Discussion
death, stiff interposition, bleeding, external annuloplasty, deaths
DISEASE PROGRESSION, BLEEDING, AORTIC DISSECTION, EVENT, DISEASE, EVENTS, COMPLICATIONS
While the perioperative outcomes of PEARS and root replacement have been compared,Our study cohort was derived from real-world clinical data and consists of a selected population of young patients with predominantly MFS, normal ejection fraction and at most mild AR undergoing elective surgery. The PEARS 200 Database represents the most extensive follow-up on PEARS to date, starting from patient 1 as the procedure was disseminated worldwide.Patients undergoing VSRR were further along in their disease progression or had a more severe CTD phenotype than those undergoing PEARS. Most remarkable were differences in age, root diameter, EuroSCORE II and preoperative AR (With no perioperative deaths and a median EuroSCORE II of 1.6, VSRR was safe in this study, yet 7% of patients required a reintervention for bleeding. There was a 4.4% incidence of coronary complications observed with PEARS, including one death. This may be partially related to the learning curve of this emerging procedure, reflected by the fact that these events occurred early in the experience. On the other hand, this issue may not be wholly abolished as the procedure is technically challenging.In this selected group of patients, both PEARS and VSRR seem to offer favourable and statistically similar mid-term survival and freedom from reintervention, both in the total and matched populations. While the reintervention rate after PEARS was 0.55% per year, the reintervention rate for VSRR was 1.4% per year, higher than the 0.6% per year found in a recent meta-analysis on the outcomes of root replacement in MFS.The absence of type A dissections after PEARS in 159 patients with 542 years of follow-up indicates that this procedure has the potential to prevent aortic dissection, yet continued follow-up is needed. The elevated risk of type B dissection and reintervention, while not significant, in patients undergoing VSRR suggests that earlier intervention or more aggressive management of the distal aorta may be indicated. Furthermore, a stiff interposition graft as used in VSRR causes a marked increase in wall stress distally, while the PEARS mesh becomes incorporated histologically and has a gradual reduction in hoop strength from proximal to distal.There are several important limitations to our study. This retrospective, multicentre study used two different databases, including 301 patients operated at 33 centres between 1996 and 2021. While outcomes after PEARS were reported according to intention to treat, data were extracted from the AVIATOR Database per completed procedure. We could therefore not identify patients who underwent an intraoperative conversion during VSRR. Due to low event rates and differences in follow-up, our description of late outcomes was predominantly descriptive. While the outcomes of VSRR are influenced by procedure type (reimplantation and remodelling with or without external annuloplasty in this study) and patient selection, our study does not factor procedure type into the comparison with PEARS. As we did not have data on aortic valve morphology in the PEARS group, we were unable to compare patients accordingly. Furthermore, we only had data on one late echocardiography for PEARS patients while VSRR patients had more extensive follow-up. Our echocardiographic data should be interpreted in the setting of a multicentre study. Using a PS analysis, we aimed to quantify differences between patient populations and correct for selection bias between groups, yet, are unable to determine whether differences in AR grade after PEARS or VSRR are related to uncorrected confounders, different follow-up duration or the development of AR after VSRR. Using our matching approach, patients with outlying aortic root diameters may be excluded. We focused on variables indicative of disease severity while not including CTD phenotype in the PS model as we did not have data available on the underlying genetic mutations which are strongly related to disease severity.