Interact CardioVasc Thorac Surg 2009;8:134-147. doi:10.1510/icvts.2008.186544
© 2009 European Association of Cardio-Thoracic Surgery
Best evidence topic - Aortic and aneurysmal |
Is aortic valve-sparing operation or replacement with a composite graft the best option for aortic root and ascending aortic aneurysm?
Christos Tourmousoglou* and
Chris Rokkas
Department of Cardiothoracic Surgery, Attikon University Hospital, Athens, Greece
Received 20 June 2008;
received in revised form 14 September 2008;
accepted 2 October 2008
*Corresponding author. 29 Bournazou Street, 11521, Athens, Greece. Tel.: +30 210 6468674; fax: +30 210 7757545.
E-mail address: christostourmousoglou{at}hotmail.com; chtourmou{at}med.uoa.gr (C. Tourmousoglou).
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is better to preserve the aortic valve in patients with aortic root or ascending aortic aneurysms. Altogether 380 papers were found using the reported search, of which 23 represented the best evidence to answer the clinical question. The authors, journal, date, country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All the studies identified are retrospective. Sixteen papers reported a 10-year reoperative-free survival from 54% to 98% for valve-sparing operations and 67–81% for replacement operations in two further studies. Six papers reported their 10-year freedom from re-operation as 75–97% for valve-sparing operations. Our findings suggest that the results of both techniques are excellent and comparable, and the operating surgeon may safely make his decision as to which technique to select based on patient factors and his own experience without compromising the long-term outcomes of the patient.
Key Words: Aortic root aneurysm; Ascending aorta aneurysm; Valve-sparing operation; Composite graft replacement
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
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2. Three-part question
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In [patients with an aortic root aneurysm] is [root replacement or a valve-sparing procedure] the best operation in order to optimize [event free survival]?
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3. Clinical scenario
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You are seeing a 67-year-old patient with an aneurysm of the aortic root. There is dilation of the sinotubular junction with aortic insufficiency. You say to him that there are two options of surgical treatment: the aortic valve-sparing operation and the replacement of the ascending aorta and aortic valve with a composite graft. The patient asks which operation is suitable. You wonder whether the aortic valve-sparing operation or the composite graft is better for this patient.
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4. Search strategy
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Medline 1950 to July 2008 using OvidSP interface.
[valve-sparing.mp OR valve-preserving.mp OR valve reimplantation.mp].
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5. Search outcome
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Using the reported search, 380 papers were identified of which 23 papers provided the best evidence to answer the question. These papers are summarized in Table 1.
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6. Results
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The search was wide. There were 24 retrospective studies and no RCT or meta-analysis.
Yacoub et al. [3] were the first who operated using the valve-sparing techniques. They found that actuarial survival for patients operated on electively for chronic aneurysm was 96.8%, 91.2%, 82% and 60% at 1, 5, 10 and 15 years, respectively, and the probability of needing reoperation was 3.0%±2%, 11%±0.5% and 11%±0.5% at 1, 5 and 10 years, respectively. At the end of follow-up, trivial or no aortic regurgitation was demonstrated in 63.6% of patients, mild to moderate in 33.3% and severe in 3%.
David et al. [4] were the other pioneers, who invented the valve-sparing techniques. They detected that 10-year survival rate was 88%±3% and the freedom from moderate or severe aortic insufficiency at 10 years was 85%±5% for all patients; it was 94%±4% after reimplantation and 75%±10% after remodeling. Freedom from aortic valve replacement at 10 years was 95%±3%.
Kallenbach et al. [5] found that actuarial survival with valve-sparing procedures was 98.7%, 96.8% and 96.8% at 1, 3 and 5 years, respectively, and the freedom from reoperation was 98.6% (±1%), 96.8 (±2%) and 96.8 (±2%) at 1, 3 and 5 years, respectively.
Aicher et al. [8] operated using the valve-sparing procedures and showed that hospital mortality was 3.6%, freedom from reoperation was 96% at 5 and 10 years and freedom from valve replacement was 98% at 5 and 10 years.
The above results about aortic valve-sparing operations were supported by 12 papers. The authors found that 10-year survival rates were from 54% to 98%; freedom from aortic valve replacement at 10 years was from 85% to 97% and freedom from reoperation at 5 years was from 84% to 98% [2, 6–9, 11–13, 19, 20, 23, 24].
However, comparable results were found with aortic root replacements [10, 14–18, 21].
Gott et al. [10] described that actuarial survival was 89% at 5 years, 81% at 10 years, 76% at 15 years and 67% at 20 years; the actuarial freedom from reoperation was 74% at 20 years.
Kouchoukos et al. [15] presented their results and actuarial survival at 7 years was 65% and actuarial freedom from reoperation at 7 years was 89%, but it was 78% for patients with Marfan syndrome.
Zehr et al. [16] found that actuarial survival at 5, 10, 15 and 20 years was 93%, 79%, 67% and 52%, respectively, and the freedom from reoperation was 88%, 86%, 79% and, 72% at 5, 10, 15 and 20 years, respectively.
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7. Clinical bottom line
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Sixteen papers reported a 10-year reoperative-free survival from 54% to 98% for valve-sparing operations and 67% to 81% for replacement operations in two further studies. Six papers reported their 10-year freedom from re-operation as 75–97% for valve-sparing operations.
Our findings suggest that the results of both techniques are excellent and comparable and the operating surgeon may safely make his decision as to which technique to select based on patient factors and his own experience without compromising the long-term outcomes of the patient.
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References
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Abstract
1. Introduction