Division of Cardiac Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga.
Division of Cardiac Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga.
J Thorac Cardiovasc Surg. 2019 Jan;157(1):14-23.e1. doi: 10.1016/j.jtcvs.2018.10.059. Epub 2018 Oct 23.
Valve-sparing root replacement (VSRR) is an attractive option in type A aortic dissection (TAAD) repair for a young patient with normal cusp anatomy, but conventional root replacement using a composite valved-conduit (ROOT) remains the gold standard in this emergent clinical setting. We examine the long-term safety and durability of the David V VSRR compared with ROOT in TAAD repair.
From March 2004 to April 2017, 136 patients underwent repair of acute TAAD using either ROOT (n = 77; 56.6%) or VSRR (n = 59; 43.4%). Annual echocardiograms were performed for follow-up in VSRR patients. Univariable regression, Kaplan-Meier, and competing risk analyses were performed.
Preoperative characteristics were similar between groups, except that VSRR patients were younger (mean age 43.5 ± 11.4 years VSRR vs 50.4 ± 3.0 years ROOT; P = .001). Both groups had similar rates of preoperative malperfusion or shock (29.3% VSRR vs 37.0% ROOT; P = .35) and ≥3+ aortic insufficiency (63% VSRR vs 76.8% ROOT). Thirty-day mortality in the VSRR group was 2/59 (3.4%) and 11/77 in the ROOT group (14.3%; P < .001). All-cause survival at 9 years was 92% (VSRR) and 59% (ROOT; P = .002). The incidence of aortic reintervention was similar between groups (20%-23% at 5 years; P = .81). At 9 years of follow-up, 5/52 (9.6%) VSRR patients had ≥2+ aortic insufficiency, and 1 patient required valve reintervention.
In highly-selected patients, the David V VSRR provides a safe repair of acute TAAD with concomitant root pathology and valve insufficiency. In our center, the incidence of valve-related reintervention at long-term follow-up is low after emergent repair.
对于解剖结构正常的年轻患者，保留瓣膜的主动脉根部替换术（VSRR）是治疗 A 型主动脉夹层（TAAD）的一种有吸引力的选择，但在这种紧急临床情况下，使用复合带瓣管道的传统根部替换术（ROOT）仍然是金标准。我们研究了 David V VSRR 与 ROOT 在 TAAD 修复中的长期安全性和耐久性。
2004 年 3 月至 2017 年 4 月，136 例急性 TAAD 患者接受 ROOT（n=77；56.6%）或 VSRR（n=59；43.4%）修复。VSRR 患者每年进行超声心动图随访。采用单变量回归、Kaplan-Meier 和竞争风险分析。
两组患者的术前特征相似，但 VSRR 患者年龄较小（VSRR 组平均年龄 43.5±11.4 岁，ROOT 组 50.4±3.0 岁；P=0.001）。两组患者术前灌注不良或休克发生率相似（29.3% VSRR 与 37.0% ROOT；P=0.35），主动脉瓣关闭不全≥3 级（63% VSRR 与 76.8% ROOT）。VSRR 组 30 天死亡率为 2/59（3.4%），ROOT 组为 11/77（14.3%）；P<0.001。VSRR 组 9 年全因生存率为 92%（VSRR），ROOT 组为 59%（ROOT；P=0.002）。两组主动脉再干预发生率相似（5 年时为 20%-23%；P=0.81）。9 年随访时，5/52（9.6%）VSRR 患者出现≥2 级主动脉瓣关闭不全，1 例患者需要瓣膜再干预。
在高度选择的患者中，David V VSRR 为伴有根部病变和瓣叶关闭不全的急性 TAAD 提供了安全的修复。在我们中心，紧急修复后长期随访时，与瓣膜相关的再干预发生率较低。
