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Perezgrovas-Olaria et al. Vessel Plus 2023;7:10 https://dx.doi.org/10.20517/2574-1209.2022.54 Page 3 of 11

Inclusion and exclusion criteria
All consecutive adult patients who underwent aortic valve and root replacement with either mCVG or
bCVG between May 1997 and December 2019 at our institution were included. Valve-sparing aortic root
procedures were excluded.

Study outcomes
The primary outcomes were follow-up mortality (defined as any death from the time of operation until last
follow-up) and reoperation rate (considering all reoperations related either to the valve or the graft). The
secondary outcomes were operative mortality (defined as death within 30 days after surgery or during index
hospitalization) and major adverse events (MAEs) including operative mortality, myocardial infarction,
cerebrovascular accident, dialysis, tracheostomy, and re-exploration for bleeding.

Indications for surgery and selection of composite valve graft
Indications for the Bentall-De Bono operation were related to the severity of valvular dysfunction and the
size of aortic dilatation, following the American Heart Association/American College of Cardiology
[2]
guidelines . The type of composite valve graft used was determined using guideline recommendations, but
also individualized based on patients’ preferences. In brief, most patients younger than 50 years without
major risk factors for bleeding while on anticoagulation (e.g., no contact sports), likely to be compliant with
dietetic restrictions and INR monitoring, those having additional indications for long-term anticoagulation
(e.g., atrial fibrillation) or those in which a reoperation would be high-risk (e.g., porcelain aorta, prior
radiation) were counseled to receive a mCVG. Conversely, most patients older than 65 years, unlikely to be
compliant with dietary restrictions or INR monitoring, those at high risk of bleeding while on
anticoagulation or patients considered good candidates for potential future valve-in-valve replacement were
counseled to receive a bCVG.

Surgical technique
Details of the surgical technique have been previously published . In brief, all operations were carried out
[7]
using a median sternotomy incision, standard hypothermic cardiopulmonary bypass and myocardial
protection with cold antegrade blood cardioplegia. When concomitant arch disease was present, deep
hypothermic circulatory arrest with retrograde cerebral perfusion was utilized for cerebral protection; ε-
aminocaproic acid was used as an antifibrinolytic . Both mCVG and bCVG were implanted using the
[8]
[9]
modified Bentall technique . After establishing cardioplegic arrest, the ascending aorta was resected down
to the annulus, leaving 3-4 mm of aortic tissue. Coronary buttons were cut from the surrounding aortic
tissue. The annulus was sized. The mCVG were prefabricated mechanical valve-conduit grafts. For patients
in need of a bCVG, a stented valve (porcine or bovine) was sewn inside a polyester graft (Dacron) 3 to 5 mm
larger than the valve using a continuous 3-0 polypropylene suture. Mattressed 2-0 Ethibond pledgeted
sutures were placed through the annulus using an everting intra-annular technique and passed through the
valve conduit. The conduit was tied down and the left coronary button was reimplanted. The distal
anastomosis was performed and then the right coronary button was reimplanted. Four different surgeons
were responsible for the total surgical volume.

Statistical analysis
Categorical data were presented as frequency count and percentage and compared across groups using χ2 or
Fisher’s test, as appropriate, while continuous data were presented as median and interquartile range (IQR)
or mean with standard deviation and compared using Mann-Whitney U test or t-test after testing for
normality. Follow-up mortality was assessed using the Kaplan-Meier method. Cumulative incidence of
reoperation was calculated using the Fine and Gray method , accounting for the competing risk of death.
[10]