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Ann Thorac Surg 2001;71:33-38
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Emergency operation for acute type A aortic dissection: neurologic complications and early mortality

^a Department of Cardiac Surgery, University of Rome "La Sapienza," Rome, Italy

Accepted for publication May 24, 2000.

Address reprint requests to Dr Sinatra, Istituto di Chirurgia del Cuore e dei Grossi Vasi, Policlinico Umberto I, Università "La Sapienza," Viale del Policlinico 155, 00161 Roma, Italia
e-mail: rsinatra{at}uniroma1.it

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Acute type A aortic dissection is a surgical emergency still associated with high postoperative complications. The aim of this study was to investigate factors for hospital mortality and neurologic deficit in patients undergoing emergency operation for acute type A aortic dissection.

Methods. Eighty-five consecutive patients (age range, 20 to 82 years) operated on for acute type A aortic dissection over a 6-year period were evaluated. Univariate and stepwise multiple logistic regression analyses were conducted among 32 perioperative variables.

Results. All patients underwent surgical procedures under deep hypothermic circulatory arrest. Antegrade or retrograde cerebral perfusion was used in 23 patients (27.1%) and 18 patients (21.2%), respectively. Forty-three patients underwent arch/hemiarch replacement and the ascending aorta was replaced in 42 patients. Overall mortality rate was 25.9% (22 of 85 patients). Multiple logistic regression analysis showed that lack of cerebral perfusion (p = 0.021) and postoperative renal failure (p = 0.006) were the best predictors for hospital death. Twenty-one patients (24.7%) experienced neurologic accidents. The risk factor for postoperative neurologic complication was lack of cerebral perfusion (p = 0.013). Hospital mortality was 13% (3 of 23 patients) and 16.7% (3 of 18 patients) in the antegrade and retrograde cerebral perfusion groups (p > 0.05) and neurologic deficit was 13% (3 of 23 patients) and 11.1% (2 of 18 patients), respectively (p > 0.05).

Conclusions. Hospital mortality and neurologic complications in patients undergoing emergent operation for acute type A aortic dissection were reduced when cerebral perfusion was used with deep hypothermic circulatory arrest.

	Introduction

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Acute dissections involving the ascending aorta are at high risk for rupture of the aortic wall with cardiac tamponade, massive aortic regurgitation, or malperfusion. Mortality is increased dramatically in patients not receiving timely surgical therapy: in the largest review of patients with aortic dissection who did not receive surgical treatment, the mortality was between 36% and 72% within the first 48 hours [1]. The early diagnosis and the recent advances in surgical techniques and postoperative care have reduced mortality rates for these severely ill patients [2–6]. Different intraoperative circulatory management strategies have been used to perform an accurate operation and to provide a better organ protection, particularly for the brain [7–12]. Neurologic deficits are one of the major causes of hospital mortality in patients operated on for acute type A aortic dissection [13].

To assess factors influencing early mortality and postoperative neurologic outcome, we present our experience with the management of patients undergoing emergency operation for acute type A aortic dissection.

	Material and methods

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Patients
Between April 1992 and May 1998, 85 consecutive patients were operated on for acute type A aortic dissection at the Institute of Cardiac Surgery, University of Rome "La Sapienza."

Preoperative clinical symptoms, which included precordial pain, back pain, or abdominal pain, were present in all patients. Mean time between symptoms onset and operation was 22.9 ± 15.6 hours (range, 6 to 43 hours). Complications at hospital admission and incremental risk factors for death and neurologic deficit are listed in Table 1.

Operative technique
The heart, ascending aorta, and aortic arch were exposed through a median sternotomy in all patients. After heparinization, the cardiopulmonary bypass (CPB) was instituted by femoral arterial and right atrial cannulation. A left atrial vent was inserted through the right superior pulmonary vein. Myocardial protection was provided by intermittent, antegrade, cold, crystalloid cardioplegia. Barbiturate was administered in all the patients who underwent DHCA without cerebral perfusion (n = 44, 51.8%) and the patients’ heads were packed in ice bags. To increase the tolerance of the neurologic tissue for ischemia, 1 g of methylprednisolone was given to all patients immediately before circulatory arrest. The patient’s rectal temperature was cooled to about 17°C by extracorporeal circulation and circulatory arrest was started.

In 23 patients (27.1%) who underwent DHCA+ACP, the innominate artery was isolated during the cooling phase and after the ascending aorta was opened, it was cannulated with a 5F perfusion cannula during a short period of total circulatory arrest with careful direct inspection. The perfusion catheter was then connected (through a sidearm of the arterial line) using a Y piece. The perfusion flow rate ranged between 250 and 700 mL/min. The left carotid and left subclavian arteries were not always clamped and blood was in any case verified to be emanating from the brachiocephalic orifices as sign of carotid patency and functional circle of Willis.

In 18 patients (21.1%) who underwent DHCA+RCP, the caval veins were cannulated separately. The venous line was connected to the arterial line of the extracorporeal circuit, snaring the superior caval catheter and occluding the cannula in the inferior cava. Retrograde perfusion flow was so adjusted not to exceed 25 mm Hg of central venous pressure with a range from 200 to 700 mL/min.

The ascending aorta was opened widely and the pathologic condition of the interior of the transverse arch and origin of the arch vessels was appraised. The intimal tear in the ascending aorta or arch was then resected and replaced with a Dacron (C.R. Bard, Haverhill, PA) tube graft.

Operation on the aortic valve or root was performed according to their pathology. Suture lines incorporated both the inner and outer layers of the aorta that were reinforced by applying Teflon felt and cemented together with the use of gelatin-resorcin-formol biologic glue. In all patients, once the distal anastomoses had been completed, the graft was cannulated and proximally cross-clamped, antegrade systemic circulation was restarted, antegrade or retrograde cerebral perfusion interrupted, and during rewarming, the proximal anastomosis performed. Cardiopulmonary bypass was continued until the patient’s temperature has risen to 36°C or 37°C.

Statistical analysis
All statistical analysis was performed using the R 0.64.0 statistical package (Free Software Foundation, Inc, Boston, MA). Measurements considered for calculations are listed in Table 1: 10 preoperative, 12 intraoperative, and 10 postoperative variables were analyzed to find the best predictor of hospital death and postoperative neurologic complications. Univariate analysis was performed by means of the ² test (the exact test of Fisher was used when necessary) and the Student’s t test for unpaired data. Interval-scaled variables such as age, bypass time, cross-clamp time, and circulatory arrest time were analyzed by simple univariate linear regression test. Variables found to be statistically significant in the univariate analysis were put into a stepwise multivariable logistic regression model. A p value of 0.05 or less was considered statistically significant.

	Results

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Mean age of the study population was 60.1 ± 11.6 years (range, 20 to 82 years). Sixty-four patients (75.3%) were men and 21 (24.7%) were women. Operative data and postoperative complications are listed in Table 1. Mean bypass time was 202.2 ± 64.2 minutes (range, 105 to 410 minutes). Mean circulatory arrest time was 59.9 ± 36.9 minutes (range, 15 to 174 minutes).

One patient that had undergone a previous Bentall’s operation for acute type A aortic dissection presented in hemodynamic shock for acute rupture of mitral chordae and tricuspid regurgitation. The transesophageal echocardiogram showed a new intimal tear in the arch, distally to the distal anastomosis. The patient was reoperated on under DHCA+ACP for a hemiarch replacement with associated replacement of the mitral valve and tricuspid valve anuloplasty.

The rate of total arch replacements performed was higher in the cerebral perfusion group of patients (Table 2), particularly in the DHCA+ACP group.

Date of operation, circulatory arrest time, bypass time, or operation on the aortic arch were not found to be statistically significant risk factors for death or postoperative neurologic deficit (Table 1).

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
This study identified, in a large series of patients, factors for hospital mortality and neurologic complications after emergent operation for acute type A aortic dissection. The main goals of surgical treatment of patients with an acute type A are to prevent aortic rupture, reverse organ ischemia, and correct aortic valve pathology, but the operation must be performed before these complications occur or their effect become irreversible.

Despite the recent advances in circulatory and anesthesiology management with improved results, acute type A aortic dissection is a catastrophic event and still a challenge for the surgeon. Surgical mortality rates are reported to range between 10% and 40% [4–6, 14–19]. This large variability is due to the different patient selection (age, preoperative status, risk factors for cardiovascular disease) and the different surgical approaches. In our series, the overall mortality rate was 25.9% and if even still high, this rate is similar to that recently reported from other authors. At Stanford University, Fann and coworkers [9] had a mortality rate of 27% in the latest series of patients operated on for acute type A aortic dissection. Ehrlich and colleagues [6] and Bavaria and coworkers [18] had mortality rates of 30% and 29%, respectively. In our study, 41.2% of patients were in critical condition at hospital admission and the higher hospital mortality we found among patients that underwent DHCA alone (36.4%) is comparable to that in the same groups of patients in these latter investigations [6, 18].

Circulatory arrest allows a bloodless inspection and repair of intimal tears, in particular in the aortic arch where leaving an intimal tear can compromise early and late outcome of these patients [13]. A complete intimal adventitial reapproximation in the distal anastomosis and avoidance of any clamp injury to the fragile dissected aortic tissue can be carried out safely with this technique. Organ protection is provided by profound hypothermia during circulatory arrest. With this method, the metabolic rate of the neural tissue and the oxygen consumption are reduced, but there is a time limit for the use of DHCA. Cerebral ischemia times of longer than 45 minutes are associated with higher risk of stroke and longer than 65 minutes with higher mortality rates [7, 8]. In the present study, the postoperative neurologic deficit rate was 24.7% and statistical analysis showed that neurologic outcome was not related to the time of circulatory arrest but to the lack of cerebral perfusion. This large proportion of patients experiencing postoperative neurologic dysfunction was due mainly to the high rates of brain damage occurring among the DHCA group and it was the main cause of death in this group of patients.

From multivariate analysis, lack of cerebral perfusion was found to be a statistically significant predictor both of death and neurologic deficit in our series. Hospital death was also significantly related to postoperative acute renal failure, which in our experience was often associated with other major complications such as multiple organ failure or low output cardiac syndrome. Bavaria and colleagues [18] showed by univariate analysis that in a series of patients undergoing operation for acute type A aortic dissection, the use of retrograde cerebral perfusion significantly reduced postoperative stroke and mortality rates compared with a group of patients managed with DHCA alone. In the study from Ehrlich and coworkers [6], lack of retrograde cerebral perfusion and older age were the best predictors of early death in a similar setting of patients and the rates of neurologic complications were significantly reduced in patients who underwent operation with DHCA+RCP.

Forty-one patients from our series underwent operation under DHCA with perfusion of the brain, antegradely or retrogradely. Hospital mortality among these patients was 14.6% and neurologic deficits were found in 5 patients (11.1%) postoperatively, both significantly lower than the rates found among patients managed with DHCA alone.

Antegrade perfusion of the brain has the advantage of being more physiologic with a supposed unlimited time to perform the distal aortic repair [11]. The difficulty in identifying the true lumen and the possible risk of air or atheromatous embolization from aortic manipulation and artery cannulation are the main problems of this technique [10]. We avoided this problem by carefully inspecting the interior of the arch and the innominate artery, during a short period of total circulatory arrest, before the insertion of the antegrade perfusion cannula. In this subgroup, even with longer circulatory arrest times and more complex and complete operations, hospital mortality was 13% and postoperative neurologic deficit 13%; CT scans revealed one embolic episode in 1 patient with a fragile and heavily calcified aortic wall. In a recent multicenter Japanese study [19], mortality was 21% (16% within 30 days after the operation) and stroke rate 19% for patients operated on for acute type A aortic dissection under DHCA+ACP.

Retrograde perfusion through the superior vena cava was originally described as a method to avoid accidental air embolism during CPB [20]. This technique is easier to perform than antegrade cerebral perfusion and has the advantage of permitting particulate and gaseous microemboli removal from the arterial tree before CPB reinstitution. Whether retrograde perfusion is of benefit because of its cerebral perfusion capability, removal of cerebral waste products, or by ensuring a better distribution of cold to the brain, remains unclear [11]. In the present study, rates of hospital death and neurologic dysfunction for patients undergoing DHCA+RCP were 16.7% and 11.1%, respectively. For this particular setting, other authors have reported mortality rates ranging between 14% and 21% [4, 5, 19, 21] and postoperative neurologic deficit of 9% [4], 10% [5], and 16% [19], respectively.

In conclusion, acute type A aortic dissection is an unpredictable and severe pathology with high postoperative complications. The intraoperative management with deep hypothermic arrest and the use of antegrade or retrograde cerebral perfusion is significantly related to a lower incidence of mortality and neurologic deficits, even if hospital mortality is related to different preoperative, intraoperative, and postoperative variables.

This study does not validate the use of either antegrade or retrograde cerebral perfusion for brain protection. Antegrade cerebral perfusion permitted a significantly higher "safe" period for brain protection, as demonstrated by the longer circulatory arrest time in the DHCA+ACP group of our series experiencing similar or even lower postoperative neurologic deficits or mortality rates.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank Professor Sir Magdi Yacoub for his kind review of our manuscript.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Riccardo Sinatra Brenno Fiorani Giovanni Ruvolo Benedetto Marino Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Sinatra, R. Articles by Marino, B. Search for Related Content PubMed PubMed Citation Articles by Sinatra, R. Articles by Marino, B. Related Collections Great vessels