Background: Type A aortic dissection (TAAD) is a life-threatening condition which requires prompt diagnosis and surgical treatment. When TAAD involves the aortic root, aortic valve-sparing or Bentall procedures are the main surgical treatment options. Method: The subjects of this analysis were 3735 patients included in the European Registry of Type A Aortic Dissection (ERTAAD). Propensity score matching was performed by estimating a propensity score from being treated with the Bentall or the David procedure using multilevel mixed-effects logistics, considering the cluster effect of the participating hospitals. Results: A Bentall procedure was performed in 862 patients, while a David operation was performed in 139 patients. The proportion of aortic root replacement, as well as the different techniques of aortic root replacement, varied significantly between the participating hospitals (p < 0.001). After propensity score matching, we obtained two groups of 115 patients each, and no statistical differences were reported in terms of postoperative outcomes, except for the rate of dialysis, which was higher in the patients requiring a Bentall procedure (17.4% vs. 7.0%, p-value 0.016). In the unmatched cohorts, the David procedure was associated with a lower 10-year mortality rate compared to the Bentall procedure (30.1% vs. 45.6%, p-value 0.004), but no difference was observed after matching (30.0% vs. 43.9%, p-value 0.082). After 10 years, no differences were observed in terms of proximal aortic reoperation (3.9% vs. 4.1%, p-value 0.954), even after propensity score matching (2.8% vs. 1.8%, p-value 0.994). Conclusions: The David and Bentall procedures are durable treatment methods for TAAD. When feasible, it is advisable that the David procedure is performed for acute TAAD by surgeons with experience with this demanding surgical technique.

Cardiac Surgery Molinette Hospital University of Turin 10126 Turin Italy

Cardiothoracic Department Azienda Sanitaria Universitaria Friuli Centrale 33100 Udine Italy

Cardiovascular Surgery Department University Hospital Gregorio Marañón 28007 Madrid Spain

Department of Cardiac Surgery Centre Hospitalier Annecy Genevois 74370 Epagny Metz Tessy France

Department of Cardiac Surgery Cologne University Hospital 50937 Cologne Germany

Department of Cardiac Surgery Glenfield Hospital Leicester LE3 9QP UK

Department of Cardiac Surgery Hôpitaux Universitaires Henri Mondor Assistance Publique Hôpitaux de Paris 94000 Créteil France

Department of Cardiac Surgery LMU University Hospital Ludwig Maximilian University 80336 Munich Germany

Department of Cardiac Surgery Martin Luther University Halle Wittenberg 06108 Halle Germany

Department of Cardiac Surgery Saint Luc Hospital 1200 Louvain Belgium

Department of Cardiac Surgery University Hospital Kralovske Vinohrady Charles University 10000 Prague Czech Republic

Department of Cardiothoracic Surgery University Hospital Muenster 48149 Muenster Germany

Department of Cardiovascular Surgery Centro Cardiologico Monzino IRCCS 20138 Milan Italy

Department of Cardiovascular Surgery Hospital Clínic de Barcelona University of Barcelona 08036 Barcelona Spain

Department of Cardiovascular Surgery University Heart and Vascular Center of Hamburg 20251 Hamburg Germany

Department of Medicine South Karelia Central Hospital University of Helsinki 53130 Lappeenranta Finland

Department of Thoracic and Cardiovascular Surgery University of Franche Comte 25000 Besancon France

Division of Cardiac Surgery Cardio Thoracic and Vascular Department Azienda Sanitaria Universitaria Giuliano Isontina 34148 Trieste Italy

Division of Cardiac Surgery University of Verona Medical School 37134 Verona Italy

Faculty of Medicine University of Oulu 90220 Oulu Finland

German Centre for Cardiovascular Research Partner Site Munich Heart Alliance 80336 Munich Germany

Heart and Lung Center Helsinki University Hospital University of Helsinki 00029 Helsinki Finland

Liverpool Heart and Chest Hospital Liverpool L14 3PE UK

Unit of Biostatistics Centro Cardiologico Monzino IRCCS 20138 Milan Italy

Université Paris Est Créteil Inserm IMRB U955 CEpiA Team 94000 Créteil France

See more in PubMed

Elsayed R.S., Cohen R.G., Fleischman F., Bowdish M.E. Acute type A aortic dissection. Cardiol. Clin. 2017;35:331–345. doi: 10.1016/j.ccl.2017.03.004. PubMed DOI

Isselbacher E.M., Preventza O., Hamilton Black Iii J., Augoustides J.G., Beck A.W., Bolen M.A., Braverman A.C., Bray B.E., Brown-Zimmerman M.M., Chen E.P., et al. 2022 ACC/AHA Guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J. Am. Coll. Cardiol. 2022;80:e223–e393. doi: 10.1016/j.jacc.2022.08.004. PubMed DOI PMC

Arabkhani B., Verhoef J., Tomšič A., van Brakel T.J., Hjortnaes J., Klautz R.J.M. The aortic root in acute type A dissection: Repair or replace? Ann. Thorac. Surg. 2023;115:1396–1402. doi: 10.1016/j.athoracsur.2022.06.041. PubMed DOI

Khachatryan Z., Herajärvi J., Leontyev S., Borger M.A. Valve-sparing aortic root replacement can be done safely and effectively in acute type A aortic dissection. J. Thorac. Cardiovasc. Surg. 2022;164:814–819. doi: 10.1016/j.jtcvs.2021.02.101. PubMed DOI

Khachatryan Z., Leontyev S., Magomedov K., Haunschild J., Holzhey D.M., Misfeld M., Etz C.D., Borger M.A. Management of aortic root in type A dissection: Bentall approach. J. Card. Surg. 2021;36:1779–1785. doi: 10.1111/jocs.15271. PubMed DOI

Biancari F., Mariscalco G., Yusuff H., Tsang G., Luthra S., Onorati F., Francica A., Rossetti C., Perrotti A., Chocron S., et al. European registry of type A aortic dissection (ERTAAD)—Rationale, design and definition criteria. J. Cardiothorac. Surg. 2021;16:171. doi: 10.1186/s13019-021-01536-5. PubMed DOI PMC

Halstead J.C., Spielvogel D., Meier D.M., Rinke S., Bodian C., Malekan R., Arisanergin M., Griepp R. Composite aortic root replacement in acute type A dissection: Time to rethink the indications? Eur. J. Cardiothorac. Surg. 2005;27:626–632. doi: 10.1016/j.ejcts.2004.12.059. PubMed DOI

Leshnower B.G., Myung R.J., McPherson L., Chen E.P. Midterm results of David V valve-sparing aortic root replacement in acute type A aortic dissection. Ann. Thorac. Surg. 2015;99:795–800. doi: 10.1016/j.athoracsur.2014.08.079. PubMed DOI

Rosenblum J.M., Leshnower B.G., Moon R.C., Lasanajak Y., Binongo J., McPherson L., Chen E.P. Durability and safety of David V valve-sparing root replacement in acute type A aortic dissection. J. Thorac. Cardiovasc. Surg. 2019;157:14–23.e1. doi: 10.1016/j.jtcvs.2018.10.059. PubMed DOI

Yang B., Patel H.J., Sorek C., Hornsby W.E., Wu X., Ward S., Thomas M., Driscoll A., Waidley V.A., Norton E.L., et al. Sixteen-Year Experience of David and Bentall procedures in acute type A aortic dissection. Ann. Thorac. Surg. 2018;105:779–784. doi: 10.1016/j.athoracsur.2017.09.029. PubMed DOI

Mosbahi S., Stak D., Gravestock I., Burgstaller J.M., Steurer J., Eckstein F., Ferrari E., A Berdajs D. A systemic review and meta-analysis: Bentall versus David procedure in acute type A aortic dissection. Eur. J. Cardiothorac. Surg. 2019;55:201–209. doi: 10.1093/ejcts/ezy266. PubMed DOI

Chikwe J., Cavallaro P., Itagaki S., Seigerman M., Diluozzo G., Adams D.H. National outcomes in acute aortic dissection: Influence of surgeon and institutional volume on operative mortality. Ann. Thorac. Surg. 2013;95:1563–1569. doi: 10.1016/j.athoracsur.2013.02.039. PubMed DOI

Levy G., DeAnda A., Jr. Valve-sparing root replacement in type A dissection: Age and experience matter. J. Thorac. Cardiovasc. Surg. 2019;157:24–25. doi: 10.1016/j.jtcvs.2018.10.043. PubMed DOI