Aortic root surgery improves long-term survival after acute type A aortic dissection

https://doi.org/10.1016/j.ijcard.2015.02.020Get rights and content

Abstract

Objective

Our objective was to analyze the long term survival of patient operated on for acute type A aortic dissection.

Methods

Between 1990 and 2010, 226 patients underwent emergency surgical operation for acute type A aortic dissection. We have followed the long-term outcomes.

Results

144 patients were operated on with a supracommissural replacement of the ascending aorta (SCR) and 82 with an aortic root surgery (ARS, including 77 Bentall procedures and 5 Tirone David operations). Aortic cross-clamp was longer in ARS group (150.8 vs. 103.6 min, p < 0.0001). Overall in-hospital mortality was lower in ARS group (20% vs. 34%, p 0.03). Median follow-up was 11.6 years. 10-year survival was higher in ARS group (85.7% vs. 65.9%, p 0.03) and 10-year freedom from aortic root reoperation was significantly lower in ARS group (93.4% vs. 82.9%, p 0.02). In a multivariate analysis aortic root surgery was an independent protective factor for proximal reoperations OR 0.393, CI 95% [0.206–0.748], p = 0.005.

Conclusions

Our study suggests that complete aortic root replacement in type A aortic dissection does not burden short-term outcomes, improves long-term survivals and decreases the rate of late reoperation. Whether this approach has to be preferred in younger patient has to be demonstrated in further studies.

Introduction

Surgical management of acute type A aortic dissection remains challenging. Perioperative results have been widely reported yet there is no full consensus in the literature regarding the choice of proximal repair surgical technique and it still may remain a decision made on surgeon's discretion or center's tradition. On one hand, the supracommissural replacement allows the preservation of the native aortic valve without an anticoagulant treatment, but on the other hand, the complete root replacement, a more demanding operation, may reduce later high risk proximal reoperations [1], [2], [3]. Whether a long term result might be influenced by perioperative proximal management has not yet been demonstrated.

Aims of the present study were to evaluate early and late outcomes of a consecutive cohort of patient operated on in our center on an emergency basis for an acute type A dissection. The primary endpoint was to determine whether perioperative proximal surgical strategy had improved late survival. The second endpoint was to evaluate the late mortality and the reoperations' rate. A composite endpoint so called event-free survival was made with the probability to be free from late death and proximal reoperation.

Section snippets

Population

This was a retrospective study of 226 consecutive patients operated on, in an emergency basis, for acute type A aortic dissection between January 1990 and December 2010. The whole cohort of patients had a mean age of 59.2 (± 19.9) years and there was mostly male (66%). Patients were operated according two surgical strategies: supracommissural replacement (SCR n = 144 patients); or aortic root surgery with or without aortic valve replacement (ARS n = 82 patients, 77 Bentall and 5 Tirone David). The

Results

Table 1 resumes preoperative characteristics among the two groups. The proximal intimal tear of the aortic dissection was more frequently found in the ascending aorta in the ARS group (93% vs. 80%, p 0.006). Also, in the ARS group, coronary bypasses at the end of the CPB were more frequent (9% vs. 1%, p = 0.007). This was related to the dissecting process in all cases (dissection of the coronary ostium or artery). Table 2 illustrates the perioperative data between the groups.

Overall in-hospital

Comment

Simon Kupilik et al. [5] showed in vitro and in vivo that the supracommissural replacement of the aorta by a vascular prosthesis induced significant hemodynamic changes at the level of the aortic root by increasing parietal tension as a result of the rigidity of the adjacent vascular prosthesis. Ergin et al. [6] first proposed the complete replacement of the aortic root for acute type A aortic dissection as a surgical technique potentially reducing long-term reoperations. We have summarized in

Funding

None.

Conflicts of interest

None to declare.

Cited by (23)

  • The Aortic Root in Acute Type A Dissection: Repair or Replace?

    2023, Annals of Thoracic Surgery
    Citation Excerpt :

    Despite the implemented extension in surgical strategy, inevitably resulting in longer operation time and procedure complexity, we observed no detrimental effect on the rate of postoperative complications. Our findings are comparable to those of earlier reports and support the safety of a more extensive surgical strategy in ATAAD.9,10 Early mortality in our study was comparable to data from the International Registry of Acute Aortic Dissection database, reporting early mortality rates of 16% to 27%.11

  • Patch Neointima Technique in Acute Type A Aortic Dissection: Midterm Results of 147 Cases

    2021, Annals of Thoracic Surgery
    Citation Excerpt :

    Traditionally, patients less than 55 years of age who undergo aortic root replacement receive a mechanical valve and have the accompanying burden of lifelong anticoagulation therapy in the Bentall procedure. In aortic dissection patients, anticoagulation therapy may prevent false lumen thrombosis in downstream residually dissected aorta in addition to hemorrhagic and thromboembolic risks.7,14 In addition, if the bioprosthetic valve is used, its deterioration is always a great concern for surgeons, especially in young patients.15

View all citing articles on Scopus

“All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation”.

View full text