Mechanical versus bioprosthetic conduits for the bentall procedure: a 10-year propensity score-matched analysis of early and long-term outcomes

OBJECTIVES: The optimal conduit choice for the Bentall procedure-mechanical (MC) or biological (BC)-is confounded by significant baseline selection bias. We aimed to evaluate the impact of conduit choice on early and long-term outcomes after mitigating this bias in a contemporary surgical cohort. METHODS: We retrospectively reviewed 442 consecutive patients undergoing elective Bentall procedures between 2015 and 2025 (365 MC vs 77 BC). Propensity score matching (1:1 nearest-neighbor, caliper 0.1) was performed based on 10 baseline covariates (including age, EuroSCORE II, and comorbidities) to generate a balanced cohort of 154 patients (77 per group). Operative outcomes, 30-day morbidity/mortality, long-term overall survival, and reoperation-free survival were compared using paired statistical tests and Kaplan-Meier (Log-rank) analysis. RESULTS: PSM successfully balanced baseline covariates, eliminating significant differences in age (mean 64.1 [MC] vs 65.7 [BC] years, p = 0.403) and EuroSCORE II (p = 0.698). The median follow-up was 36.0 months (IQR: 18.0-78.0). In the propensity-matched cohort, no significant differences were found in long-term overall survival (p = 0.574) or reoperation-free survival (p = 0.944) between the mechanical and biological groups. Early mortality was also comparable (p = 0.344). However, the biological group demonstrated a significantly higher rate of early re-exploration for bleeding (24.7% vs 6.5%, p = 0.003), associated with a 3.8-fold increased risk (OR: 4.72, 95% CI: 1.66-13.40). CONCLUSIONS: In this 10-year propensity-matched analysis, both mechanical and bioprosthetic conduits demonstrated comparable long-term durability and survival outcomes. Although biological conduits were associated with a higher risk of early re-exploration for bleeding, this did not adversely affect early mortality or long-term reoperation-free survival. These findings suggest that bioprosthetic conduits offer robust mid-term effectiveness, provided that meticulous intraoperative hemostasis is ensured to mitigate early bleeding risks.