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Ryan R. Davies
Divakar Mandapati
Donald M. Botta
John A. Elefteriades
Michael A. Coady
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Ann Thorac Surg 2007;83:1593-1602
© 2007 The Society of Thoracic Surgeons

Thoracic Surgery Directors Association Award

What Is the Optimal Management of Late-Presenting Survivors of Acute Type A Aortic Dissection?

Ryan R. Davies, MDa, Marcus P. Coe, BAb, Divakar Mandapati, MDc, Amy Gallo, MDd, Donald M. Botta, MDb, John A. Elefteriades, MDb, Michael A. Coady, MD, MPHc,*

a Department of Surgery, Columbia University College of Physicians and Surgeons, New York, New York
b Section of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut
c Department of Surgery, Landmark Medical Center/Beth Israel Deaconess Medical Center, Woonsocket, Rhode Island
d Stanford University Medical Center, Stanford, California

Accepted for publication December 11, 2006.

* Address correspondence to Dr Coady, Cardiac Surgery, Landmark Medical Center, 206 Cass Ave, Woonsocket, RI 02895 (Email: macoady{at}gmail.com).

Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.

Background: Although type A aortic dissections represent a surgical emergency, some patients present late after the onset of symptoms. Optimal management of this cohort has not been defined.

Methods: Data on 195 patients with type A dissections followed up at a single institution between 1985 and 2005 were collected prospectively. Of these, 93 patients (47.2%) presented 48 hours or later after the initial onset of pain (group A), and the remaining 102 patients underwent immediate operative repair (group B). Median follow-up was 41.8 months (range, 0 to 386 months).

Results: Patients in group A were older (68.8 versus 59.3 years, p = 0.0005) and had a higher incidence of coronary artery disease (42.5% versus 14.6%, p < 0.0001), pulmonary disease (26.6% versus 8.4%, p = 0.0023), and congestive heart failure (14.1% versus 1.0%, p = 0.0004). Long-term survival was similar, although group B showed a trend toward improved 30-day mortality (16.5% versus 8.7%, p = 0.1035). Of the 92 patients in group A, 53 (57.6%) eventually underwent operative repair a median of 8.2 days after symptom onset. There was a trend toward improved long-term survival among patients undergoing repair (p = 0.1031).

Conclusions: Initial medical management with interval operative repair of selected patients referred greater than 2 days following an acute type A dissection is a viable option. Delayed repair after optimization of the clinical condition and detailed evaluation of concomitant diseases results in excellent long-term results.






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