Effects of a protocol-based management of type A aortic dissections

Background: Type A aortic dissection (TAAD) is a complex cardiovascular disease that is associated with high perioperative morbidity and mortality. The most effective approach is still being debated-such as the best cannulation technique, and conservative versus extensive initial surgery. We reviewed our experience over the last 20 years and examined for variables that correlated with observed outcomes.Methods: All patients who underwent TAAD repair were reviewed. Chi-Square tests, Fisher Exact tests and Wilcoxon tests were performed where appropriate. Survival and freedom from reoperations were analyzed with the Kaplan-Meier actuarial method.Results: Acute TAAD was associated with a higher incidence of permanent stroke (P=0.010), renal failure (P=0.025), prolonged mechanical ventilator support (P=0.004), higher operative mortality (P=0.039) and higher 30-day mortality (P=0.003) compared to chronic TAAD. There was a trend towards higher risk for transient neurologic events among patients who were reoperated on (P=0.057). Extensive proximal repair led to longer perfusion and cross clamp times (P<0.001) and the need for temporary mechanical support postoperatively (P=0.011). More patients that had extensive distal repair underwent circulatory arrest (P=0.009) with no significant differences in the incidence of peri-operative complications, early, middle and long-term survival compared to the conservative management group. Overall survival in our series was 66.73% and 46.30% at 5 and 10 years respectively (median survival time: 9.38 years). There was a significant improvement in operative mortality (P=0.002) and 30-day mortality (P=0.033) in the second decade of our study.Conclusion: TAAD is a complex disease with several options for its surgical management. Each technique has its own advantages and complications and surgical management should be individualized depending on the clinical presentation. We propose our present approach to maximize benefits in both the short and long term.

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Surgical management and outcomes of type A dissection—the Mayo Clinic experience

Cabasa¹,

Pochettino²

2016

“…Although regional networks for the rapid triage and transfer of ST-segment elevation myocardial infarction (STEMI) (7,8) and trauma patients to specialized centers are well established, ATAAD patients are less amenable to centralization than other emergent/unstable patients due to the inability to diagnose ATAAD in the prehospital setting and the exceedingly small number of high-volume aortic dissection centers in the United States (4)(5)(6). Nonetheless, centralization of acute aortic dissection (AAD) care is an emerging focus of national quality improvement in cardiovascular medicine and likely offers the single best opportunity to improve outcomes from this challenging disease (9)(10)(11)(12)(13)(14)(15)(16), aside from prevention (17)(18)(19).…”

Section: Introductionmentioning

confidence: 99%

The utility of the aortic dissection team: outcomes and insights after a decade of experience

Andersen¹,

Benrashid²,

Ross³

et al. 2016

Background: Mortality rates following acute type A aortic dissection (ATAAD) repair are reduced when operations are performed by a high-volume acute aortic dissection (AAD) team, leading to efforts to centralize ATAAD care. Here, we describe our experience with ATAAD repair by our AAD team over the last 10 years, with a focus on patient selection, transfer protocols, operative approach, and volume trends over time.Methods: An AAD team was implemented at our institution in 2005, with dedicated high-volume AAD surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. Further process improvements were made in 2013 to facilitate the rapid transfer of ATAAD patients to our institution using stream-lined triage, diagnostic, and transfer protocols for patients with suspected ATAAD (RACE-AD protocol). Volume trends and outcomes were assessed longitudinally over this period. in-hospital mortality rates of less than 10% were maintained over the study period.Conclusions: Centralization of ATAAD care has begun to occur at our center, with maintenance of low mortality rates for ATAAD repair. These data confirm a net positive impact on regional ATAAD outcomes through transfer of patients to a high-volume center with dedicated AAD surgeons.

“…Overall operative mortality reported by North American centers varies from 5% to 17% (13)(14)(15)(16)(17)(18)(19)(20)(21)(22)(23) and may improve after protocol-based management is implemented and a thoracic aortic team is assembled (30,34). Mortality associated specifically with iatrogenic acute type A dissection has been recently reported as 27% after open surgical repair and up to 33-50% after TEVAR (6)(7)(8).…”

Section: Treatmentmentioning

confidence: 99%

“…These high mortality rates may be explained by the superimposed, complex, or extensive dissection that characterizes iatrogenic cases; advanced patient age; or the need to revise the original cardiac procedure in addition to repairing the iatrogenic ascending dissection. The surgical mortality rate for acute type A aortic dissection in patients with hemodynamic instability varies from 25.3% to 47% (34,35). Outcome data from North American cardiac surgery centers are shown in Table 2.…”

Section: Treatmentmentioning

confidence: 99%

Differential aspects of ascending thoracic aortic dissection and its treatment: the North American experience

Preventza

Coselli²

2016