What is the clinical evidence from this study?

Study design: Cohort. Population: Acute Type A aortic dissection (n=189). Intervention: Aortic valve replacement (AVR) vs. Aortic valve (AV) resuspension. Primary outcome: 10-year actuarial survival (p=0.011).

April 1, 2016Open Access

Techniques of Proximal Root Reconstruction and Outcomes Following Repair of Acute Type A Aortic Dissection

TGTyler GunnCedars-Sinai Medical Center SSSotiris C. StamouInterventional / Structural Cardiology NKNicholas T. KouchoukosInterventional / Structural Cardiology

Key Result

Aortic valve replacement during acute Type A aortic dissection repair was associated with a significantly lower 10-year actuarial survival rate (36%) compared to aortic valve resuspension (72%).

Study Design

Type

Cohort (n=189)

Multicenter

Yes

Structured PICO

Does the technique of proximal root reconstruction (AV resuspension, AVR, or root replacement) affect early outcomes and long-term survival in patients undergoing repair of acute Type A aortic dissection?

Population

189 patients who underwent surgical repair for acute Type A aortic dissections with a concomitant aortic valve (AV) procedure between January 2000 and October 2010 at four academic institutions in the United States. Excluded: patients who required only supracoronary graft placement without any intervention of the AV or aortic root.

Intervention

Aortic valve replacement (AVR) (n=21) or aortic root replacement (Bentall procedure) (n=57) during acute Type A aortic dissection repair.

Comparator

Aortic valve (AV) resuspension (n=111) during acute Type A aortic dissection repair.

Outcome

Early clinical outcomes (including operative mortality) and 10-year actuarial survival rates.hard clinical

In patients undergoing repair of acute Type A aortic dissection, aortic valve resuspension and root replacement procedures are associated with significantly better 10-year survival compared to aortic valve replacement, despite similar operative mortality.

Main Result

Absolute Event Rate: 36% vs 72%

p-value: p=0.011

Limitations

Retrospective multi-institution study design
Evolution of surgical techniques and experience over the 10-year study period
Aortic valve-sparing root replacement (David procedure) was not included
Potential bias from multiple surgeons across different institutions
Small sample size precluded risk-adjusted multivariate analysis for late survival

Abstract

BACKGROUND: The goal of this study was to compare the early and late outcomes of different techniques of proximal root reconstruction during the repair of acute Type A aortic dissection, including aortic valve (AV) resuspension, aortic valve replacement (AVR), and a root replacement procedure. METHODS: All patients who underwent acute Type A aortic dissection repair between January 2000 and October 2010 at four academic institutions were compiled from each institution's Society of Thoracic Surgeons Database. This included 189 patients who underwent a concomitant aortic valve (AV) procedure; 111, 21, and 57 patients underwent AV resuspension, AVR, and the Bentall procedure, respectively. The median age of patients undergoing a root replacement procedure was significantly younger than the other two groups. Early clinical outcomes and 10-year actuarial survival rates were compared. Trends in outcomes and surgical techniques throughout the duration of the study were also analyzed. RESULTS: = 0.035). CONCLUSIONS: The 10-year actuarial survival was significantly lower in those receiving AVR compared to those receiving root replacement procedures or AV resuspension. Operative mortality was comparable between the three groups.

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