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Ann Thorac Surg 2003;76:1209-1214
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Is extended arch replacement for acute Type A aortic dissection an additional risk factor for mortality?

^a Departments of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
^b Cardiology Research and Statistical Analysis, St. Antonius Hospital, Nieuwegein, The Netherlands
^c Clinical Perfusion, St. Antonius Hospital, Nieuwegein, The Netherlands

Accepted for publication April 18, 2003.

^* Address reprint requests to Dr Tan, St. Antonius Hospital, Department of Cardiothoracic Surgery, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands.
e-mail: erwin.tan{at}tiscali.nl

BACKGROUND: We report our experience with surgery for acute type A aortic dissection with involvement of the aortic arch.

METHODS: From January 1986 to December 2001, 277 patients underwent surgery for acute type A aortic dissection. In 70 patients (25.3%), surgery was extended into the aortic arch: hemiarch and total arch replacement in 53 (75.7%) and 17 (24.3%) patients, respectively. Deep hypothermic circulatory arrest was used in 19 patients, antegrade selective cerebral perfusion in 38, and combined deep hypothermic circulatory arrest with antegrade selective cerebral perfusion in 13.

RESULTS: Operative mortality was 18.6% (13/70) after extended replacement into the arch versus 21.7% (45/207) after surgery limited to the ascending aorta (p = 0.62). Multivariate analysis did not reveal significant risk factors for operative mortality. Postoperatively, 5 patients (8.1%) had a new postoperative cerebral vascular accident (CVA).Multivariate analysis showed an earlier date of operation as the only independant determinant for a new postoperative CVA (p = 0.0162, RR = 0.80/year, 95% CI = 0.67 to 0.96). None of the patients, operated on with antegrade selective cerebral perfusion, had a new cerebral deficit. Comparing the different methods of cerebral protection, multivariate risk analysis revealed antegrade selective cerebral perfusion as a significant protective factor against new postoperative CVA (p = 0.0110, OR = 0.12, 95% CI = 0.02 to 0.61). Survival at 5 and 10 years was 66.6.5% and 40.0%, respectively, after replacement of the aortic arch versus 68.7% and 57.7%, respectively, after replacement of the ascending aorta (p = 0.96). Freedom from aortic arch reoperation was 96.3% at 5 and 77.0% at 10 years versus 86.6% and 75.1% in both groups, respectively (p = 0.21).

CONCLUSIONS: Extended replacement into the aortic arch during surgery for acute type A dissection does not influence early and late results. The best cerebral protection seems to be obtained with antegrade selective cerebral perfusion.

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