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Ann Thorac Surg 1999;67:1999-2001
© 1999 The Society of Thoracic Surgeons

Surgery for acute type A aortic dissection

^a Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada

Address correspondence to Dr David, 200 Elizabeth St, 13EN219, Toronto, Ont, Canada M5G 2C4

Presented at the Aortic Surgery Symposium VI, April 30–May 1, 1998, New York, NY.

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Several innovative approaches have been introduced in the surgical treatment of acute type A aortic dissection. This study examines the effects of these new techniques on the early and late outcomes of patients with this disease.

Methods. The records of patients who had surgery for acute type A aortic dissection during an 18 year interval were reviewed. There were 109 patients: 81 men and 28 women, with a mean age of 57 years, range 23 to 80. Most patients were acutely ill and 15 were in shock at the time of surgery. Operations were performed under cardiopulmonary bypass with femoral artery and right atrial cannulation. In 55 patients, the aorta was clamped and retrograde femoral perfusion was used throughout the procedure (group I). In 54 patients, no clamp was used; under circulatory arrest the primary tear was resected whether in the ascending aorta or transverse arch, and antegrade cardiopulmonary bypass was started after completion of the distal anastomosis (group II). Postoperative computed tomographic or magnetic resonance scans were completed annually.

Results. There were 16 operative deaths (15%): 11 (20%) in group I, and 5 (9.2%) in group II (p = 0.10). There were 10 strokes: 8 (14.5%) in group I and 2 (3.7%) in group II (p = 0.05). After a mean follow-up time of 59 ± 45 months for group I, 31 (56%) patients were alive, and after a mean follow-up time of 45 ± 26 months for group II, 44 (81%) patients were alive. The actuarial survival of group II was higher than group I, but the difference was not significant (p = 0.09). Postoperatively, a patent false lumen was found in 91% of group I patients and in 59% of group II (p = 0.01).

Conclusions. This study suggests that avoidance of aortic clamping, resection of the primary tear in the ascending aorta or transverse arch, and antegrade perfusion after completion of the distal anastomosis improve the early and late outcomes of surgery for acute type A aortic dissection.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
In our hospital, the operation traditionally performed for acute type A aortic dissection involved placing the patient on cardiopulmonary bypass and replacing the ascending aorta during aortic cross-clamping; retrograde femoral perfusion was used throughout the time the patient was on bypass. This approach was changed over the years: the aorta was no longer clamped, the intimal tear in the ascending aorta or arch was resected, and antegrade arterial perfusion was always used after completion of the distal anastomosis. In addition, a more aggressive approach toward dissected aortic sinuses was also adopted. In this study, we review our experience with surgery for acute type A aortic dissection and examine the effect of newer operative techniques on short and long-term outcome.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
All patients operated on for acute type A aortic dissection at the Toronto Western Hospital from 1979 to 1989, and all patients operated on at the Toronto General Hospital from 1990 to 1996 were entered into this study. The operations were performed by 8 attending surgeons. There were 109 patients, 81 men and 28 women, whose mean age was 57 ± 14 years, ranging from 23 to 80. All but 9 patients were in New York Heart Association functional class IV, and 15 were in shock. Nine patients were mentally obtunded, and 4 had signs of acute neurologic deficit (hemiplegia in 3 and paraplegia in 1). Twenty-nine patients had Marfan syndrome. The acute dissection occurred in the operating room during routine open heart procedures in 4 patients, and during coronary angioplasty in 1 patient. Four patients had had previous cardiac surgery for coronary artery and/or aortic valve disease. Preoperative coronary angiography was not performed, but 16 patients were known to have coronary artery disease.

Diagnosis was made by echocardiography alone in 71 patients, computed tomographic (CT) scan in 10, angiography in 15 and intraoperatively in 4. Forty patients had a normal aortic valve; 3 had stenosis of the aortic valve; 64 had aortic insufficiency, and 2 had a prosthetic aortic valve. Three patients had severe mitral insufficiency.

Operative techniques
Cardiopulmonary bypass was established by femoral artery and right atrial cannulation in all patients. In 55 patients, the ascending aorta was clamped, resected and replaced with a tubular Dacron graft. In addition, partial or complete replacement of the transverse arch was performed in 9 patients under deep hypothermic circulatory arrest. The aortic root was replaced or repaired depending on the pathology of the aortic valve. Retrograde femoral arterial perfusion was used throughout the time the patient was on cardiopulmonary bypass (group I).

In 54 patients, the ascending aorta was opened under moderate hypothermic circulatory arrest and no clamp was used. The primary tear was resected whether in the ascending aorta or transverse aortic arch. In 40 patients without a tear in the transverse arch, the ascending aorta was transected just below the origin of the innominate artery, and was replaced with a tubular Dacron graft. In patients with an intimal tear in the arch (13 patients) or proximal descending thoracic aorta (1 patient), the transverse arch was replaced. An arterial cannula was inserted in the graft and antegrade cardiopulmonary bypass restarted (group II).

The aortic valve was repaired or replaced depending upon its pathology. Table 1 shows the clinical profile, operations, and outcomes in groups I and II.

View larger version (21K): [in this window] [in a new window]   Fig 1. Actuarial survival of patients from groups I and II.

	Results

Top Abstract Introduction Patients and methods Results Comment References

There were 10 strokes: 8 in group I and 2 in group II (p = 0.05). Five of these 10 patients died, all from group I. Eighteen patients required re-exploration of the mediastinum for bleeding: 11 in group I and 7 in group II(p = 0.03). Five patients required renal dialysis; 4 were from group I. One patient developed a sternal infection (group I).

Patients were followed from 12 to 168 months, with a mean of 52. Table 1 shows the follow-up times for groups I and II and the causes of late death. Only one patient from group I was lost to follow-up. There were 17 late deaths. The actuarial survival of all patients was 67 ± 6% at 8 years. Figure 1 shows the actuarial survival for groups I and II. Although the survival for group II was better than for group I, the difference did not reach statistical significance (p = 0.09).

Postoperative CT or magnetic resonance (MR) scans were completed annually to determine the fate of the false lumen. Forty of 44 patients who survived surgery from group I had a patent false lumen, whereas only 29 of 49 patients from group II had a patent false lumen (p = 0.01). Nine patients from group I have required reoperation: 2 for aortic root replacement, and 7 for replacement of the entire thoracic and thoracoabdominal aorta. Two patients died; 1 became paraplegic. There was no reoperation required in group II (p = 0.01).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
In a recent review of autopsy patients with acute type A aortic dissection, we found that unoperated patients often had 1 entry and 1 re-entry tear, whereas operated patients had multiple tears [1]. Our explanation for this difference in pathologic findings was that operated patients had had cardiopulmonary bypass with retrograde arterial perfusion: when a clamp was applied to the ascending aorta, it caused pressurization of the false lumen, with consequent multiple tears or malperfusion. These observations suggested to us that the ascending aorta should not be clamped during cooling of a patient with an acute type A aortic dissection, and that after the distal anastomosis is completed, cardiopulmonary bypass should be reinitiated with antegrade arterial perfusion. Since the introduction of this surgical approach in our institution, the operative mortality for acute type A aortic dissection has fallen from 20% to 9%, as shown in this study. This reduction in mortality rate did not reach statistical significance however, probably because of the relatively small sample size.

Although the ascending aorta is the most common site of the primary tear in patients with acute type A aortic dissection, the transverse arch must be explored because it is where the primary tear occurs in 20% to 25% of the cases [1, 2]. With current methods of cerebral protection, we believe that it is safe to replace the transverse aortic arch in these patients, and that replacing the arch actually may decrease the risk of stroke and of late complications related to the false lumen. In our study, the risk of perioperative stroke was greatly reduced by this new approach. We presently use moderate systemic hypothermia and cold retrograde perfusion during circulatory arrest in these patients [3].

Patients with acute type A aortic dissection frequently have preexisting disease of the aortic root [2, 4–7]. Dilatation of the aortic root with or without Marfan syndrome, and bicuspid aortic valve disease are common preexisting lesions in these patients, and dissection of the aortic sinuses is often found at operation. European surgeons tend to preserve the native aortic root more often than American surgeons, probably because of their experience with gelatin-resorcinol-formol (GRF) glue [2, 4–6]. Although we do not have access to the GRF glue, in the last decade we have often preserved the native aortic valve by using an aortic valve-sparing operation [8, 9]. In these operations, the aortic sinuses are completely excised, and the aortic root is reconstructed with a tubular Dacron graft. The results of these operations have been excellent [10]. If the aortic valve is bicuspid or has any other abnormality, we agree with those surgeons who recommend aortic root replacement with a valved conduit [4, 7].

Most patients with type A aortic dissection have a persistent false lumen after replacement of the ascending aorta [11]. We believe that a patent false lumen is a major cause of late mortality and morbidity in these patients [12]. Unfortunately, even with newer operative techniques, this problem remains of concern because the majority of false lumens remain patent postoperatively. In our study, flow into the false lumen was identified postoperatively in 91% of patients who had retrograde arterial perfusion, and in 59% of patients who had antegrade arterial perfusion. For this reason, patients with type A aortic dissection require continued surveillance after surgery. They should be treated with a beta adrenergic blocking agent, and have annual CT or MR scans of the aorta to measure its diameter and the extent of the false lumen. A number of these patients will require replacement of the remaining thoracic and abdominal aorta.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Van Arsdell G.S., David T.E., Butany J. Autopsies in acute type A aortic dissection. Circulation 1998(Suppl II):II299-II303.
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3. Moshkovitz Y., David T.E., Caleb M., Feindel C.M., de Sa M.P.L. Circulatory arrest under moderate systemic hypothermia and cold retrograde cerebral perfusion. Ann Thorac Surg 1998;66:1179-1181.[Abstract/Free Full Text]
4. Ergin M.A., McCullough J., Galla J.D., Lansman S.L., Griepp R.B. Radical replacement of the aortic root in acute type A dissection: indications and outcome. Eur J Cardiothorac Surg 1996;10:840-845.[Abstract/Free Full Text]
5. Von Segesser L.K., Lorenzetti E., Lachat M., et al. Aortic valve preservation in acute type A aortic dissection: is it sound?. J Thorac Cardiovasc Surg 1996;111:381-391.[Abstract/Free Full Text]
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8. David T.E., Feindel C.M. An aortic valve sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992;103:617-622.[Abstract]
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