Twenty-five year outcomes following composite graft aortic root replacement

[DJM 18]

I thought some people here might take interest in this study on Composite Graft Aortic Root Replacement (Bentall De Bono procedure). This is a very complete single surgeon (Yale / Dr. Elefteriades) series of 449 patients over a 25 year period. Quite remarkable and perhaps a time to reflect on how far this procedure has progressed. If anyone here likes looking at data, this series is quite complete and very encouraging.

"At 5, 10, and 20 years, freedom from major events and reoperations on the rootwere 97.8, 95.4, and 94.39%, and 99.0, 99.0,and 97.9%,respectively. Survival in patients aged <60 years was 92.0, 90.1, and 79.8% at five, 10, and 20 years versus 88.4, 67.9, and 42.6% in patients aged ≥60 years (p=0.001). Compared with age- and gender-matched controls, survival was not significantly different (p=0.20)."

"CONCLUSIONS: Composite graft aortic root replacement is associated with low operative risk, excellent long-term survival, and low incidence of reoperation and late event"

Note: the operative mortality at 14/449 accounts for 11 patients with Acute type A dissection, urgent/emergent procedures, patients over the age of 80 and patients with significant comorbidities.

A recent guest asked for data and in my mind this is as good as it gets. Below are links to the study and to a slide presentation from this study.

https://pdfs.semanticscholar.org/f0e...1ab335f84c.pdf

https://promedicacme.com/wp-content/...iades-John.pdf

 

[amarG]

Do people with just a leaky bicuspid valve but not much aortic enlargement go for this procedure? Or is it meant for folks w anyuerisms?

 

[DachsieMom]

This is my surgeon! Dr Elefteriades is amazing. I was 42 at the time of surgery - St Jude valve conduit. He advised that I should most likely have a normal life expectancy.

 

[cldlhd]

Thanks for the post and the links. I had the David V and my root, ascending and hemi arch replaced with a graft so good toe hear. How you doing Amar?

 

[amarG]

Preop at Stanford on Thursday Chris. Getting a little anxious. So many suboptimal options to choose from. The path the Stanford guy is recommending (David V) is not recommended by Cleveland guy. I'm caught in the middle and will just have to pick a path I think. I wish the experts would arrive at a consensus.

 

[pellicle]

Hi

... So many suboptimal options to choose from. The path the Stanford guy is recommending (David V) is not recommended by Cleveland guy. I'm caught in the middle and will just have to pick a path I think. I wish the experts would arrive at a consensus.

if you feel like giving a brief summary of the choices you have I'm sure a few of us would have a crack at suggestions.

Experts are experts, but that doesn't mean they all have the same experience or that because they support different views that one is right and the other wrong.

At the end of the day it is us who should rightly make the choices as to our own destiny. The Experts are there to inform us ... they aren't usually choosing for themselves.

 

[cldlhd]

Preop at Stanford on Thursday Chris. Getting a little anxious. So many suboptimal options to choose from. The path the Stanford guy is recommending (David V) is not recommended by Cleveland guy. I'm caught in the middle and will just have to pick a path I think. I wish the experts would arrive at a consensus.

That crystal ball would be nice eh? The David V is what I had .My point to the surgeon was I didn't want the valve repaired if he was doing it as a challenge ( they do have egos ) and he thought it wouldn't last. In that case I chose mechanical. I got lucky and he put my repair in his top 10, unless he says that to everyone... I assume the guy at Cleveland gave you his reason(s)?

 

[tom in MO]

Preop at Stanford on Thursday Chris. Getting a little anxious. So many suboptimal options to choose from. The path the Stanford guy is recommending (David V) is not recommended by Cleveland guy. I'm caught in the middle and will just have to pick a path I think. I wish the experts would arrive at a consensus.

A philosopher said that if you have two hard choices take comfort in the fact that they are hard because they have equal merit as well as equal risk, thus both are good choices

If you want a consensus, can you get the Cleveland guy and the Stanford guy to talk to each other? This path has worked for some with difficult medical problems.

 

[amarG]

Thanks folks.... so here are my choices:

* Dr Woo in Stanford wants to repair my valve. And he wants to do it by doing a David V. He thinks the repair will hold 10 years and then he will "TAVR". Dr Woo has not done any AV repairs yet. I will be doing a much more complex operation and still getting the same 10 years as I would with a tissue valve. To Chris's point, I think this may be more to the Dr's benefit than mine. Of course, there is a benefit to native tissue vs prosthetic....

* Dr Svensson in Cleveland puts a 50% - 70% probability of repairing my valve. He has done 300+ AV repairs. He recommends replacing with a tissue valve. He is surprised that a David V was offered for me since I have no aneurism (3.9mm). Says the outcomes w David V for bicuspid repairs are not that great.

* My cardiologist thinks I should just go mechanical and be done with it.

* Dr Svensson has also done trials with the new Edwards Inspira Resilia valve. And is now offering that as a valve choice. (I see another person in this forum just got that done thru him). Stanford thinks its too risky/early to go with this valve. Of course, there is a promise of much better hemodynamics and 20-30 yr life with this valve, but there is no human data. I will be one of the first few in the world to go with it.

I meet Dr Woo tomorrow for pre-op. Question is..... which of the four paths should I pick.....

Any advise or suggestion?

thanks

 

[cldlhd]

https://www.youtube.com/watch?v=_iVVmBgWsiE&t=64s
Maybe I'm mistaken and it wasn't Dr. Woo or I'm thinking of a different debate. I read a lot in a brief period of time on the subject, too much for my feeble mind. That debate has some interesting points.

 

[pellicle]

Hi

Thanks folks.... so here are my choices:

firstly, may I ask how old you are?

* Dr Woo in Stanford wants to repair my valve. And he wants to do it by doing a David V. He thinks the repair will hold 10 years and then he will "TAVR".

ok ... "thinks" ... as an Engineer do you go with "gut feels" more or calculations? Does he have some stats (and propensity match those with your age group) to go on?

Surgery however is very much a qualitative field more than a quantitative one.

Next, the current state of affairs is that TAVI will last about half (or less) the duration of a regular tissue prosthesis. Then (if your valve diameter is large enough) a valve in valve can be done, which I read lasts about half that duration. So something like 7 years then 4 years from the TAVI before you need a regular OHS ... if you are (as the procedure IS INTENDED FOR) elderly or too frail for regular surgery then that may just be "the term of your natural life" anyway ... again, do the numbers on your actual age. And remember ... they don't fail suddenly, you have a few years of slow failure and more tests and more waiting room time ahead of you. Plus the concern of "if it lasts" on the repair ...

* Dr Svensson in Cleveland puts a 50% - 70% probability of repairing my valve. He has done 300+ AV repairs. He recommends replacing with a tissue valve. He is surprised that a David V was offered for me since I have no aneurism (3.9mm). Says the outcomes w David V for bicuspid repairs are not that great.

seems straight forward to me ... if I was given a bit over a 50-50 choice I'd walk away from it ... would you taser yourself with a taser that was in a group of 3 and I said one is charged the others aren't? Tasers aren't fatal so its a good comparison.

* My cardiologist thinks I should just go mechanical and be done with it.

personally that's what I picked with my valve choice in 2011 ... after two previous surgeries over 30 years.

* Dr Svensson has also done trials with the new Edwards Inspira Resilia valve. And is now offering that as a valve choice. (I see another person in this forum just got that done thru him). Stanford thinks its too risky/early to go with this valve. Of course, there is a promise of much better hemodynamics and 20-30 yr life with this valve, but there is no human data. I will be one of the first few in the world to go with it.

do a search here for how many latest generation valves didn't give their owners the "brochure" claim of "up to" X years ... and got under 10

Consider also the age groups that those figures are talking to and juxtapose that with your own age group.

Consider also the factor of "will you be OK with a mechanical. Not everyone sits well with it and some focus on how irritating it is to hear the clicks. It was distressing for me at first too ... but then I got a few life lessons on "relative pain" and that settled clearly in my own mind that the ticking was nothing compared to the other **** I had to endure.

Feel free to PM me and we can whatsapp or skype if you want to thrash more ideas around.

I'd also read and consider every other reply here to your question too ...

 

[amarG]

Thanks Pellicle. I'll be 53 in a couple of months. I appreciate all the thoughtful replies. And Chris, thanks for posting the debate video.

I am seeing the Dr in a couple of hours. Will keep you posted on how out it .

Thanks for all your help. You are a wonderful support group

 

[cldlhd]

Good luck and thanks but no need as it's really a symbiotic situation out here.

 

[Agian]

I click, therefore I am.

I saw Eraserhead last night (now that's some weird ****) and the clicking added to the suspense.

 

[Superman]

I teach a couple college courses. In a sequence, so I get a few repeat students. A student that took another course I teach during a test last week says, "I forgot how loud that thing can be." That was funny.