Comparison of outcomes following valve-sparing aortic root replacement in patients with bicuspid and tricuspid aortic valves: A meta-analysis

Abstract

BACKGROUND

Aortic root dilation, linked to bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV), risks aneurysm and dissection. Valve-sparing aortic root replacement (VSARR) preserves native valves, avoiding prosthetic valve complications. Long-term VSARR durability, especially in BAV patients, is debated. We hypothesize that VSARR outcomes differ between BAV and TAV patients in short-term and long-term settings.

AIM

To investigate short-term and long-term outcomes of VSARR in BAV vs TAV patients.

METHODS

This Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant meta-analysis included observational studies comparing VSARR in adult BAV vs TAV patients. PubMed, ScienceDirect, and EMBASE were searched from inception to June 2025. Outcomes included mortality, reintervention, and procedural times. Pooled relative risk (RR) and mean differences (MD) with 95%CI were calculated. Risk of bias was assessed using Risk of Bias in Non-randomized Studies of Interventions; evidence certainty via GRADE.

RESULTS

Thirteen observational studies involving 1419 BAV and 2349 TAV patients were included. In-hospital mortality (RR = 0.34, 95%CI: 0.10–1.14, P = 0.08) and reoperation (RR = 1.04, 95%CI: 0.64–1.69, P = 0.87) showed no significant differences. All-cause mortality risk was significantly lower in BAV patients (RR = 0.34, 95%CI: 0.13–0.86, P = 0.02). Overall reintervention risk was significantly greater in BAV patients (RR = 2.64, 95%CI: 1.96–3.55, P < 0.00001). Aortic cross-clamp (MD = 3.35 minutes, 95%CI: -5.06 to 11.76, P = 0.43) and cardiopulmonary bypass times (MD = 3.96 minutes, 95%CI: -10.26 to 18.18, P = 0.59) showed no significant differences but substantial heterogeneity. The certainty of evidence was moderate for reintervention, low for mortality risk and in-hospital reoperation, and very low for procedural times.

CONCLUSION

VSARR demonstrates comparable short-term safety between BAV and TAV patients. However, BAV patients face a significantly higher long-term reintervention risk, highlighting the need for tailored strategies and further research.

Keywords: Valve-sparing aortic root replacement; Bicuspid aortic valve; Tricuspid aortic valve; Reintervention; Mortality

Core Tip: Valve-sparing aortic root replacement (VSARR) preserves native valves in patients with bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV), reducing prosthetic valve complications. Our meta-analysis reveals comparable short-term safety between BAV and TAV patients but a significantly higher long-term reintervention risk in BAV patients. These findings highlight the need for tailored surgical strategies and vigilant long-term monitoring to optimize outcomes in BAV patients undergoing VSARR.