title: Aortic valve reimplantation for aortic root aneurysms: trainer and trainee differences on long-term results.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Thoracic- and Cardiovascular Surgery, Goethe University Hospital, 60590, Frankfurt a.M., Germany, nadi037@aol.com.
authors.forename: Nadejda
authors.initials: N
authors.lastname: Monsefi
authors.forename: Patrick
authors.initials: P
authors.lastname: Primbs
authors.forename: Aleksandra
authors.initials: A
authors.lastname: Miskovic
authors.forename: Sandra
authors.initials: S
authors.lastname: Folkmann
authors.forename: Anton
authors.initials: A
authors.lastname: Moritz
mesh_terms: D000328:Adult; D000368:Aged; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D002983:Clinical Competence; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D019918:Heart Valve Prosthesis Implantation / Q000379:methods; D017052:Hospital Mortality; D006801:Humans; D007396:Internship and Residency; D008297:Male; D008505:Medical Staff, Hospital; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D011859:Radiography; D012092:Replantation / Q000379:methods* / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods