„ Editorial

All that glitters is not gold

J Scott Rankin
Heart and Vascular Institute, West Virginia University, Morgantown, WV, United States

Related article

by Deja et al.

“All that glisters is not gold

Often have you heard that told.

Many a man his life hath sold

But my outside to behold.

Gilded tombs do worms enfold.

Had you been as wise as bold,

Young in limbs, in judgment old,

Your answer had not been inscrolled

Fare you well. Your suit is cold”

William Shakespeare, Merchant of Venice, Act II Scene 7

Correspondence to:

Prof. J Scott Rankin, MD, PhD,

Heart and Vascular Institute,

West Virginia University,

1 Medical Center Drive, Morgantown, WV 26506, United States,

phone: 615 969 1543,

e-mail: jsrankinmd@cs.com

Copyright by the Author(s), 2022

DOI: 10.33963/KP.a2022.0095

Received: April 4, 2022

Accepted: April 5, 2022

Early publication date: April 5, 2022

Mister Hugh H Bentall was an innovative cardiothoracic surgeon, participating in the first cardiopulmonary bypass cases in Europe [1] and inventing potassium cardioplegia [2]. He also was an expert on 18th century English tall-case clocks (Figure 1) and an excellent educator at the Royal Postgraduate Medical School, Hammersmith Hospital, London. But it was his invention of composite aortic valve-root conduit replacement [3] that sustains his name in current clinical practice almost 60 years later. Most of us learned about his operation in the 1970s, and it has been a mainstay of cardiac surgery for the past half-century. The procedure, however, is limited by its inclusion of a valve prosthesis in the aortic position, with consequent valve-related complications. One might argue that the Bentall procedure should no longer be considered the “gold standard” treatment for aortic root aneurysms. The excellent follow-up data presented in the current issue by the Katowice group would support this view.

Rankin.jpeg

Figure 1. London tall-case clock from 1770 selected by Mr. Bentall for the author in 1986 — still gracing the author’s entry hall almost 40 years later while keeping perfect time

In assessing outcomes in 204 patients with aortic root aneurysms managed surgically over a 10-year period, Gocol and associates [4] have contributed importantly to current knowledge. It is appropriate to start with a comment about the biostatistics used in this study. Single-center series have advantages, primarily related to detailed understanding by the authors of every aspect of each patient’s course. The disadvantage, of course, is a small sample size. With only 23 deaths, 6 reoperations, and 30 other events in the entire study, any multivariable analysis could only support 23 variables an inadequate number for proper risk adjustment (and the full multivariable model is never presented). However, a descriptive review of the data always is valuable, and several concepts are evident in this series. First, selection bias is present with older patients being selected for bio-Bentall procedures, which is standard. Without a proper multivariable analysis, much of the inferior survival associated with bio-Bentall operations could have been related to older age at baseline. However, tissue valves tend to deteriorate faster beyond 10 years, so even more significant decrements in bio-Bentall outcomes are likely past the duration of this study.

The most striking finding of this analysis is the dearth of valve-related complications after aortic valve repair (valve-sparing root replacement). This observation is consistent with other reports [5, 6], and if a composite major adverse cardiac event (MACE) outcome were to be analyzed [7], valve repair likely would win hands down. Moreover, the mechanical Bentall group was younger, so proper risk adjustment might have lowered associated survival, and especially with longer follow-up, accumulating valve-related complications might have compromised survival [8]. So, the data clearly suggest the superiority of valve repair for aortic root aneurysms, as compared to Bentall procedures employing either type of prosthetic valve. The Katowice group should be complemented on achieving an approximately 50% repair rate in their series. Even in experienced centers, the rule is 27% repair for aortic insufficiency [9, 10] in recent years. However, the goal of cardiac surgical practice now should be to increase repair rates for all patients with aortic insufficiency toward 90%, as in the case of mitral repair [11]. The advent of aortic ring annuloplasty could help in that regard [12, 13], but expanding aortic valve repair clearly is an appealing next developmental step. In summary, one must conclude that Mister Bentall’s reputation and contributions may still “glitter”, but his operation no longer is the “gold standard” for management of aortic root aneurysms.

Article information

Conflict of interest: None declared.

Open access: This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially. For commercial use, please contact the journal office at kardiologiapolska@ptkardio.pl.

REFERENCES

  1. Aird I, Melrose DG, Cleland WP, et al. Assisted circulation by pump-oxygenator during operative dilatation of the aortic valve in man. BMJ. 1954; 1(4874): 12841287, doi: 10.1136/bmj.1.4874.1284.
  2. Melrose DG, Dreyer B, Bentall HH, et al. Elective cardiac arrest. Lancet. 1955; 269(6879): 2122, doi: 10.1016/s0140-6736(55)93381-x, indexed in Pubmed: 14382605.
  3. Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax. 1968; 23(4): 338339, doi: 10.1136/thx.23.4.338, indexed in Pubmed: 5664694.
  4. Gocoł R, Bis J, Malinowski M, et al. Outcomes comparison of different approaches to aortic root aneurysm. Kardiol Pol. 2022; 80(4): 436444, doi: 10.33963/KP.a2022.0045, indexed in Pubmed: 35152397.
  5. Aicher D, Fries R, Rodionycheva S, et al. Aortic valve repair leads to a low incidence of valve-related complications. Eur J Cardiothorac Surg. 2010; 37(1): 127132, doi: 10.1016/j.ejcts.2009.06.021, indexed in Pubmed: 19643618.
  6. Price J, De Kerchove L, Glineur D, et al. Risk of valve-related events after aortic valve repair. Ann Thorac Surg. 2013; 95(2): 60612; discussion 613, doi: 10.1016/j.athoracsur.2012.07.016, indexed in Pubmed: 22959573.
  7. Jabagi H, Chan V, Ruel M, et al. Aortic valve repair decreases risks of VRE in AI at 10 years: a propensity score-matched analysis. Ann Thorac Surg. 2021 [Epub ahead of print], doi: 10.1016/j.athoracsur.2021.06.020, indexed in Pubmed: 34228974.
  8. de Meester C, Pasquet A, Gerber BL, et al. Valve repair improves the outcome of surgery for chronic severe aortic regurgitation: a propensity score analysis. J Thorac Cardiovasc Surg. 2014; 148(5): 19131920, doi: 10.1016/j.jtcvs.2014.02.010, indexed in Pubmed: 24656668.
  9. Yang LT, Michelena HI, Scott CG, et al. Outcomes in chronic hemodynamically significant aortic regurgitation and limitations of current guidelines. J Am Coll Cardiol. 2019; 73(14): 17411752, doi: 10.1016/j.jacc.2019.01.024, indexed in Pubmed: 30846339.
  10. Alashi A, Khullar T, Mentias A, et al. Long-Term outcomes after aortic valve surgery in patients with asymptomatic chronic aortic regurgitation and Preserved LVEF: impact of baseline and follow-up global longitudinal strain. JACC Cardiovasc Imaging. 2020; 13(1 Pt 1): 1221, doi: 10.1016/j.jcmg.2018.12.021, indexed in Pubmed: 30772216.
  11. Rankin JS, Grau-Sepulveda M, Shahian DM, et al. The impact of mitral disease etiology on Operative mortality after mitral valve operations. Ann Thorac Surg. 2018; 106(5): 14061413, doi: 10.1016/j.athoracsur.2018.04.053, indexed in Pubmed: 29777670.
  12. Rankin J, Wei L, Downey R, et al. Aortic valve repair using geometric ring annuloplasty. Operative Techniques in Thoracic and Cardiovascular Surgery. 2021; 26(2): 173188, doi: 10.1053/j.optechstcvs.2020.11.008.
  13. Gerdisch MW, Reece TB, Emerson D, et al. Early results of geometric ring annuloplasty for bicuspid aortic valve repair during aortic aneurysm surgery. AATS 2021 [Presented May 1, 2021; in press].

Regulations

Important: This website uses cookies. More >>

The cookies allow us to identify your computer and find out details about your last visit. They remembering whether you've visited the site before, so that you remain logged in - or to help us work out how many new website visitors we get each month. Most internet browsers accept cookies automatically, but you can change the settings of your browser to erase cookies or prevent automatic acceptance if you prefer.

By VM Media Sp. z o.o. VM Group Sp.k., ul. Świętokrzyska 73 , 80–180 Gdańsk, Poland

phone:+48 58 320 94 94, fax:+48 58 320 94 60, e-mail: viamedica@viamedica.pl