Comparing outcomes between valve-sparing root replacement and the Bentall procedure in proximal aortic aneurysms: systematic review and meta-analysis

Abstract

In aortic root aneurysms, the challenge of a valve-sparing aortic root replacement (VSRR) procedure is to ensure durable aortic valve function without reintervention. Although the Bentall procedure defers the durability of valve function to the prosthesis, short- and long-term complications tend to be higher. The aim of this study was to compare the outcomes of VSRR and Bentall procedures in patients with aortic root aneurysms. A systematic literature review was conducted using PubMed regarding the outcomes of the Bentall procedure compared with those of VSRR from the inception of the 2 procedures until July 2018. Studies with short- and long-term comparative data were included. An initial search yielded 9517 titles. Thirty-four studies were finally included for meta-analysis (all retrospective, non-randomized), comprising 7313 patients (2944 valve-sparing and 4369 Bentall procedures) with no evidence of publication bias. Operative mortality was found to be significantly lower in the VSRR group [odds ratio (OR) 0.51, 95% confidence interval (CI) 0.37–0.70; P < 0.001] despite overall higher cardiopulmonary bypass and aortic cross-clamp times. The 5-year survival rate was also more favourable in the VSRR group (OR 1.93 95% CI 1.15–3.23; P < 0.05). Significantly lower rates of cerebral thromboembolism (OR 0.668, 95% CI 0.477–0.935; P = 0.019) and heart block (OR 0.386, 95% CI 0.195–0.767; P = 0.007) were also found after VSRR. There was no significant difference in rates of reoperation between the groups at long-term follow-up (OR 1.32, 95% CI 0.75–2.33; P = 0.336). Meta-regression of patient and operative covariates yielded no influence on the main outcomes (P > 0.05). These findings suggest that VSRR is an appropriate and potentially better treatment option for a root aneurysm when the aortic valve is repairable.

A novel device for technical standardization of valve-sparing aortic root reimplantation

“…Compared with either mechanical or biological valve replacements, valve-sparing aortic root replacement has proved to be advantageous owing to its noninferior, even superior, perioperative mortality and follow-up reoperation rates, as well as lower rates of bleeding, and prosthesis-related complications, and improved quality of life. [22,23] The aortic root is a complex anatomic structure with its components: the aortoventricular junction or aortic annulus, aortic cusps, aortic commissures, aortic sinuses, and the sinotubular junction, each of which having crucial roles for competent aortic valve function, particularly coaptation. [5] All aortic root dimensions, including the effective height, have been shown to be highly patient-specific and correlated with the body weight and size, and body surface area.…”

Management of the aortic root in type A aortic dissection: A valve sparing approach

“…In aortic root disease, the prosthetic valve component is a major drawback and should be avoided if possible, particularly in the young. In aortic root replacement, Salsami et al 21 meta‐analysis reported a lower operative mortality, better 5‐year survival, lower thromboembolic events in favor for VSRR in comparison with Bentall; however and increase in reoperation rate was noted (odds ratio: 1.3; 95% confidence interval: 0.72–2.33).…”

Short- and long-term outcomes of aortic root-sparing repair and replacement in acute type A aortic dissection repair

“…1 Despite the surgical advances over the years, there remains a never-ending debate about the fate of the aortic root; whether it should be repaired using a conservative root-sparing approach such as supra-commissural repair or replaced with an aggressive approach using the Bentall method or with a valve-sparing root replacement (VSRR). [2][3][4] The VSRR approach is performed using the Yacoub or David procedures, whilst the Bentall procedure includes the replacement of the aortic valve and aortic root. The conservative approach which can be termed "root-sparing repair" describes the procedure of undertaking aortic valve resuspension as part of supra-coronary repair; hence, the native root is not replaced and being left untouched.…”

“…On one hand, pursuing the extensive approach encompasses longer operating times but potentially allows reduced rates of re-operation. 2 However, there remains the controversy whether this approach can be pursued without further risk on mortality in comparison to conservative methods, with desirable outcomes, however, with possible risks of re-intervention in future.…”