Structural Anomalies on Cardiac Computed Tomography After Full-Root Aortic Valve Replacement With a Stentless Porcine Aortic Root Xenograft

BACKGROUND: The Medtronic Freestyle is widely used for full-root aortic valve replacement, offering excellent hemodynamics. However, structural valve deterioration, including pseudoaneurysm formation, raises concerns. METHODS: Our single-center retrospective and prospective cohort study of adult patients who underwent modified Bentall procedures with the Medtronic Freestyle between September 2015 and November 2023 analyzed early and late complications, echocardiographic results, and survival. A cross-sectional computed tomographic angiography (CTA) evaluation assessed postoperative structural abnormalities. RESULTS: Included were 153 patients (median European System for Cardiac Operative Risk Evaluation 2011 revision, 3.4%). The 1- and 5-year actuarial survival rates were 96.7% and 87.2%, respectively. Postoperative mean and maximal transvalvular gradients were 5.8 mm Hg (interquartile range, 4.3-7.6 mm Hg) and 11.1 mm Hg (interquartile range, 8.2-14.9 mm Hg). Of the 98 patients (77.8% of eligible patients) who underwent CTA imaging, 23.5% had structural abnormalities. Pseudoaneurysms were the most common (15.3%) and warranted reintervention in 3 cases. Routine echocardiography failed to detect the pseudoaneurysms. Multivariate analysis identified previous cardiac surgery as an independent predictor of pseudoaneurysm development (odds ratio, 4.32; P = .046). The cumulative risk of CTA-detectable structural abnormalities may reach 22.7% at 5 years. CONCLUSIONS: The Medtronic Freestyle displays excellent hemodynamic performance. However, silent structural deterioration is not rare. Routine echocardiography may miss these lesions, supporting the role of systematic postoperative CTA imaging, especially for redo patients. Further studies are needed to guide optimal imaging surveillance protocols.