Short- and long-term outcomes of david versus bentall procedures in acute type a aortic dissection: a meta-analysis with reconstructed individual patient data for time-to-event analysis.

BACKGROUND

Acute Type A Aortic Dissection (ATAAD) involving the aortic root is managed with either the Bentall or valve-sparing David procedure, but the optimal approach remains debated. Prior meta-analyses are limited by outdated cohorts, indirect comparisons, and high heterogeneity. We conducted an updated meta-analysis of recent studies (2020–2025) comparing David and Bentall procedures, incorporating reconstructed individual patient data to assess long-term survival.

METHODS

A systematic search identified studies directly comparing the David and Bentall procedures in ATAAD. Statistical analyses were performed using RevMan 8.13.0, reporting odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI), and heterogeneity assess via I² statistic. Time-to-event data were reconstructed from Kaplan–Meier curves using digitisation and the IPDfromKM algorithm, with pooled hazard ratios calculated using a Cox frailty model.

RESULTS

Seven studies comprising 1,666 patients were included, of whom 432 (25.9%) underwent the David procedure. Compared to the Bentall procedure, the David technique was associated with significantly lower odds of mortality [OR 0.47; 95% CI 0.31–0.71; p = 0.004], shorter hospital stay [MD − 3.81 days; 95% CI − 6.80 to − 0.82; p = 0.03], reduced blood loss [MD − 33.45 mL; 95% CI − 65.24 to − 1.65; p = 0.05] and lower odds of atrial fibrillation [OR 0.42; 95% CI 0.27–0.64; p = 0.02], acute kidney injury (AKI) [OR 0.50; 95% CI 0.32–0.79; p = 0.003], and prolonged mechanical ventilation [OR 0.60; 95% CI 0.49–0.75; p = 0.02]; all with I² = 0%. Long-term analysis showed a 62% reduction in mortality risk with David [HR 0.38; 95% CI 0.28 to 0.52; p < 0.001], with consistently lower 10-year mortality on reconstructed Kaplan–Meier curves.

CONCLUSION

The David procedure demonstrated favourable outcomes compared to the Bentall procedure in ATAAD patients, including significantly lower mortality, shorter hospital stays, and reduced incidence of AKI, AF, prolonged ventilation, and long-term survival. These findings suggest the David technique as a safe, effective, and durable alternative to the Bentall procedure. However, the potential for selection bias remains considerable, as the David procedure is often reserved for younger, haemodynamically stable patients with favourable anatomy.