the comprehensive aortic root and valve repair ( carvar ) procedure is , basically , one of the valve sparing surgical techniques for aortic valve or aortic root disease .
three basic surgical procedures of this technique are annular reduction , reduction of sinotubular junction ( stj ) and leaflet correction.1)2 ) for reduction of the annulus or stj , a commercially available sizing device , strip or ring and template ( sciencity co , seoul , korea ) are used.3 ) carvar procedure and devices , named and designed by dr .
mg song , are under evaluation for list up process as new health technology by the health insurance review and assessment service ( hira ) from 2007 . during this process ,
han et al.4 ) reported 5 clustered cases of coronary ostial stenosis after carvar procedure .
they also reported several cases of re - operation from valvular dysfunction or endocarditis and even cases of mortality after operation to the korea food and drug administration . under the debates on the safety and effectiveness of the cavar procedure , the ministry of health and welfare , korea offered a prospective randomized study .
for the design and production of patient information for prospective study , it was required to establish a data of safety from previously performed operations.5 )
vitualy the entire carvar procedure was performed by a single operator ( dr . myeong gun song ) at 2 university hospitals : from march 2007 to july 2007 at asan medical center ( seoul , korea ) and from october 2007 to november 2009 at konkuk university hospital ( seoul , korea ) .
three hundred ninety seven patients ( 26 cases at asan medical center , 371 cases at konkuk university hospital ) received carvar operation during this period and were enrolled for this study .
data from medical records were gathered by a trained investigator from national evidence - based health care collaborating agency ( neca ) . to obtain more complete information , a follow up was performed via 2 tracks including medical records of the out patient department and claim data of medical service in hira .
four major threatening clinical events including serious surgical bleeding requiring transfusion over 20 units of packed red blood cell , endocarditis , re - operation from any cause and death were focused for evaluation of safety .
clinical events at out patients ' department were followed up till march 2010 . to compare with conventional valve replacement surgery
, 337 patients without aortic root disease { aortic valve disease ( avd ) only group } were analyzed separately .
total incidence during the follow up period ( % ) and 1-year cumulative incidence ( % /year ) were calculated by the kaplan - meier method .
this study was approved by the institutional review board of neca ( necairb 10 - 001 ) and organized data review board with 6 professional experts from the korean society of thoracic and cardiovascular surgery and the korean society of cardiology for peer data review .
importantly , there were 9 cases of age under 19 and 8 cases of older than 80 years - old .
there were 20 fatal cases and 25 re - operated cases and 19 cases of endocarditis . even in the avd only group , the 1 year cumulative death rate was 4.41%/year and risk of re - operation was 5.81%/year .
for the treatment of avd , aortic valve replacement is regarded as a standard treatment .
but , aortic valve sparing surgery can be applied to aortic regurgitation due to dilatation of the aortic root or ascending aorta without significant leaflet deformity . theoretically , carvar is one of the aortic valve sparing surgical techniques .
hahm et al.1 ) described that the advantages of this technique are a wide range of indication , preservation of aortic root function , easy surgical technique and low recurrence of valvular dysfunction .
but , from the results of this study , the carvar technique failed to show any advantage in mortality and morbidity . in a recently reported 28 years experience ( from 1982 ) of the bentall procedure ,
the operative mortality was 5.5% , and risk of late reoperation and endocarditis were 3.2% and 1.4% respectively.6 ) moreover , lim et al.6 ) reported that , in patients with aortic root dilatation with advanced aortic regurgitation , operative mortality was 2.4% in the bentall procedure group and 0% in the valve - sparing operation group.7 ) compared with those data , in patients with carvar surgery , mortality seems quite higher than recently reported results and the risk of endocarditis and re - operation are much higher than in previous reports . in the least ,
it was restricted in gathering enough clinical data from medical records , hence we could not evaluate data comprehensively .
nontheless , the primary aim of this study is to provide basic safety data for further prospective randomized study .
therefore , it can be suggested that the carvar procedure should undergoe more in - depth investigation in consideration for the safety of patients .
 comprehensive aortic root and valve repair ( carvar ) is a recently introduced surgical technique for aortic valve disease . 
 the national evidence - based health care collaborating agency was offered by the ministry of health and welfare , korea to perform a restrospective outcome analysis for this surgical procedure . 
 the aims of this study were to evaluate the safety of patients who underwent carvar surgery and to provide a rationale for further prospective randomized study . during the period of march 2007 to november 2009 
 , 397 patients received this procedure and enrolled in this study . 
 clinical events including major bleeding , endocarditis , re - operation and death were followed - up till march 2010 by medical records . during the follow - up periods , 1-year cumulative incidence of major bleeding , re - operation , endocarditis and death were 3.55 , 5.65 , 5.05 and 5.33%/year respectively . 
 this study showed that the carvar technique is not beneficial , and is indeed even more harmful than conventional valve replacement surgery . 
Introduction
Subjects and Methods
Results
Discussion