Aortic valve-sparing operations in aortic root aneurysms: remodeling or reimplantation?

Abstract

A best evidence topic was written according to a structured protocol. The question addressed was whether the reimplantation (David) technique or the remodeling (Yacoub) technique provides the optimum event free survival in patients with an aortic root aneurysm suitable for an aortic valve-sparing operation. In total, 392 papers were found using the reported search criteria, of which 14 papers provided the best evidence to answer the clinical question. A total of 1338 patients (Yacoub technique in 606 and David technique in 732) from 13 centres were included. In most series, cardiopulmonary bypass time and aortic cross-clamp time were longer for the David technique compared to the Yacoub technique. Early mortality was comparable between the two techniques (0-6.9% for the Yacoub technique and 0-6% for the David technique). There is a tendency for a higher freedom from significant long-term aortic insufficiency in the David group than the Yacoub group, which does not necessarily result in a higher reoperation rate in the Yacoub group. In the largest series reported, freedom from a moderate-to-severe aortic insufficiency at 12 years was 82.6 ± 6.2% in the Yacoub and 91.0 ± 3.8% in the David group (P=0.035). Freedom from reoperation at the same time point was 90.4 ± 4.7% in the Yacoub group and 97.4 ± 2.2% in the David group (P=0.09). In another series, freedom from reoperation at a follow-up time of about four years was 89 ± 4% in the Yacoub group and 98 ± 2% in the David group. Although some authors merely preferred the Yacoub technique for a bicuspid aortic valve, the accumulated evidence in the current review indicates comparable results for both techniques in a bicuspid aortic valve. Current evidence is in favour of the David rather than the Yacoub technique in pathologies such as Marfan syndrome, acute type A aortic dissection, and excessive annular dilatation that may impair aortic root integrity. Careful selection of patients for each technique and successful restoration of normal cusp geometry are the keys to success in aortic valve-sparing operations.

Changes in operative strategy for patients enrolled in the International Registry of Acute Aortic Dissection interventional cohort program

“…In addition, many surgeons have developed their own preferences over time. 11 When aortic valve replacement was required, we observed a trend in increased use of xenograft biological prostheses with a concomitant decrease in mechanical valve substitutes. This phenomenon may be explained by the improved longevity of current era biological valves as well as improved reported results of reoperative surgery for failed prosthetic aortic valves.…”

Bicuspid aortic valve repair: systematic review on long-term outcomes

“…More patients had 2+ AR in the remodeling group; however, this did not result in greater need for reoperation. Finally, in patients with connective tissue disorders, acute aortic dissection and excessive annular dilatation, evidence appeared to favor VSRR over remodeling (40).…”

Aortic Valve Sparing Operations: A Review

“…It has been established that in young patients with inherited connective tissues disorder reimplantation of the aortic valve provides more stable aortic valve function than remodeling of the aortic of the aortic root [20,23,24,47,48]. The main cause of early failure of aortic valve sparing operations is technical errors [49] and probably lack of recognition of cusp prolapse.…”