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Surgeon Frequency of Aortic Root Enlargement and Long-Term Survival in Medicare Beneficiaries Undergoing Surgical Aortic Valve Replacement
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Surgeon Frequency of Aortic Root Enlargement and Long-Term Survival in Medicare Beneficiaries Undergoing Surgical Aortic Valve Replacement
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Journal Article
Surgeon Frequency of Aortic Root Enlargement and Long-Term Survival in Medicare Beneficiaries Undergoing Surgical Aortic Valve Replacement
2025
Overview
Aortic root enlargement (ARE) is a variably performed during surgical aortic valve replacement (SAVR) to minimize patient-prothesis mismatch (PPM), but its impact on survival remains under-evaluated. We retrospectively analyzed Medicare beneficiaries (1999–2019) undergoing isolated SAVR with or without non-Konno ARE. Procedural details were doubly-adjudicated by ICD and CPT codes. Overlap propensity score weighting adjusted for confounders. Restricted mean survival times (RMST) at 30-days and 20-years were compared. Surgeons were stratified by ARE frequency, and survival was analyzed using risk-adjusted Kaplan-Meier estimates in both “as-treated” (SAVR vs SAVR+ARE) and “surgeon-preference” (never-ARE vs frequent-ARE surgeons) analyses. Of 214,266 beneficiaries undergoing isolated SAVR, 6,652 (3.1%) underwent SAVR+ARE. From 1999 to 2019, ARE utilization increased from 2.1% to 6.4% (Cochran-Armitage Z-statistic: 15.2). Among 3,018 surgeons, 1,513 never performed ARE (69,389 beneficiaries), 1,227 performed ARE in <10% of cases (128,258 beneficiaries), and 278 performed ARE in ≥10% of cases (16,619 beneficiaries). After risk-adjustment, survival was significantly lower in SAVR+ARE compared to SAVR recipients: 30-day RMST 28.73 (28.60,28.87) versus 29.35 (29.26,29.45) days (p = 0.013) and 20-year RMST 9.15 (8.96,9.35) vs 9.49 (9.30,9.69) years (p = 0.018). Similarly, beneficiaries treated by frequent-ARE surgeons experienced worse early risk-adjusted survival without any late survival benefit: 30-day RMST 29.19 (29.11,29.27) versus 29.33 (29.25-29.40) days (p = 0.013), 20-year RMST 9.04 (8.90,9.18) versus 9.13 (9.00,9.27) (p = 0.351). Landmark analysis of 1-year survivors showed no late survival difference (p = 0.456 “as-treated” analysis; p = 0.943 “surgeon-preference” analysis). Even among frequent-ARE surgeons, SAVR+ARE was associated with higher 30-day and reduced 20-year RMST relative to SAVR alone. In conclusion, ARE was associated with higher early mortality and no long-term survival advantage compared to SAVR alone (even among frequent-ARE surgeons), as was undergoing surgery by a frequent ARE surgeon. Further studies are required to assess the potential utility of ARE in younger patients, those with small annuli, and those at risk for PPM.
Publisher
Elsevier Inc,Elsevier Limited
Subject
/ Aorta
/ Aortic Valve Stenosis - mortality
/ Aortic Valve Stenosis - surgery
/ Codes
/ Female
/ Heart Valve Prosthesis Implantation - methods
/ Humans
/ Male
/ Medicare
/ Patients
/ Surgeons
/ Surgeons - statistics & numerical data
/ Surgical aortic valve replacement
/ Survival
