Techniques of Proximal Root Reconstruction and Outcomes Following Repair of Acute Type A Aortic Dissection

Tyler M. Gunn; Sotiris C. Stamou; Nicholas T. Kouchoukos; Kevin W. Lobdell; Kamal Khabbaz; Lawrence H. Patzelt; Robert C. Hagberg

doi:10.12945/j.aorta.2016.14.039

AORTA, Inhaltsverzeichnis

CC BY 4.0 · Aorta (Stamford) 2016; 04(02): 33-41
DOI: 10.12945/j.aorta.2016.14.039

Original Research Article

Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Techniques of Proximal Root Reconstruction and Outcomes Following Repair of Acute Type A Aortic Dissection

Tyler M. Gunn

¹Department of Cardiothoracic Surgery, Baystate Medical Center, Springfield, Massachusetts, USA

,

Sotiris C. Stamou

¹Department of Cardiothoracic Surgery, Baystate Medical Center, Springfield, Massachusetts, USA

,

Nicholas T. Kouchoukos

²Division of Cardiothoracic Surgery, Missouri Baptist Medical Center, Saint Louis, Missouri, USA

,

Kevin W. Lobdell

³Department of Thoracic and Cardiovascular Surgery, Sanger Heart and Vascular Institute, Carolinas Medical Center, Charlotte, North Carolina, USA

,

Kamal Khabbaz

⁴Division of Cardiothoracic Surgery, Department of Surgery and The Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA

,

Lawrence H. Patzelt

⁵Thoracic and Cardiovascular Surgery, Spectrum Health, Fred and Lena Meijer Heart and Vascular Institute, Grand Rapids, Michigan, USA

,

Robert C. Hagberg

⁶Department of Cardiac Surgery, Hartford Hospital, Hartford, Connecticut, USA

› Institutsangaben

Abstract

Background: The goal of this study was to compare the early and late outcomes of different techniques of proximal root reconstruction during the repair of acute Type A aortic dissection, including aortic valve (AV) resuspension, aortic valve replacement (AVR), and a root replacement procedure.

Methods: All patients who underwent acute Type A aortic dissection repair between January 2000 and October 2010 at four academic institutions were compiled from each institution’s Society of Thoracic Surgeons Database. This included 189 patients who underwent a concomitant aortic valve (AV) procedure; 111, 21, and 57 patients underwent AV resuspension, AVR, and the Bentall procedure, respectively. The median age of patients undergoing a root replacement procedure was significantly younger than the other two groups. Early clinical outcomes and 10-year actuarial survival rates were compared. Trends in outcomes and surgical techniques throughout the duration of the study were also analyzed.

Results: The operative mortality rates were 17%, 29%, and 18%, for AV resuspension, AVR, and root replacement, respectively. Operative mortality (p = 0.459) was comparable between groups. Hemorrhage related re-exploration did not differ significantly between groups (p = 0.182); however, root replacement procedures tended to have decreased rates of bleeding when compared to AVR (p = 0.067). The 10-year actuarial survival rates for the AV resuspension, Bentall, and AVR groups were 72%, 56%, and 36%, respectively (log-rank p = 0.035).

Conclusions: The 10-year actuarial survival was significantly lower in those receiving AVR compared to those receiving root replacement procedures or AV resuspension. Operative mortality was comparable between the three groups.

Key Words

Aorta - Aortic aneurysm - Aortic root - Aortic valve

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Referenzen

References
1 Bavaria JE, Brinster DR, Gorman RC, Woo YJ, Gleason T, Pochettino A. Advances in the treatment of acute Type A dissection: an integrated approach. Ann Thorac Surg 2002; 74: S1848-52 ; DOI: 10.1016/S0003-4975(02)04128-0
2 Mehta RH, Suzuki T, Hagan PG, Bossone E, Gilon D, Llovet A. , et al. Predicting death in patients with acute Type a aortic dissection. Circulation 2002; 105: 200-206 . DOI: 10.1161/hc0202.102246
3 Stamou SC, Kouchoukos NT, Hagberg RC, Smith CR, Nussbaum M, Hooker RL. , et al. Differences in clinical characteristics, management, and outcomes of intraoperative versus spontaneous acute Type A aortic dissection. Ann Thorac Surg 2013; 95: 41-45 . DOI: 10.1016/j.athoracsur.2012.08.050
4 Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL. , et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000; 283: 897-903 . DOI: 10.1001/jama.283.7.897
5 Mészáros I, Mórocz J, Szlávi J, Schmidt J, Tornóci L, Nagy L. , et al. Epidemiology and clinicopathology of aortic dissection. Chest 2000; 117: 1271-1278 . DOI: 10.1378/chest.117.5.1271
6 Pacini D, Di Marco L, Fortuna D, Belotti LM, Gabbieri D, Zussa C. , et al. Acute aortic dissection: epidemiology and outcomes. Int J Cardiol 2013; 167: 2806-2812 . DOI: 10.1016/j.ijcard.2012.07.008
7 Olsson C, Thelin S, Ståhle E, Ekbom A, Granath F. Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002. Circulation 2006; 114: 2611-2618 . DOI: 10.1161/CIRCULATIONAHA.106.630400
8 Erbel R, Alfonso F, Boileau C, Dirsch O, Eber B, Haverich A. , et al. Diagnosis and management of aortic dissection. Eur Heart J 2001; 22: 1642-1681 . DOI: 10.1053/euhj.2001.2782
9 Krüger T, Conzelmann LO, Bonser RS, Borger MA, Czerny M, Wildhirt S. , et al. Acute aortic dissection Type A. Br J Surg 2012; 99: 1331-1344 . DOI: 10.1002/bjs.8840
10 Feldman M, Shah M, Elefteriades JA. Medical management of acute Type A aortic dissection. Ann Thorac Cardiovasc Surg 2009; 15: 286-293 . PMID: 19901881
11 Krüger T, Weigang E, Hoffmann I, Blettner M, Aebert H. GERAADA Investigators. Cerebral protection during surgery for acute aortic dissection Type A: results of the German Registry for Acute Aortic Dissection Type A (GERAADA). Circulation 2011; 124: 434-443 . DOI: 10.1161/CIRCULATIONAHA.110.009282
12 Kouchoukos NT, Dougenis D. Surgery of the thoracic aorta. N Engl J Med 1997; 336: 1876-1888 . DOI: 10.1056/NEJM199706263362606
13 Klodell CT, Karimi A, Beaver TM, Hess PJ, Martin TD. Outcomes for acute Type A aortic dissection: effects of previous cardiac surgery. Ann Thorac Surg 2012; 93: 1206-1212 ; DOI: 10.1016/j.athoracsur.2011.12.076
14 Subramanian S, Leontyev S, Borger MA, Trommer C, Misfeld M, Mohr FW. Valve-sparing root reconstruction does not compromise survival in acute Type A aortic dissection. Ann Thorac Surg 2012; 94: 1230-1234 . DOI: 10.1016/j.athoracsur.2012.04.094
15 Lai DT, Miller DC, Mitchell RS, Oyer PE, Moore KA, Robbins RC. , et al. Acute Type A aortic dissection complicated by aortic regurgitation: composite valve graft versus separate valve graft versus conservative valve repair. J Thorac Cardiovasc Surg 2003; 126: 1978-1986 . DOI: 10.1016/S0022-5223(03)01279-0
16 Goda M, Imoto K, Suzuki S, Uchida K, Yanagi H, Yasuda S. , et al. Risk analysis for hospital mortality in patients with acute Type a aortic dissection. Ann Thorac Surg 2010; 90: 1246-1250 . DOI: 10.1016/j.athoracsur.2010.05.069
17 Kazui T, Washiyama N, Bashar AH, Terada H, Suzuki T, Ohkura K. , et al. Surgical outcome of acute Type A aortic dissection: analysis of risk factors. Ann Thorac Surg 2002; 74: 75-81 . DOI: 10.1016/S0003-4975(02)03603-2
18 Olsson C, Hillebrant CG, Liska J, Lockowandt U, Eriksson P, Franco-Cereceda A. Mortality in acute Type A aortic dissection: validation of the Penn classification. Ann Thorac Surg 2011; 92: 1376-1382 . DOI: 10.1016/j.athoracsur.2011.05.011
19 Sabik JF, Lytle BW, Blackstone EH, McCarthy PM, Loop FD, Cosgrove DM. Long-term effectiveness of operations for ascending aortic dissections. J Thorac Cardiovasc Surg 2000; 119: 946-962 . DOI: 10.1016/S0022-5223(00)70090-0