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

Abstract

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.

Regional Practice Patterns and Outcomes of Surgery for Acute Type A Aortic Dissection

“…It is clear that at least some of the impact on improving survival is related to these factors (18, 19). The overall operative mortality rate of 18.9% in this cohort, is consistent with the current literature (6–9, 16–18, 20–22). Mody et al demonstrated significant improvement in 30-day mortality for Medicare patients from 30.7% in 2000 to 21.4% in 2011, similar to an IRAD analysis where in-hospital mortality decreased from 25.0% in an era starting in 1996 to 18.4% currently (7, 8).…”

“…The current literature is replete with contemporary outcomes from high volume hospitals or consortiums of aortic centers reporting improving outcomes with mortalities of 5–19% (3–5, 7, 9, 16, 17). These analyses suffer from the simple fact that their aortic teams, high volume aortic surgeons, and surgical and intensive care infrastructure may not be representative of the resources available to a majority of patients suffering TAAD.…”

“…However, there is some evidence that this may not translate into increased operative risk (16, 22, 24, 26–28). After risk-adjustment neither root nor arch operations independently increased risk of major morbidity or mortality in this cohort.…”

Acute Type A Aortic Dissection: Managing More Than Just the Entry-Tear

“…(Table 2). 10,12 In addition, when freedom from distal aortic reintervention was evaluated in these studies, extended or total arch aortic repair was not consistently shown to be better than the conventional limited repair group. 8,13,14 Initial Hybrid Aortic Repair…”

“…Aortic valve repair is necessary in over 50% of patients and is combined with proximal repair. 10 Aortic valve repair is beyond the scope of this review and will not be further discussed here. Early mortality rates for all proximal aortic repairs have continued to improve with reported rates from 4.4% to 9.9% at experienced sites and overall 1-year survival of more than 82%.…”