiu et al. (2011), Eur J Cardiothorac Surg, Germany [9] Cohort study (level 2b)	100 patients underwent AV repair for insufficient bicuspid AV (n = 43) and tricuspid AV (n = 57). AR more than moderate was present in 31 of 43 (72%) patients in the bicuspid AV group and in 21 of 57 (37%) patients in the tricuspid AV group, respectively. A root replacement with the reimplantation technique was performed in 16 of 43 (37%) and 21 of 57 (37%) patients with a BAV and a TAV, respectively. A root replacement with the remodelling technique was performed in 4 of 43 (9%) and 3 of 57 (5%) patients diagnosed with a BAV and a TAV, respectively. Mean age was 39.5 ± 14 years for BAV group and 52.9 ± 19.6 years for TAV group	Mean follow-up Deaths during initial hospitalization Deaths during follow-up Overall actuarial 3 years' survival Overall actuarial 3 years’ freedom from AV-related reoperation Reoperations for AV-related disorders after discharge Overall actuarial 3 years’ freedom from recurrent AR≥ moderate Overall actuarial 3 years’ freedom from recurrent AR≥ trace 3-year freedom from thromboembolic events	22 months 3 of 100 (0.03%) patients 1 of 97 survivors 93 ± 4.2% [80 ± 18% in the BAV group and 94 ± 3.2% in the TAV group] 86 ± 5.1% (85 ± 9.7% in the BAV group and 86 ± 6.0% in the TAV group, P = 0.98) 8 patients (7 AVR and 1 Ross) 100% 71.3 ± 8.2% (76.5 ± 11.7% for BAV and 71.4 ± 9.4% for TAV, P = 0.97) 97.9 ± 2% (not significantly different between two groups, P = 0.31)	The main limitation was the small number of patients in both subgroups The reduced follow-up time might also lead to a misestimation of the results There was no statistically significant difference in terms of early or mid-term complications mortality, valve-related reoperation or recurrent AV regurgitation between patients who presented with bicuspid or tricuspid AVs
Boodhwani et al. (2011), J Thorac Cardiovasc Surg, Belgium [10] Cohort study (level 2b)	111 patients with tri-leaflet aortic valve had aortic valve repair 50 of 111 (45%) patients had isolated cusp prolapse and 61 of 111 (55%) patients had cusp prolapse with ascending aortic dilatation Mean age was 57 ± 17 years 4 of 50 (8%) patients of the isolated group and 8 of 61 (13%) patients of the associated group had previously undergone a Ross procedure. Patients with isolated AI had more severe insufficiency (P = 0.005) and larger left ventricular diameters. An eccentric jet was found in 83% of patients in the isolated group and 63% of the associated group (P = 0.02). A fibrous band was identified in 67% of patients in the isolated group and 34% of the associated group (P = 0.001) A diagnosis of cusp prolapse could be made in 85% of the isolated group and 66% of the associated group	Mean follow-up Clinical follow-up In-hospital mortality Early AV reintervention Permanent pacemaker postoperatively Re-exploration for bleeding Post-repair intraoperatively AI (0, 1+) AI (2+) At discharge AI (2+) AI (0 or 1+) Deaths during follow-up AV reoperation during follow-up Freedom from AV reoperation at 8 years Freedom from recurrent AI (>2+) at 5 years Overall freedom from thromboembolism, bleeding or endocarditis at 8 years	3.8 years 100% None None 4 of 111 (3.6%) 10 of 111 (9%) 105 (95%) patients 6 (5%) patients 13 (12%) patients 88% patients 5 of 111 (4.5%) patients 4 of 111 (4%) patients 100% in the isolated group and 93 ± 4% in the associated group (P = 0.33) 90 ± 5% in the isolated group and 85 ± 8% in the associated group (P = 0.54) 98 ± 2%	A limitation was that it was a single-centre study in which techniques and indications had evolved over the past 15 years The choice of surgical technique did not affect aortic insufficiency recurrence at follow-up Patients with mild preoperative AI are unlikely to require cusp repair In patients in whom residual AI is found after a valve-sparing root replacement procedure, the presence of an eccentric AI jet suggests uncorrected cusp prolapse and can be localized and corrected The outcome of AV repair in the setting of patients having AV-sparing operations is durable in the mid-term and is associated with a lot of incidence of valve-related events The most commonly repaired cusp was the right coronary cusp (n = 75), followed by the non-coronary cusp (n = 38) and the left coronary cusp (n = 31)
Mokhles et al. (2012), Eur Heart J, Netherlands [11] Cohort study (level 2b)	161 patients underwent the Ross operation Mean age was 20.9 ± 13.7 years 123 patients (76.4%) had congenital AV disease (including BAV) 46 patients (28.6%) had AR, 47 (29.2%) patients had AS and 68 (42.2%) patients had mixed AV disease	Mean follow-up Early mortality Deaths during follow-up Overall survival up to 18 years Patients required reintervention related to the Ross operation during follow-up Freedom from reoperation for autograft failure after 10 and 18 years Freedom from reintervention for allograft failure after 10 and 18 years Freedom from reintervention for autograft or allograft failure Endocarditis of the autograft during follow-up Freedom from any valve-related event after 10 and 18 years	11.6 ± 5.7 years 4 (2.5%) patients 8 patients 89% 57 of 161(35%) patients 84 and 51%, respectively 90 and 81%, respectively 80 and 41%, respectively 2 patients (0.11%/patient-year) 79 and 40%, respectively	This study was the first to show the long-term patient survival after the Ross operation at the end of the second postoperative decade A limitation was the absence of a control group The survival rate of Ross patients showed a decline in the second postoperative decade compared with the general population The main cause for autograft reoperation was the progressive dilatation of the neo-aortic root. Over half of the autografts failed prior to the end of the second decade Causes for pulmonary allograft reintervention were mainly structural failure, calcification or degeneration of the valve

AI: aortic insufficiency; AS: aortic stenosis; AV: aortic valve; AR: aortic regurgitation; AVR: aortic valve replacement; TAV: tricuspid aortic valve; BAV: bicuspid aortic valve.

RESULTS

The search was wide. There were 10 retrospective studies and no RCT or meta-analysis.

Casselman et al. [2] reported that freedom from reoperation at 1, 5 and 7 years after aortic valve repair was 95, 87 and 84%, respectively. At late follow-up, aortic regurgitation (≥2+) was observed in 22 of 60 (37%) patients who underwent triangular resection and in 10 of 26 (38%) patients who underwent plication (P = 0.7).

Davierwala et al. [3] showed that freedom from aortic valve reoperation at 5 years was 91 ± 5% in the repair group and 94 ± 6% in the replacement group (P = 0.2). Freedom from moderate or severe AI at 5 years was 79 ± 8% for the repair group and 94 ± 6% for the replacement group (P = 0.024).

Talwar et al. [4] showed that 79.4% (46 of 58) of survivors who underwent aortic valve repair for rheumatic aortic valve disease had no or trivial or mild aortic regurgitation at closing interval. Actuarial and reoperation-free survival at 160 months were 95.2 ± 2.8% and 85.4 ± 6.7%, respectively. Freedom from significant aortic stenosis or aortic regurgitation (AR) at 160 months was 52.4 ± 16.9%.

de Kerchove et al. [5] analysed 218 patients that who underwent the Ross operation with two techniques and found that, in the root and inclusion groups, 10-year overall survival was 94 ± 4% and 97 ± 4%, respectively. Freedom from autograft reoperation at 10 years was 81 ± 10% and 84 ± 13%, respectively. Freedom from autograft regurgitation (moderate or greater) at 10 years was 73 ± 14% and 76 ± 10%, respectively.

Ashikhmina et al. [6] showed that freedom from valve replacement at 1, 5 and 10 years after aortic valve repair was 96, 89 and 49%, respectively. Freedom from reoperation at 5 and 10 years between the two matched groups (aortic valve [AV] repair vs aortic valve replacement [AVR]) was 90 vs 98% and 72 vs 64%, respectively. BAV repair was a viable alternative to replacement with a bioprosthesis. After initial repair, approximately half of the patients required AVR within 10 years.

Boodhwani et al. [7] found that freedom from aortic valve reoperation for patients with bicuspid aortic valve (BAV) at 5 and 8 years was 94 ± 2% and 83 ± 5%, respectively. Freedom from AVR at 5 and 8 years was 96 ± 2% and 90 ± 5%, respectively. Freedom from recurrent AI (>2+) at 5 years was 94 ± 3%.

David and co-workers [8] analysed 212 patients who underwent the Ross operation. Freedom from reoperation in the pulmonary autograft at 15 years was 92.1 ± 2.3%. Freedom from moderate or severe AI at 15 years was 89.7%. Freedom from moderate or severe pulmonary insufficiency at 15 years was 70.8 ± 6.8%.

Badiu et al. [9] compared the results after AV repair in BAVs with those in tricuspid aortic valve and found that overall actuarial 3 years' freedom from AV-related reoperation was 86 ± 5.1% without significant differences between the two groups. Overall actuarial 3 years' freedom from AR > trace was 71.3 ± 8.2% without significant differences between the two groups.

Boodhwani et al. [10] analysed the results of aortic valve repair for tri-leaflet AV and found that freedom from aortic valve reoperation at 8 years was 100% in the isolated group and 93 ± 5% in the associated group (P = 0.33). Freedom from recurrent aortic insufficiency (>2+) at 5 years was 90 ± 5% in the isolated and 85 ± 8% in the associated group (P = 0.54).

Mokhles et al. [11] studied 161 patients who underwent the Ross operation. Freedom from autograft reoperation and allograft reintervention at 18 years was 51 and 82%, respectively.

CLINICAL BOTTOM LINE

Three papers reported the results about the Ross operation for AV disease. Freedom from autograft reoperation at 10 years was from 81 to 84%, at 15 years 92% and at 18 years 51%. Freedom from AI (moderate to severe) at 15 years was 89.7%. Four papers reported that freedom from AV reoperation after AV repair at 5 years was from 86 to 94% and at 8 years was from 83 to 93%. Freedom from recurrent AI (>2+) at 5 years was from 85 to 94%. One study showed that reoperation-free survival after AV repair for rheumatic valve disease at 160 months was 85%. Two papers compared AV repair with AVR with a bioprosthetic valve and found that freedom from AV reoperation at 5 years was from 90 to 91% for the repair group and 94 to 98% for AVR. Freedom from AI (moderate or severe) at 5 years was 79% for the repair group and 94% for AVR. Aortic valve repair yields good early and mid-term results. It is a viable alternative to replacement with a bioprosthesis, especially for young patients who did not like to take warfarin. The Ross operation appears to be a good choice for selected patients with AV disease.

Conflict of interest: none declared.