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Ann Thorac Surg 1998;66:779-784
© 1998 The Society of Thoracic Surgeons

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Original articles: Cardiovascular

Early and late risk factors in surgical treatment of acute type A aortic dissection

^a Department of Cardiac Surgery, University of Torino, Torino, Italy
^b Department of Cardiology, University of Torino, Torino, Italy

Accepted for publication April 6, 1998.

Address reprint requests to Dr Pansini, Via Vittorio Veneto 25, 10028 Trofarello, (TO), Italy

	Abstract

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Preoperative and... References

 
Background. Morbidity and mortality of emergency repair of type A dissecting aneurysms of the aorta are high. This is an attempt to investigate the risk determinants of early and late results.

Methods. A series of preoperative and operative variables were retrospectively collected from the clinical records of 291 patients operated on between January 1, 1979, and December 31, 1995. Risk factors for surgical death were investigated with univariate analysis and stepwise logistic regression. Follow-up was conducted between December 1995 and February 1996. Analysis of late results was conducted by means of actuarial survival curves (life method). After removing the surgical deaths, risk factors for late deaths were analyzed by a Cox model.

Results. The in-hospital mortality rate was 36.1%. Significant independent determinants of operative or early death were preoperative shock, preoperative neurologic impairment, operation before 1986, perioperative bleeding, and prolonged clamping time. The 10-year survival rate was 36.9% ± 4.4%. Twenty-six patients required repeat operation. The long-term prognosis was significantly worse in patients who needed reoperation.

Conclusions. Growing awareness of this disease and quicker diagnosis have increased the number of patients with acute dissection of the ascending aorta who are taken early to operation. This new challenge must be met by better preoperative support and intraoperative monitoring, and by surgical techniques that focus on lowering the rate of late complications, for which lifelong follow-up must be provided.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Preoperative and... References

 
Dissection of the ascending aorta is increasingly diagnosed and surgically treated in its early phase. Over the years, advances have been made in the diagnostic and surgical techniques, with a trend toward a reduction of the operating risk [1–6].

The aim of this article was to analyze our experience of the past 16 years, to identify determinants of early and late results.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Preoperative and... References

 
Patients
From 1979 to 1995, 291 patients (218 men and 73 women) with type A (Stanford classification) dissection of the aorta were operated upon as an emergency—that is, immediately after the diagnosis was made or confirmed. The delay from the onset of symptoms to the operation ranged from a few hours to 7 days; in 80% of cases the operation occurred within 48 hours. The age of the patients varied from 22 to 79 years (mean 56 ± 11 years). On admission to our hospital 129 of the patients were in very serious condition because of the presence of major complications (Table 1).

Procedures
In 240 patients (Table 2) the operation was limited to the ascending aorta (with or without aortic root replacement); in 49 patients it was deemed necessary to replace (partially or totally) or repair the aortic arch as well. In two instances a total rupture of the aorta ensued from sternotomy, with subsequent unrestrainable hemorrhage and death of the patients. In seven cases other operations were associated: five coronary artery bypass grafts, one mitral valve replacement, and one redo aortic prosthesis replacement.

In the early years, when the intimal tear could be clearly identified, we simply replaced the ascending aorta under moderate hypothermia. Otherwise, we first explored the arch under circulatory arrest and then, when indicated, we repaired or replaced the aortic arch under deep hypothermia.

Since 1985 we have always explored the aortic arch during a short circulatory arrest at a nasopharyngeal temperature of 24°C. If a lesion was found we clamped the aorta again, cooled down the patient to 18° to 20°C, and proceeded with an open aorta technique [7]. This was done not only in the 49 cases with a tear in the aortic arch, but also in 62 other patients in whom the distal suture was performed with the open aorta technique because of technical necessity or preference of the surgeon. Such an option become very frequent after 1990.

Selective carotid perfusion was sporadically employed (four cases). More recently we have adopted the technique of jugular reverse perfusion [8] in nine cases.

The replacement technique always included the interposition of a Dacron tube with Teflon strip reinforcement of the aortic stumps.

The aortic valve was examined and, if necessary, resuspended with commissural stitches. When this procedure was deemed inappropriate or inadequate because the cusps were damaged, the valve was replaced (26 cases). Aortic root replacement with composite prosthesis and reimplantation of the coronary arteries by the Bentall or Cabrol technique was performed in all cases with conspicuous dilation of the aortic root (Table 2).

Simple repair of the ascending aorta (Berger procedure) was limited to the early years of our experience: 19 cases between 1979 and 1983. Six additional patients were treated by this technique after 1983. More recently, a repair according to the Carpentier technique [9] was attempted in four cases.

The intervention was extended to the aortic arch in 49 cases. In all of those cases, the intimal tear was present or extended to the aortic arch. Repair rather than replacement of the aortic arch was chosen by the surgeon on the basis of the anatomy of lesion, surgical exposure, and estimated overall duration of the operation in case of associated procedures. Repair always consisted of Teflon suturing of the intimal tear. Since 1986 we have routinely used resorcin glue in preparing the aortic stumps and arch tears to be repaired.

Follow-up
Follow-up was conducted between December 1995 and February 1996. We either examined the patients at the outpatient clinic or interviewed them or their referring physicians by telephone. One hundred percent of answers was attained. The time interval from the operation varied between 1 and 205 months (mean, 31.7 ± 40 months).

Analysis
A series of preoperative and operative variables (Appendix 1) was retrospectively gathered from clinical records. Then, a search of early risk factors for surgical death (death within 30 days from operation or before dismissal) was done, at first with univariate analysis (parametric test). Variables that reached a p less than or equal to 0.2 in this analysis were then included into a stepwise logistic regression and analyzed as possible independent risk factors of surgical mortality.

Analysis of late results was conducted by means of the actuarial survival curves calculated following the life method. The global survival curve included surgical deaths. After removing these, a search of risk factors for late deaths was performed. A univariate analysis was done first. The curves were stratified on the basis of binary variables and were compared with the Mantel–Breslow test.

Variables that reached a p value less than 0.2 with this analysis were then included as covariates into a Cox model. We considered a p value lower than 0.05 to be significant and a p value equal to or less than 0.1 as probably significant. All data were analyzed with BMDP statistical software (BMDP, Sepulveda, CA).

	Results

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Preoperative and... References

 
In-hospital events
A total of 105 patients died within 30 days after operation or before discharge, with a mortality rate of 36% (70% confidence interval [CI], 33% to 39%). The most frequent causes of death were hemorrhage (29 patients), major neurologic damage (22 patients), and myocardial infarction and low output (28 patients). Postoperative complications were stroke in 36 patients, reoperation for bleeding in 48, and acute renal failure in 24.

Mortality was 53.3% (CI, 44% to 62%) for the 45 cases from 1979 to 1985; from 1986 to 1991 (95 patients) it was 35.8% (CI, 30% to 42%); and from 1992 to 1995 (151 patients) it was 31% (CI, 27% to 35%) (p = 0.0274).

Risk factors of early death
As shown in Table 3, signs of hemodynamic impairment, neurologic damage, hypertension, age, and year of operation were significant preoperative determinants of death by univariate analysis. Among the operative variables, a ruptured aorta and redo for bleeding were significant. This latter event has significantly decreased since 1986 (27% for 45 patients versus 15% for 247 patients; p = 0.0446). Also, the clamp time was significantly longer (97 ± 38 minutes versus 87 ± 34 minutes; p = 0.019) and bleeding more profuse (1,317 ± 1,854 versus 860 ± 683 mL; p = 0.024) in those who died, compared with the survivors. According to the logistic regression analysis (Table 4) the independent risk determinants were preoperative shock, focal preoperative neurologic damage, operation performed before 1986, clamping time longer than 70 minutes, and postoperative bleeding greater than 1,000 mL in the first 24 hours.

Overall survival
Forty-six patients died after discharge from the hospital. The probability of survival, including hospital deaths, after 1, 5, 10, and 15 years was 59.9% ± 2.9%, 45% ± 3.4%, 36.9% ± 4.4%, and 25.1% ± 7.8%, respectively (Fig 1). The causes of late deaths are listed in Table 5.

View larger version (9K): [in this window] [in a new window]   Fig 1. Overall survival after operation on acute type A dissection of the aorta.

	Comment

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Preoperative and... References

 
This is a retrospective study spanning a period of 16 years. Mortality has decreased since 1986, when we began using resorcin glue. Since then, the incidence of reopening of the chest for bleeding has significantly decreased, without ill effects. It is not certain, however, that this improvement was obtained through the use of the glue only, as other materials have improved as well and the sheer number of cases has increased (possibly through a learning curve effect). However, even in the 151 patients operated on since 1992, our mortality rate remained higher than that commonly reported in the literature [1–6]. Crawford and associates [1], who reports a surgical mortality rate of 21% in patients operated on within 14 days, remarked that "the interval between dissection and operation was shorter in those who died within 30 days of operation than in those who did not." In our series more than 80% of patients entered the operating room within 48 hours after the onset of symptoms.

Early results
The preoperative conditions [2, 10] and the extension of surgical maneuvers to the aortic arch [6, 11, 12] are reported by most surgeons as leading risk factors. Early operation, naturally desirable because of the high early mortality in the natural history of the illness, probably increases the surgical risk [1] by including a larger number of patients with severe complications who are about to die.

A major complication (ie, neurologic deficit, anuria, tamponade, shock, need for intubation) was present in 129 patients. If these patients are excluded, the mortality rate drops to 22% (70% CI, 19% to 26%).

Unstable patients would benefit from the approach suggested by Crawford and colleagues [1], who start a partial femoro-femoral cardiopulmonary bypass under local anesthesia before proceeding to induction and general anesthesia.

The type of surgical intervention did not appear to affect the early results in our experience. In particular, the separate technique (aortic valve replacement plus ascending aorta replacement) was not found to be an independent risk determinant. At any rate, this technique was selected only in patients with diseased aortic valve and nondilated aortic root.

Hemorrhage, once a frequent, serious complication, appears to be better controlled, as exemplified by a significantly lower need for reopening of the chest. Certainly the use of the resorcin glue, new materials, and the ever growing use of the sandwich technique have contributed to the reduction of problems associated with hemorrhaging.

Postoperative neurologic damage has occurred frequently in our experience. This complication has been correlated with the use of deep hypothermia and circulatory arrest [12–14]. Twenty-two of our patients died from neurologic complications, but the open aorta technique was not found to be a statistically significant determinant. It may be prudent despite this to lower the patient’s temperature to 16°C instead of the customary 18°C, or, in any case, to 2°C below the electroencephalogram electrical silence [15].

The open aorta technique is mandatory whenever a tear is demonstrated during arch exploration, but it may also be employed in cases without a lesion of the arch. With this technique the distal suture is easier to perform [6, 11]. Moreover, one could avoid clamping the dissected aorta near the innominate artery. Upon releasing the clamp we often noticed the presence of secondary tears near the innominate artery, probably due to the aortic clamp itself [16]. With the traditional technique, such unnoticed lesions may have caused neurologic damage.

Although we do not have direct proof, we suspect that faulty perfusion of the supraaortic vessels, clinically silent during cardiopulmonary bypass, may be a frequent cause of postoperative neurologic sequelae. In a recent case, at the beginning of retrograde cardiopulmonary bypass from the left femoral artery, intraoperative transesophageal echocardiography showed that only the false lumen was perfused, with no blood flowing to the supraaortic arteries. There were no pupillary signs to warn of this impending neurologic catastrophe. We therefore consider it mandatory to use transesophageal echocardiography during the operation and, as suggested by Laas and colleagues [17], to discontinue cardiopulmonary bypass and search for alternative arterial routes to maintain a forward cerebral perfusion in these circumstances.

Widespread use of the open aorta technique, however, brings with it the risk of secondary coagulopathy [12]. Furthermore, cardiopulmonary bypass and total operation time are significantly increased because of the need for long cooling and rewarming times [15, 18]. This increases the risk of respiratory insufficiency and infections [12, 18]. However, we believe that such drawbacks result from the advantage of being allowed to perfect the surgical repair under very favorable conditions, when intimal tears are found. In our experience, however, use of the open aorta technique did not bring a greater risk of death or of neurologic damage. Another frequent cause of death in our cases was myocardial infarction. In a few cases this was due to an extension of the dissection to the coronary arteries. However, severe coronary arterial lesions were demonstrated in 6 of the 7 patients who died after myocardial infarction or in low output state and were submitted to autopsy. We do not require routine coronary angiography in aortic dissections, in accordance with the conclusions of Kern and colleagues [19]. Even if the patient may have silent coronary lesions, the need to reduce diagnostic times to a minimum by using quick, noninvasive techniques such as transesophageal echocardiography [20] is surely the prime goal in acute type A dissections. On the other hand, whenever for any reason an aortography is performed, we would suggest trying to add a coronary angiogram as well. The time spent in such an attempt, however, should be kept to a minimum, given the circumstances and the difficulties [21].

Late results
Surgical therapy of type A aortic dissection cannot be considered a cure. A significant late mortality rate exists that depends on persistent risk factors (hypertension and Marfan’s aorta), residual lesions, and their evolution [22]. Glower and co-workers [23] reported a 10-year survival rate of 29% for type 1 and 46% for type 2. Haverich and associates [22] described a 10-year survival rate of 64% for 135 surgically corrected patients for dissection type A or B, without a significant difference between the two groups. In our series the survival rate (including surgical deaths) is 37% at 10 years.

Evolution of residual false lumen
Four late deaths were caused by rupture of the distal aortic arch. Three other patients died suddenly, but we have no autopsy control. In our series there were no repeat operations on thoracic or abdominal aorta for aneurysmatic evolution. However, no systematic evaluation was done, by echo or other techniques, of this complication. Frequent controls during follow-up are mandatory [22].

Proximal redissection
Redissection or dilation of the aortic root (with severe aortic valve incompetence) was the cause of reoperation in 11 patients. In four instances redissection was demonstrated at autopsy. In the past we underestimated the importance of the remaining aortic root. Although conservative repair of the ascending aorta was not a determinant of late risk in our series, we maintain some reservations about it: In 1996, 2 patients operated on with the Carpentier technique [9] had to be reoperated upon early because of redissection.

We do not replace the aortic root unless it is severely dilated, but we think it advisable to remove as much of the diseased proximal aortic wall as possible, by reinforcing the aortic stump at the lowest level with Teflon strips to prevent proximal redissection [17].

Aortic valve regurgitation
In agreement with others [3, 24], we consider it unadvisable to change an aortic valve that shows no primary pathologic changes. In the presence of annuloaortic dilation, however, and particularly in Marfan’s syndrome, it is advisable to replace the aortic root with a composite prosthesis or to adopt the David’s root remodeling procedure [25], with which we have no experience so far. In 7 patients in whom the aortic valve was in a normal condition, however, we had to reoperate later for aortic valve regurgitation. In none of these cases had we performed a cusp resuspension in the first operation, and now we maintain the importance of performing it in all cases. If the aortic root is small and the aortic valve diseased, implanting a composite prosthesis may prolong the clamping time, and thus the risk. We would not exclude the separate technique from our options in such cases.

In conclusion, the early mortality rate in our experience is high. It does not seem to have been influenced by the surgical technique chosen, but principally by the clinical condition of the patient. The high number of deaths by neurologic or myocardial damage calls for greater attention to the problems of faulty perfusion during the operation and to the presence of silent coronary artery disease.

	Appendix 1. Preoperative and operative variables analyzed

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Preoperative and... References

 

Sex

Age

Weight

Height

Hypertension

Marfan’s syndrome

Previous cardiac operation

Previous aortic valve replacement

Previous thoracic trauma

Cardiac tamponade

Coma I–II

Focal neurologic damage

Stroke

Paraparesis

Anuria

Endotracheal intubation

Shock

Site of intimal tears

Aortic rupture

Technique of capitonnage

Type of operation

Associated operations

Aortic arch operation

Site of arterial cannula

Blood flow during cardiopulmonary bypass

Arterial catheter resistance during cardiopulmonary bypass

Diameter of arterial cannula

Temperature (rectal and rhinopharigeal) at clamping

Open aorta technique

Temperature of arrest

Time of arrest

Flux in the prosthesis at restart

Prosthesis cannulation

Time of aortic cross-clamp

Bleeding (milliliters in first 24 hours)

Revision for bleeding

	References

Top Abstract Introduction Patients and methods Results Comment Appendix 1. Preoperative and... References

 

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