Does Preoperative Left Ventricular Ejection Fraction Impact the Results After Aortic Root Surgery? Decision-Making Between Aortic Valve–Sparing Techniques and Bentall Operation - 22/01/26

Doi : 10.1016/j.hlc.2025.08.025

Carlotta Brega, MD ^a,^⁎ , Diego Sangiorgi, MSc ^a, Mikita Karalko, MD ^b, Matteo Pettinari, MD ^c, Vincent Chauvette, MD ^d, Alejandro Crespo de Hubsch, MD ^e, Igor Rudez, MD, PhD ^f, Olivier Bouchot, MD ^g, Frederiek de Heer, MD ^h, Rubina Rosa, MD ⁱ, Peter Verbrugghe, MD, PhD ^j, Bardia Arabkhani, MD ^k, Giulio Folino, MD ^l, Thierry Bourguignon, MD, PhD ^m, Adrian Kolesar, MD ⁿ, Zuzana Hlubocka, MD ^o, Vladislav Aminov, MD ^p, Maciej Matuszewski, MD ^q, Hans-Joachim Schäfers, MD, PhD ^r, Emmanuel Lansac, MD, PhD ^s, Carlo Savini, MD, PhD ^a,^t

^a Cardiovascular Department, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy

^b Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital, Hradec Kralove, Czech Republic

^c Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint Luc, Bruxelles, Belgium

^d Division of Cardiac Surgery, Montréal Heart Institute, Montréal, Québec, Canada

^e European Association for Cardio-thoracic Surgery (EACTS), The Spanish Society of Cardiavascular and Endovascular Surgery (SECCE), Hospital de Cruces, Bilbao, Spain

^f Department of Cardiac and Transplant Surgery, University Hospital Dubrava, Zagreb, Croatia

^g Department of Cardiovascular and Thoracic Surgery, Dijon University Hospital, Dijon, France

^h Department of Cardiothoracic Surgery, Amsterdam UMC, (Location AMC), Amsterdam, The Netherlands

ⁱ Cardiothoracic and Vascular Department, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy

^j Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium

^k Department of Cardiothoracic Surgery, Leiden University Medical Center, Rotterdam, The Netherlands

^l Department of Cardiac Surgery, European Hospital, Rome, Italy

^m Department of Cardiac Surgery, Tours University Hospital, Tours, France

ⁿ Eastern Slovak Institute for Cardiovascular Diseases, University of Pavol Jozef Safarik, Košice, Slovakia

^o Department of Cardiovascular Medicine, General University Hospital, Prague, Czech Republic

^p Cardiac Surgery Department, Federal Centre for Cardiovascular Surgery, Chelyabinsk, Russia

^q Heart and Lung Centre, New Cross Hospital, Wolverhamptom, United Kingdom

^r Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany

^s Cardiothoracic Surgery, University Hospital Pitié Salpêtrière, Paris, France

^t Department of Experimental Diagnostic and Surgical Medicine (DIMEC), University of Bologna, Bologna, Italy

^∗ Corresponding author at: Maria Cecilia Hospital, GVM Care & Research, Via Corriera 1 48033 Cotignola (RA), Italy. Maria Cecilia Hospital GVM Care & Research Via Corriera 1 48033 Cotignola (RA) Italy

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Thursday 22 January 2026

Abstract

Aim

Whether aortic valve sparing (valve sparing root replacement [VSRR]) and Bentall surgery differently affect myocardial dysfunction is not clear. This study aimed to clarify whether the type of aortic root surgery, in case of at least grade 2 aortic regurgitation associated with myocardial dysfunction, affects the outcomes.

Method

Extraction from the Heart Valve Society aortic valve database (Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry [AVIATOR]) was performed and two groups of patients operated between July 2007 and December 2022 were identified: Group 1 including patients undergoing VSRR with ejection fraction (EF) ≤50% (n=279) and Group 2 including patients undergoing Bentall with EF ≤50% (n=46). All patients had at least grade 2 aortic regurgitation.

Results

Similar cardiopulmonary bypass and cross-clamping time were reported. No statistically significant difference was reported between the groups in terms of postoperative bleeding, transfusion rate, reoperations, pacemaker rate implantation, ischaemic complications, and acute kidney injury. Follow-up mortality was similar between the groups, without any significant differences, and the weighted mixed-effect linear models showed improvement in EF in both groups; progressive inverse left ventricular remodelling is significantly higher in Group 2.

Conclusions

While both techniques can improve left ventricular function in patients with reduced EF, the Bentall procedure offers marginally better results in terms of left ventricular inverse remodelling. However, the choice between Bentall and VSRR should ultimately be determined by the surgeon's expertise and familiarity with each technique.

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Keywords : Aortic root surgery, Remodelling, Valve sparing, Bentall, Aortic valve replacement, Reduced ejection fraction, Low EF