Aneurysms of the aortic root and ascending aorta often require surgical correction. Currently, two common alternatives exist: The Bentall procedure has traditionally been used successfully for many decades, utilising an aortic valve prosthesis to replace the aortic valve and a conduit to replace the aneurysmic aorta. The more recent approach has been to reimplant suitable aortic valves utilising a dacron graft as well as replacing the affected aortic segment. The most widely used technique thereof is the David procedure. The decision for either operation depends greatly on patient circumstance and preference, as well as the recommendation of the operating surgeon. This is due to the associated features and disadvantages of the procedures at hand that make the careful choice of technique vital. Previous research has shown promising results for the equivalence, if not superiority, of the David procedure in certain patient groups, as well as in comparison to the
Bentall procedure overall. At the same time, there are concerns about the David approach regarding the durability, perioperative risk, and long-term outcomes, among others. Regardless, avoidance of anticoagulation postoperatively has made it an attractive choice for patients who do not want to or cannot receive anticoagulants. While the David procedure has shown these beneficial properties, it has been widely limited to cases where the aortic valve is deemed suitable. Over the last decade, several studies have assessed the usage of David procedure for cases that did not previously seem to be a fit, such as patients with bicuspid aortic valves, who are now deemed suitable. With the David procedure becoming more widely applied and the application of the operation being extended, the question arises, whether the Bentall procedure remains the gold standard for correction of aortic root pathology. Several studies have been conducted over the years, but because cases are comparatively
few, evidence is still lacking. For this, we conducted a study into the short and long-term outcomes of patients who underwent either Bentall or David procedures at the Leipzig Heart Centre between 2000 and 2015. Pre-operative, operative and post-operative data was gathered, and a follow-up was conducted through questionnaires, reports by physicians and telephone surveys. Statistical analysis was performed to gain data on perioperative mortality, adverse outcomes and long-term effects, such as bleeding incidents, reoperation rates and overall mortality, among others. This resulted in two publications that form the basis of this dissertation: Publication A sought to compare the outcomes of David cases with those who received correction with the Bentall procedure, including both mechanical valve prostheses and biological replacements. Publication B compared David cases to biological Bentall replacements. This subgroup analysis was done because both procedures avoid long term-anticoagulation. We found that both the David and Bentall operation had excellent early and long-term results, with comparable outcomes for early and late mortality among others. Furthermore, we did not see an increased risk of reoperation for the David procedure during our observational period. We recorded a higher incidence of serious bleeding events in the Bentall group (Publication A). The comparison of bioprosthetic Bentall cases to the David group showed equivalent
outcomes for both procedures without significant difference in endpoints. While patient preferences and circumstances should still be considered, our investigations
showed clear advantages for the David procedure in the analysed patient group. We
concluded that the David operation is the preferable operation in patients with appropriate pathoanatomy, because long-term complications associated with prosthetic heart valves remain a major concern and it has shown to mitigate said complications.
| Identifer | oai:union.ndltd.org:DRESDEN/oai:qucosa:de:qucosa:75288 |
| Date | 01 July 2021 |
| Creators | Schamberger, Lukas |
| Contributors | Universität Leipzig |
| Source Sets | Hochschulschriftenserver (HSSS) der SLUB Dresden |
| Language | English |
| Detected Language | English |
| Type | info:eu-repo/semantics/publishedVersion, doc-type:doctoralThesis, info:eu-repo/semantics/doctoralThesis, doc-type:Text |
| Rights | info:eu-repo/semantics/openAccess |
| Relation | 10.1016/j.athoracsur.2019.10.020, 10.1007/s12055-019-00873-4 |
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