Aortic root geometry following composite valve graft implantation: Implications for future valve-in-valve procedures

Objectives: Biological composite valve grafts (CVGs) are being performed more frequently, which increases the need for interventions treating bioprosthetic valve failure. The feasibility of valve-in-valve procedures in this population is uncertain. This study aimed to assess changes in aortic root geometry and coronary height following CVG implantation to better understand future interventions. Methods: We retrospectively identified 64 patients following bioprosthetic CVG replacement with pre-and postoperative computed tomography angiography. Root assessment was conducted as in preprocedural transcatheter aortic valve evaluation using a virtual valve simulation. Results: In 64 patients (age, 67.6 +/- 9.3 years; 76.6% men) the preoperative coronary height was 14.3 +/- 6.8 mm for the left coronary artery (LCA) and 17.9 +/- 5.9 mm for the right coronary artery (RCA), which significantly decreased after CVG implantation, with 8.7 +/- 4.4 mm for the LCA and 11.3 +/- 4.4 mm for the RCA (P <.001). The virtual valve-to-coronary distances measured 4.0 +/- 1.3 mm (LCA) and 4.6 +/- 1.4 mm (RCA). Overall, 59.4% (n = 38) of patients with bio-CVGs would have been at risk for coronary obstruction, 29.7% (n = 19) for LCA, 10.9% (n = 7) for RCA, and 18.8% (n = 12) for combined LCA and RCA. Conclusions: Coronary height significantly decreased following CVG implantation. The majority of patients after bio-CVG were at a potential risk for coronary obstruc-tion in future valve-in-valve procedures. Further studies are needed to identify the best possible technique for coronary reimplantation and other measures to diminish the risk for future coronary obstruction in this population. (J Thorac Cardiovasc Surg 2023;166:1635-43)