New Paradigms and Improved Results for the Surgical Treatment of Acute Type A Dissection

Abstract

ObjectiveTo examine the effect of an integrated surgical approach to the treatment of acute type A dissections. Summary Background DataAcute type A dissection requires surgery to prevent death from proximal aortic rupture or malperfusion. Most series of the past decade have reported a death rate in the range of 15% to 30%. MethodsFrom January 1994 to March 2001, 104 consecutive patients underwent repair of acute type A dissection. All had an integrated operative management as follows: intraoperative transesophageal echocardiography; hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP) to replace the aortic arch; HCA established after 5 minutes of electroencephalographic (EEG) silence in neuromonitored patients (66%) or after 45 minutes of cooling in patients who were not neuromonitored (34%); reinforcement of the residual arch tissue with a Teflon felt "neo-media"; cannulation of the arch graft to reestablish cardiopulmonary bypass at the completion of HCA (antegrade graft perfusion); and remodeling of the sinus of Valsalva segments with Teflon felt "neo-media" and aortic valve resuspension (78%) or replacement with a biologic or mechanical valved conduit (22%). ResultsMean age was 59 Ϯ 15 (range 22-86) years, with 71% men and 13% redo sternotomy after a previous cardiac procedure. Mean cardiopulmonary bypass time was 196 Ϯ 50 minutes. Mean HCA with RCP time was 42 Ϯ 12 minutes (range 19 -84). Mean cardiac ischemic time was 140 Ϯ 45 minutes. Eleven percent of patients presented with a preoperative neurologic deficit, and 5% developed a new cerebrovascular accident after dissection repair. The in-hospital death rate was 9%. Excluding the patients who presented neurologically unresponsive or with ongoing cardiopulmonary resuscitation (n ϭ 5), the death rate was 4%. In six patients adverse cerebral outcomes were potentially avoided when immediate surgical fenestration was prompted by a sudden change in the EEG during cooling. Forty-five percent of neuromonitored patients required greater than 30 minutes to achieve EEG silence. ConclusionThe authors have shown that the surgical integration of sinus segment repair or aortic root replacement, the use of EEG monitoring, partial or total arch replacement using RCP, routine antegrade graft perfusion, and the uniform use of transesophageal echocardiography substantially decrease the death and complication rates of acute type A dissection repair.Aortic dissection is the most common acute aortic catastrophe requiring emergent surgical therapy.1 Urgent surgical treatment of acute type A dissection is mandated because medical treatment is associated with a 60% in-hospital death rate.2 Since the first description of the successful repair of an aortic arch aneurysm by DeBakey et al 3 in 1955, numerous advances have been described in the diagnosis and management of thoracic aortic diseases. 4,5 Despite these advances, acute aortic dissection remains one of the most challenging operations to the cardiovascular surgeon. During the past decade, there have b...

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

“…It should also be acknowledged that the small sample size of our single-institution experience limits the utility of statistical comparisons of mortality rates and volume trends between time intervals. Nonetheless, we consider a 30-day/in-hospital ATAAD repair operative mortality rate of 10% or less to be the current benchmark number for high-volume aortic centers and the general target number for our program (27,(34)(35)(36)(37).…”

“…Solu-Medrol (1 gram, intravenously) is administered for pharmacologic neuroprotection to all patients preoperatively. The standard operation involves aortic valve resuspension with ascending aorta and hemiarch replacement (26,27). Aortic root replacement is performed selectively for aortic root aneurysm, intrinsic aortic valve pathology not amenable to repair, or extensive destruction of the intima of the aortic root by the dissection process.…”

Comparison between antegrade and retrograde cerebral perfusion or profound hypothermia as brain protection strategies during repair of type A aortic dissection

“…Our study found no difference in operative mortality with respect to ACP, RCP or DHCA during repair of acute type A aortic dissection. Other studies have also concluded that there is no difference in operative mortality between ACP and RCP (10,(14)(15)(16). While the method of cerebral perfusion may be a less important predictor of operative mortality, cerebral perfusion in general seems to be important for minimizing mortality.…”

“…RCP patients demonstrated a trend towards a higher rate of postoperative stroke that may be attributed to the fact that more patients in the RCP group had a history of cerebrovascular accident. Other studies have also demonstrated no difference between RCP and ACP for postoperative stroke; however, RCP tended to have more cases of transient neurological damage (4,6,12,14). The most important risk factors for stroke are circulatory arrest time over 40 minutes and prolonged CPB time (15).…”

Cerbral Protection Strategies for

“…Bavaria and colleagues demonstrated a significant improvement over previous reported series of Type A aortic dissection repairs using DHCA and RCP. In their series of 104 patients, these investigators reported a 9% mortality rate and 5% stroke rate with a mean duration of DHCA+RCP of 42 minutes in 104 consecutive patients undergoing emergent repair of Type A aortic dissection (27). In a series of 479 patients undergoing arch surgery with DHCA for aneurysmal disease or dissection, Coselli compared the results using DHCA alone vs. DHCA+RCP.…”