Outcome of Valve-sparing vs Bentall Procedure in Acute Type A Aortic Dissection

Objectives: Valve-sparing aortic surgery is increasingly used in contrast to the Bentall procedure in patients with an enlarged aortic root and normal aortic leaflets, despite the more complex operative technique in valve sparing root remodeling. To what extend complex valve sparing aortic surgery is feasible in acute aortic dissection type A (AADA) is not quite clear. In this study we analyze the long-term outcome after different valve sparing and Bentall procedures in AADA patients.

Methods: 398 AADA operations were performed in our center between 8/1993 and 7/2017. We analyzed outcome with different approaches of the aortic valve (valve replacement with ascending/arch replacement, Bentall, valve sparing with David or Yacoub technique). Maximum follow-up was 25 years.

Results: 254 patients received ascending/arch replacement without intervention on the aortic valve, 17 patients ascending/arch replacement with aortic valve replacement with a biological or mechanical valve and 48 patients a Bentall procedure. A valve sparing procedure with the David technique was performed in 48 patients and with the Yacoub technique in 29 patients. The [Table 1] shows the demographic and intraoperative data. Patients with a Bentall or David procedure were significantly younger and more male gender. Despite a significant longer bypass and X-clamp time, both operative techniques lead to a similar postoperative outcome in the long-term. The Yacoub technique was performed in an older patient group with low bypass and X-clamp times and showed a slightly lower average survival time of 10.5 years. Interestingly, the aortic valve replacement in AADA patients had worst long-term survival with 3.5 years.

Conclusion: If the aortic root or the aortic valve is involved in acute AADA patients a Bentall or David procedure is the best option for stable long-term survival, despite initial longer bypass and X-clamp time. An aortic valve replacement with supracommissural ascending replacement should not be the first choice.

Table 1

	Ascending/arch replacement w/o aortic valve	Ascending/arch replacement w/ aortic valve replacement	Bentall	David	Yacoub	p-value
N	254	17	48	48	29
Age, years	68.7 ± 17.9	68.2 ± 12.3	58.3 ± 12.9	55.8 ± 16.9	64.8 ± 18.2	<.0001
Gender, male	58.7%	70.6%	81.3%	78.7%	60.0%	0.007
Bypass time, min	224 ± 92	289 ± 89	259 ± 85	249 ± 62	206 ± 42	0.001
X-clamp, min	136 ± 67	184 ± 67	186 ± 68	195 ± 53	157 ± 32	0.001
Circulatory arrest time, min	49 ± 28	56 ± 27	40 ± 25	44 ± 30	35 ± 15	0.017
Average Survival, years	10.2 ± 0.6	3.5 ± 0.9	13.1 ± 1.4	13.1 ± 1.4	10.5 ± 1.6	0.058