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Outcomes After Type A Aortic Dissection Repair
Study Questions:
What are the perioperative and long-term outcomes of aortic root repair and aortic root replacement in acute type A aortic dissection?
Methods:
From 1996 to 2017, 491 patients underwent aortic root repair (n = 307) or aortic root replacement (n = 184, 62% bioprosthesis) for acute type A aortic dissection. Indications for aortic root replacement were intimal tear at the aortic root, root measuring ≥4.5 cm, connective tissue disease, or unrepairable aortic valvulopathy. Primary outcomes were in-hospital mortality, long-term survival, and reoperation rate for root pathology.
Results:
The median patient age was 61 years in the aortic root repair group and 56 years in the aortic root replacement group. The aortic root replacement group had higher rates of preoperative renal failure requiring dialysis, previous cardiac intervention or surgery, heart failure, coronary malperfusion syndrome, acute myocardial infarction, and severe aortic insufficiency; and higher rates of concomitant coronary artery bypass grafting, tricuspid valve repair, and longer cardiopulmonary bypass and aortic cross-clamp times; but similar arch procedures. Perioperative outcomes were similar in the aortic root repair and aortic root replacement groups, including in-hospital mortality (8.5% and 8.2%), new-onset renal failure requiring permanent dialysis, stroke, myocardial infarction, and sepsis. Kaplan-Meier 10-year survival was 62% and 65%, and the 15-year cumulative incidence of reoperation was 11% and 7% in the aortic root repair and aortic root replacement groups, respectively. The primary indication for root reoperation was aortic root aneurysm in the aortic root repair group and bioprosthetic valve deterioration in the aortic root replacement group.
Conclusions:
Aortic root repair and aortic root replacement are appropriate surgical options for acute type A aortic dissection repair, with favorable short- and long-term outcomes. The authors concluded that aortic root replacement should be performed for patients with acute type A aortic dissection presenting with an intimal tear at the aortic root, root aneurysm ≥4.5 cm, connective tissue disease, or unrepairable aortic valvulopathy.
Perspective:
This large, long-term, single-center experience describes the short- and long-term outcomes following aortic root repair or aortic root replacement among 491 patients presenting with acute type A dissection. Based on the practice of the authors, they recommend the use of aortic root replacement in specific scenarios of aortic root intimal tear (the intimal flap extending into the sinuses of Valsalva), underlying connective tissue disease (with a high risk of subsequent aneurysm development), aortic root diameter ≥4.5 cm (with the risk of aneurysm progression), or unrepairable aortic valve pathology (at least moderate aortic stenosis or regurgitation and an unrepairable valve); and otherwise the use of aortic root repair. These results reinforce the role of large-volume reference centers for the management of patients who require complex and high-risk interventions.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Vascular Medicine, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Structural Heart Disease, Interventions and Vascular Medicine
Keywords: Aneurysm, Dissecting, Aortic Valve Stenosis, Bioprosthesis, Cardiac Surgical Procedures, Cardiopulmonary Bypass, Connective Tissue Diseases, Coronary Artery Bypass, Heart Failure, Heart Valve Diseases, Hospital Mortality, Myocardial Infarction, Renal Dialysis, Renal Insufficiency, Sepsis, Stroke, Tricuspid Valve, Vascular Diseases
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