Reported Outcome After Valve-Sparing Aortic Root Replacement for Aortic Root Aneurysm: A Systematic Review and Meta-Analysis
2015; Elsevier BV; Volume: 100; Issue: 3 Linguagem: Inglês
10.1016/j.athoracsur.2015.05.093
ISSN1552-6259
AutoresBardia Arabkhani, Aart Mookhoek, Isabelle Di Centa, Emmanuel Lansac, Jos A. Bekkers, Rob de LInd van Wijngaarden, Ad J.J.C. Bogers, Johanna J.M. Takkenberg,
Tópico(s)Cardiac Valve Diseases and Treatments
ResumoValve-sparing aortic root techniques have progressively gained ground in the treatment of aortic root aneurysm and aortic insufficiency. By avoiding anticoagulation therapy they offer a good alternative to composite graft replacement. This systematic review describes the reported outcome of valve-sparing aortic root replacement, focusing on the remodeling and reimplantation technique.A systematic literature search on the characteristics of and outcomes after valve-sparing aortic root replacement revealed 1,659 articles. The inclusion criteria were a focus on valve-sparing aortic root replacement in adults with aortic root aneurysm, presentation of survival data, and inclusion of at least 30 patients. Data were pooled by inverse variance weighting and analyzed by linear regression.Of 1,659 articles published between January 1, 2000, and January 1, 2014, 31 were included (n = 4,777 patients). The mean age at operation was 51 ± 14.7 years, and 14% of patients had a bicuspid aortic valve. The reimplantation technique was used in 72% and remodeling in 27% (1% other). No clinical advantage in terms of survival and reoperation of one technique over the other was found. Cusp repair was performed in 33%. Pooled early mortality was 2% (n = 103). During follow-up (21,716 patient-years), 262 patients died (survival 92%), and 228 (5%) underwent reoperation, mainly valve replacement. Major adverse valve-related events were low (1.66% patient-years). Preoperative severe aortic valve regurgitation showed a trend toward higher reoperation rate.Remodeling and reimplantation techniques show comparable survival and valve durability results, providing a valid alternative to composite valve replacement. The heterogeneity in the data underlines the need for a collaborative effort to standardize outcome reporting. Valve-sparing aortic root techniques have progressively gained ground in the treatment of aortic root aneurysm and aortic insufficiency. By avoiding anticoagulation therapy they offer a good alternative to composite graft replacement. This systematic review describes the reported outcome of valve-sparing aortic root replacement, focusing on the remodeling and reimplantation technique. A systematic literature search on the characteristics of and outcomes after valve-sparing aortic root replacement revealed 1,659 articles. The inclusion criteria were a focus on valve-sparing aortic root replacement in adults with aortic root aneurysm, presentation of survival data, and inclusion of at least 30 patients. Data were pooled by inverse variance weighting and analyzed by linear regression. Of 1,659 articles published between January 1, 2000, and January 1, 2014, 31 were included (n = 4,777 patients). The mean age at operation was 51 ± 14.7 years, and 14% of patients had a bicuspid aortic valve. The reimplantation technique was used in 72% and remodeling in 27% (1% other). No clinical advantage in terms of survival and reoperation of one technique over the other was found. Cusp repair was performed in 33%. Pooled early mortality was 2% (n = 103). During follow-up (21,716 patient-years), 262 patients died (survival 92%), and 228 (5%) underwent reoperation, mainly valve replacement. Major adverse valve-related events were low (1.66% patient-years). Preoperative severe aortic valve regurgitation showed a trend toward higher reoperation rate. Remodeling and reimplantation techniques show comparable survival and valve durability results, providing a valid alternative to composite valve replacement. The heterogeneity in the data underlines the need for a collaborative effort to standardize outcome reporting. The Appendices can be viewed at the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2015.05.093] on http://www.annalsthoracicsurgery.org.There are no comprehensive recommendations in the literature regarding the surgical treatment of aortic root aneurysms other than that it should be concentrated in centers with proven expertise with the procedure [1Nishimura R.A. Otto C.M. Bonow R.O. et al.2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.J Am Coll Cardiol. 2014; 148: e1-e132Google Scholar]. Various valve-sparing aortic root replacement (VSARR) techniques have been developed in the past decades to preserve the native aortic valve and to avoid anticoagulation therapy, as is needed with the standard composite aortic root replacement (Bentall procedure) [2Bentall H. De Bono A. A technique for complete replacement of the ascending aorta.Thorax. 1968; 23: 338-339Crossref PubMed Scopus (1172) Google Scholar]. The two most widely used techniques are the remodeling and the reimplantation techniques. In the Yacoub procedure, the aortic root is reduced, and neosinuses of Valsalva are created with synthetic tube graft, thereby producing a nearly physiologic reconstruction of the aortic root. However, the aortic annulus remains untreated [3Sarsam M.A. Yacoub M. Remodeling of the aortic valve anulus.J Thorac Cardiovasc Surg. 1993; 105: 435-438PubMed Google Scholar]. The David procedure, the most widely used reimplantation technique, involves reimplantation of the aortic valve within a synthetic tube, whereby the sinotubular junction and the annulus are reduced, but includes the interleaflet triangles, thus impairing root expansibility and possibly valve dynamics [4David T.E. Feindel C.M. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta.J Thorac Cardiovasc Surg. 1992; 103 (discussion 622): 617-621PubMed Google Scholar]. Over the years numerous modifications to these techniques have been described, such as a standardized and physiologic approach to the valve-sparing procedure with the association of a remodeling root reconstruction to an aortic ring annuloplasty to combine the advantages of both original techniques [5Lansac E. Di Centa I. Bonnet N. et al.Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valve-sparing procedure?.Eur J Cardiothorac Surg. 2006; 29: 537-544Crossref PubMed Scopus (70) Google Scholar, 6El Arid J.M. Azzaoui R. Koussa M. Modine T. A technique to facilitate the native valve reimplantation during the David procedure.J Card Surg. 2014; 29: 485-486Crossref PubMed Scopus (2) Google Scholar, 7Hechadi J. De Kerchove L. Tamer S. El Khoury G. Modified valve-sparing reimplantation technique for para-commissural coronary ostia.Eur J Cardiothorac Surg. 2014; 45: 937-938Crossref PubMed Scopus (4) Google Scholar]. The Appendices can be viewed at the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2015.05.093] on http://www.annalsthoracicsurgery.org. To contribute to the debate on which type of valve operation is most appropriate in patients with aortic root aneurysms, we conducted a systematic review of observational reports on characteristics of, and mortality and morbidity after, VSARR, and we explored the factors potentially influencing outcome. This systematic review and meta-analysis was conducted by use of the guidelines of the Meta-Analysis of Observational Studies in Epidemiology proposed by Stroup and colleagues [8Stroup D.F. Berlin J.A. Morton S.C. et al.Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.JAMA. 2000; 283: 2008-2012Crossref PubMed Scopus (16301) Google Scholar]. On January 10, 2014, a search was executed in Embase, MEDLINE, Cochrane database, and Web of Science (Appendix 1). All studies published from January 1, 2000 to January 1, 2014 were screened by two reviewers (B.A. and A.M.) using the following inclusion criteria: reporting on mortality and morbidity after VSARR, study size 30 or more patients, mean age 18 years or older. The exclusion criteria were solely acute aortic dissections, more than 50% children included, studies reporting state of the art, case reports, experimental studies, and reviews. In case of disagreement, studies were assessed by a third, independent reviewer (R.L.W.), and agreement was negotiated. In case of multiple publications on the same patient cohort, the most complete study in terms of outcome with the greatest number of patients included was selected. All selected studies were used for cross-referencing. Microsoft Office Excel (Microsoft, Redmond, WA) was used for data extraction. Data extraction was performed in duplicate by two of the authors (B.A. and A.M.). Outcome events in individual studies were registered according to the 2008 American Association for Thoracic Surgery/Society of Thoracic Surgeons/European Association for Cardiothoracic Surgery guidelines for reporting mortality and morbidity after cardiac valve interventions [9Akins C.W. Miller D.C. Turia M.I. et al.Guidelines for reporting mortality and morbidity after cardiac valve interventions.Ann Thorac Surg. 2008; 85: 1490-1495Abstract Full Text Full Text PDF PubMed Scopus (376) Google Scholar]. Events were not included in our database when adherence to the reporting guidelines could not be ascertained. For each article with missing information on important variables, the corresponding author was requested to provide the missing data. 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Expanding indications for valve-sparing aortic root reconstruction: early and midterm results.Ann Thorac Surg. 2013; 95: 579-585Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]. Data analysis was performed with Microsoft Excel (Microsoft Office 2010, Microsoft) and IBM SPSS version 21.0 (IBM, Somers, NY). Linearized occurrence rates of valve-related adverse events were calculated as number of events divided by number of patient-years for each study and pooled on a logarithmic scale with the use of the inverse variance method in a random-effect model, to minimize the variance of the weighted average. Each random variable is weighted in inverse proportion to its variance. Reported study characteristics are quoted as mean ± standard deviation for continuous variables and percentages for discrete variables. Baseline characteristics are reported as means. For dichotomous or ordinal outcomes, individual and pooled statistics were calculated as occurrence rates and 95% confidence intervals. When the total number of patient-years was not reported, it was calculated by multiplying the number of patients with the mean follow-up time. If a certain event did not occur in an individual study, then we assumed that 0.5 events occurred for that particular outcome, to allow calculation of pooled occurrence rates. When a particular event was not reported in a study, this study was excluded from the analysis of that particular event. Subgroup analyses of outcome were performed for surgical technique (reimplantation vs remodeling), preoperative aortic regurgitation (AR) severity, bicuspid valve disease, connective tissue disease, and cusp repair. To assess the association of these variables with late mortality and reoperation, linear regression was performed with correction for age as a possible confounder. Regression analysis was weighted by study size according to the inverse variance method. Heterogeneity between the studies was assessed with the use of the I2 test in Excel. Funnel plots were used to study publication bias. The initial literature search yielded 1,659 publications. The selection procedure of this systematic review is shown in Figure 1. A total of 31 studies were included in this systematic review, with a total number of 4,777 patients and 21,716 patient-years. An overview of the included publications and study characteristics is given in Appendix 3. The pooled preoperative and perioperative characteristics are shown in Table 1. Early mortality occurred in 103 patients (pooled early mortality 2.2%).Table 1Pooled Preoperative and Perioperative CharacteristicsVariablePooled DataRangeIncluded Studies (n)Total patient number4.77732–43031Surgical period1988–201231Mean age (years)51.029–6330Gender, male (%)71.057%–8530Comorbidity Connective tissue disease (%)23.90–10035 Severe aortic regurgitation (%)46.16.4–10025 Bicuspid aortic valve (%)14.10–3328Prior cardiac operation (%)4.492–1214Other indications Acute type A dissection (%)10.50–3328Reexploration for bleeding (%)6.40–2327Concomitant procedure Aortic (hemi)arch repair (%)22.10–6826 Cusp repairaPeroperative cusp repair to tailor the aortic valve. (%)33.20–7630 CABG (%)9.10–1925 Mitral valve procedure (%)5.30–1225Extracorporeal circulation time, min15766–28122Aortic cross-clamping time, min12236–22322Early mortality (%)2.20–731Causes of early mortalitybMajor causes of early mortality. Low cardiac output (%)29.60–60 Hemorrhage (%)1.00–33 Multiorgan failure (%)12.60–40 Stroke (%)1.00–25 Unknown/unreported (%)55.8CABG = coronary artery bypass grafting.a Peroperative cusp repair to tailor the aortic valve.b Major causes of early mortality. Open table in a new tab CABG = coronary artery bypass grafting. The mean follow-up time after VSARR was 4.4 years (range, 1.5 to 13.2 years). Late mortality occurred in 262 cases and was unknown or unreported in 19% of deaths. The main causes of late mortality were noncardiac (39%). Cardiac valve-related and cardiac non–valve-related death occurred in 37% and 5% of deaths, respectively. The linearized occurrence rates of late mortality, reoperation on the aortic root, hemorrhage, thromboembolism, endocarditis, and major adverse valve-related events are presented along with a measure of statistical heterogeneity in Table 2 and Appendix 3.Table 2Linearized Occurrence Rates of Late Outcome EventsPooled Late Outcome EventsLOR + 95% CIHeterogeneity (I2)Included Studies (n)Events (n)Patient Years (n)Late mortality1.53 (1.19–1.96)82.63126221,274Reoperation on aortic valve1.32 (1.0–1.74)72.33122821,274Hemorrhage0.23 (0.13–0.42)78.7261519,158Thromboembolism0.41 (0.22–0.77)27.6264219,158Endocarditis0.23 (0.11–0.51)0.00302920,930MAVRE1.66 (1.24–2.23)1002030019,158CI = confidence interval; LOR = linearized occurrence rates; MAVRE = major adverse valve-related events. Open table in a new tab CI = confidence interval; LOR = linearized occurrence rates; MAVRE = major adverse valve-related events. Analysis of the funnel plots revealed evidence of underreporting of late mortality in studies with smaller patient numbers. For other factors, no evidence of publication bias was found. A total of 12 studies reported using both the remodeling and the reimplantation techniques. Four studies reported using solely the remodeling technique and 15 studies solely the reimplantation technique. Data about severity of postprocedural AR was mentioned in nine studies and further specified as AR grade II or more in six of these studies, with a total of 41 patients (3.5% of these studies). Additionally, there were no data regarding leaflet heights and coaptation surfaces of the repaired valves. Surgical technique was not associated with higher survival or reoperation rates. Figure 2 represents the association between preoperative AR severity and reoperation hazard based on pooled linearized occurrence rates. Correcting for age, we found a trend (p = 0.07) toward an association of preoperative severe AR with a higher risk of reoperation. Other analyses did not show any significant associations. No other factors were found to be associated with survival, reoperation rates, or both. This systematic review and meta-analysis gives an overview of published contemporary evidence on the characteristics and outcomes after VSARR. It shows acceptable outcomes in terms of survival and freedom from both reoperation and valve-related events in the first 5 postoperative years, regardless of the surgical technique used (remodeling or reimplantation). Moreover, it illustrates that current evidence is fragmented and heterogeneous, and it does not allow for further exploration of potential determinants of outcome. The observed pooled early and late mortality in this systematic review is low. Additionally, there is a low incidence of thromboembolism, endocarditis, and hemorrhagic events after VSARR. Previous reports, including a less exhaustive review conducted by Rahnavardi and colleagues [40Rahnavardi M. Yan T.D. Bannon P.G. Wilson M.K. Aortic valve-sparing operations in aortic root aneurysms: remodeling or reimplantation?.Interact CardioVasc Thorac Surg. 2011; 13: 189-197Crossref PubMed Scopus (32) Google Scholar], confirm our observation of low early mortality and 4-year reoperation hazard, and that bicuspid aortic valves are not associated with a significant higher reoperation rate. The rate of bicuspid repair is low (14%) in this meta-analysis, as confirmed by Badiu and colleagues [17Badiu C.C. Eichinger W. Bleiziffer S. et al.Should root replacement with aortic valve-sparing be offered to patients with bicuspid valves or severe aortic regurgitation?.Eur J Cardiothorac Surg. 2010; 38: 515-522Crossref PubMed Scopus (36) Google Scholar] that BAV is not associated with a higher reoperation hazard, but there is a trend toward higher reoperation hazard for patients with preoperative severe AR. Only nine studies in our systematic review described their direct postoperative echocardiographic aortic valve regurgitation data. Thus, on the basis of our systematic review, it is not possible to make assumptions about the association between direct postoperative AR and reoperation hazard. Although there are no large reports on VSARR and cusp prolapse, a report by Schäfers and colleagues [41Schafers H.J. Aicher D. Langer F. Correction of leaflet prolapse in valve-preserving aortic replacement: pushing the limits?.Ann Thorac Surg. 2002; 74: S1762-S1764Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar] emphasized that symmetric cusp prolapse should be corrected during VSARR to avoid AR by the measurement of cusp effective height with a dedicated caliper. This was confirmed by Lansac and colleagues [21Lansac E. Di Centa I. Sleilaty G. et al.An aortic ring: from physiologic reconstruction of the root to a standardized approach for aortic valve repair.J Thorac Cardiovasc Surg. 2010; 140: S28-35Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar], who defined the absence of cusp effective height resuspension as an independent risk factor for AR grade 2 or higher and for reoperation. There were no reports about leaflet heights and cusp anatomy; therefore, we were not able to test any assumption about their possible association with reoperation or other valve-related adverse events. Of course, given the limited follow-up duration of most studies in this review, the reported late outcomes cannot be extended beyond the first postoperative decade. No clinical advantages, in terms of survival and reoperation, of either technique over the other is evident from our meta-analysis of the literature. Although the remodeling technique provides physiologic cusp movements within the three reconstructed neosinuses, thus preserving root expansibility through the interleaflet triangles, it does not address annulus dilatation, which has been identified as a risk factor of failure (>25 to 28 mm) [7Hechadi J. De Kerchove L. Tamer S. El Khoury G. Modified valve-sparing reimplantation technique for para-commissural coronary ostia.Eur J Cardiothorac Surg. 2014; 45: 937-938Crossref PubMed Scopus (4) Google Scholar, 8Stroup D.F. Berlin J.A. Morton S.C. et al.Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.JAMA. 2000; 283: 2008-2012Crossref PubMed Scopus (16301) Google Scholar, 13Erasmi A.W. Sievers H.H. Bechtel J.F. Hanke T. Stierle U. Misfeld M. Remodeling or reimplantation for valve-sparing aortic root surgery?.Ann Thorac Surg. 2007; 83 (discussion S785–90): S752-S756Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar, 14Patel N.D. Weiss E.S. Alejo D.E. et al.Aortic root operations for Marfan syndrome: a comparison of the Bentall and valve-sparing procedures.Ann Thorac Surg. 2008; 85 (discussion 2010–1): 2003-2010Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar, 15de Kerchove L. Boodhwani M. Glineur D. et al.Effects of preoperative aortic insufficiency on outcome after aortic valve-sparing surgery.Circulation. 2009; 120: S120-S126Crossref PubMed Scopus (66) Google Scholar]. In the reimplantation procedure as an inclusion technique, the surgeon performs a subvalvular annuloplasty through the proximal suture of the graft but withdraws the sinuses of Valsalva and includes the interleaflet triangles within the noncompliant prosthesis, thus impairing root dynamics [8Stroup D.F. Berlin J.A. Morton S.C. et al.Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group.JAMA. 2000; 283: 2008-2012Crossref PubMed Scopus (16301) Google Scholar, 14Patel N.D. Weiss E.S. Alejo D.E. et al.Aortic root operations for Marfan syndrome: a comparison of the Bentall and valve-sparing procedures.Ann Thorac Surg. 2008; 85 (discussion 2010–1): 2003-2010Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar]. Therefore, insamuch as annulus dilatation has been identified as a risk factor for repair failure for dystrophic aortic roots with bicuspid and tricuspid valves, there is a consensus among authors to favor valve-sparing root replacement, providing an aortic annuloplasty through either a proximal suture in the reimplantation technique or an annuloplasty ring device in combination with the remodeling technique. The VSARR technique offers patients with aneurysms of the ascending aorta several advantages over composite graft replacement (Bentall), such as no need for oral anticoagulation, thereby avoiding increased bleeding risk, international normalized ratio monitoring, and lifestyle adjustments (eg, sports, alcohol intake). In addition, there is evidence that patients receiving a VSARR may experience a better overall quality of life compared with patients who receive a mechanical valve [42Aicher D. Holz A. Feldner S. Kollner V. Schafers H.J. Quality of life after aortic valve surgery: replacement versus reconstruction.J Thorac Cardiovasc Surg. 2011; 142: e19-e24Abstract Full Text Full Text PDF PubMed Scopus (97) Google Scholar]. On the downside, after VSARR more reoperations are expected compared wth the Bentall procedure. Although the Bentall procedure yields a lower risk of reoperation, especially in longer follow-up times, there is a lower hemorrhagic risk and thromboembolism seems to occur less often in patients receiving a VSARR because of anti-coagulation therapy needed after the Bentall [43Tourmousoglou C. Rokkas C. Is aortic valve-sparing operation or replacement with a composite graft the best option for aortic root and ascending aortic aneurysm?.Interact Cardiovasc Thorac Surg. 2009; 8: 134-147Crossref PubMed Scopus (13) Google Scholar, 44Lim J.Y. Kim J.B. Jung S.H. Choo S.J. Chung C.H. Lee J.W. Surgical management of aortic root dilatation with advanced aortic regurgitation: Bentall operation versus valve-sparing procedure.Korean J Thorac Cardiovasc Surg. 2012; 45: 141-147Crossref PubMed Scopus (13) Google Scholar]. This is particularly important in patients with an active lifestyle and in women who desire pregnancy after the operation [45Arabkhani B. Heuvelman H.J. Bogers A.J. et al.Does pregnancy influence the durability of human aortic valve substitutes?.J Am Coll Cardiol. 2012; 60: 1991-1992Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar, 46Heuvelman H.J. Arabkhani B. Cornette J.M. et al.Pregnancy outcomes in women with aortic valve substitutes.Am J Cardiol. 2013; 111: 382-387Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar]. Patient characteristics, such as age at the time of operation, and proportion of patients with connective tissue disease and aortic arch repair, are similar between the two studies. Given the observed heterogeneity, it is obvious from this systematic review that there is a need for uniform standardized reporting of VSARR procedures and their outcomes. Also, there is a need for collaboration between centers in their reporting of VSARR procedures because that will accelerate our knowledge building of this complex surgical procedure and its outcomes. Within the Heart Valve Society the AVIATOR registry was initiated: a multicenter, prospective registration with the goal of combining forces and sharing experience to advance knowledge in the field of surgical treatment of patients with aortic root dilatation, aortic valve regurgitation, or both [47The AVIATOR registry database: an overview of the intentions and goals of this collaborative working group on aortic valve and root treatment. Available at www.researchonline.org/link/study/aviator. Accessed July 24, 2015.Google Scholar]. It is hoped that this initiative will provide an evidence base to enable tailoring of the most suitable surgical treatment, such as valve-sparing procedures, to the individual patient. The available guidelines on reporting after heart valve interventions were not applied in several studies included in our systematic review, and this deficiency may have resulted in misinterpretation of the available data. It is obvious that the included studies represent a heterogeneous population of patients in their 30s through 60s, with varying aortic aneurysm, bicuspid valve, and AR prevalence. These patients of various cohorts were operated on between 1988 and 2011, spanning more than 20 years. In this light, the observed outcomes should be weighted carefully. Additionally, the limited follow-up duration of the included studies does not allow for conclusions beyond the first 5 postoperative years. The pooled linearized occurrence rates for reoperation and mortality data were based on heterogeneous data, under the linearity assumption, and should be treated with considerable caution. We included only studies with cohorts greater than 30 patients; in addition, where available, we selected the largest series of published data from a center, thus selecting more experienced surgeons and centers. This may have led to selection bias. Finally, because of the retrospective nature of the available and included studies, underreporting of events, in particular nonfatal events, is likely. The VSARR technique is an acceptable option for the treatment of aortic root aneurysm, with or without AR, especially in young active patients and patients in whom anticoagulation therapy is less desirable because of lifestyle or medical history. Severe preoperative aortic valve regurgitation is associated with a trend toward a higher reoperation rate. Therefore, to improve the results, VSARR would benefit from a technical standardization that resuspends cusp effective height and reduces the dilated aortic annulus (either by an annuloplasty device in case of remodeling or a proximal suture when using the reimplantation technique) and restores proper valve coaptation. The observed lack of standardization in data reporting has led to an international prospective multicenter registry for aortic valve-sparing/repair and replacement surgical procedures (AVIATOR). In addition, the most suitable surgical procedure should be determined on an individual basis, patient preference also being taken into account.
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