Type A Aortic Dissection After Nonaortic Cardiac Surgery

Abstract

A cute type A aortic dissections (AADs) are life-threatening conditions that are conventionally treated with emergency operations. Population-based studies suggest an incidence of ≈20 to 30 cases per million people per year which roughly translates to an estimated >6000 new AAD cases annually in the United States and >14 000 in Europe. [1][2][3][4][5] The clinical presentation, natural history, management, and outcome of spontaneous AADs are well described.2,5-7 Despite improvements in imaging, surgical techniques, and management, the overall in-hospital mortality of patients with spontaneous acute AAD remains high with a range of 15% to 32%, 7-10 with early death resulting mainly from rupture and tamponade. Editorial see p 1593 Clinical Perspective on p 1611AAD can complicate routine cardiac surgery unexpectedly at any time, either intraoperatively and early or late afterward, suddenly converting a low-risk elective procedure into a highrisk situation with excessive operative mortality.11,12 Previous reports suggest that AAD occurs in 0.12% to 0.16% of patients Background-Cardiac surgery with cardiopulmonary bypass is associated with mechanical manipulation of the ascending aorta that occasionally leads to type A aortic dissection (AAD). Methods and Results-One hundred three patients with surgical repair for AAD following nonaortic cardiac surgery were identified. With the use of logistic regression modeling, coronary artery bypass surgery (CABG), either isolated or combined with another procedure in the initial operation, was associated with significantly higher operative mortality in comparison with patients with non-CABG procedures at the time of AAD repair both for all patients (odds ratio, 2.90; 95% confidence interval, 1.09-7.72; P=0.033) and for patients with acute and chronic AAD ≥30 days after the initial operation (odds ratio, 3.62; 95% confidence interval, 1.13-11.54; P=0.03). In patients who developed AAD late after the initial operation, operative mortality was highest in patients without preoperative coronary angiography and appropriate management of their native coronary artery disease and graft disease (odds ratio, 5.36; 95% confidence interval, 1.68-17.0; P=0.002). Nearly all the intimal dissection tears were located at sites of previous surgical trauma. Most of the ascending aortas that had dissected initially had a diameter ≥40 mm with histological evidence of medial degeneration in resected tissue samples. Conclusions-In patients who have undergone previous cardiac surgery, preexisting aortic wall pathology contributes to AAD with typical intimal damage at sites of mechanical trauma. The operative mortality was the highest in patients with previous CABG in comparison with patients with non-CABG procedures. Preoperative coronary angiography and operative management of native coronary and graft disease were significantly associated with outcome in patients with previous CABG. (Circulation. 2013;128:1602-1611.)

Iatrogenic aortic dissection after minimally invasive aortic valve replacement: a case report

“…Recently, in a multicenter study by Stanger et al [5], IAAD following cardiac surgery is classified into intraoperative , early postoperative (symptoms of aortic dissection within 30 days of surgery with high risk of aortic rupture and intraoperative mortality) and late postoperative (after 30 days from cardiac surgery). They further classified late postoperative IAAD into acute (patients required intervention within 2 weeks of symptoms) and chronic (late incidental finding of dissection with no acute symptoms, candidates for elective surgery) (Table 1).…”

“…Most dissection sites mentioned in the literature after open cardiac surgery were related to aortic cannulation, aortic cross-clamping, aortotomy, vein anastomosis during CABG, the cardioplegia cannula, direct aortic injury and injury related to flow of the bypass to the aortic arch or descending thoracic aorta [5, 9–12]. Reviewing the literature in 3 single center and 1 multicenter studies showed nearly the same trends in sites of IAAD over that last 35 years (Table 1) [5, 10–12].…”

Post-cardiotomy type A aortic dissection

“…Symptomatic patients are considered having late acute dissection, however late chronic dissection is a radiological incidental finding without acute symptoms. In the latest report [4], the mortality rates for intraoperative, early postoperative, late acute and chronic AAAD were 17, 42, 32 and 22%, respectively. Another important finding is the valuable effect of preoperative coronary angiography implementation to assess coronary artery and grafts status especially in patients with previous coronary artery bypass grafting surgery.…”

“…Once again, the mortality rate was high in this subset of patients at 35.5% for those diagnosed perioperatively and exceedingly high at 60% for those detected in the early postoperative period. More recently, the largest post-cardiotomy AAAD report [4] has been published with similarly high in-hospital mortality rate. Of note, the overall operative mortality observed was 27% in a cohort of 103 patients.…”

“…Therefore, for accurate comparison of data for future reporting, Stanger et al [4] advocated using the following definitions. AAAD should be categorized into four different entities depending on the time interval between the primary cardiac surgery and the diagnosis of the dissection.…”