The fate of residual aortic regurgitation after ascending aorta replacement in type A aortic dissection

Abstract

Objective: This study aimed to evaluate the changes in postoperative aortic regurgitation (AR) and determine the predictors of significant AR and root reoperation after ascending aortic replacement (AAR) in patients with acute type A aortic dissection.Methods: From January 1995 to December 2017, 271 consecutive patients underwent valve/root-preserving AAR (n ¼ 225) and root replacement (n ¼ 46). AR grade trend over time was analyzed by the ordinal mixed-effects model. Significant AR was defined as AR grade !3þ during the follow-up period. Predischarge and follow-up echocardiograms were obtained in 95.6% and 88.8% of enrolled patients, respectively.Results: At predischarge, postoperative !2þ AR was present in 20 (9.3%) and 1 (2.3%) patients in the AAR and root replacement groups, respectively. With increasing time after surgery, the grade of AR increased. At 10 years, 4.6% of patients had developed 3þ or 4þ AR. Considering death as the competing risk, the 10-year cumulative incidence of significant AR was significantly higher in the AAR than in the root replacement group (12.3% vs 2.2%; P ¼ .047). The risk of root reoperation at 10 years was not different between the groups (P ¼ .118). On Cox analysis, preoperative !3þ AR (P ¼ .002), postoperative !2þ AR (P ¼ .040), and false to true lumen ratio (P ¼ .005) were associated predictors of significant AR.Conclusions: Although valve/root-preserving AAR demonstrated reasonable longterm outcomes when compared with root replacement, preoperative !3þ AR, postoperative !2þ AR, and high false to true lumen ratio significantly increased the risk of significant AR. Therefore, careful echocardiographic surveillance may be warranted in patients with postoperative !2þ AR and small true lumen.

Commentary: Moving the goalposts

“…Kim and colleagues 6 examine the fate of aortic regurgitation after TAAD repair, comparing outcomes of patients who had root replacement with those who had preservation of the root and valve. As described by the authors, the size criterion for root replacement was >55 mm.…”

“…What is known from registry data is that aortic regurgitation of at least moderate degree is not rare, occurring in 18.9% of TAAD patients in the Society of Thoracic Surgeons database 7 and 23.3% of patients in the German Registry for Acute Aortic Dissection Type A, 8 similar to the 20% found in the population studied by Kim and colleagues. 6 This remains then a persistent clinical question for surgeons treating TAAD. The most common approach remains the supracoronary aortic replacement with commissural resuspension.…”

“…9 Still, root replacement in the United States remains fairly frequent at >25% in the Society of Thoracic Surgeons database 7 and even higher in the more recent years of IRAD data. 8 The article by Kim and colleagues 6 suggests a slightly different approach reflected in the root replacement rate of only 17%. In the nonroot replacement group, the more conservative approach was associated with respectable short-term mortality outcomes of 9.8%, but a 12.3% risk of significant aortic insufficiency (AI) and 8.1% root reoperation at 10 years.…”

“…Another consideration would be avoidance of the use of bioglue, for which increasing data suggest its etiology as a mode of failure. 10 At the very least, The study by Kim and colleagues 6 should prompt aortic surgeons in general to consider operative strategies to reduce long-term risk of root pathology, just as the field has trended toward reduction of late distal aortic events.…”

Commentary: Progressive aortic valve regurgitation after replacement of the dissected ascending aorta: An unsolved dilemma

“…In a recent report by Ikeno and colleagues, 6 AAR was associated with a progressive root dilatation and aortic valve incompetence during the first 5 years from surgery and linked to redo surgery in 2.5% of AAD survivors and a 14.5% aortic-related mortality. 6 Kim and colleagues 7 address this important question. The investigators retrospectively analyzed in their singlecenter study the long-term durability (100% complete follow-up at 8.6 AE 5.8 years) of AAR in 225 AAD patients with special focus on aortic valve regurgitation (AR), need for redo root surgery and survival.…”