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Ann Thorac Surg 2005;80:523-529
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Long-Term Results After 27 Years of Surgical Treatment of Acute Type A Aortic Dissection

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

Accepted for publication February 18, 2005.

^_* Address reprint requests to Dr Tan, St. Antonius Hospital, Department of Cardiothoracic Surgery, Koekoekslaan 1, 3435 CM, Nieuwegein, the Netherlands (Email: erwin.tan{at}tiscali.nl).

	Abstract

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BACKGROUND: This study investigates the determinants of long-term outcome and modalities of late death after surgical treatment of acute type A dissection.

METHODS: Between 1974 and 2001, 315 consecutive patients were operated on for acute type A aortic dissection. Operative mortality was 22.9%. A series of 243 survivors of surgical treatment were followed up for as long as 27 years. Endpoints were death, cardiovascular reoperation, and neurologic events. Median follow-up was 4.5 years. Follow-up was 99.6% complete.

RESULTS: Cumulative survival of discharged patients was 96.4% ± 1.3%, 67.7% ± 4.7%, and 39.4% ± 12.0% at 1, 10, and 20 years, respectively. During follow-up, 47 patients died. Cause of death was cardiac failure in 7, hemorrhage due to rupture of the distal aorta in 7, stroke in 4, respiratory insufficiency in 4, sepsis in 3, malignancy in 2, and unknown in 20 patients. Multivariate analysis revealed advanced patient age and postoperative hemodialysis as perioperative indicators of late death (p < 0.05). Freedom from cardiovascular reoperation was 90.7% ± 2.0% at 1 year, 60.9% ± 5.1% at 10 years and 41.9% ± 15.0% at 20 years. A total of 58 patients required 86 cardiovascular reoperations; aortic root or ascending aorta replacement was performed in 20, distal ascending aorta and arch replacement in 13, descending aorta replacement in 6, thoracoabdominal aorta replacement in 7, abdominal aorta replacement in 7, and miscelleanous reoperations in 6 patients. Multivariate analysis revealed male sex and left coronary artery dissection as significant determinants for late cardiovascular reintervention (p <0.05). Cumulative incidence of stroke after 20 years was 3.8%.

CONCLUSIONS: Acute type A dissection represents an emergency situation with acceptable long-term results for discharged survivors of surgical treatment.

	Introduction

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The long-term survival of patients after surgical repair for type A aortic dissection has improved since the early reports of Hirst and colleagues [1] and Anagnostopoulos and associates [2]. However, the early mortality rates remain still as high as 40% [3]. We have previously reported on our short-term results after surgery for acute type A aortic dissection [4]. The purpose of this retrospective study is to report our experiences in the surgical treatment of patients with acute type A dissection over a 27-year period, with special emphasis on long-term outcome and modalities of late death.

	Material and Methods

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Between November 1974 and December 2001, 315 consecutive patients (205 men and 110 women) were operated on for acute type A aortic dissection at the St. Antonius Hospital, Nieuwegein, The Netherlands. The mean patient age was 58 ± 12 years. If chest pain or other symptoms occurred less than 14 days before operation, the dissection was defined as acute [5]. The type of the aortic dissection was considered, according to the Stanford classification, to be type A if the ascending aorta was involved [6]. The diagnosis of type A aortic dissection was confirmed by either aortography especially in the early experience, transoesophageal echocardiography (64%, n = 203), computed tomography (29.8%, n = 94), magnetic resonance imaging, or operative exploration. The present study reports on our experience of a series of 243 patients, who survived surgical treatment for acute type A dissection and were discharged from the hospital, to establish the long-term outcome and modalities of late death after emergency operation for acute dissection. The cohort of survivors was routinely followed up and underwent systematic imaging controls on a periodical basis. Ten patients in this series had Marfan’s syndrome. All patients received anticoagulation therapy postoperatively with coumadin for 3 months and were then switched to antiplatelet therapy unless they were in atrial fibrillation or had undergone a Bentall procedure or separate aortic valve replacement.

Surgical Technique
Throughout the years of the study, there was a substantial variability in cardiothoracic surgeons (15) and, owing to changed insights, in surgical technique. The following reflects our general approach. The operation was performed using femoral artery cannulation, venous return through the right atrium, median sternotomy approach, total cardiopulmonary bypass, and cardiac arrest with cold oxygenated crystalloid cardioplegia. A left ventricular drain was inserted through the right upper pulmonary vein. After administration of cardioplegia, the ascending aorta was opened, and the aortic valve was inspected. Whenever possible, attempts were made to repair the aortic valve. The aortic arch was explored under circulatory arrest, and if an intimal tear was present, parts of or the complete aortic arch were replaced. The brain was protected either by deep hypothermia or antegrade cerebral perfusion. The segment of aorta containing the intimal tear was usually resected and replaced with a Dacron prosthesis, and frequently the aortic stumps were reinforced with Teflon strips. Gelatin-resorcinon-formalin (GRF) adhesive (Colle biologique; Fii, Saint Just Malmont, France) or fibrinous glue (Tissu-col; Immuno AG, Vienna, Austria) were not routinely used. In the later years, if the aorta was cross-clamped, the clamping region was always replaced.

Isolated ascending aorta replacement was performed in 132 patients (54.3%), with concomitant hemiarch replacement in 42 (17.3%), total arch replacement in 10, and elephant trunk in 1 patient. Bentall and ascending aorta replacement was performed in 28 patients (11.5%), with concomitant hemiarch replacement in 3, and total arch replacement in 1. Ten patients in the earlier series had primary repair of an intimal tear without graft replacement of the ascending aorta. Aortic valve replacement with ascending aorta replacement was performed in 15 patients (6.2%), and with concomitant total arch replacement in 1. A mechanical valve was implanted in 14 patients, and a biological valve was used in the remaining 2. In 104 patients (42.8%) it was possible to resuspend the aortic valve, in 9 patients the aortic valve was reimplanted in a tubular Dacron graft according to David and Feindel [7] and in 2 patients according to the technique described by Yacoub and colleagues [8]. The native aortic valve remained untouched in the remaining 80 patients. Concomitant coronary bypass grafting was necessary in 9 patients.

Deep hypothermic circulatory arrest (DHCA) was used in 96 patients (39.5%) to allow for an open distal anastomosis or for arch replacement. Antegrade selective cerebral perfusion (ASCP) was applied in 81 patients (33.3%) during circulatory arrest of the body [9, 10]. We have used retrograde cerebral perfusion (RCP) only once, while the remaining 65 patients (26.8%) have been operated upon with simple aortic cross-clamping without DHCA, ASCP, or RCP.

Follow-Up
From January to April 2002, we performed a cross-sectional follow-up of all patients not known to be dead. Data were obtained by retrospective review of hospital records. Follow-up information was collected by written and telephone contacts with patients, relatives, or physicians. Follow-up was 99.6% complete. One patient remained untracked because of emigration with unknown current address or relatives. Total cumulative follow-up extendend to 1,292 patient-years with a median of 4.5 years.

Statistical Analysis
Statistical Analysis Software (version 8.2 for Windows; SAS Institute, Cary, North Carolina) was used for all analyses. Univariate analysis of potential risk factors (see Appendix) was performed to identify statistically significant perioperative risk factors (p < 0.05) for endpoints as death, cardiovascular reoperation, and neurologic events. The univariate analysis was followed by logistic regression analysis (binary outcome) or Cox proportional hazard regression analysis (time-related binary outcome) to determine independent perioperative risk factors. Kaplan-Meier life tables were constructed to estimate long-term survival rates for operative survivers. Groups were compared using log-rank tests. Continuous data are expressed as means ± SD.

	Results

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Survival
The overall operative mortality rate was 22.9%; 243 patients survived surgical treatment and were discharged from the hospital. Among the discharged patients, cumulative survival was 96.4% ± 1.3%, 67.7% ± 4.7%, and 39.4% ± 12.0% at 1, 10, and 20 years, respectively (Fig 1). Median survival time was 16.0 years. During the follow-up period, 47 patients died (19.3%). Seven patients died of cardiac failure, 7 patients had fatal rupture of the distal aorta, and 4 patients died of a stroke (Table 1). Three patients died of sepsis, 1 case initiated by peritoneal dialysis infection, 2 by prosthetic graft infection. Multivariate analysis of the operative survivors revealed advanced patient age at surgery and postoperative need for hemodialysis as predictors that were associated with late death (Table 2).

View larger version (10K): [in this window] [in a new window]   Fig 1. Survival of operative survivors.

View larger version (10K): [in this window] [in a new window]   Fig 2. Freedom from late cardiovascular reintervention.

View larger version (13K): [in this window] [in a new window]   Fig 3. Freedom from aortic root intervention.

View larger version (9K): [in this window] [in a new window]   Fig 4. Freedom from late neurologic event.

	Comment

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Survival
Previous reports on long-term survival after treatment for acute type A dissection have included follow-up data up to 20 years. According to these prior reports, 10-year survival rates are 30% to 60% [12–20]. Although the patient characteristics are not completely comparable, our long-term results seem comparable and acceptable. Operative techniques did not improve the long-term survival significantly. Other surgeons have advocated that only resection of the dissected ascending aorta is justified, because the principal goal of the operation is the survival of the patient. Their argument is that the risks of a more extensive operation with replacement of the arch, done by surgeons with inadequate experience with aortic dissection, outweighs the long-term benefit [19]. In our series, more extensive operations with arch replacements did not affect the late results, although all of our surgeons, some of them less trained in aortic surgery, contributed to all operations. On the other hand, we agree with other authors, because more advanced patient age at surgery is significantly influencing the late survival rate, that the potential benefit of extensive surgery on late survival has to be related to the limited life expectancy of patients at an advanced age [21]. However, we believe that surgery for acute type A dissection should not be denied on the sole consideration of advanced age.

Late Cardiovascular Reoperations
In all patients, if the intimal tear is located in the ascending aorta, the ascending aorta should be totally replaced, and the aortic valve preserved whenever possible. When the intimal tear is located in, or extends into, the aortic arch, this segment should be partially or totally replaced [12]. Failure to resect the intimal tear and replace the transverse arch in those cases might predispose to late reoperation. However, in accordance with the results of other authors [11], also in our series male sex and coronary artery disease were determinants of late aortic reoperation, and the treatment method did not significantly influence the rate of late aortic reoperation. Although all patients were treated with ß-blockers for arterial hypertension, 33 patients required late graft replacement of the remaining native distal aorta to exclude their postdissection aneurysm with patent false lumen. For this reason, all survivors of type A aortic dissection should be treated with a ß-adrenergic-blocking agent, and require continued surveillance with annual computed tomography or magnetic resonance imaging scans of the aorta [15, 17].

We showed that the long-term results regarding aortic root reoperation between patients with a native aortic valve and patients with an aortic valve replacement were not significantly different (p = 0.92). This is comparable with previously published results focusing on our relatively durable results of aortic valve preservation and root reconstruction in patients who underwent surgery for acute type A aortic dissection with involvement of the aortic root [20]. In the mentioned study, the use of fibrin glue (relative risk 8.7, p = 0.03) and an aortic annulus greater than 27 mm (relative risk 4.2, p = 0.04) were identified as significant risk factors for aortic root reoperation. Additionally in the same study, the use of GRF also seemed to compromise the long-term durability, which is in accordance with the results of other authors who claimed that gluing dissected aortic wall tissue carries a high risk of redissection [22]. Therefore we might agree with Sabik and coworkers [18] that aggressive routine complete aortic root replacement is not always justified.

Late Neurologic Events
Other authors have reported that patients receiving a mechanical prosthesis, and therefore indefinite anticoagulation, are threatened by potential catastrophe as a neurologic event [5]. However, this has not been confirmed in our series; 2 patients with a Bentall procedure had late neurologic deficits. Nevertheless, we emphasize the desirability of preserving the native valve whenever possible.

Also in our series, there was no influence of year of operation on the late results although, of course, we still need to consider the retrospective, nonrandomized nature of this study and its results of different surgeons using a variety of available techniques. Nevertheless, we agree with Ehrlich and colleagues [19] that any other further reduction of mortality rate in patients with a predilection for dissection might come from earlier recognition of risk factors such as hypertension and aortic dilatation, followed by elective operation with its much lower mortality and morbidity. The numerous changes in operative techniques, methods of perfusion, and cerebral protection have not substantially changed our long-term results.

Limitations of the Study
The current series is a retrospective review with a nonrandomized nature covering a long time interval. Accordingly, many surgeons have operated on the patients included in this study. Although each surgeon might have a personal approach, the techniques used were relatively uniform. In addition, the decision to perform a certain repair or use a certain technique was made intraoperatively and depended on the surgeon’s preference and estimation of the feasibility. This practice is, of course, very subjective and might have contributed to a selection bias of patients undergoing a combination of different specific repairs. This bias, however, should have been accounted for by the statistical analysis.

In conclusion, although acute type A aortic dissection is still considered to represent an emergency situation that requires immediate surgical treatment, it seems that for discharged survivors of surgical treatment the long-term results are good. The late survival rates may be enhanced in the future by closer surveillance of the aorta and earlier reintervention before the development of dissection-related complications.

	Appendix

 
Examined Preoperative and Perioperative Patient-Related Variables
Demographic characteristics: Sex, age.

Comorbidities: Diabetes mellitus, preoperative anticoagulantia.

Predisposing factors for dissection: Cardiac catheterization, previous cardiac surgery, Marfan syndrome.

Preoperative status: Acute pain at presentation, time onset to treatment, any neurologic dysfunction, peripheral neurologic deficit, central neurologic deficit, limb malperfusion, oliguria or anuria, cardiac tamponade, cardiogenic shock at presentation, cardiogenic shock at start surgery, cardiopulmonary resuscitation, preoperative pericardial drainage, preoperative serum creatinine, left ventricular function.

Aortic pathology: Aortic valve regurgitation, ruptured ascending aorta, location of entry tear, dissection of left coronary artery, dissection of right coronary artery, macroscopic normal aortic valve, calcified aortic valve, aortic annulus greater than 27 mm.

Procedure: Emergency sternotomy, date of operation, electroencephalogram at induction, hemopericardium, change of arterial cannulation site, deep hypothermic circulatory arrest, antegrade selective cerebral perfusion, diameter proximal aortic prosthesis, aortic valve resuspension, teflon felt, gelatin-resorcinon-formalin glue, Blalock for distal anastomosis, fibrin glue, additional surgical procedure, aortic cross-clamping, antegrade reperfusion distal prosthesis, Bentall procedure, ascending aorta replacement, aortic arch replacement, aortic valve replacement, end-to-end reanastomosis, extracorporeal circulation time, myocardial ischemia time, deep hypothermic circulatory arrest time, brain ischemia time, antegrade selective cerebral perfusion time, body ischemia time, blood temperature, rectal temperature, nasopharyngeal temperature.

	Acknowledgments

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We appreciate the surgical expertise and editorial assistance contributed by associate operative surgeons Paul J. Knaepen, MD, Jo J. A. M. Defauw, MD, Henry A. van Swieten, MD, PhD, and Wim-Jan van Boven, MD.

	References

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