Is valve-sparing root replacement a safe option in acute type A aortic dissection? A systematic review and meta-analysis

Abstract

OBJECTIVESThere are conflicting views regarding the status of valve-sparing root replacement (VSRR) as a proper treatment for acute type A aortic dissection (AAAD). Our goal was to compare the early and late outcomes of VSRR versus those of the Bentall procedure in patients with AAAD.METHODSWe performed a systematic review and meta-analysis of 9 studies to compare the outcomes of VSRR with those of the Bentall procedure in patients with AAAD. We focused on the following issues: early and late mortality rates, re-exploration, thromboembolization/bleeding events, infective endocarditis and reintervention rates.RESULTSA total of 706 patients with AAAD who underwent aortic root surgery were analysed; 254 patients were treated with VSRR and 452 with the Bentall procedure. VSRR was associated with a reduced risk of early death [odds ratio (OR) 0.34; 95% confidence interval (CI) 0.21–0.57] and late death (OR 0.34; 95% CI 0.21–0.57) compared with the Bentall procedure. No statistically significant difference was observed between the VSRR and Bentall groups with pooled ORs (OR 0.77; 95% CI 0.47–1.27, OR 0.61; 95% CI 0.32–1.18 and OR 0.71; 95% CI 0.23–2.15) for re-exploration, thromboembolization/bleeding and postoperative infective endocarditis, respectively. An increased risk of reintervention was observed for the VSRR compared to the Bentall group (OR 3.79; 95% CI 1.27–11.30). The pooled rate of reintervention incidence was 1.6% (95% CI 0.0–3.7%) and 0.4% (95% CI 0.0–1.3%) for the VSRR and the Bentall groups, respectively.CONCLUSIONSVSRR in patients with AAAD can be performed in experienced centres with excellent short- and long-term outcomes compared to those with the Bentall procedure and thus should be recommended especially for active young patients.

Management of Aortic Root in Type A Dissection: Bentall Approach

“…However, limited comparisons can be made to other ATAAD series for a variety of reasons. The majority of isolated Bentall studies available in the literature report the results either in a mixed aortic pathology population, or in a relatively small group of ATAAD patients with various root interventions [19,20]. In addition, most ATAAD series include a large number of patients who underwent either very minor (eg.…”

Does adding a root replacement in type A aortic dissection repair provide better outcomes?

“…10 In the recent meta-analysis of 9 studies comprising 706 patients treated for ATAAD, VSRR was systematically reviewed as an option for intervention. 11 Junlin Wu et al…”

“…It should be noted that the authors had clearly stated that these amazing results for VSRR, are only achieved by the carefully considered patient selection process for the procedure. 11…”

“…A short follow up period which is also not well completed, adds significant limitations to the literature discussing the fate of the aortic root. [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][24][25][26][27] Given that much of the literature, as seen in Table B1, is already weakened by their retrospective studies based on a single center, [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][24][25][26][27] such further limitations have strong impacts on the already hindered reliability, bias, and reduced statistical power from the small sample sizes.…”

“…[4][5][6][7] Acute aortic dissection repair can necessitate a variety of operations, from simple replacement of the ascending aorta to aortic root replacement or a version of total arch replacement. There are differing opinions regarding what constitutes the "appropriate" repair of the acutely dissected aorta, [4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] a tear tailored approach is a trend that we normally follow; however, this is not generalizable across many different centers.…”