The rapid development of China's social economy has improved the national standard of living and medical care. These changes have helped decreased the case fatality and disability rates, which have led to increasing life expectancy. Thus, China’s healthcare system is facing increasing challenges [1], especially in terms of managing and follow-up postoperative patients of AD. Aortic dissection (AD) is deadly and its treatment is challenging for cardiovascular surgeons. In particular, some provinces in China with underdeveloped medical conditions. And in China, the majority of AD patients are relatively young. The occurrence of AD typically involves distal extension of a medial tear in the aortic wall, as well as proximal extension to the aortic root, which leads to aortic sinus dilation, aortic valve insufficiency, and coronary artery dissection [2, 3]. Severe aortic insufficiency can subsequently lead to acute left heart failure, cardiac tamponade, increased surgical risk, and postoperative complications and mortality [4]. Several strategies can be used to preserve the aortic valve, although these strategies remain technically challenging and prone to complications [5, 6].

However, it is unclear whether middle-aged patients with acute DeBakey I AD should undergo valve-sparing procedures or the Bentall procedure in an emergency setting. Therefore, this study aimed to investigate retrospectively mid-term effects of the valve-sparing procedures and the Bentall procedure in an emergency setting in middle-aged patients with acute DeBakey I AD.

The 213 eligible patients included 117 patients who underwent VSARR with ascending aortic and hemiarch replacement and triple-branched stent implantation (Group A) and 96 patients who underwent the Bentall procedure with hemiarch replacement and triple-branched stent implantation as the control group (Group B). No significant differences were observed in the two groups’ baseline and preoperative characteristics (Table 1).

The rapid development of acute DeBakey I AD is associated with a high risk of mortality and necessitates emergency surgery, which can significantly reduce the mortality rate [13]. There are two classic and commonly used methods for treating dissection that involves the aortic root, which are the Bentall procedure and the David procedure. Thus, the choice of treatment is based on whether the aortic root is involved, the course of the disease, and the surgeon's expertise [14‐17].

The Bentall procedure is simpler and shorter than the David procedure, but all patients received oral warfarin anticoagulation after surgery. We encountered 3 patient who developed mechanical valve dysfunction, and two of them led to acute left heart failure, and one patient subsequently died because of low cardiac output syndrome after emergency surgery. In this setting, thrombus abscission from the mechanical valve can lead to cerebral infarction, myocardial infarction, and other embolic events. It can also led to gastrointestinal hemorrhage, cerebral hemorrhage and other warfarin—related bleeding events. Valve aging of biovalves is another concern, especially in patients with diabetes, uremia, and other complications, which can accelerate the valve aging processand lead to sclerosis, calcification, and contracture at the biovalves [18]. Moreover, the proliferation of tissue around the valvecan lead to the narrowing of the left ventricular outflow tract, and perivalvular leakage may also occur after prosthetic valve replacement and increase the risk of re-operation [19, 20].

The David procedure provides good short-term and long-term effects [21], although it is a complex and technically challenging procedure. This procedure is considered difficult for our hospital’s situation as most patients with acute DeBakey I AD were transported to our hospital from throughout the region and often arrived during the night. Thus, emergency surgery was often performed overnight by the team of surgeons that were on duty, and David’s procedure was considered impractical because of the surgical complexity and poor general condition of the patients, who are frequently have co-existing diseases. To address these issues, we developed a patch neointima technique that provides a short-term and mid-term curative effect [8, 10]. Moreover, this technique was relatively simple, provides good hemostasis and surgical outcomes, and has a short learning curve, which has allowed many surgeons to adopt and widely perform it at our hospital.

The present study compared the mid-term outcomes of the VSARR and the Bentall procedure as emergency treatment for middle-aged Chinese patients with acute DeBakey I AD. Acute DeBakey I AD is associated with systemic coagulation abnormalities, which leads to a large-scale consumption of platelets and prothrombin complexes, as well as AD lesions, severe vascular wall edema, and brittle vascular tissues. And some patients have various risks associated with their frequent co-existence diseases, and poor physical condition. Moreover, These factors increase intraoperative bleeding and the technical challenges of the procedure [22]. We did not encounter any uncontrolled bleeding during the operations, and esophageal ultrasonography revealed good repair at the aortic root. We attribute the good short-term outcomes for the patch neointima technique to its technical simplicity and short learning curve.

We did not detect any significant differences between the two groups in terms of operative time, CPB time, AC time, SBP time, intraoperative blood loss, intraoperative RBC infusionLow cardiac output syndrome, 24 h pericardial drainage volume, or re-thoracotomy for hemostasis. The advantages of the patch neointima technique are a simple procedure during which the patch is sutured to the aortic root, with proximal aortic anastomosis above the aortic valve connection. This technique provides a better surgical field and may help facilitate intraoperative hemostasis. Thus, the patch neointima technique may be useful for a broad range of root replacement surgeries in terms of shortening the operative time, reducing intraoperative bleeding, reducing the volume of blood products used, and reducing surgical complications, especially in younger patients.

The present study was also unable to detect any significant differences in postoperative neurological complications, acute renal failure, acute liver failure, gastrointestinal bleeding, sepsis, or spinal cord injury. It is possible that use of a triple-branched stent for total arch replacement helped reduce the postoperative complications in our patients [23]. This could be because the procedure is short, simple, requires fewer anastomoses, and provides a broad repair range, which could also contribute to reductions in the operative time, AC time, and SBP time. These factors greatly reduce the incidences of surgical mortality and postoperative complications.

In cases of acute DeBakey I AD, the major controversy is regarding whether the aortic valve should be preserved or replaced, as there are limited data regarding long-term survival and valvular complications in these patients. One report indicated that patients with acute DeBakey I AD who underwent valve-sparing survival had limited long-term survival, moderate re-operation risk, and a low risk of valve-related complications [3]. A meta-analysis by Benedetto et al. also raised concerns regarding long-term durability of valve-sparing repair [24]. However, none of our patients in group A required re-operation for AR during the follow-up, which suggests that the aortic valve-sparing patch technique helped maintain the valve’s function with only a mild expansion. (Table 3) Some reports have indicated that the Bentall procedure for acute DeBakey I AD provides reliable long-term survival, albeit with a considerable incidence of valvular complications [25, 26]. We also found that group B had a significantly increased postoperative aortic valve re-operation rate (1/111 patients [0.9%] vs. 8/90 patients [8.9%], P = 0.020) because of the anticoagulation-related thromboembolism/bleeding events. A patient who with a mechanical valve should oral warfarin anticoagulant therapy for lifelong. Therefore, the descending aorta fasle lumen was difficult to thromboticand and associated with a higher rate of endoleakage at the distal end of the triple-branched stent (0/111 patients [0.0%] vs. 6/90 patients [6.7%], P = 0.022). These outcomes support the existing concerns regarding long-term outcomes of the Bentall procedure, which suggest that aortic valve-sparing repair may be useful for managing the aortic root in acute DeBakey I AD cases. In this setting, the mechanical valve need for oral warfarin therapy, which is associated with various adverse effects.

Among middle-aged Chinese patients with acute DeBakey I AD, VSARR were associated with a lower rate of endoleakage at the distal end of the triple-branched stent, thromboembolism/bleeding events and aortic valve re-operation, relative to the Bentall procedure.