Acute Type A Aortic Dissection Repair

Study Questions:

What are the short-term outcomes following direct aortic root and arch repair in patients with acute type A aortic dissection (ATAAD) without technical adjuncts (e.g., Teflon felt or biological glue)?

Methods:

Between 2012 and 2016, 94 consecutive patients with ATAAD underwent surgical repair, including aortic root repair (n = 45), root replacement (n = 39), or no root procedure (n = 10). Aortic root repair was achieved using a 5-0 Prolene circumferential running suture at the sinotubular junction, and reinforcing the coronary ostia. The aortic root and arch were anastomosed to the Dacron graft using 5-0 Prolene without Teflon felt or biological glue.

Results:

Postoperative new-onset myocardial infarction, stroke, renal failure, and complete heart block occurred in 0%, 4%, 13%, and 0% of patients, respectively; and 30-day mortality was 4%. The incidences of permanent neurologic deficit and renal failure were 1% and 2%, respectively. Up to 5 years, the aortic root repair group was free from residual or recurrent aortic root dissection, major change in the aortic root diameter, and moderate to severe aortic regurgitation; the entire cohort was free of anastomotic pseudoaneurysm and reoperation for proximal aortic pathology or significant change in diameter of the aortic arch and descending thoracic aorta. Overall survival was 85% at 4 years, and was significantly enhanced in the aortic root repair group compared with patients who underwent a Bentall procedure (n = 24; 93% vs. 57%, p = 0.035).

Conclusions:

Direct aortic root and arch repair with approximation of the aortic wall without use of technical adjuncts is safe and effective among patients with ATAAD. The authors concluded that, if warranted, preservation of the native aortic valve should be considered for a potential survival benefit.

Perspective:

Because the dissected aorta is extremely fragile, technical adjuncts including Teflon felt and biological glue have been widely used during surgical repair of ATAAD. However, this has been associated with pseudoaneurysm at the anastomoses, repeat dissection, and aortic root aneurysm. This relatively large single-center experience suggests that repair of the aortic root and arch in ATAAD without the use of adjuncts was associated with excellent perioperative and short-term outcomes, and stable aorta size and freedom from moderate to severe aortic regurgitation through 5 years.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Vascular Medicine, Implantable Devices, Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease, Interventions and Vascular Medicine

Keywords: Aneurysm, Dissecting, Aneurysm, False, Aorta, Thoracic, Aortic Valve Insufficiency, Cardiac Surgical Procedures, Heart Block, Myocardial Infarction, Polyethylene Terephthalates, Polypropylenes, Polytetrafluoroethylene, Renal Insufficiency, Reoperation, Stroke, Vascular Diseases


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