Original Cardiovascular
Is Bentall Procedure Still the Gold Standard for Acute Aortic Dissection with Aortic Root Involvement? Erik Beckmann1, Andreas Martens1, Firas Abd Alhadi1 Fabio Ius1 Nurbol Koigeldiyev1 Felix Fleissner1 Penelope Stiefel1 Tim Kaufeld1 Axel Haverich1 Malakh Shrestha1 1 Department of Cardiac Surgery, Hannover Medical School, Hannover,
Germany Both authors contributed equally.
Address for correspondence Erik Beckmann, MD, Department of Cardiac Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30165, Germany (e-mail: [email protected]).
Abstract
Keywords
► acute aortic dissection ► valve-sparing aortic root surgery ► David procedure ► Bentall procedure
Introduction The “ideal” treatment of acute aortic dissection type A (AADA) with dissected and dilated root is controversial. We compared the outcome of classical Bentall procedure (biological and mechanical) with valve-sparing David procedure. Methods Between January 2002 and July 2011, 119 patients with AADA and aortic root involvement underwent surgery at our center. Thirty-one patients (group 1) received biological conduits, 41 (group 2) received mechanical conduits, and 47 (group 3) underwent David procedures. Results Cross-clamp, cardiopulmonary bypass, and circulatory arrest times were 151 52, 232 84, and 36 30 minutes (group 1); 148 44, 237 91, and 45 29 minutes (group 2); and 160 46, 231 63, and 35 17 minutes (group 3), respectively. The 30-day mortality rates were 32.3% (group 1), 22% (group 2), and 12.8% (group 3). The 1-year rates for freedom from valve-related reoperation were 100% (group 1), 92.5% (group 2), and 95.2% (group 3) (p ¼ 0.172). The 1-year survival rates were 61% (group 1), 61% (group 2), and 84.1% (group 3) (p ¼ 0.008). Conclusion Even in AADA patients with root involvement, David procedure has acceptable results. David procedure (if possible) or a Bio-Bentall (for pathological valves) seems to be the optimal technique.
Introduction Acute aortic dissection type A (AADA) represents a lifethreatening condition with a 30-day mortality of up to 50%.1 Emergent surgical intervention is the treatment of choice. When the aortic root is not only dissected but also dilated, composite replacement with a mechanical valved conduit has been the standard procedure.2 However, the need for lifelong anticoagulation with associated possible thromboembolic and bleeding complications as well as the increasing age of patients has led to a shift toward the use of tissue-valved conduits. But
received February 1, 2015 accepted after revision March 16, 2015
tissue-valved conduits also suffer from disadvantages, such as valve degeneration with the risk of reoperation. As the aortic dissection usually does not affect the aortic leaflets, valve-sparing aortic root replacement appears to be an appealing alternative.3,4 Valve-sparing surgery involves multiple techniques, including the remodeling technique (Yacoub procedure5) and the reimplantation technique (David procedure3). Preserving the native aortic valve offers the potential benefit of physiological valve function and the absence of need for long-term anticoagulation. On the other hand, valvesparing aortic root surgery is technically more challenging.
© Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0035-1552580. ISSN 0171-6425.
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The available literature on valve-sparing surgery for the treatment of AADA comprises a limited number of studies with a small number of patients. Various groups, including ours, published their experience, demonstrating the feasibility and efficacy of valve-sparing surgery in the setting of AADA.6–11 Nevertheless, valve-sparing surgery is still criticized for being too time consuming and complex during surgery for AADA. Against this background, it remains unclear whether or not valve-sparing aortic root replacement is an appropriate treatment for AADA. Thus, we set out to compare the outcome of valve-sparing aortic root surgery (David I) with the outcome of Bentall procedures with mechanical and tissuevalved conduits in the setting of AADA.
Materials and Methods Patient Characteristics The Ethics Committee of the Hannover Medical School, Germany, approved this study. We reviewed our hospital database for patients undergoing surgery for AADA between January 2002 and July 2011. In this period, a total of 313 patients underwent surgery for AADA at our center. Retrospective analysis of the chart and operation report was performed to identify AADA patients with extensive aortic root involvement not eligible for surgical repair with glue. We identified patients receiving an aortic root procedure while showing a noncalcified aortic valve. A total of 119 patients were classified into one of the following groups: group 1 (n ¼ 31) received a Bentall procedure with tissue-valved conduit, group 2 (n ¼ 41) received a Bentall procedure with mechanical conduit, and group 3 (n ¼ 47) underwent aortic valve-sparing David I procedure. Of note, all three techniques were performed during the same time period, depending on the surgeon’s expertise. In all cases, the indication for operation was AADA with dilated and dissected aortic sinuses. The diagnosis was established by computed tomography and/or echocardiography and/or cardiac catheterization. Surgery was performed on an emergency basis in all cases. It has been our policy to accept all patients who arrive alive at the hospital for surgery regardless of the preoperative clinical status or age. Only patients with noncalcified aortic valves were included in our study. The final decision whether to proceed with aortic valve-sparing surgery or Bentall procedure was taken by the surgeon. Only surgeons with experience in elective David procedures performed the surgery.
depend on the surgeon’s preference as well as the intraoperative usage of Teflon felt, glue, and pericardial bands.
Valve-Sparing Aortic Root Surgery Technique The aortic root was mobilized from outside to a level directly below the nadir of the aortic annulus. The coronary ostia were excised as buttons and the aortic sinuses were resected to leave a rim of 5 mm of the aortic wall. The three commissures were elevated by stay sutures. After achieving optimal cusp coaptation, the diameter was measured by insertion of a Hegar dilator into the aortic annulus. A Dacron prosthesis one size larger than the annulus size was chosen (e.g., 28-mm Dacron graft for a 26-mm aortic annulus). The maximum prosthesis size used was 30 mm. Nine to twelve threads of 2/0-coated polyester fiber (Ethibond; Ethicon Inc., Norderstedt, Germany) were placed insideout horizontally below the valve in a circumferential way and anchored in the Dacron prosthesis. The prosthesis was fixed by tying these threads. Care was taken not to narrow down the diameter of the aortic annulus. Afterwards the commissures were maximally pulled up without stretching the Dacron graft and then fixed within the graft using 4/0 poly-propylene sutures (Prolene, Ethicon Inc.). Using three additional 4/0 poly-propylene sutures, the remnants of the aortic sinuses and the aortic annulus were sutured into the straight graft (David I procedure). Even though a straight Dacron graft was used, these sutures create small neosinuses. The coronary ostia were reimplanted to their respective neosinuses using 5/0 poly-prolene suture.
Bentall Technique The surgical techniques for both the Bentall procedure using tissue-valved and the mechanical valved conduits are similar. When a mechanical conduit was implanted, usually an ATS Medical (Minneapolis, Minnesota, United States) or St. Jude Medical (Saint Paul, Minnesota, United States) product was used. When a tissue-valved conduit was implanted, either the conduit assembled at the operation table using a Dacron prosthesis and a tissue valve or a prefabricated tissue valved conduit (Vascutek BioValsalva, BioValsalva prosthesis, Vascutek, Hamburg, Germany) was used. Both the aortic valve and the dissected ascending aorta were resected. The mechanical or tissue-valved conduit was implanted using a modified Bentall technique with reimplantation of the coronary ostia as buttons. The conduit was implanted into the aortic annulus using pledgeted threads (Ethibond, Ethicon Inc.). Next, the coronary ostia were reimplanted into the conduit using a 5/0 poly-prolene suture.
General Surgical Technique
Aortic Arch Surgery
After a standard median sternotomy and systemic heparinization, cardiopulmonary bypass (CPB) was initiated usually with direct cannulation of the ascending aorta and the right atrium. This technique of direct aortic cannulation even in AADA patients has been described previously by our group.12 In some patients, arterial cannulation was performed via the femoral artery. Cold blood cardioplegia (Buckberg) is the preferred method of myocardial protection at our institution. Whether the root or the arch repair should be performed first
In addition to the root procedure, either a proximal aortic arch or total aortic arch replacement was performed depending on the pathology under moderate hypothermic circulatory arrest (temperatures between 25 and 27°C) and bilateral selective antegrade cerebral perfusion.
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Anticoagulation Therapy After surgery, patients receiving a tissue-valved conduit were anticoagulated with Coumadin for the first 3 months only.
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Acute Aortic Dissection with Aortic Root Involvement
Thereafter, the patients received a life-long therapy with aspirin. Patients with a mechanical conduit received a lifelong anticoagulation therapy with Coumadin. Patients undergoing valve-sparing David procedure were anticoagulated either with Coumadin for 3 months or life-long aspirin.
Follow-up Informed and written consent from all patients was obtained for follow-up examination. All patients were contacted for follow-up, which was done according to common guidelines.13 We also acquired and reviewed the most recent medical data from the primary care physicians and/or cardiologists.
Statistical Analysis Continuous variables are stated as mean standard deviation or as median þ range, respectively. Categorical variables are stated as absolute numbers and proportions. Data analysis was performed using SPSS 22 Statistics software (IBM, Herrenberg, Germany). Kaplan–Meier analysis was used for evaluation of survival and freedom from valve-related reoperation. Differences in categorical variables were analyzed using the χ2 test. Differences in continuous variables were tested using t-test, one-way ANOVA analysis, or Mann–Whitney U-test, respectively. Multivariate analysis was performed using a binary logistic regression model to discriminate independent risk factors for 30-day mortality. We stated the Odds ratio (OR) and the 95% confidence interval (CI). A value of p < 0.05 was considered statistically significant.
Results The preoperative patient characteristics are shown in ►Table 1. The preoperative patient variables were relatively similar among the three groups. However, the mean age was lower in group 3 (54 years), followed by group 2 (60 years) and group 1 (71 years). This difference was statistically significant (p < 0.001). The 30-day mortality rate of all patients (n ¼ 313) undergoing surgery for AADA at our institution was 20.5%. The 30day mortality rate of AADA patients without root involvement was 19.1%. In the present study, the 30-day mortality rates were 32.3% (group 1), 22% (group 2), and 12.8% (group 3). Although the 30-day mortality was lower in group 3 than in group 1 and group 2, this difference was not statistically significant (p ¼ 0.116). When comparing the 30-day mortality of the whole Bentall group (including both tissue- and mechanical-valved conduits) with the David group, a statistically significant difference was found (p ¼ 0.037). However, logistic regression analysis did not identify the operative technique as independent risk factor for early mortality. Logistic regression showed that CPB time (OR, 1.05; CI, 1.013–1.089; p ¼ 0.008) and age (OR, 1.11; CI, 1.012–1.218; p ¼ 0.027) were significant predictors for early mortality. The reasons for 30-day mortality in group 1 were cardiac failure in three patients, bleeding in three patients, multiorgan failure in two patients, and unknown reasons in two patients. The reasons for 30-day mortality in group 2 were
Beckmann et al.
cardiac failure in three patients, sepsis in two patients, cerebral hemorrhage in one patient, multiorgan failure in one patient, mesenterial ischemia in one patient, and stroke in one patient. The reasons for 30-day mortality in group 3 were sepsis in two patients, cerebral dysregulation in one patient, intracranial hemorrhage in one patient, multiorgan failure in one patient, and unknown reason in one patient. The results of the intra- and perioperative data are given in ►Tables 2 and 3. The results of the intraoperative and discharge echocardiography examinations of group 3 are given in ►Table 4. The majority (36/38, 94.7%) were discharged with aortic valve insufficiency of grade I or less. The follow-up was 100% complete for the total patient cohort. The mean follow-up times were 4.2 (group 1), 3.5 (group 2), and 6.3 (group 3) years. The Kaplan–Meier survival curves are shown in ►Fig. 1. The 1-year survival estimates for the three groups were 61% (group 1), 61% (group 2), and 85% (group 3). The 5-year survival estimates for the three groups were 47% (group 1), 58% (group 2), and 75% (group 3). The differences in long-term survival in the Kaplan–Meier analysis were found to be statistically significant (p ¼ 0.008). Valve-related reoperation rates were 0% (n ¼ 0, group 1), 5% (n ¼ 2, group 2), and 14.9% (n ¼ 7, group 3). The mortality rates of reoperations were 0% (0/2, group 2) and 14.3% (1/7, group 3). The Kaplan–Meier curves for freedom from valve-related reoperation are depicted in ►Fig. 2. The 1-year estimates for freedom from valve-related reoperation are 100% (group 1), 92.5% (group 2), and 95.2% (group 3). The 5-year estimates for freedom from valve-related reoperation are 100% (group 1), 92.5% (group 2), and 84.1% (group 3), respectively. No statistically significant difference was found in the Kaplan– Meier analysis for freedom from valve-related reoperations (p ¼ 0.172). The two patients who underwent reoperation in group 2 were caused by endocarditis. Five out of the seven David patients who needed reoperation were discharged with aortic valve insufficiency of grade 0. The reasons for reoperation were severe aortic valve insufficiency in two cases (one early at 3 months), prosthetic infection/endocarditic in three cases, severe aortic valve stenosis in one case, and for unknown reason in one case.
Discussion AADA remains a life-threatening disease with high morbidity and mortality. If the aortic dissection involves the aortic root, the optimal surgical treatment is still a matter of debate, especially if the aortic root is dilated. Valve-sparing surgery in the setting of AADA is often criticized for being too time consuming and complex. In fact, critics recommend not to use this technique for the treatment of AADA. However, we found that the total operative times as well as the CPB times were similar in the David group compared with the two Bentall groups. The aortic cross-clamp time was only slightly longer in the David group than in both the Bentall groups. This difference was Thoracic and Cardiovascular Surgeon
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Acute Aortic Dissection with Aortic Root Involvement
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1 (3.2%) 12 (39%) 8 (26%) 3 (9.7%) 1 (3.2%)
Bicuspid aortic valve (n, %)
Hemorrhagic pericardial effusion (n, %)
Malperfusion (n, %)
Preoperative critical state (n, %)
Previous cardiac surgery (n, %)
3 (7.3%)
12 (29%)
8 (20%)
18 (44%)
2 (4.9%)
1 (2.4%)
1 (2.4%)
27 (65%)
1 (2.1%)
7 (15%)
7 (15%)
16 (34%)
2 (4.3%)
2 (4.3%)
0 (0%)
32 (69%)
27 4
178 (170–185)
83 (75–93)
52 (46–61)
Group 3 David n ¼ 47 (39.5%)
4 (6%)
15 (21%)
16 (22%)
30 (42%)
3 (4%)
3 (4%)
1 (1%)
45 (62%)
27 4
172 (170–180)
80 (70–90)
67 (57–73)
All Bentalls n ¼ 72
0.457
0.076
0.393
0.638
0.981
0.981
0.417
0.651
0.511
0.148
0.130
0.000
p-Value All Bentalls Vs. David
0.362
0.415
0.239
0.404
0.942
0.702
0.383
0.533
0.631
0.222
0.132
0.000
p-Value Bio vs. Mechanical vs. David
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Abbreviation: BMI, body mass index. Notes: Preoperative critical state was defined as the need for catecholamines, resuscitation, ventilation, or any combination. Malperfusion was clinically defined as the presence of significant arterial vessel occlusion or stenosis caused by acute aortic dissection type A (e.g., leading to stroke, paraplegia, visceral ischemia, or peripheral limb ischemia) preoperatively.
0 (0%) 2 (6.5%)
18 (58%)
Male (n, %)
Chronic aortic dissection type B (n, %)
26 4
Marfan syndrome (n, %)
180 (170–180)
170 (165–175)
Height (cm)
BMI (kg/m2) 27 4
80 (70–95)
78 (66–86)
Weight (kg)
62 (53–69)
Group 2 Mechanical n ¼ 41 (34.5%)
71 (67–76)
Group 1 Biological n ¼ 31 (26%)
Age (y)
Characteristic
Table 1 Preoperative data
Acute Aortic Dissection with Aortic Root Involvement Beckmann et al.
0.363 19 (26%) 9 (19%) 12 (29%) 7 (23%) Coronary artery bypass grafting (n, %)
Combined procedures
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statistically not significant. Of note, the surgical procedures and the concomitant procedures were distributed relatively equally in all the three groups. During the time interval of this study, the mortality rates of all patients undergoing surgery for AADA and of the patients without root involvement were 20.5% and 19.1%, respectively. These numbers are comparable to the results of other centers,9,10 especially in view of the fact that we operated on all patients arriving alive at our hospital regardless of their age and clinical condition. Furthermore, while we focused exclusively on aortic root procedures, most published studies include supracommissural aortic replacements, which are technically less complex, thus resulting in a lower mortality rate. To some extent, the high rate of rethoracotomy may also be explained by our hospital policy to treat all patients regardless of their condition. Among the three groups of the study cohort, the 30-day mortality tended to be the highest in the Bio-Bentall group, followed by the Mechanical-Bentall group and the David group, respectively. At first sight, this might be confusing, as one might expect that the replacement with a valved conduit is the fastest, thus safest surgical approach to treat the dissection. Although most demographic factors are relatively evenly distributed among all groups, the mean patient age was significantly higher in patients receiving a biological valved conduit. As increased age usually correlates with a higher incidence of comorbidities, one has to assume that especially the patients of group 1 were more prone to a higher complication and mortality rate. Due to the nature of AADA with its sudden onset and the need for immediate treatment, there is usually a lack of detailed screening of these patients for comorbidities preoperatively. This problem is represented in our study as well, as it was not possible to compile an extensive and complete list of comorbidities. The lack of a detailed screening of AADA patients may also explain the relatively small number of individuals with Marfan disease in our study, as we documented only genetically confirmed cases. The David group showed the lowest 30-day mortality rate and the lowest mortality rate during the follow-up period, presumably because of the younger age and lower risk profile. The younger patient age might have also led to a higher rate for valve-related reoperation. In fact, the higher patient age and the higher mortality in both Bentall groups might have led to a lower rate for valve-related reoperations. The David group had the highest rate of valve-related reoperations. The lower number of patients might explain that this difference was not found to be statistically significant. The potential mid- and long-term risks of a reoperation caused by a failing David procedure have to be weighed carefully against the excellent perioperative results. Approximately half of the valve-related reoperations in the David group were caused by a failing aortic valve. Although a higher rate of valve-related reoperations has to be expected in the early to midterm follow-up in patients receiving valve-sparing aortic root reoperations, it remains unclear whether late reoperation rates might be similar or lower in the David group especially compared with patients receiving a biological Thoracic and Cardiovascular Surgeon
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0.531
0.446 0.543 5 (7%) 7 (15%) 2 (7%) Frozen elephant trunk (n, %)
3 (7%)
0.227
0.164 0.702
0.404 30 (42%)
14 (19%) 6 (13%)
16 (34%) 14 (34%)
9 (22%)
16 (52%)
5 (16%)
Total aortic arch replacement (n, %)
Elephant trunk (n, %)
0.752
0.147 0.306
0.851 4 (6%)
36 (53%) 28 (60%)
3 (6%)
14 (45%) Proximal arch replacement (n, %)
3 (7%) 1 (3%) Ascending aortic replacement (n, %)
Surgical procedures
24 (59%)
0.249 0.006 41 29 (n ¼ 69) 45 29 (n ¼ 39) 36 30 (n ¼ 30) Circulatory arrest time (min)
35 17 (n ¼ 45)
0.923
0.461 0.228
0.769 235 87
149 47 151 52
231 63 237 91
148 44
232 84 Cardiopulmonary bypass time (min)
Aortic cross-clamp time (min)
160 46
354 132 341 146 Operative time (min)
Operative characteristic
Table 2 Perioperative data
Group 1 Biological Bentall
Group 2 Mechanical Bentall
Group 3 David
329 85
348 137
All Bentalls
0.401
p-Value All Bentalls Vs. David
0.637
p-Value Bio vs. Mechanical vs. David
Acute Aortic Dissection with Aortic Root Involvement
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Beckmann et al. Table 4 Intraoperative/discharge echocardiography of group 3 Group 3 David, n ¼ 38 Aortic insufficiency
n, %
AI—grade 0 (none)
28 (73.7%)
AI—grade I (minimal)
8 (21%)
AI—grade II (moderate)
2 (5.3%)
Abbreviation: AI, aortic insufficiency.
valved conduit. Compared with mechanical valved conduits, a possibly higher reoperation rate after David procedures has to be weighed against a higher risk for thromboembolic and bleeding complications under life-long anticoagulation in patients receiving a mechanical valve. Future studies with a larger patient population and a longer patient follow-up should certainly address this issue. We believe that only surgeons who are familiar with the David procedure in an elective setting should proceed with this technique in the context of AADA. In addition, significant aortic insufficiency (higher than grade I) after aortic valve reimplantation should be considered as an important risk factor for valve-related reoperations and should be corrected intraoperatively. Nevertheless, in our view this study shows that valve-sparing David procedure can be performed with acceptable short- and mid-term results in the setting of AADA and should be considered especially in younger patients. Generally, one reason to implant a valved conduit instead of proceeding with valve-sparing aortic root surgery is the lack of experience of the surgeon with the latter procedure. Although it might be technically feasible and safe in the hand of the experienced surgeon to perform a David procedure in
Fig. 1 Survival. Kaplan–Meier survival curves including all patients (p ¼ 0.008).
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Abbreviation: ICU, intensive care unit. Notes: Prolonged ventilation was defined as the need for mechanical ventilation for more than 48 hours. Prolonged catecholamine was defined as the need for adrenaline, noradrenaline, dobutamine, or any combination for more than 48 hours.
0.116 0.075 21 (29%) 6 (12.8%) 10 (32.3%) 30-d mortality (n, %)
9 (22%)
0.863 0.694 7 (10%) 3 (6.4%) 3 (9.7%) Stroke (n, %)
4 (9.8%)
0.276
0.038 0.152
0.341 14 (19%)
33 (46%) 13 (27.7%)
6 (12.8%) 10 (24.4%) Dialysis (n, %)
22 (53.7%) 11 (35.5%)
4 (12.9%)
Prolonged catecholamines (n, %)
0.357 0.166 40 (56%) 20 (42.6%) 18 (58%) Prolonged ventilation (n, %)
22 (53.7%)
0.631
0.496 0.496
0.338 21 (29%)
8 10 79 9 11 7 10
9 (29%)
ICU stay (d)
Rethoracotomy (n %)
Characteristic
10 (21.3%)
p-Value All Bentalls versus David All Bentalls Group 3 David Group 2 Mechanical Bentall Group 1 Biological Bentall Table 3 Early postoperative outcome
12 (29.3%)
p-Value Bio vs. Mechanical vs. David
Acute Aortic Dissection with Aortic Root Involvement
Acute Aortic Dissection with Aortic Root Involvement
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In summary, Bentall procedure with a tissue-valved conduit can be considered for older patients, but in younger patients, valve-sparing root replacements should be considered if the surgical team is experienced.
Acknowledgments Both authors, Erik Beckmann and Andreas Martens, contributed equally to this manuscript. The authors were equally responsible for the study design, data collection, analysis, and interpretation. Further, the authors also wrote all parts of the manuscript together and worked together on the revisions. As both authors were equally involved in the study and the generation of this manuscript, we acknowledge that both Erik Beckmann and Andreas Martens receive credit for this work as “equally contributing authors”. This has been approved by the study team and the principal investigator.
Fig. 2 Freedom from valve-related reoperation. Kaplan–Meier estimates for freedom from valve-related reoperation including all patients (p ¼ 0.172).
the setting of AADA, we do not advocate this technique as an “all-comer” and “every surgeon” solution because the primary goal in AADA has to be to bring out the patient alive. Replacing the aortic root with a valved conduit in these patients may be a perfectly reasonable choice. Furthermore, appropriate patient selection is of great importance. Ideally, valve-sparing surgery should only be applied to relatively young patients with less comorbidities and relatively intact aortic valves without morphological abnormalities (e.g., prolapse, calcifications). Excessive additional leaflet repair might lead to a higher perioperative and long-term failure rate and prolongs the procedure. It should be avoided in this high-risk population of patients. Instead, under these conditions, AADA patients might benefit more from a Bentall procedure.
Limitations One limitation of this study is its retrospective nature. Furthermore, there is selection bias, as the final decision whether to proceed with a Bentall or David procedure is made by the surgeon. Younger patients are more likely to receive valve-sparing aortic root surgery. It is likely that some of the patients who received a Bentall procedure could have also been suitable for a David procedure.
References 1 Hines G, Dracea C, Katz DS. Diagnosis and management of
2 3
4
5 6
7
8
9
Conclusion Even in AADA patients with root involvement, valve-sparing David procedure has acceptable short- and mid-term results. In view of the 5-year survival rates in which more than 40% of patients with mechanical conduits were dead, valve-sparing David procedure (if possible) or a Bio-Bentall (in case the valve is pathological) seems to be the optimal technique for these patients.
10
11
acute type A aortic dissection. Cardiol Rev 2011;19(5): 226–232 Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23(4):338–339 David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103(4):617–621, discussion 622 Shrestha M, Baraki H, Maeding I, et al. Long-term results after aortic valve-sparing operation (David I). Eur J Cardiothorac Surg 2012;41(1):56–61, discussion 61–62 Sarsam MA, Yacoub M. Remodeling of the aortic valve anulus. J Thorac Cardiovasc Surg 1993;105(3):435–438 Leyh RG, Schmidtke C, Bartels C, Sievers HH. Valve-sparing aortic root replacement (remodeling/reimplantation) in acute type A dissection. Ann Thorac Surg 2000;70(1):21–24 Leyh RG, Fischer S, Kallenbach K, et al. High failure rate after valvesparing aortic root replacement using the “remodeling technique” in acute type A aortic dissection. Circulation 2002;106(12, Suppl 1):I229–I233 Erasmi AW, Sievers HH, Bechtel JFM, Hanke T, Stierle U, Misfeld M. Remodeling or reimplantation for valve-sparing aortic root surgery? Ann Thorac Surg 2007;83(2):S752–S756, discussion S785– S790 Erasmi AW, Stierle U, Bechtel JFM, Schmidtke C, Sievers HH, Kraatz EG. Up to 7 years’ experience with valve-sparing aortic root remodeling/reimplantation for acute type A dissection. Ann Thorac Surg 2003;76(1):99–104 Graeter TP, Langer F, Nikoloudakis N, Aicher D, Schäfers HJ. Valvepreserving operation in acute aortic dissection type A. Ann Thorac Surg 2000;70(5):1460–1465 Subramanian S, Leontyev S, Borger MA, Trommer C, Misfeld M, Mohr FW. Valve-sparing root reconstruction does not compromise survival in acute type A aortic dissection. Ann Thorac Surg 2012; 94(4):1230–1234 Thoracic and Cardiovascular Surgeon
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Conflict of Interest None declared.
Acute Aortic Dissection with Aortic Root Involvement
Beckmann et al. 13 Akins CW, Miller DC, Turina MI, et al. Guidelines for reporting
tion in acute aortic dissection type A: the Hannover experience. Eur J Cardiothorac Surg 2008;34(4):792–796, 796
mortality and morbidity after cardiac valve interventions. Eur J Cardiothorac Surg 2008;33(4):523–528
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12 Khaladj N, Shrestha M, Peterss S, et al. Ascending aortic cannula-
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Is Bentall Procedure Still the Gold Standard for Acute Aortic Dissection with Aortic Root Involvement? Erik Beckmann1, Andreas Martens1, Firas Abd Alhadi1 Fabio Ius1 Nurbol Koigeldiyev1 Felix Fleissner1 Penelope Stiefel1 Tim Kaufeld1 Axel Haverich1 Malakh Shrestha1 1 Department of Cardiac Surgery, Hannover Medical School, Hannover,
Germany Both authors contributed equally.
Address for correspondence Erik Beckmann, MD, Department of Cardiac Surgery, Hannover Medical School, Carl Neuberg St. 1, Hannover 30165, Germany (e-mail: [email protected]).
Abstract
Keywords
► acute aortic dissection ► valve-sparing aortic root surgery ► David procedure ► Bentall procedure
Introduction The “ideal” treatment of acute aortic dissection type A (AADA) with dissected and dilated root is controversial. We compared the outcome of classical Bentall procedure (biological and mechanical) with valve-sparing David procedure. Methods Between January 2002 and July 2011, 119 patients with AADA and aortic root involvement underwent surgery at our center. Thirty-one patients (group 1) received biological conduits, 41 (group 2) received mechanical conduits, and 47 (group 3) underwent David procedures. Results Cross-clamp, cardiopulmonary bypass, and circulatory arrest times were 151 52, 232 84, and 36 30 minutes (group 1); 148 44, 237 91, and 45 29 minutes (group 2); and 160 46, 231 63, and 35 17 minutes (group 3), respectively. The 30-day mortality rates were 32.3% (group 1), 22% (group 2), and 12.8% (group 3). The 1-year rates for freedom from valve-related reoperation were 100% (group 1), 92.5% (group 2), and 95.2% (group 3) (p ¼ 0.172). The 1-year survival rates were 61% (group 1), 61% (group 2), and 84.1% (group 3) (p ¼ 0.008). Conclusion Even in AADA patients with root involvement, David procedure has acceptable results. David procedure (if possible) or a Bio-Bentall (for pathological valves) seems to be the optimal technique.
Introduction Acute aortic dissection type A (AADA) represents a lifethreatening condition with a 30-day mortality of up to 50%.1 Emergent surgical intervention is the treatment of choice. When the aortic root is not only dissected but also dilated, composite replacement with a mechanical valved conduit has been the standard procedure.2 However, the need for lifelong anticoagulation with associated possible thromboembolic and bleeding complications as well as the increasing age of patients has led to a shift toward the use of tissue-valved conduits. But
received February 1, 2015 accepted after revision March 16, 2015
tissue-valved conduits also suffer from disadvantages, such as valve degeneration with the risk of reoperation. As the aortic dissection usually does not affect the aortic leaflets, valve-sparing aortic root replacement appears to be an appealing alternative.3,4 Valve-sparing surgery involves multiple techniques, including the remodeling technique (Yacoub procedure5) and the reimplantation technique (David procedure3). Preserving the native aortic valve offers the potential benefit of physiological valve function and the absence of need for long-term anticoagulation. On the other hand, valvesparing aortic root surgery is technically more challenging.
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DOI http://dx.doi.org/ 10.1055/s-0035-1552580. ISSN 0171-6425.
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The available literature on valve-sparing surgery for the treatment of AADA comprises a limited number of studies with a small number of patients. Various groups, including ours, published their experience, demonstrating the feasibility and efficacy of valve-sparing surgery in the setting of AADA.6–11 Nevertheless, valve-sparing surgery is still criticized for being too time consuming and complex during surgery for AADA. Against this background, it remains unclear whether or not valve-sparing aortic root replacement is an appropriate treatment for AADA. Thus, we set out to compare the outcome of valve-sparing aortic root surgery (David I) with the outcome of Bentall procedures with mechanical and tissuevalved conduits in the setting of AADA.
Materials and Methods Patient Characteristics The Ethics Committee of the Hannover Medical School, Germany, approved this study. We reviewed our hospital database for patients undergoing surgery for AADA between January 2002 and July 2011. In this period, a total of 313 patients underwent surgery for AADA at our center. Retrospective analysis of the chart and operation report was performed to identify AADA patients with extensive aortic root involvement not eligible for surgical repair with glue. We identified patients receiving an aortic root procedure while showing a noncalcified aortic valve. A total of 119 patients were classified into one of the following groups: group 1 (n ¼ 31) received a Bentall procedure with tissue-valved conduit, group 2 (n ¼ 41) received a Bentall procedure with mechanical conduit, and group 3 (n ¼ 47) underwent aortic valve-sparing David I procedure. Of note, all three techniques were performed during the same time period, depending on the surgeon’s expertise. In all cases, the indication for operation was AADA with dilated and dissected aortic sinuses. The diagnosis was established by computed tomography and/or echocardiography and/or cardiac catheterization. Surgery was performed on an emergency basis in all cases. It has been our policy to accept all patients who arrive alive at the hospital for surgery regardless of the preoperative clinical status or age. Only patients with noncalcified aortic valves were included in our study. The final decision whether to proceed with aortic valve-sparing surgery or Bentall procedure was taken by the surgeon. Only surgeons with experience in elective David procedures performed the surgery.
depend on the surgeon’s preference as well as the intraoperative usage of Teflon felt, glue, and pericardial bands.
Valve-Sparing Aortic Root Surgery Technique The aortic root was mobilized from outside to a level directly below the nadir of the aortic annulus. The coronary ostia were excised as buttons and the aortic sinuses were resected to leave a rim of 5 mm of the aortic wall. The three commissures were elevated by stay sutures. After achieving optimal cusp coaptation, the diameter was measured by insertion of a Hegar dilator into the aortic annulus. A Dacron prosthesis one size larger than the annulus size was chosen (e.g., 28-mm Dacron graft for a 26-mm aortic annulus). The maximum prosthesis size used was 30 mm. Nine to twelve threads of 2/0-coated polyester fiber (Ethibond; Ethicon Inc., Norderstedt, Germany) were placed insideout horizontally below the valve in a circumferential way and anchored in the Dacron prosthesis. The prosthesis was fixed by tying these threads. Care was taken not to narrow down the diameter of the aortic annulus. Afterwards the commissures were maximally pulled up without stretching the Dacron graft and then fixed within the graft using 4/0 poly-propylene sutures (Prolene, Ethicon Inc.). Using three additional 4/0 poly-propylene sutures, the remnants of the aortic sinuses and the aortic annulus were sutured into the straight graft (David I procedure). Even though a straight Dacron graft was used, these sutures create small neosinuses. The coronary ostia were reimplanted to their respective neosinuses using 5/0 poly-prolene suture.
Bentall Technique The surgical techniques for both the Bentall procedure using tissue-valved and the mechanical valved conduits are similar. When a mechanical conduit was implanted, usually an ATS Medical (Minneapolis, Minnesota, United States) or St. Jude Medical (Saint Paul, Minnesota, United States) product was used. When a tissue-valved conduit was implanted, either the conduit assembled at the operation table using a Dacron prosthesis and a tissue valve or a prefabricated tissue valved conduit (Vascutek BioValsalva, BioValsalva prosthesis, Vascutek, Hamburg, Germany) was used. Both the aortic valve and the dissected ascending aorta were resected. The mechanical or tissue-valved conduit was implanted using a modified Bentall technique with reimplantation of the coronary ostia as buttons. The conduit was implanted into the aortic annulus using pledgeted threads (Ethibond, Ethicon Inc.). Next, the coronary ostia were reimplanted into the conduit using a 5/0 poly-prolene suture.
General Surgical Technique
Aortic Arch Surgery
After a standard median sternotomy and systemic heparinization, cardiopulmonary bypass (CPB) was initiated usually with direct cannulation of the ascending aorta and the right atrium. This technique of direct aortic cannulation even in AADA patients has been described previously by our group.12 In some patients, arterial cannulation was performed via the femoral artery. Cold blood cardioplegia (Buckberg) is the preferred method of myocardial protection at our institution. Whether the root or the arch repair should be performed first
In addition to the root procedure, either a proximal aortic arch or total aortic arch replacement was performed depending on the pathology under moderate hypothermic circulatory arrest (temperatures between 25 and 27°C) and bilateral selective antegrade cerebral perfusion.
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Anticoagulation Therapy After surgery, patients receiving a tissue-valved conduit were anticoagulated with Coumadin for the first 3 months only.
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Acute Aortic Dissection with Aortic Root Involvement
Thereafter, the patients received a life-long therapy with aspirin. Patients with a mechanical conduit received a lifelong anticoagulation therapy with Coumadin. Patients undergoing valve-sparing David procedure were anticoagulated either with Coumadin for 3 months or life-long aspirin.
Follow-up Informed and written consent from all patients was obtained for follow-up examination. All patients were contacted for follow-up, which was done according to common guidelines.13 We also acquired and reviewed the most recent medical data from the primary care physicians and/or cardiologists.
Statistical Analysis Continuous variables are stated as mean standard deviation or as median þ range, respectively. Categorical variables are stated as absolute numbers and proportions. Data analysis was performed using SPSS 22 Statistics software (IBM, Herrenberg, Germany). Kaplan–Meier analysis was used for evaluation of survival and freedom from valve-related reoperation. Differences in categorical variables were analyzed using the χ2 test. Differences in continuous variables were tested using t-test, one-way ANOVA analysis, or Mann–Whitney U-test, respectively. Multivariate analysis was performed using a binary logistic regression model to discriminate independent risk factors for 30-day mortality. We stated the Odds ratio (OR) and the 95% confidence interval (CI). A value of p < 0.05 was considered statistically significant.
Results The preoperative patient characteristics are shown in ►Table 1. The preoperative patient variables were relatively similar among the three groups. However, the mean age was lower in group 3 (54 years), followed by group 2 (60 years) and group 1 (71 years). This difference was statistically significant (p < 0.001). The 30-day mortality rate of all patients (n ¼ 313) undergoing surgery for AADA at our institution was 20.5%. The 30day mortality rate of AADA patients without root involvement was 19.1%. In the present study, the 30-day mortality rates were 32.3% (group 1), 22% (group 2), and 12.8% (group 3). Although the 30-day mortality was lower in group 3 than in group 1 and group 2, this difference was not statistically significant (p ¼ 0.116). When comparing the 30-day mortality of the whole Bentall group (including both tissue- and mechanical-valved conduits) with the David group, a statistically significant difference was found (p ¼ 0.037). However, logistic regression analysis did not identify the operative technique as independent risk factor for early mortality. Logistic regression showed that CPB time (OR, 1.05; CI, 1.013–1.089; p ¼ 0.008) and age (OR, 1.11; CI, 1.012–1.218; p ¼ 0.027) were significant predictors for early mortality. The reasons for 30-day mortality in group 1 were cardiac failure in three patients, bleeding in three patients, multiorgan failure in two patients, and unknown reasons in two patients. The reasons for 30-day mortality in group 2 were
Beckmann et al.
cardiac failure in three patients, sepsis in two patients, cerebral hemorrhage in one patient, multiorgan failure in one patient, mesenterial ischemia in one patient, and stroke in one patient. The reasons for 30-day mortality in group 3 were sepsis in two patients, cerebral dysregulation in one patient, intracranial hemorrhage in one patient, multiorgan failure in one patient, and unknown reason in one patient. The results of the intra- and perioperative data are given in ►Tables 2 and 3. The results of the intraoperative and discharge echocardiography examinations of group 3 are given in ►Table 4. The majority (36/38, 94.7%) were discharged with aortic valve insufficiency of grade I or less. The follow-up was 100% complete for the total patient cohort. The mean follow-up times were 4.2 (group 1), 3.5 (group 2), and 6.3 (group 3) years. The Kaplan–Meier survival curves are shown in ►Fig. 1. The 1-year survival estimates for the three groups were 61% (group 1), 61% (group 2), and 85% (group 3). The 5-year survival estimates for the three groups were 47% (group 1), 58% (group 2), and 75% (group 3). The differences in long-term survival in the Kaplan–Meier analysis were found to be statistically significant (p ¼ 0.008). Valve-related reoperation rates were 0% (n ¼ 0, group 1), 5% (n ¼ 2, group 2), and 14.9% (n ¼ 7, group 3). The mortality rates of reoperations were 0% (0/2, group 2) and 14.3% (1/7, group 3). The Kaplan–Meier curves for freedom from valve-related reoperation are depicted in ►Fig. 2. The 1-year estimates for freedom from valve-related reoperation are 100% (group 1), 92.5% (group 2), and 95.2% (group 3). The 5-year estimates for freedom from valve-related reoperation are 100% (group 1), 92.5% (group 2), and 84.1% (group 3), respectively. No statistically significant difference was found in the Kaplan– Meier analysis for freedom from valve-related reoperations (p ¼ 0.172). The two patients who underwent reoperation in group 2 were caused by endocarditis. Five out of the seven David patients who needed reoperation were discharged with aortic valve insufficiency of grade 0. The reasons for reoperation were severe aortic valve insufficiency in two cases (one early at 3 months), prosthetic infection/endocarditic in three cases, severe aortic valve stenosis in one case, and for unknown reason in one case.
Discussion AADA remains a life-threatening disease with high morbidity and mortality. If the aortic dissection involves the aortic root, the optimal surgical treatment is still a matter of debate, especially if the aortic root is dilated. Valve-sparing surgery in the setting of AADA is often criticized for being too time consuming and complex. In fact, critics recommend not to use this technique for the treatment of AADA. However, we found that the total operative times as well as the CPB times were similar in the David group compared with the two Bentall groups. The aortic cross-clamp time was only slightly longer in the David group than in both the Bentall groups. This difference was Thoracic and Cardiovascular Surgeon
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1 (3.2%) 12 (39%) 8 (26%) 3 (9.7%) 1 (3.2%)
Bicuspid aortic valve (n, %)
Hemorrhagic pericardial effusion (n, %)
Malperfusion (n, %)
Preoperative critical state (n, %)
Previous cardiac surgery (n, %)
3 (7.3%)
12 (29%)
8 (20%)
18 (44%)
2 (4.9%)
1 (2.4%)
1 (2.4%)
27 (65%)
1 (2.1%)
7 (15%)
7 (15%)
16 (34%)
2 (4.3%)
2 (4.3%)
0 (0%)
32 (69%)
27 4
178 (170–185)
83 (75–93)
52 (46–61)
Group 3 David n ¼ 47 (39.5%)
4 (6%)
15 (21%)
16 (22%)
30 (42%)
3 (4%)
3 (4%)
1 (1%)
45 (62%)
27 4
172 (170–180)
80 (70–90)
67 (57–73)
All Bentalls n ¼ 72
0.457
0.076
0.393
0.638
0.981
0.981
0.417
0.651
0.511
0.148
0.130
0.000
p-Value All Bentalls Vs. David
0.362
0.415
0.239
0.404
0.942
0.702
0.383
0.533
0.631
0.222
0.132
0.000
p-Value Bio vs. Mechanical vs. David
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Abbreviation: BMI, body mass index. Notes: Preoperative critical state was defined as the need for catecholamines, resuscitation, ventilation, or any combination. Malperfusion was clinically defined as the presence of significant arterial vessel occlusion or stenosis caused by acute aortic dissection type A (e.g., leading to stroke, paraplegia, visceral ischemia, or peripheral limb ischemia) preoperatively.
0 (0%) 2 (6.5%)
18 (58%)
Male (n, %)
Chronic aortic dissection type B (n, %)
26 4
Marfan syndrome (n, %)
180 (170–180)
170 (165–175)
Height (cm)
BMI (kg/m2) 27 4
80 (70–95)
78 (66–86)
Weight (kg)
62 (53–69)
Group 2 Mechanical n ¼ 41 (34.5%)
71 (67–76)
Group 1 Biological n ¼ 31 (26%)
Age (y)
Characteristic
Table 1 Preoperative data
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0.363 19 (26%) 9 (19%) 12 (29%) 7 (23%) Coronary artery bypass grafting (n, %)
Combined procedures
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statistically not significant. Of note, the surgical procedures and the concomitant procedures were distributed relatively equally in all the three groups. During the time interval of this study, the mortality rates of all patients undergoing surgery for AADA and of the patients without root involvement were 20.5% and 19.1%, respectively. These numbers are comparable to the results of other centers,9,10 especially in view of the fact that we operated on all patients arriving alive at our hospital regardless of their age and clinical condition. Furthermore, while we focused exclusively on aortic root procedures, most published studies include supracommissural aortic replacements, which are technically less complex, thus resulting in a lower mortality rate. To some extent, the high rate of rethoracotomy may also be explained by our hospital policy to treat all patients regardless of their condition. Among the three groups of the study cohort, the 30-day mortality tended to be the highest in the Bio-Bentall group, followed by the Mechanical-Bentall group and the David group, respectively. At first sight, this might be confusing, as one might expect that the replacement with a valved conduit is the fastest, thus safest surgical approach to treat the dissection. Although most demographic factors are relatively evenly distributed among all groups, the mean patient age was significantly higher in patients receiving a biological valved conduit. As increased age usually correlates with a higher incidence of comorbidities, one has to assume that especially the patients of group 1 were more prone to a higher complication and mortality rate. Due to the nature of AADA with its sudden onset and the need for immediate treatment, there is usually a lack of detailed screening of these patients for comorbidities preoperatively. This problem is represented in our study as well, as it was not possible to compile an extensive and complete list of comorbidities. The lack of a detailed screening of AADA patients may also explain the relatively small number of individuals with Marfan disease in our study, as we documented only genetically confirmed cases. The David group showed the lowest 30-day mortality rate and the lowest mortality rate during the follow-up period, presumably because of the younger age and lower risk profile. The younger patient age might have also led to a higher rate for valve-related reoperation. In fact, the higher patient age and the higher mortality in both Bentall groups might have led to a lower rate for valve-related reoperations. The David group had the highest rate of valve-related reoperations. The lower number of patients might explain that this difference was not found to be statistically significant. The potential mid- and long-term risks of a reoperation caused by a failing David procedure have to be weighed carefully against the excellent perioperative results. Approximately half of the valve-related reoperations in the David group were caused by a failing aortic valve. Although a higher rate of valve-related reoperations has to be expected in the early to midterm follow-up in patients receiving valve-sparing aortic root reoperations, it remains unclear whether late reoperation rates might be similar or lower in the David group especially compared with patients receiving a biological Thoracic and Cardiovascular Surgeon
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0.531
0.446 0.543 5 (7%) 7 (15%) 2 (7%) Frozen elephant trunk (n, %)
3 (7%)
0.227
0.164 0.702
0.404 30 (42%)
14 (19%) 6 (13%)
16 (34%) 14 (34%)
9 (22%)
16 (52%)
5 (16%)
Total aortic arch replacement (n, %)
Elephant trunk (n, %)
0.752
0.147 0.306
0.851 4 (6%)
36 (53%) 28 (60%)
3 (6%)
14 (45%) Proximal arch replacement (n, %)
3 (7%) 1 (3%) Ascending aortic replacement (n, %)
Surgical procedures
24 (59%)
0.249 0.006 41 29 (n ¼ 69) 45 29 (n ¼ 39) 36 30 (n ¼ 30) Circulatory arrest time (min)
35 17 (n ¼ 45)
0.923
0.461 0.228
0.769 235 87
149 47 151 52
231 63 237 91
148 44
232 84 Cardiopulmonary bypass time (min)
Aortic cross-clamp time (min)
160 46
354 132 341 146 Operative time (min)
Operative characteristic
Table 2 Perioperative data
Group 1 Biological Bentall
Group 2 Mechanical Bentall
Group 3 David
329 85
348 137
All Bentalls
0.401
p-Value All Bentalls Vs. David
0.637
p-Value Bio vs. Mechanical vs. David
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Beckmann et al. Table 4 Intraoperative/discharge echocardiography of group 3 Group 3 David, n ¼ 38 Aortic insufficiency
n, %
AI—grade 0 (none)
28 (73.7%)
AI—grade I (minimal)
8 (21%)
AI—grade II (moderate)
2 (5.3%)
Abbreviation: AI, aortic insufficiency.
valved conduit. Compared with mechanical valved conduits, a possibly higher reoperation rate after David procedures has to be weighed against a higher risk for thromboembolic and bleeding complications under life-long anticoagulation in patients receiving a mechanical valve. Future studies with a larger patient population and a longer patient follow-up should certainly address this issue. We believe that only surgeons who are familiar with the David procedure in an elective setting should proceed with this technique in the context of AADA. In addition, significant aortic insufficiency (higher than grade I) after aortic valve reimplantation should be considered as an important risk factor for valve-related reoperations and should be corrected intraoperatively. Nevertheless, in our view this study shows that valve-sparing David procedure can be performed with acceptable short- and mid-term results in the setting of AADA and should be considered especially in younger patients. Generally, one reason to implant a valved conduit instead of proceeding with valve-sparing aortic root surgery is the lack of experience of the surgeon with the latter procedure. Although it might be technically feasible and safe in the hand of the experienced surgeon to perform a David procedure in
Fig. 1 Survival. Kaplan–Meier survival curves including all patients (p ¼ 0.008).
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Abbreviation: ICU, intensive care unit. Notes: Prolonged ventilation was defined as the need for mechanical ventilation for more than 48 hours. Prolonged catecholamine was defined as the need for adrenaline, noradrenaline, dobutamine, or any combination for more than 48 hours.
0.116 0.075 21 (29%) 6 (12.8%) 10 (32.3%) 30-d mortality (n, %)
9 (22%)
0.863 0.694 7 (10%) 3 (6.4%) 3 (9.7%) Stroke (n, %)
4 (9.8%)
0.276
0.038 0.152
0.341 14 (19%)
33 (46%) 13 (27.7%)
6 (12.8%) 10 (24.4%) Dialysis (n, %)
22 (53.7%) 11 (35.5%)
4 (12.9%)
Prolonged catecholamines (n, %)
0.357 0.166 40 (56%) 20 (42.6%) 18 (58%) Prolonged ventilation (n, %)
22 (53.7%)
0.631
0.496 0.496
0.338 21 (29%)
8 10 79 9 11 7 10
9 (29%)
ICU stay (d)
Rethoracotomy (n %)
Characteristic
10 (21.3%)
p-Value All Bentalls versus David All Bentalls Group 3 David Group 2 Mechanical Bentall Group 1 Biological Bentall Table 3 Early postoperative outcome
12 (29.3%)
p-Value Bio vs. Mechanical vs. David
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In summary, Bentall procedure with a tissue-valved conduit can be considered for older patients, but in younger patients, valve-sparing root replacements should be considered if the surgical team is experienced.
Acknowledgments Both authors, Erik Beckmann and Andreas Martens, contributed equally to this manuscript. The authors were equally responsible for the study design, data collection, analysis, and interpretation. Further, the authors also wrote all parts of the manuscript together and worked together on the revisions. As both authors were equally involved in the study and the generation of this manuscript, we acknowledge that both Erik Beckmann and Andreas Martens receive credit for this work as “equally contributing authors”. This has been approved by the study team and the principal investigator.
Fig. 2 Freedom from valve-related reoperation. Kaplan–Meier estimates for freedom from valve-related reoperation including all patients (p ¼ 0.172).
the setting of AADA, we do not advocate this technique as an “all-comer” and “every surgeon” solution because the primary goal in AADA has to be to bring out the patient alive. Replacing the aortic root with a valved conduit in these patients may be a perfectly reasonable choice. Furthermore, appropriate patient selection is of great importance. Ideally, valve-sparing surgery should only be applied to relatively young patients with less comorbidities and relatively intact aortic valves without morphological abnormalities (e.g., prolapse, calcifications). Excessive additional leaflet repair might lead to a higher perioperative and long-term failure rate and prolongs the procedure. It should be avoided in this high-risk population of patients. Instead, under these conditions, AADA patients might benefit more from a Bentall procedure.
Limitations One limitation of this study is its retrospective nature. Furthermore, there is selection bias, as the final decision whether to proceed with a Bentall or David procedure is made by the surgeon. Younger patients are more likely to receive valve-sparing aortic root surgery. It is likely that some of the patients who received a Bentall procedure could have also been suitable for a David procedure.
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Conclusion Even in AADA patients with root involvement, valve-sparing David procedure has acceptable short- and mid-term results. In view of the 5-year survival rates in which more than 40% of patients with mechanical conduits were dead, valve-sparing David procedure (if possible) or a Bio-Bentall (in case the valve is pathological) seems to be the optimal technique for these patients.
10
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acute type A aortic dissection. Cardiol Rev 2011;19(5): 226–232 Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23(4):338–339 David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103(4):617–621, discussion 622 Shrestha M, Baraki H, Maeding I, et al. Long-term results after aortic valve-sparing operation (David I). Eur J Cardiothorac Surg 2012;41(1):56–61, discussion 61–62 Sarsam MA, Yacoub M. Remodeling of the aortic valve anulus. J Thorac Cardiovasc Surg 1993;105(3):435–438 Leyh RG, Schmidtke C, Bartels C, Sievers HH. Valve-sparing aortic root replacement (remodeling/reimplantation) in acute type A dissection. Ann Thorac Surg 2000;70(1):21–24 Leyh RG, Fischer S, Kallenbach K, et al. High failure rate after valvesparing aortic root replacement using the “remodeling technique” in acute type A aortic dissection. Circulation 2002;106(12, Suppl 1):I229–I233 Erasmi AW, Sievers HH, Bechtel JFM, Hanke T, Stierle U, Misfeld M. Remodeling or reimplantation for valve-sparing aortic root surgery? Ann Thorac Surg 2007;83(2):S752–S756, discussion S785– S790 Erasmi AW, Stierle U, Bechtel JFM, Schmidtke C, Sievers HH, Kraatz EG. Up to 7 years’ experience with valve-sparing aortic root remodeling/reimplantation for acute type A dissection. Ann Thorac Surg 2003;76(1):99–104 Graeter TP, Langer F, Nikoloudakis N, Aicher D, Schäfers HJ. Valvepreserving operation in acute aortic dissection type A. Ann Thorac Surg 2000;70(5):1460–1465 Subramanian S, Leontyev S, Borger MA, Trommer C, Misfeld M, Mohr FW. Valve-sparing root reconstruction does not compromise survival in acute type A aortic dissection. Ann Thorac Surg 2012; 94(4):1230–1234 Thoracic and Cardiovascular Surgeon
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Conflict of Interest None declared.
Acute Aortic Dissection with Aortic Root Involvement
Beckmann et al. 13 Akins CW, Miller DC, Turina MI, et al. Guidelines for reporting
tion in acute aortic dissection type A: the Hannover experience. Eur J Cardiothorac Surg 2008;34(4):792–796, 796
mortality and morbidity after cardiac valve interventions. Eur J Cardiothorac Surg 2008;33(4):523–528
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