Aortic root surgery improves long-term survival after acute type A aortic dissection☆
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.
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Cited by (23)
2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines
2023, Journal of Thoracic and Cardiovascular SurgeryThe Aortic Root in Acute Type A Dissection: Repair or Replace?
2023, Annals of Thoracic SurgeryCitation 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
Outcomes of Reoperative Aortic Root Replacement After Previous Acute Type A Dissection Repair
2023, Seminars in Thoracic and Cardiovascular Surgery2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines
2022, Journal of the American College of Cardiology2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection
2021, Journal of Thoracic and Cardiovascular SurgeryPatch Neointima Technique in Acute Type A Aortic Dissection: Midterm Results of 147 Cases
2021, Annals of Thoracic SurgeryCitation 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
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“All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation”.