Comparison of outcomes between aortic root replacement and supra‐coronary interposition graft for type A aortic dissection: A retrospective case series

Abstract

Background The decision to conserve or replace the native aortic valve following acute type‐A aortic dissection (ATAAD) is an area of cardiac surgery without standardized practice. This single‐center retrospective study analysed the long‐term performance of the native aortic valve and root following surgery for ATAAD. Methods Between 2009 and 2018 all cases ATAAD treated at Royal Brompton and Harefield NHS Foundation Trust were analysed. Patients were divided into two groups: (a) ascending aorta (interposition) graft (AAG) without valve replacement and (b) nonvalve‐sparing aortic root replacement (ARR). Preoperative covariates were compared, as well as operative characteristics and postoperative complications. Long‐term survival and echocardiographic outcomes were analysed using regression analysis. Results In total, 116 patients were included: 63 patients in the AAG group and 53 patients in the ARR group. In patients where the native aortic valve was conserved, nine developed severe aortic regurgitation and two patients developed dilation of the aortic root requiring subsequent replacement during the follow‐up period. Aortic regurgitation at presentation was not found to be associated with subsequent risk of developing severe aortic regurgitation or reintervention on the aortic valve. Overall mortality was observed to be significantly lower in patients undergoing AAG (17.5% vs. 41.5%, p = .004). Conclusions With careful patient selection, the native aortic root shows good long‐term durability both in terms of valve competence and stable root dimensions after surgery for ATAAD. This study supports the consideration of conservation of the aortic valve during emergency surgery for type‐A dissection, in the absence of a definitive indication for root replacement, including in cases where aortic regurgitation complicates the presentation.

Replace it or preserve it? How outcomes differ using different techniques

“…Furthermore, a recent study in 2017 by Valdis 5 and colleagues yielded 30‐day mortality of 20.4%. The deviation against current literature by Hartley 1 and colleagues potentially highlights an issue with smaller sample size, being more prone to statistical variability. The concept of statistical variability continued into mortality statistics.…”

“…A possible confounding variable in Hartley 1 and colleagues' study, favouring AAG, is surgeon preference. Hartley et al 1 acknowledged that surgeons prefer the root replacement technique in patients who present with more extensive disease.…”

“…The remaining 116 patients compromised the cohort of this study and were divided into two groups, the ascending aorta interposition graft (AAG) and the nonvalve sparing aortic root replacement (ARR) group. No patients underwent valve‐sparing root replacement for ATAAD 1 …”

“…The long‐term freedom from significant regurgitation across the native aortic valve was addressed by Hartley 1 and colleagues. The study claims that valve resuspension can have good long‐term results, however, there are several points to consider 7 .…”

“…In addition, there was no clear mention of the reintervention rate in the AAG group. It could be deducted from the figures that 5 patients (8.5%) required reintervention within the first 5 years of follow‐up 1 . It would have been of value to clarify the outcome of these reinterventions 8 …”