The Tirone David procedure in acute type of aortic dissection – when, how, and why? The experience of Professor Dr. George I.M. Georgescu Institute of Cardiovascular Diseases

Abstract

Introduction. Acute type A aortic dissection represents a life-threatening cardiovascular emergency with catastrophic natural history and extremely high mortality in the absence of prompt surgical intervention. Over the last decades, surgical management has evolved from supracoronary replacement and composite root replacement (Bentall procedure) towards valve-sparing strategies, among which the Tirone David reimplantation procedure has gained increasing acceptance. Material and methods. We performed a single-center, retrospective observational study at the Professor Dr. George I.M. Georgescu Institute of Cardiovascular Diseases, Iasi, Romania, reviewing all patients undergoing surgery for acute type A aortic dissection over a 25-year period (January 2000 – January 2025). According to intraoperative anatomy and hemodynamic status, patients were treated with one of the following strategies: supracoronary ascending aortic replacement (with or without valve replacement), composite root replacement (Bentall), or valve-sparing aortic root replacement (Tirone David). Results. A total of 256 patients were operated for acute type A aortic dissection. Mean age was 55.8 years, with male predominance (69%). Hypertension was the most frequent risk factor (75%), and severe aortic regurgitation was present in 48% of cases. Valve-sparing root replacement was performed in 73% of patients (84% in the last 4 years), of which 16% were Tirone David procedures. Operative mortality was 13.7%, with a favorable downward trend over time. The most common complications were acute renal failure (21.5%, with hemodialysis in 16.8%), atrial fibrillation (18%), infectious complications (14-17%), neurological events (9.9%), and re-exploration for bleeding (11.3%). Median ICU stay was 9.8 days, and median hospital stay 17 days. Conclusions. In carefully selected patients with repairable cusps and reconstructable aortic root, the Tirone David procedure is our operation of choice, providing preservation of physiological hemodynamics and avoidance of lifelong anticoagulation. The Bentall operation remains indicated for irreparable valves, severely fragile tissue, or critical hemodynamic instability, where procedural simplicity and predictability are paramount. Our institutional experience demonstrates that the Tirone David procedure is feasible and safe in the acute setting, with encouraging early outcomes and a trend toward improved survival.