Pascal J. Govers, Michał Kawczyński, Samuel Heuts, Kevin M. Veen, Laurent de Kerchove, Emmanuel Lansac, Philippe Demers, Peter Verbrugghe, Igor Rudež, Aline Laubriet, Jan Vojacek, Elham Bidar, Johanna Takkenberg, Jolanda Kluin, Bardia Arabkhani, Claudia Romagnoni, Frederiek de Heer, Jesper Hjortnaes, Adrián Kolesár, Alejandro Crespo Hubsch, Christian Dinges, Jaroslav Hlubocký, Carlotta Brega, Ruggero De Paulis, Mauro Masat, Francesco Patane, Matteo Pettinari, Maciej Matuszewski, Gianclaudio Mecozzi, Jan Nijs, Marek Jasinski, Javier Estigarribia, Massimo Mariani, Pallav Shah, Diana Aicher, Didier Chatel, Aayush Poddar, V. V. Aminov, Éric Bergoend, Aude Boignard, Guillaume Geuzebroek, Takeshi Miyairi, German Chaud, Ignacio Bibiloni, Evaldas Girdauskas, Guido van Aarnhem, Said Soliman, Mladen Kocica, Alberto Forteza, Carlos Porras, Plamen Panayotov, Yutaka Okita, Thierry Bourguignon, C Coulon, Nadia Mansour, Kathy Louro, Vincent Chauvette, Bart Meuris, Davor Barić, Daniel Unić, Olivier Bouchot, Mikita Karalko, Pavel Žáček, Rubina Rosa, Andrea Mangini, Tomáš Toporcer, Johannes Steindl, Robert Novotny, Andrey Slautin, Giulio Folino, Fabrizio Ceresa, Carlijn Van Der Ven, Patrick Yiu, Ryan Accord, Cristóbal Alvarado, Joaquín Gundelach, Gregorio Rábago, Leona Schultz, Dejan Lazović, Carlos Martin, Gemma Sánchez-Espín, M. Slavov
OBJECTIVES: Valve-sparing aortic root replacement (VSARR) is technically demanding and may vary in institutional procedural volumes, rendering the establishment of thresholds for centres of expertise challenging. This study aims to identify an annual case volume that could define a high-volume centre for VSARR using data from the Heart Valve Society Aortic Valve (HVS AV) database. METHODS: All consecutive elective patients undergoing VSARR within the HVS AV database were included. The primary early outcome was a composite of mortality, thromboembolic events, reinterventions, intraoperative conversions, and recurrent aortic regurgitation grade ≥2 within 30 days. The primary long-term outcome was freedom from AV reintervention. Volume-outcome (V-O) associations were modelled using restricted cubic splines; the high-volume threshold was derived using the elbow method. Analyses were adjusted for EuroSCORE II. RESULTS: In total, 2668 patients from 37 centres were included. Annual volume was not significantly associated with the early composite outcome (P = .8003). However, a significant non-linear V-O association was found for long-term AV reintervention-free survival (P = .0023), with improved outcomes at centres performing ≥12 cases per year (95% CI, 10-12). These results were consistent in sensitivity analyses (P < .0001). CONCLUSIONS: An annual institutional volume of ≥12 VSARRs is associated with improved long-term valve durability and survival, while early postoperative outcomes appear less sensitive to annual case load given their low event rates. This high-volume threshold may serve as a benchmark for centres already experienced in AV and/or root surgery and guide quality improvement efforts.