Does the extent of proximal or distal resection influence outcome for type A dissections?

doi:10.1016/S0003-4975(00)02610-2

The Annals of Thoracic Surgery

Volume 71, Issue 4, April 2001, Pages 1244-1249

https://doi.org/10.1016/S0003-4975(00)02610-2 Get rights and content

Abstract

Background. The extent of proximal and distal aortic resection that should be performed for acute type A aortic dissections remains controversial.

Methods. From 1984 to 1999, 119 patients underwent repair of an acute type A dissection. Distal resection was to the ascending aorta in 78 (66%) and hemiarch in 41 (34%) patients. Proximally, the aortic valve was preserved in 69 (58%) patients, 40 (34%) underwent composite valve grafting, and 10 (8%) underwent separate graft and valve replacement.

Results. Operative mortality was higher for separate graft and valve (50% ± 16%) than for valve preservation (16% ± 5%) or composite grafts (20% ± 7%) (p < 0.05). Hemiarch replacement did not increase operative risk compared to distal reconstruction to the ascending aorta (17% ± 6% versus 22% ± 5%, p > 0.71). At 10 years, freedom from reoperation was 81% ± 7% and long-term survival was 60% ± 8%, but neither was related to the proximal or distal surgical technique (p > 0.15). Risk factors for late reoperation included a nonresected primary tear and Marfan syndrome (p < 0.05).

Conclusions. An aggressive surgical approach, including a full root or hemiarch replacement, is not associated with increased operative risk and should be considered when type A dissections extensively involve the valve, sinuses, or arch.

Section snippets

Material and methods

This retrospective review includes 119 consecutive patients who underwent surgical repair of an acute type A aortic dissection at Washington University Medical Center (Barnes-Jewish Hospital) from June 1984 through December 1999 by 18 different surgeons (see Appendix). Patients were contacted for follow-up by telephone during a 3-month closing interval ending February 2000. Cumulative long-term follow-up totaled 454 patient-years, and was 98% complete. There were 69 (58%) men and 50 (42%)

Operative morbidity

Reexploration for bleeding was necessary in 16 (13% ± 3%) patients, but was not influenced by either the proximal (p > 0.90) or distal (p > 0.56) surgical technique. Multivariate regression analysis identified three factors to be independent predictors for reexploration for bleeding: 1) nonresected primary tear (p < 0.004); 2) preoperative malperfusion syndrome (p < 0.02); and 3) Marfan syndrome (p < 0.02). Neurologic complications (including delirium or coma beyond 24 hours) were common,

Proximal surgical technique: aortic valve preservation or replacement?

Historically, some surgeons have felt that there was increased risk with radical root replacement, such that conservative root repair or separate GV replacement was preferred for acute dissections, however, recent reports have not found this to be the case. Lytle, Sabik, and colleagues 1, 2 from the Cleveland Clinic reported similar mortality rates with CVG (22% ± 8%), separate GV replacement (20% ± 13%), and root reconstruction (13% ± 4%) (p > 0.30). The Mount Sinai group reported good results

References (17)

B.W Lytle et al.
Replacement of the ascending aorta. Early and late results
J Thorac Cardiovasc Surg
(1990)
A.C Galloway et al.
Surgical repair of type A aortic dissection by the circulatory arrest-graft inclusion technique in sixty-six patients
J Thorac Cardiovasc Surg
(1993)
J.E Bachet et al.
Aortic dissection. Prevalence, cause, and results of late reoperations
J Thorac Cardiovasc Surg
(1994)
L.K von Segesser et al.
Aortic valve preservation in acute type A dissection. Is it sound?
J Thorac Cardiovasc Surg
(1996)
T.M Sundt et al.
Options for repair of a bicuspid aortic valve and ascending aortic aneurysm
Ann Thorac Surg
(2000)
J.I Fann et al.
Preservation of aortic valve in type A aortic dissection complicated by aortic regurgitation
J Thorac Cardiovasc Surg
(1991)
R Pessotto et al.
Preservation of the aortic valve in acute type A dissection complicated by aortic regurgitation
Ann Thorac Surg
(1999)
J.P Mazzucotelli et al.
Preservation of the aortic valve in acute aortic dissection. Long-term echocardiographic assessment and clinical outcome
Ann Thorac Surg
(1993)

There are more references available in the full text version of this article.

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Original article: cardiovascularDoes the extent of proximal or distal resection influence outcome for type A dissections?

Abstract

Section snippets

Material and methods

Operative morbidity

Proximal surgical technique: aortic valve preservation or replacement?

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Original article: cardiovascular
Does the extent of proximal or distal resection influence outcome for type A dissections?