Background and aim of the study This study aims to provide an overview of clinical outcome after bioprosthetic aortic root replacement and lifetime event-risk estimates of mortality and valve-related events, and the potential effect of type of prosthesis used. Methods A systematic literature search was conducted between January 2000 and August 2019. Inclusion criteria: aortic root replacement in adults. Data were pooled by inverse-variance weighting and entered a microsimulation model to calculate lifetime event-risk and (event-free) life expectancy. Results Of 2,106 publications, 31 were included (N = 5,227 patients, 74% stentless valves). Mean age was 65.4 years (74% male). Pooled early mortality was 5.5% (95% CI: 4.3-7.2%). During follow-up (mean 4.1 years, total 22.706 patient-years), late mortality was 4.8%/patient-year and reoperation 0.9%/patient-year. Linearized-occurrence-rates for thromboembolism, endocarditis, and hemorrhagic events:1.2; 0.9 and 0.5 %/patient-year; no significant difference between stented and stentless prosthesis. Translating into a 60-year-old patient, an estimated life expectancy of 14 years (general population: 22 years) and lifetime risks of thromboembolism, endocarditis and reintervention of 21%, 13%, and 8%, respectively is expected. Conclusions The study shows impaired survival and a notable lifetime risk of valve-related events after bioprosthetic aortic root replacement. The risk of thromboembolism is prominent, especially during earlier follow-up, suggesting higher risk of thromboembolism early after operation. Type of prosthesis, stented or stentless, is not associated with higher valve-related events. Moreover, this study could be used as a benchmark to compare outcome with other aortic root replacement procedures.

Background and aim of the study This study aims to provide an overview of clinical outcome after bioprosthetic aortic root replacement and lifetime event-risk estimates of mortality and valve-related events, and the potential effect of type of prosthesis used. Methods A systematic literature search was conducted between January 2000 and August 2019. Inclusion criteria: aortic root replacement in adults. Data were pooled by inverse-variance weighting and entered a microsimulation model to calculate lifetime event-risk and (event-free) life expectancy. Results Of 2.106 publications, 31 were included (N = 5.227 patients, 74% stentless valves). Mean age was 65.4 years (74% male). Pooled early mortality was 5.5% (95% CI: 4.3-7.2%). During follow-up (mean 4.1 years, total 22.706 patient-years), late mortality was 4.8%/patient-year and reoperation 0.9%/patient-year. Linearized-occurrence-rates for thromboembolism, endocarditis, and hemorrhagic events:1.2; 0.9 and 0.5 %/patient-year; no significant difference between stented and stentless prosthesis. Translating into a 60-year-old patient, an estimated life expectancy of 14 years (general population: 22 years) and lifetime risks of thromboembolism, endocarditis and reintervention of 21%, 13%, and 8%, respectively is expected. Conclusions The study shows impaired survival and a notable lifetime risk of valve-related events after bioprosthetic aortic root replacement. The risk of thromboembolism is prominent, especially during earlier follow-up, suggesting higher risk of thromboembolism early after operation. Type of prosthesis, stented or stentless, is not associated with higher valve-related events. Moreover, this study could be used as a benchmark to compare outcome with other aortic root replacement procedures.