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

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.

Florida sleeve is a safe and effective technique for valve salvage in acute stanford type A aortic dissection

OBJECTIVE

Valve-sparing root replacement is commonly used for management of aortic root aneurysms in elective setting, but its technical complexity hinders its broader adoption for acute type-A aortic dissection (ATAAD). The Florida sleeve (FS) procedure is a simplified form of valve sparing aortic root reconstruction that does not require coronary reimplantation. Here, we present our outcomes of the FS repair in patients with dilated roots in the setting of an ATAAD.

METHODS

We retrospectively reviewed 24 consecutive patients (2002-2018) treated with FS procedure for ATAAD. Demographic, operative, and postoperative outcomes were queried from our institutional database. Long term follow-up was obtained from clinic visits for local patients, and with telephone and telehealth measures otherwise.

RESULTS

Mean age was 49 ± 14 years with 19 (79%) males. Marfan syndrome was present in 4 (16.7%) patients and 14 (58.3) had ≥2+ aortic insufficiency (AI). Nine (37.2%) had preoperative mal-perfusion or shock. The FS was combined with hemi-arch replacement in 15 (62.5%) patients and a zone-2 arch replacement in 9 (37.5%) patients. There were 2 (8.3%) early postoperative mortalities. Median follow-up period was 46 months (range, 0.3-146). The median survival of the entire cohort was 143.4 months. One patient (4.2%) required redo aortic valve replacement for unrelated aortic valve endocarditis at 30 months postoperatively.

CONCLUSION

FS is simplified and reproducible valve-sparing root repair. In appropriate patients, it can be applied safely in acute Stanford type-A aortic dissection with excellent early and long-term results.

Durability and safety of David V valve-sparing root replacement in acute type A aortic dissection

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.