David valve-sparing aortic root replacement: equivalent mid-term outcome for different valve types with or without connective tissue disorder.
OBJECTIVE
Although implicitly accepted by many that the durability of valve-sparing aortic root replacement in patients with bicuspid aortic valve disease and connective tissue disorders will be inferior, this hypothesis has not been rigorously investigated.


METHODS
From 1993 to 2009, 233 patients (27% bicuspid aortic valve, 40% Marfan syndrome) underwent Tirone David valve-sparing aortic root replacement. Follow-up averaged 4.7 ± 3.3 years (1102 patient-years). Freedom from adverse outcomes was determined using log-rank calculations.


RESULTS
Survival at 5 and 10 years was 98.7% ± 0.7% and 93.5% ± 5.1%, respectively. Freedom from reoperation (all causes) on the aortic root was 92.2% ± 3.6% at 10 years; 3 reoperations were aortic valve replacement owing to structural valve deterioration. Freedom from structural valve deterioration at 10 years was 96.1% ± 2.1%. No significant differences were found in survival (P = .805, P = .793, respectively), reoperation (P = .179, P = .973, respectively), structural valve deterioration (P = .639, P = .982, respectively), or any other functional or clinical endpoints when patients were stratified by valve type (tricuspid aortic valve vs bicuspid aortic valve) or associated connective tissue disorder. At the latest echocardiographic follow-up (95% complete), 202 patients (94.8%) had none or trace aortic regurgitation, 10 (4.7%) mild, 0 had moderate to severe, and 1 (0.5%) had severe aortic regurgitation. Freedom from greater than 2+ aortic regurgitation at 10 years was 95.3% ± 2.5%. Six patients sustained acute type B aortic dissection (freedom at 10 years, 90.4% ± 5.0%).


CONCLUSIONS
Tirone David reimplantation valve-sparing aortic root replacement in carefully selected young patients was associated with excellent clinical and echocardiographic outcome in patients with either a tricuspid aortic valve or bicuspid aortic valve. No demonstrable adverse influence was found for Marfan syndrome or connective tissue disorder on durability, clinical outcome, or echocardiographic results.
Department of Cardiovascular and Thoracic Surgery, Stanford University School of Medicine, Stanford, Calif. 94305-5247, USA.
John-Peder Escobar
JP
Kvitting
Fabian A
FA
Kari
Michael P
MP
Fischbein
David H
DH
Liang
Anne-Sophie
AS
Beraud
Elizabeth H
EH
Stephens
R Scott
RS
Mitchell
D Craig
DC
Miller
D000293:Adolescent; D000328:Adult; D000368:Aged; D001011:Aorta / Q000601:surgery*; D001021:Aortic Valve / Q000002:abnormalities / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D002648:Child; D005260:Female; D006330:Heart Defects, Congenital / Q000150:complications / Q000401:mortality / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008382:Marfan Syndrome / Q000150:complications* / Q000401:mortality; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000601:surgery; D012086:Reoperation; D012092:Replantation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult