Root Repair with Valve Resuspension is Safe for Acute Type A Aortic Dissection but Results in Increased Risk of Reoperation
Peter Chiu, Jeffrey Trojan, Sarah Tsou, Andrew B. Goldstone, *Y. Joseph Woo, *Michael P. Fischbein
Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, CA
OBJECTIVES: Management of the aortic root in Acute Type A Aortic Dissection (AcA-AoD) is controversial, and opinions have varied over time on the need for routine aortic root replacement. We undertook the current study to evaluate whether limited root repair techniques with valve resuspension contributed increased risk of death or reoperation compared with root replacement in a contemporary cohort of patients.
METHODS: This was a retrospective review of patients undergoing repair for AcA-AoD at Stanford Hospital and Clinics between 1/2005 and 12/2015. Patients undergoing endovascular repair were excluded. Additionally, those with Marfan syndrome (strong indication for root replacement) were excluded. The subset of patients for whom any intervention on the aortic root was performed were identified, and propensity score analysis with inverse probability weighting to estimate the average treatment effect on the controls was used to create comparable pseudo-populations. Weighted logistic regression was used to compare in-hospital mortality. Weighted cox proportional hazards regression was used to compare overall survival between patients undergoing root repair with valve resuspension and root replacement. Reoperation on the root or valve was evaluated with death as a competing risk by estimating the subdistribution hazard with a weighted form of the Fine-Gray technique.
RESULTS: There were 390 patients with AcA-AoD who presented to our institution; 31 patients (7.9%) were managed non-operatively, 14 (3.6%) were treated with endovascular repair, and 345 (88.5%) patients underwent open repair. There were 246 patients who underwent root intervention and were eligible for the study. Patients who underwent root replacement (n = 86) were younger and had fewer comorbidites than patients who underwent a limited root repair (n = 160) with biological glue, sauvage patch, or uni-Yacoub, but perioperative mortality was low for both groups: root repair (n = 16, 10.0%) and root replacement (n = 11, 12.8%). Patients undergoing root repair with valve resuspension had shorter cardiopulmonary bypass time (202.2 vs. 270.8 minutes, p <0.001), shorter cross clamp time (118.3 vs 185.3 minutes, p <0.001), but similar nadir core temperature (p = 0.2) and circulatory arrest time (p = 0.9). Inverse probability weighting created appropriately balanced groups (except for preoperative dialysis dependence). There was no difference in the odds of in-hospital mortality after weighting (p = 0.5); additionally, there was no difference in long-term survival between the two weighted groups (Figure 1A). Within the limited root repair group, the risk of reoperation was significantly greater (9.2%, 95% CI 0.0 to 20.0% at 10.2 years follow-up) than for root replacement (0%), p <0.001 (Figure 1B).
CONCLUSIONS: At a high-volume aortic referral center, aortic root replacement did not appear to be associated with higher risk of mortality than a limited operation for AcA-AoD. Limited root repair with valve resuspension—while a safe option in appropriately selected patients—incurred a substantial increase in the risk of late reoperation suggesting that close surveillance is required for these patients.
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