Background The decision to conserve or replace the native aortic valve following acute type-A aortic dissection (ATAAD) is an area of cardiac surgery without standardised practice. This single centre retrospective study analysed the long-term performance of the native aortic valve and root following surgery for ATAAD. Methods Between 2009 and 2018 all cases ATAAD treated at Royal Brompton and Harefield NHS Foundation Trust were analysed. Patients were divided into 2 groups: a) ascending aorta (interposition) graft (AAG) without valve replacement; and b) non-valve-sparing aortic root replacement (ARR). Pre-operative covariates were compared, as well as operative characteristics and post-operative complications. Long-term survival and echocardiographic outcomes were analysed using regression analysis. Results In total, 116 patients were included: 63 patients in the AAG group and 53 patients in the ARR group. In patients where the native aortic valve was conserved, 9 developed severe aortic regurgitation and 2 patients developed dilation of the aortic root requiring subsequent replacement during the follow-up period. Aortic regurgitation at presentation was not found to be associated with subsequent risk of developing severe aortic regurgitation or reintervention on the aortic valve. Overall mortality was observed to be significantly lower in patients undergoing AAG (17.5% vs. 41.5%, p=0.004). Conclusions With careful patient selection, the native aortic root shows good long-term durability both in terms of valve competence and stable root dimensions after surgery for ATAAD. This study supports the consideration of conservation of the aortic valve during emergency surgery for type-A dissection, in the absence of a definitive indication for root replacement, including in cases where aortic regurgitation complicates the presentation.

Objectives: We sought to assess the safety of training in cardiothoracic surgery comparing outcomes of cases performed by trainees versus fully trained surgeons. Methods: EmBase, Scopus, PubMed, and OVID MEDLINE were searched in August 2021 independently by two authors. A third author arbitrated decisions to resolve disagreements. Inclusion criteria were articles on cardiothoracic surgery reporting on outcomes for trainees. Studies were assessed for appropriateness as per CBEM criteria. 892 results were obtained, 27 represented best evidence (2-Meta-analyses, 1-RCT and 24 retrospective cohort studies). Results: 474,160 operative outcomes were assessed for 434,535 CABG (431,329 on-pump vs 3206 off-pump), 3090 AVR, 1740 MVR/repair, 26,433 mixed, 3565 congenital and 4797 thoracic procedures. 398,058 cases were performed by trainees and 75,943 by consultants. 159 cases were indeterminate. There were no statistically significant differences in the patients’ pre-operative risk scores. All studies excluded extreme high-risk patients in emergency setting, patients with poor left ventricular function and re-operation cases that were undertaken by consultants. There were no differences in CPB and clamp times for CABG. Times for valve replacement and repair cases were longer for trainees. There were no differences in the post-operative outcomes including peri-operative myocardial infarction, resternotomy for bleeding, stroke, renal failure, ITU length of stay and total length of stay. One study reported no differences on angiographic graft patency at 1 year. There were no differences in in-hospital or mid-term mortality out to five-years. Discussion: Trainees can perform cardiothoracic surgery in dedicated high-volume units with outcomes comparable to those of fully trained surgeons.