Aortic valve reimplantation for aortic root aneurysms: trainer and trainee differences on long-term results.

PURPOSE: The advantages of aortic valve-preserving surgery are still hampered by a higher rate of reoperations compared to root replacement with valved conduits. This study evaluates whether valve deterioration rate is related to the method or depends on stringent adherence to technical concepts, which might be lost once trainees perform this complex surgery on their own. METHODS: From 1991 to 2011, the David procedure was performed in 209 consecutive patients. Mean age was 57 ± 14 years. The patients were operated either by the senior author or trainees under his supervision (group 1, n = 130) or by surgeons on their own after training by the senior author (group 2, n = 79). Clinical and echocardiography data were evaluated pre- and postoperatively and at follow-up (mean 6.0 ± 4 years). RESULTS: In-hospital mortality was 1.5 % in group 1 and 5 % in group 2 (p = 0.29), and late mortality was 12 % (n = 12 in group 1 and n = 14 in group 2, p = 0.11), three were cardiac related. Nine patients (4.3 %) had to be reoperated; three for endocarditis in group 1, six for structural valve deterioration in group 2 (p = 0.14). The 9-year freedom from reoperation or aortic valve insufficiency (AI) ≥2° was 93 % in group 1 and 78 % in group 2 (p < 0.01). As groups showed differences in preoperative variables, results were compared also in a propensity matched subgroup. Despite no difference in perioperative results, long-term valve competence remained inferior in group 2. CONCLUSIONS: With stringent adherence to technical concepts, structural valve deterioration may virtually be considerably reduced in aortic valve reimplantation. Once performing this operation on their own, trainees-after training by the senior-achieved results as independent surgeons well comparable to published series. As long-term performance seems to depend more on judgment of the geometry achieved intraoperatively than on technical steps, a means of measurement of effective coaptation height with a caliper might facilitate evaluation of perfect repair.

Long-term results of aortic valve resuspension in patients with aortic valve insufficiency and aortic root aneurysm.

OBJECTIVES: 'The David technique' may provide an alternative to conduit implantation in patients with an aneurysm of the ascending aorta and aortic valve insufficiency. METHODS: From 1991 to 2013, the David technique was performed in 249 consecutive patients in our department. The patient mean age was 58 ± 14 years; 71 (29%) were female and 178 (71%) male. A modification of the David technique was performed by creating a pseudosinus in 43 patients (17%) and by creating a neosinus in 123 patients (49%). The mean follow-up was 6 ± 4.5 years. RESULTS: There were six in-hospital (2.4%) and 30 late deaths (2.4%/patient-year). Cardiac-related events were the cause of death in three patients. The Kaplan-Meier estimate for 10 years survival was 77%. Four patients had perioperative neurological events, and only eight neurological events occurred during follow-up (0.6%/patient-year). Ten patients (0.8%/patient-year) required aortic valve replacement; one because of combined aortic valve stenosis and insufficiency and nine because of severe aortic valve insufficiency as a result of leaflet prolapse (n = 3), leaflet perforation (n = 1), abridgement of the right coronary leaflet (n = 1) and because of endocarditis (n = 4). Three cases of bleeding were observed (0.24%/patient-year). Freedom from reoperation or aortic valve insufficiency ≥2° was 80% at 10 years. CONCLUSIONS: Aortic valve sparing to treat patients with an ascending aortic aneurysm with aortic valve insufficiency is a durable procedure. Aortic valve function remains stable for many years. Valve-related complications are rare, and the rate of reoperations is not increased in comparison to conduit root replacement.