Highlights
- •The composite aortic valve graft replacement (CAVGR – Bentall procedure) has been considered the best approach for acute type A aortic dissection (ATAAD) with root involvement.
- •Valve-sparing aortic root replacement (VSARR) arose as an option over the last years, but long-term outcomes are controversial.
- •VSRR does not seem confer a better (or worse) survival in ATAAD, but it is associated with higher risk of reoperations.
Abstract
Objectives
To evaluate the long-term outcomes of valve-sparing aortic root replacement (VSARR)
versus composite aortic valve graft replacement (CAVGR) in the treatment of acute
type A aortic dissections (ATAAD).
Methods
We performed a pooled meta-analysis of Kaplan–Meier-derived time-to-event data from
studies with longer follow-up beyond the immediate postoperative period.
Results
Seven studies met our eligibility criteria, comprising a total of 858 patients (367
patients in the VSARR groups and 491 patients in the CAVGR group). We found no statistically
significant differences in the overall survival between the groups over time (HR 0.83,
95%CI 0.63–1.10, P = 0.192), but we observed a higher risk of reoperation in the VSARR group when compared
with the CAVGR group (HR 9.99, 95% CI 2.23–44.73, P = 0.003). The meta-regression revealed statistically significant positive coefficients
for age (P < 0.001) in the analysis of survival, which means that this covariate has a modulating
effect on this outcome. The higher the mean age, the higher the HR for overall mortality
was found to be with VSARR as compared with CAVGR. Other covariates such as female
sex, hypertension, diabetes, connective tissue disorders, bicuspid aortic valve, hemiarch
and/or total arch replacement, concomitant coronary bypass surgery did not seem to
have any effect on the outcomes.
Conclusion
VSARR did not confer a better (or worse) survival over time in patients with ATAAD,
but it was associated with higher risk of reoperations in the long run.
Graphical abstract
Graphical Abstract
Keywords
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References
- The international registry of acute aortic dissection (IRAD): new insights into an old disease.JAMA. 2000; 283: 897-903
- The Bentall procedure: is it the gold standard? A series of 597 consecutive cases.J. Thorac. Cardiovasc. Surg. 2010; 140 (discussion 86–91): 64-70
- Is Bentall procedure still the gold standard for acute aortic dissection with aortic root involvement?.Thorac. Cardiovasc. Surg. 2016; 64: 116-123
- The aortic valve-sparing operation.J. Thorac. Cardiovasc. Surg. 2011; 141: 613-615
- Remodeling of the aortic valve anulus.J. Thorac. Cardiovasc. Surg. 1993; 105: 435-438
- Up to 7 years’ experience with valve-sparing aortic root remodeling/reimplantation for acute type A dissection.Ann. Thorac. Surg. 2003; 76: 99-104
- Valve-sparing root replacement compared with composite valve graft procedures in patients with aortic root dilation.J. Am. Coll. Cardiol. 2016; 68: 1838-1847
- Expanding the indications for the David V aortic root replacement: early results.J. Thorac. Cardiovasc. Surg. 2012; 143: 879-884
- Getting to the root of the matter: management of the aortic root in type A aortic dissection.Eur. J. Cardiothorac. Surg. 2016; 50: 230-231
- Midterm results of David V valve-sparing aortic root replacement in acute type A aortic dissection.Ann. Thorac. Surg. 2015; 99: 795-801
- Root replacement surgery versus more conservative management during type A acute aortic dissection repair.Ann. Thorac. Surg. 2014; 98: 2078-2084
- Surgical management of aortic root in type A acute aortic dissection: a propensity-score analysis.Eur. J. Cardiothorac. Surg. 2016; 50: 223-229
- Aortic root remodeling leads to good valve stability in acute aortic dissection and preexistent root dilatation.J. Thorac. Cardiovasc. Surg. 2016; 152: 430-436
- The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.BMJ. 2021; 372n71
- ROBINS-I: a tool for assessing risk of bias in non-randomized studies of interventions.BMJ. 2016; 355i4919
- Enhanced secondary analysis of survival data: reconstructing the data from published Kaplan-Meier survival curves.BMC Med. Res. Methodol. 2012; 12: 9
- Reconstructing time-to event data from published Kaplan-Meier curves.Stata J. 2017; 17: 786-802
- IPDfromKM: reconstruct individual patient data from published Kaplan-Meier survival curves.BMC Med. Res. Methodol. 2021; 21: 111
- Proportional hazards tests and diagnostics based on weighted residuals.Biometrika. 1994; 81: 515-526
- Flexible parametric proportional-hazards and proportional-odds models for censored survival data, with application to prognostic modelling and estimation of treatment effects.Stat. Med. 2002; 21: 2175-2197
- Further developments of flexible parametric models for survival analysis.Stata J. 2009; 9: 265-290
- Preservation versus replacement of the aortic root for acute type A aortic dissection.J. Thorac. Cardiovasc. Surg. 2022; (Online ahead of print)https://doi.org/10.1016/j.jtcvs.2022.04.053
- Sixteen-year experience of David and Bentall procedures in acute type A aortic dissection.Ann. Thorac. Surg. 2018; 105: 779-784
- Acute aortic dissection involving the root: operative and long-term outcome after curative proximal repair.Interact. Cardiovasc. Thorac. Surg. 2016; 22: 620-626
- Clinical outcomes of valve-sparing root replacement in acute type A aortic dissection.Scand. Cardiovasc. J. 2015; 49: 331-336
- Valve-sparing root reconstruction does not compromise survival in acute type A aortic dissection.Ann. Thorac. Surg. 2012; 94: 1230-1234
- Comparison of aortic root replacement in patients with Marfan syndrome.Eur. J. Cardiothorac. Surg. 2011; 40: 1052-1057
- Clinical outcomes of the David V valve-sparing root replacement compared with bioprosthetic valve-conduits for aortic root aneurysms.Ann. Thorac. Surg. 2016; 102: 1522-1530
- The David V valve-sparing root replacement provides improved survival compared with mechanical valve-conduits in the treatment of young patients with aortic root pathology.Ann. Thorac. Surg. 2016; 102: 1522-1530
Article info
Publication history
Published online: March 31, 2023
Accepted:
March 28,
2023
Received:
March 9,
2023
Identification
Copyright
© 2023 Elsevier B.V. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Editorial: Current strategies for the management of type A aortic dissection involving the aortic root, which is better?International Journal of CardiologyVol. 382
- PreviewIntimal tear signalizes aortic dissection creating a true and false lumen. No matter where the main intimal break is, type A aortic dissection affects the ascending aorta. Acute type A aortic dissection (AAAD) is a surgical emergency. Affected individuals experience a greater chance of developing potentially fatal consequences. Without surgery, death usually may follow within hours (1–2% per hour after the beginning of symptoms) [1].
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