BACKGROUND: Both valve-sparing root replacement and composite valve graft (CVG) are acceptable options in aortic root replacement. We compare outcomes of these 2 approaches and durability of the aortic valve. METHODS: 1635 consecutive patients without acute dissection underwent primary aortic root replacement from 1997-2022. 473 (29%) underwent valve-sparing root replacement and 1162 (71%) CVG. Propensity-score matching was used to reduce baseline differences. RESULTS: The CVG group was older (59±14 vs. 49±14, p<0.001) with more comorbidities, such as hypertension (88.4% vs. 66.4%, p<0.001), diabetes (7% vs. 1.7%, p<0.001), ischemic heart disease (5.1% vs. 1.3%, p=0.001), pulmonary disease (6.6% vs. 1.3%, p<0.001), renal impairment (8.6% vs. 1.3%, p<0.001), Class III-IV heart failure (35% vs. 9.2%, p<0.001), bicuspid aortic valves (44.8% vs. 24.1%, p<0.001) and severe aortic insufficiency (50.2% vs. 13.2%, p<0.001). Operative mortality was 0.4% (0% in valve-sparing); incidence of major postoperative complications was 2.9% (3.6% vs. 1.1%, p=0.009). Ten-year survival was 93.1% (91.2% vs. 97.7%, HR 1.7 95%CI 0.9-3.3; p=0.120). Mean follow-up was 65±60 months; aortic valve reoperations were similar (5.8% vs 5.7%, HR 0.8 95%CI 0.4-1.4; p=0.401). Recurrent moderate/severe aortic insufficiency was less prevalent in CVG (6.1% vs. 11.1%, HR 0.14 95%CI 0.07-0.27; p<0.001). Propensity-matching identified 225 pairs. There was no difference in 10-year survival or reoperations. Recurrent moderate/severe aortic insufficiency was higher with valve sparing. CONCLUSIONS: Both valve-sparing operations and CVG provide excellent early and late outcomes out to 10 years. Valve-sparing is associated with a higher risk of developing aortic insufficiency but no difference in reoperations.
