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Chen C, Chen C, Chang F, Cheng Y, Wu VC, Lin C, Chan Y, Hung K, Chu P, Chen S. Mechanical Versus Bioprosthetic Aortic Valve Replacement in Patients Undergoing Bentall Procedure. J Am Heart Assoc 2024; 13:e030328. [PMID: 38156561 PMCID: PMC10863806 DOI: 10.1161/jaha.123.030328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 12/01/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND The widely used Bentall procedure is the criterion standard treatment for aortic root pathology. Studies comparing the long-term outcomes of bioprosthetic and mechanical valves in patients undergoing the Bentall procedure are limited. METHODS AND RESULTS Patients who underwent the Bentall procedure with a bioprosthetic or mechanical valve between 2001 and 2018 were identified from Taiwan's National Health Insurance Research Database. The primary outcome of interest was all-cause mortality. Inverse probability of treatment weighting was performed to compare the 2 prosthetic types. In total, 1052 patients who underwent the Bentall procedure were identified. Among these patients, 351 (33.4%) and 701 (66.6%) chose bioprosthetic and mechanical valves, respectively. After inverse probability of treatment weighting, no significant differences in the in-hospital mortality (odds ratio, 0.96 [95% CI, 0.77-1.19]; P=0.716) and all-cause mortality (34.1% vs. 38.1%; hazard ratio, 0.90 [95% CI, 0.78-1.04]; P=0.154) were observed between the groups. The benefits of relative mortality associated with mechanical valves were apparent in younger patients and persisted until ≈50 years of age. CONCLUSIONS No differences in survival benefits were observed between the valves in patients who underwent the Bentall procedure. Additionally, bioprosthetic valves may be a reasonable choice for patients aged >50 years when receiving the Bentall procedure in this valve-in-valve era.
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Affiliation(s)
- Cheng‐Yu Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical CenterChang Gung UniversityTaoyuan CityTaiwan
| | - Chun‐Yu Chen
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical CenterChang Gung UniversityTaoyuan CityTaiwan
| | - Feng‐Cheng Chang
- Department of Anesthesiology, Chang Gung Memorial Hospital, Linkou Medical CenterChang Gung UniversityTaoyuan CityTaiwan
| | - Yu‐Ting Cheng
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical CenterChang Gung UniversityTaoyuan CityTaiwan
| | - Victor Chien‐Chia Wu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical CenterChang Gung UniversityTaoyuan CityTaiwan
| | - Chia‐Pin Lin
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical CenterChang Gung UniversityTaoyuan CityTaiwan
| | - Yi‐Hsin Chan
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical CenterChang Gung UniversityTaoyuan CityTaiwan
| | - Kuo‐Chun Hung
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical CenterChang Gung UniversityTaoyuan CityTaiwan
| | - Pao‐Hsien Chu
- Department of Cardiology, Chang Gung Memorial Hospital, Linkou Medical CenterChang Gung UniversityTaoyuan CityTaiwan
| | - Shao‐Wei Chen
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical CenterChang Gung UniversityTaoyuan CityTaiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Linkou Medical CenterTaoyuan CityTaiwan
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Sá MP, Tasoudis P, Jacquemyn X, Van den Eynde J, Rad AA, Weymann A, Ruhparwar A, Caranasos TG, Ikonomidis JS, Chu D, Serna-Gallegos D, Sultan I. Long-term outcomes of valve-sparing root versus composite valve graft replacement for acute type A aortic dissection: Meta-analysis of reconstructed time-to-event data. Int J Cardiol 2023; 382:12-19. [PMID: 37004942 DOI: 10.1016/j.ijcard.2023.03.062] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/28/2023] [Indexed: 04/04/2023]
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.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America.
| | - Panagiotis Tasoudis
- Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, NC, United States of America
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Arian Arjomandi Rad
- Oxford University Clinical Academic Graduate School, University of Oxford, Oxford, UK
| | - Alexander Weymann
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Arjang Ruhparwar
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany
| | - Thomas G Caranasos
- Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, NC, United States of America
| | - John S Ikonomidis
- Department of Surgery, Division of Cardiothoracic Surgery, University of North Carolina, Chapel Hill, NC, United States of America
| | - Danny Chu
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, United States of America; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, United States of America
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Holubec T, Rashid H, Van Linden A, Moritz A. Reply to de Kerchove et al.: 'Rather addition than extension of Florida sleeve indication'. Eur J Cardiothorac Surg 2022; 62:6678983. [PMID: 36040185 DOI: 10.1093/ejcts/ezac444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/29/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tomas Holubec
- Department of Cardiovascular Surgery, Goethe University Frankfurt and University Hospital Frankfurt, Frankfurt, Germany
| | - Hiwad Rashid
- Department of Cardiovascular Surgery, Goethe University Frankfurt and University Hospital Frankfurt, Frankfurt, Germany
| | - Arnaud Van Linden
- Department of Cardiovascular Surgery, Goethe University Frankfurt and University Hospital Frankfurt, Frankfurt, Germany
| | - Anton Moritz
- Department of Cardiovascular Surgery, Goethe University Frankfurt and University Hospital Frankfurt, Frankfurt, Germany
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Huang LC, Xu Z, Dai XF. A new patch technique for valve-sparing aortic root repair in acute type A aortic dissection. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:949. [PMID: 34350264 PMCID: PMC8263875 DOI: 10.21037/atm-21-436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 04/29/2021] [Indexed: 12/03/2022]
Abstract
Valve-sparing aortic root replacement is an attractive option for younger patients with acute type A aortic dissection. This study aimed to design a new patch technique for reconstructing the aortic root and preserving the aortic valve following aortic dissection. Between July 2017 and December 2018, 35 patients underwent valve-sparing aortic root repair using this new patch technique. All participants were in the supine position, transesophageal echocardiography and median sternotomy were routinely performed. After thrombi at the aortic root were removed in acute type A dissection, the luminal aortic intimal dissection was removed until the aortic condition was normalized. In each aortic sinus involved in the dissection, a Dacron-graft patch with the shape corresponding to the defect was sutured to the normal remnant vascular wall or aortic annulus in the aortic sinus using 5-0 Prolene suture to reconstruct the aortic root. A total of 2 patients died, and 1 cerebral infarction, and 3 cases of transient brain dysfunction were recorded. The sinus tube junction and sinus diameter were within the normal ranges when they were reexamined 3 months after surgery. This new patch technique circumvents the redesign of the spatial 3D structure of the aortic valve, is simple to operate, and easy to master. It completely removes the diseased dissection tissue, avoids the use of glue, and is an alternative surgical technique, especially for beginners.
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Affiliation(s)
- Ling-Chen Huang
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Zheng Xu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Xiao-Fu Dai
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
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Dai XF, Fang GH, Yan LL, Dong Y, Zhang GC, Xu Z, Chen LW. Patch Neointima Technique in Acute Type A Aortic Dissection: Midterm Results of 147 Cases. Ann Thorac Surg 2020; 112:75-82. [PMID: 33098877 DOI: 10.1016/j.athoracsur.2020.08.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 05/17/2020] [Accepted: 08/23/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The patch neointima technique is a modified valve-sparing aortic root repair surgery for acute type A aortic dissection and the short-term outcomes are satisfactory. The midterm outcomes have not been reported. METHODS From January 2009 to December 2012, 147 patients underwent valve-sparing aortic root repair with the patch neointima technique for type A aortic dissection in our center. The midterm outcomes of the patients were evaluated by echocardiography and aortic computed tomography angiography. RESULTS Of 147 patients, 32 patients (21.8%) underwent proximal arch repair, and 115 patients (78.2%) underwent proximal arch repair combined with triple-branched stent graft implantation. The perioperative mortality was 5.4%. Preoperative aortic insufficiency (AI) was observed in 94 patients (63.9%); 131 patients (89.1%) left the operating room with 0 AI; the remaining 16 patients (10.9%) had trace or less than 1+ AI. A total of 128 patients (87.1%) completed 7-year follow-up. The mean follow-up time was 5.7 ± 1.2 years. As many as 82% of patients (105) were 0 AI and 15.6% of patients (20) were 0.5+ trace or less than 1+ AI. No reoperation was performed for the aortic root. The diameters of sinotubular junction and sinus were reduced to the normal range (28.3 ± 4.2 mm and 30.5 ± 3.6 mm, respectively) and remained stable (28.9 ± 5.6 mm, P = .300, and 30.8 ± 4.2 mm, P = .540, respectively) during 7 years of follow-up. CONCLUSIONS Valve-sparing aortic root repair with patch neointima technique was associated with stable function of the aortic valves and no expansion of the aortic root in the midterm.
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Affiliation(s)
- Xiao-Fu Dai
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Guan-Hua Fang
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Liang-Liang Yan
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Yi Dong
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Gui-Can Zhang
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Zheng Xu
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China
| | - Liang-Wan Chen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, Fujian, China.
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Tamer S, Mastrobuoni S, Momeni M, Aphram G, Navarra E, Poncelet A, Noirhomme P, Astarci P, El Khoury G, de Kerchove L. Long-term experience with valve-sparing root reimplantation surgery in tricuspid aortic valve. Indian J Thorac Cardiovasc Surg 2020; 36:71-80. [PMID: 33061187 DOI: 10.1007/s12055-019-00842-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/26/2019] [Accepted: 05/30/2019] [Indexed: 01/16/2023] Open
Abstract
Objective To analyze our long-term experience with valve-sparing reimplantation technique in treating aortic root aneurysm, aortic regurgitation, and aortic dissection in patients with tricuspid aortic valve. Methods Between March 1998 and October 2018, 303 consecutive patients underwent valve-sparing reimplantation in our institution. The mean age of this cohort was 52.9 ± 15 years. Time to event analysis was performed with the Kaplan-Meier method. Risk of death, reoperation, and aortic regurgitation (AR) recurrence were analyzed using the cox-regression method. Results In-hospital mortality was 1% (n = 3) of which two were admitted for acute aortic dissection. Median follow-up was 5.81 years ([IQR]: 2.8-10 years). Thirty-nine patients (14.4%) died during follow-up. At 5 and 10 years, overall survival was 92 ± 2%and 75 ± 4.9%, respectively. Seventeen patients required late aortic valve reoperation. Freedom from valve reoperation was 95 ± 2% and 90 ± 3%. Freedom from AR > 2+ and AR > 1+ at 10 years was 91 ± 4% and 71.5 ± 4.6%, respectively. Significant multivariate predictors of death included age, New York Heart Association dyspnea class (NYHA), type A acute dissection (TAAD), and preoperative left ventricular end-diastolic diameter (LVEDD). Significant multivariate predictors of AR recurrence included indication for surgery, previous cardiac surgery, and presence of preoperative AR. Freedom from events like major bleeding, thromboembolic events, and infective endocarditis at 10 years were 97%, 98%, and 96%, respectively. Conclusions Aortic valve-sparing with the reimplantation technique has been performed for over two decades in our institution, and the results in patients with tricuspid aortic valve (TAV) are excellent in terms of survival and freedom from valve-related adverse outcomes including valve reoperation. These results continue supporting the use of valve sparing root replacement using the reimplantation technique (VSRR) in patients with aortic aneurysm, irrespective of whether they have preoperative AR or not. VSRR is safe, durable, and reproducible, but further follow-up, well into the second decade is still necessary.
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Affiliation(s)
- Saadallah Tamer
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Stefano Mastrobuoni
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Mona Momeni
- Division of Anesthesiologyy, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gaby Aphram
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Emiliano Navarra
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Alain Poncelet
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Philippe Noirhomme
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Parla Astarci
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gebrine El Khoury
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Laurent de Kerchove
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique (IREC), Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
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Rimmer L, Ahmad MU, Chaplin G, Joshi M, Harky A. Aortic Valve Repair: Where Are We Now? Heart Lung Circ 2019; 28:988-999. [DOI: 10.1016/j.hlc.2019.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 01/20/2019] [Accepted: 02/13/2019] [Indexed: 11/26/2022]
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Aortic root surgery in Marfan syndrome. Indian J Thorac Cardiovasc Surg 2019; 35:79-86. [PMID: 33061070 DOI: 10.1007/s12055-018-0761-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 10/10/2018] [Accepted: 10/11/2018] [Indexed: 10/27/2022] Open
Abstract
Marfan syndrome (MFS) is an autosomal dominant connective disease etiologically related with FBN-1 gene mutation. The altered microfibril protein structure result in characteristic cardiovascular abnormalities including aortic root dilatation, aortic root aneurysms, and aortic dissections. Aortic root aneurysms and subsequent dissection are the major causes of reduced life expectancy in MFS patients. Prophylactic aortic root replacement has improved the survival of patients with MFS. Elective root replacement carries very low mortality and morbidity. Emergency root replacement for dissection is accompanied with higher early mortality and late deaths/interventions. Both the techniques of aortic root replacement, total root replacement (TRR) with a prosthetic valved conduit, and valve-sparing root replacement (VSRR) yield excellent early and late results. Considering the low risk of prosthetic valve-related events, the improved long-term survival, and event-free survival, TRR continues to be a very effective surgical option. VSSR also seems to be a good option for the first 10 to 15 years following surgery in MFS patients. The choice of procedure depends upon available expertise, patients' choice, feasibility of anticoagulation, possibility of pregnancy, and lifestyle of the patient. Aortic root morphology and state of valve cusps also affect the decision making. In recent times, personalized external aortic root support (PEARS) with a macroporous mesh sleeve has also emerged as a promising alternative to aortic root replacement. All these patients need close monitoring for whole life after surgical intervention.
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9
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Fate of preserved bicuspid valves at time of ascending aortic aneurysmectomy. J Card Surg 2019; 34:318-322. [DOI: 10.1111/jocs.14024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/25/2019] [Accepted: 03/05/2019] [Indexed: 12/01/2022]
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Rosenblum JM, Leshnower BG, Moon RC, Lasanajak Y, Binongo J, McPherson L, Chen EP. Durability and safety of David V valve-sparing root replacement in acute type A aortic dissection. J Thorac Cardiovasc Surg 2018; 157:14-23.e1. [PMID: 30557940 DOI: 10.1016/j.jtcvs.2018.10.059] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 09/20/2018] [Accepted: 10/01/2018] [Indexed: 11/25/2022]
Abstract
BACKGROUND Valve-sparing root replacement (VSRR) is an attractive option in type A aortic dissection (TAAD) repair for a young patient with normal cusp anatomy, but conventional root replacement using a composite valved-conduit (ROOT) remains the gold standard in this emergent clinical setting. We examine the long-term safety and durability of the David V VSRR compared with ROOT in TAAD repair. METHODS From March 2004 to April 2017, 136 patients underwent repair of acute TAAD using either ROOT (n = 77; 56.6%) or VSRR (n = 59; 43.4%). Annual echocardiograms were performed for follow-up in VSRR patients. Univariable regression, Kaplan-Meier, and competing risk analyses were performed. RESULTS Preoperative characteristics were similar between groups, except that VSRR patients were younger (mean age 43.5 ± 11.4 years VSRR vs 50.4 ± 3.0 years ROOT; P = .001). Both groups had similar rates of preoperative malperfusion or shock (29.3% VSRR vs 37.0% ROOT; P = .35) and ≥3+ aortic insufficiency (63% VSRR vs 76.8% ROOT). Thirty-day mortality in the VSRR group was 2/59 (3.4%) and 11/77 in the ROOT group (14.3%; P < .001). All-cause survival at 9 years was 92% (VSRR) and 59% (ROOT; P = .002). The incidence of aortic reintervention was similar between groups (20%-23% at 5 years; P = .81). At 9 years of follow-up, 5/52 (9.6%) VSRR patients had ≥2+ aortic insufficiency, and 1 patient required valve reintervention. CONCLUSIONS In highly-selected patients, the David V VSRR provides a safe repair of acute TAAD with concomitant root pathology and valve insufficiency. In our center, the incidence of valve-related reintervention at long-term follow-up is low after emergent repair.
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Affiliation(s)
- Joshua M Rosenblum
- Division of Cardiac Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga.
| | - Bradley G Leshnower
- Division of Cardiac Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Rena C Moon
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Yi Lasanajak
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Ga
| | - Jose Binongo
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Ga
| | - LaRonica McPherson
- Division of Cardiac Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Edward P Chen
- Division of Cardiac Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
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Yang B, Patel HJ, Sorek C, Hornsby WE, Wu X, Ward S, Thomas M, Driscoll A, Waidley VA, Norton EL, Likosky DS, Deeb GM. Sixteen-Year Experience of David and Bentall Procedures in Acute Type A Aortic Dissection. Ann Thorac Surg 2018; 105:779-784. [DOI: 10.1016/j.athoracsur.2017.09.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 08/07/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022]
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12
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Treasure T, King A, Hidalgo Lemp L, Golesworthy T, Pepper J, Takkenberg JJM. Developing a shared decision support framework for aortic root surgery in Marfan syndrome. Heart 2018; 104:480-486. [PMID: 28780581 PMCID: PMC5861390 DOI: 10.1136/heartjnl-2017-311598] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 06/28/2017] [Accepted: 06/28/2017] [Indexed: 01/23/2023] Open
Abstract
OBJECTIVE The study is an early phase of development of a decision support framework for people with Marfan syndrome who are anticipating prophylactic aortic root surgery. Implications of the timing and the nature of the operation chosen were previously elicited in focus groups. In this step, we explored the range of relative values placed by individuals on the implications of decisions made about surgery. METHODS Following the principles of the Ottawa Decision Support Framework, eight questions in the general form 'How important is it to you …' were framed by a panel. Marfan people, families and specialist doctors answered online. Quantitative and qualitative analyses were performed. RESULTS Worldwide, 142 responses were received including 25 specialist doctors. Respondents were 55% female and 46% had previous aortic root surgery. Overall, active lifestyle was more important to males (p=0.03). Patients placed more importance than doctors on not deferring surgery (p=0.04) and on avoidance of anticoagulation in the interests of childbearing (p=0.009). Qualitative analysis showed differing but cogently reasoned values that were sometimes polarised, and mainly driven by the wish to maintain a good quality of life and active lifestyle. CONCLUSIONS Given the cogency of these viewpoints, people anticipating root replacement surgery should have ample opportunity to express them and to have them acknowledged ahead of a consultation when they can then be fully explored in a mutually informed forum. If they differ from local medical practice, they can then be discussed in the process of reaching shared and individualised decisions.
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Affiliation(s)
- Tom Treasure
- Operational Research Unit, Department of Mathematics, University College London, London, UK
| | - Annette King
- Centre for Health Services Studies, University of Kent, Canterbury, Kent, UK
| | | | | | - John Pepper
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, London, UK
| | - Johanna JM Takkenberg
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
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13
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David TE. Tirone on Tirone David operation and types. Gen Thorac Cardiovasc Surg 2017; 67:66-69. [PMID: 28849328 DOI: 10.1007/s11748-017-0819-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/12/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, 200 Elizabeth St. 4N453, Toronto, ON, M5G 2C4, Canada.
- University of Toronto, Toronto, ON, Canada.
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14
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Treasure T, Takkenberg JJM, Pepper J. Republished review: Surgical management of aortic root disease in Marfan syndrome and other congenital disorders associated with aortic root aneurysms. Postgrad Med J 2016; 92:112-7. [PMID: 26811510 PMCID: PMC4752614 DOI: 10.1136/postgradmedj-2013-305132rep] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Elective root replacement in Marfan syndrome has improved life expectancy in affected patients. Three forms of surgery are now available: total root replacement (TRR) with a valved conduit, valve sparing root replacement (VSRR) and personalised external aortic root support (PEARS) with a macroporous mesh sleeve. TRR can be performed irrespective of aortic dimensions and a mechanical replacement valve is a secure and near certain means of correcting aortic valve regurgitation but has thromboembolic and bleeding risks. VSRR offers freedom from anticoagulation and attendant risks of bleeding but reoperation for aortic regurgitation runs at 1.3% per annum. A prospective multi-institutional study has found this to be an underestimate of the true rate of valve-related adverse events. PEARS conserves the aortic root anatomy and optimises the chance of maintaining valve function but average follow-up is under 5 years and so the long-term results are yet to be determined. Patients are on average in their 30s and so the cumulative lifetime need for reoperation, and of any valve-related complications, are consequently substantial. With lowering surgical risk of prophylactic root replacement, the threshold for intervention has reduced progressively over 30 years to 4.5 cm and so an increasing number of patients who are not destined to have a dissection are now having root replacement. In evaluation of these three forms of surgery, the number needed to treat to prevent dissection and the balance of net benefit and harm in future patients must be considered.
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Affiliation(s)
- Tom Treasure
- Clinical Operational Research Unit, University College London, London, UK
| | - J J M Takkenberg
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - John Pepper
- NIHR Cardiovascular BRU, Royal Brompton Hospital, London, UK Institute of Cardiovascular Medicine and Science (ICMS), London, UK
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Overview of current surgical strategies for aortic disease in patients with Marfan syndrome. Surg Today 2015; 46:1006-18. [DOI: 10.1007/s00595-015-1278-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Accepted: 11/02/2015] [Indexed: 01/16/2023]
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Miyahara S, Matsueda T, Izawa N, Yamanaka K, Sakamoto T, Nomura Y, Morimoto N, Inoue T, Matsumori M, Okada K, Okita Y. Mid-Term Results of Valve-Sparing Aortic Root Replacement in Patients With Expanded Indications. Ann Thorac Surg 2015; 100:845-51; discussion 852. [DOI: 10.1016/j.athoracsur.2014.09.091] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Revised: 08/31/2014] [Accepted: 09/09/2014] [Indexed: 10/23/2022]
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Žáček P, Vojáček J, Dominik J, Harrer J. A history of the surgical treatment of aortic regurgitation. COR ET VASA 2015. [DOI: 10.1016/j.crvasa.2015.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Leshnower BG, Myung RJ, McPherson L, Chen EP. Midterm Results of David V Valve-Sparing Aortic Root Replacement in Acute Type A Aortic Dissection. Ann Thorac Surg 2015; 99:795-800; discussion 800-1. [DOI: 10.1016/j.athoracsur.2014.08.079] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 08/18/2014] [Accepted: 08/25/2014] [Indexed: 11/24/2022]
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Treasure T, Takkenberg JJM, Pepper J. Surgical management of aortic root disease in Marfan syndrome and other congenital disorders associated with aortic root aneurysms. Heart 2015; 100:1571-6. [PMID: 24986892 PMCID: PMC4215278 DOI: 10.1136/heartjnl-2013-305132] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Elective root replacement in Marfan syndrome has improved life expectancy in affected patients. Three forms of surgery are now available: total root replacement (TRR) with a valved conduit, valve sparing root replacement (VSRR) and personalised external aortic root support (PEARS) with a macroporous mesh sleeve. TRR can be performed irrespective of aortic dimensions and a mechanical replacement valve is a secure and near certain means of correcting aortic valve regurgitation but has thromboembolic and bleeding risks. VSRR offers freedom from anticoagulation and attendant risks of bleeding but reoperation for aortic regurgitation runs at 1.3% per annum. A prospective multi-institutional study has found this to be an underestimate of the true rate of valve-related adverse events. PEARS conserves the aortic root anatomy and optimises the chance of maintaining valve function but average follow-up is under 5 years and so the long-term results are yet to be determined. Patients are on average in their 30s and so the cumulative lifetime need for reoperation, and of any valve-related complications, are consequently substantial. With lowering surgical risk of prophylactic root replacement, the threshold for intervention has reduced progressively over 30 years to 4.5 cm and so an increasing number of patients who are not destined to have a dissection are now having root replacement. In evaluation of these three forms of surgery, the number needed to treat to prevent dissection and the balance of net benefit and harm in future patients must be considered.
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Affiliation(s)
- Tom Treasure
- Clinical Operational Research Unit, University College London, London, UK
| | - J J M Takkenberg
- Department of Cardio-Thoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - John Pepper
- NIHR Cardiovascular BRU, Royal Brompton Hospital, London, UK
- Institute of Cardiovascular Medicine and Science (ICMS), London, UK
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A quarter of a century of experience with aortic valve-sparing operations. J Thorac Cardiovasc Surg 2014; 148:872-9; discussion 879-80. [DOI: 10.1016/j.jtcvs.2014.04.048] [Citation(s) in RCA: 147] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2014] [Revised: 03/29/2014] [Accepted: 04/02/2014] [Indexed: 11/19/2022]
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Van Dyck M, Glineur D, de Kerchove L, El Khoury G. Complications after aortic valve repair and valve-sparing procedures. Ann Cardiothorac Surg 2013; 2:130-9. [PMID: 23977571 DOI: 10.3978/j.issn.2225-319x.2012.12.03] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2012] [Accepted: 12/12/2012] [Indexed: 12/18/2022]
Affiliation(s)
- Michel Van Dyck
- Department of Acute Medicine, Division of Anesthesiology, Cliniques Universitaires St-Luc, Université catholique de Louvain, Brussels, Belgium
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Maselli D, Weltert L, Scaffa R, De Paulis R. How to achieve an aortic root remodelling by performing an aortic root reimplantation. Eur J Cardiothorac Surg 2012; 42:e136-7. [DOI: 10.1093/ejcts/ezs447] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Leshnower BG, Guyton RA, Myung RJ, Puskas JD, Kilgo PD, McPherson L, Chen EP. Expanding the indications for the David V aortic root replacement: early results. J Thorac Cardiovasc Surg 2012; 143:879-84. [PMID: 22329981 DOI: 10.1016/j.jtcvs.2012.01.048] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Revised: 12/25/2011] [Accepted: 01/16/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To examine the early results of the David V valve-sparing aortic root replacement procedure in expanded, higher risk clinical scenarios with appropriately selected patients. METHODS From 2005 to 2011, 150 David V valve-sparing aortic root replacements were performed within Emory Healthcare. A total of 78 patients (expanded group) had undergone the David V in expanded, difficult clinical settings such as emergent type A dissection (n = 29), grade 3+ or greater aortic insufficiency (AI) (n = 53), or reoperative cardiac surgery (n = 14). These patients were evaluated and compared with a group of 72 patients (traditional group) with less than grade 3+ AI who underwent a David V in a traditional, elective setting. The mean follow-up was 19 months (range, 1-72), and the follow-up data were 88% complete. RESULTS There were 3 operative deaths (2.2%), all occurring in the expanded group. The overall patient survival at 6 years was 95%. Three patients required aortic valve replacement: two for severe AI and one for fungal endocarditis. Both groups had concomitant cusp repairs performed in conjunction with the David V (traditional, n = 10; and expanded, n = 16; P = .27). At follow-up, freedom from moderate AI was 93%, and the freedom from aortic valve replacement was 98%. No significant difference was observed in the freedom from moderate AI between the expanded and traditional groups (91% vs 95%, respectively; P = .16). CONCLUSIONS In selected patients possessing appropriate aortic cusp anatomy, the David V can be safely and effectively performed for the expanded indications of aortic dissection, severe AI, and reoperative cardiac surgery with low operative risk. Valve function has remained excellent in the short term, providing evidence of durability and a low rate of valve-related complications.
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Affiliation(s)
- Bradley G Leshnower
- Clinical Research Unit, Division of Cardiothoracic Surgery, Joseph B Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
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