title: Decision-making in aortic root surgery in Marfan syndrome: bleeding, thromboembolism and risk of reintervention after valve-sparing or mechanical aortic root replacement.
abstract: OBJECTIVE
  Valve-sparing root replacement (VSRR) is thought to reduce the rate of thromboembolic and bleeding events compared with aortic root replacement using a mechanical aortic root replacement (MRR) with a composite graft by avoiding oral anticoagulation. But as VSRR carries a certain risk for subsequent reinterventions, decision-making in the individual patient can be challenging.
  
  
  METHODS
  Of 100 Marfan syndrome (MFS) patients who underwent 169 aortic surgeries and were followed at our institution since 1995, 59 consecutive patients without a history of dissection or prior aortic surgery underwent elective VSRR or MRR and were retrospectively analysed.
  
  
  RESULTS
  VSRR was performed in 29 (David n = 24, Yacoub n = 5) and MRR in 30 patients. The mean age was 33 ± 15 years. The mean follow-up after VSRR was 6.5 ± 4 years (180 patient-years) compared with 8.8 ± 9 years (274 patient-years) after MRR. Reoperation rates after root remodelling (Yacoub) were significantly higher than after the reimplantation (David) procedure (60 vs 4.2%, P = 0.01). The need for reinterventions after the reimplantation procedure (0.8% per patient-year) was not significantly higher than after MRR (P = 0.44) but follow-up after VSRR was significantly shorter (P = 0.03). There was neither significant morbidity nor mortality associated with root reoperations. There were no neurological events after VSRR compared with four stroke/intracranial bleeding events in the MRR group (log-rank, P = 0.11), translating into an event rate of 1.46% per patient-year following MRR.
  
  
  CONCLUSIONS
  The calculated annual failure rate after VSRR using the reimplantation technique was lower than the annual risk for thromboembolic or bleeding events. Since the perioperative risk of reinterventions following VSRR is low, patients might benefit from VSRR even if redo surgery may become necessary during follow-up.
authors: Department of Cardiovascular Surgery, University Hospital Berne, Bern, Switzerland.
authors: Florian S
authors: FS
authors: Schoenhoff
authors: Department of Cardiovascular Surgery, University Hospital Berne, Bern, Switzerland.
authors: Bettina
authors: B
authors: Langhammer
authors: Department of Cardiology, University Hospital Berne, Bern, Switzerland.
authors: Kerstin
authors: K
authors: Wustmann
authors: Department of Cardiovascular Surgery, University Hospital Berne, Bern, Switzerland.
authors: David
authors: D
authors: Reineke
authors: Department of Cardiovascular Surgery, University Hospital Berne, Bern, Switzerland.
authors: Alexander
authors: A
authors: Kadner
authors: Department of Cardiovascular Surgery, University Hospital Berne, Bern, Switzerland thierry.carrel@insel.ch.
authors: Thierry
authors: T
authors: Carrel
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001011:Aorta / Q000601:surgery; D001014:Aortic Aneurysm / Q000601:surgery*; D001021:Aortic Valve / Q000601:surgery*; D016063:Blood Loss, Surgical / Q000517:prevention & control / Q000706:statistics & numerical data*; D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D008382:Marfan Syndrome / Q000601:surgery*; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013923:Thromboembolism / Q000453:epidemiology* / Q000209:etiology; D055815:Young Adult
keywords: Aortic root surgery; Aortic surgery; Connective tissue disease; Marfan syndrome; Valve-sparing surgery