Extensive aortic surgery in acute aortic dissection type A on outcome – insights from 25 years single center experience

Abstract

BackgroundThis single center study compares the different surgical techniques used in the treatment of acute aortic dissection type A (AADA) analyzing the influence of the extent of the surgical approach on outcome.MethodsFrom 1988 to 2012, 407 patients were operated for AADA. The cohort was divided into subgroups according to the surgical approach. These groups were compared with the supracommissural replacement group (SCR; n = 141). Groups included aortic valve sparing techniques (AVS; n = 29), Composite replacement (COMP; n = 119), COMP with total arch replacement (COMP+TAR; n = 27) and SCR with TAR (n = 75).ResultsCompared to SCR alone, operation (p = 0.005), bypass-, cross-clamp and circulatory arrest times were longer in SCR + TAR (all p < 0.001). Moreover, operation, bypass and cross clamp times were longer in COMP+TAR (p = 0.003, p = 0.002 and p < 0.001 respectively). COMP alone and AVS required longer cross-clamp time, too (p < 0,001 and p = 0.002, respectively). Overall 30-day mortality was 21% with the observed lowest rate after AVS (14%, SCR 18%, COMP 25%) but differences in 30-day mortality were not statistically significant. The estimated 10-year survival was 42%, especially AVS demonstrated a good 10-year survival (69%). David technique was superior to Yacoub technique concerning incidence of redo interventions (p = 0.036). Risk factors for early mortality included age, circulatory arrest, general malperfusion, bypass and operation time. Circulatory arrest per se was revealed as risk factor for long-term survival.ConclusionsWithin our single center retrospective study concomitant aortic root repair or aortic arch replacement for AADA demonstrated acceptable early and long-term survival. Circulatory arrest, long bypass and operation times per se might be important risk factors for early mortality. AVS techniques can be performed safely and have good outcomes in acute aortic dissection repair.

The Impact of Age in Acute Type A Aortic Dissection: a Retrospective Study

“…Compared to the patients older than 70 years, the surgical strategies are totally different. More extensive surgical methods are applied for younger patients in order to avoid re-intervention because of aortic events [19][20][21][22][23]. Our study demonstrated that the recurrence rate of aTAAD was signi cantly lower in younger patients between 30 to 50 years old.…”

Acute type A aortic dissection and the consequences of a patent false lumen

“…Earlier reports have reported 10-year survival in all-comers ranging from 42% to 68%. 29 , 30 , 31 , 32 However, the recently reported Nordic Consortium for Acute Type A Aortic Dissection registry revealed medium-term survival at 5 and 8 years of 86% and 76%, respectively. 33 One of the contributing factors to long-term mortality after ATAAD repair remains a patent FL and lack of adequate surveillance and follow-up in patients who would otherwise require a surgical reintervention for aortic growth.…”

“… 22 , 27 , 28 Secondary aortic reoperation occurs in 25% to 50% of patients, with increasing hazard over time. 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 The cumulative risk of reintervention has a significant impact on long-term mortality and morbidity, with additional intervention requiring a redo sternotomy or left thoracotomy. Interestingly, in patients undergoing an aortic reintervention, the FL was patent in 92% to 96% of cases, reinforcing the importance of sealing the FL at the initial life-saving operation.…”

Valve sparing root replacement with the reimplantation technique in patients presenting with acute type A aortic dissections

“…A graft-to-graft anastomosis is then performed to create an ascending aortic length of 5-6 cm without distortion of the root which might adversely affect valve competence or coronary perfusion (Figure 4). well as a unique set of complex surgical challenges (8,9).…”