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A tailored strategy for repair of acute type A aortic dissection

Published:January 11, 2021DOI:https://doi.org/10.1016/j.jtcvs.2020.12.113

      Abstract

      Objective

      Innumerable surgical techniques are currently deployed for repairing acute type A aortic dissection (ATAAD). We analyzed our results using a conservative approach of root-sparing and hemiarch techniques in higher-risk patients and root and total arch replacement for lower-risk patients.

      Methods

      We queried our aortic database for consecutive patients who underwent ATAAD repair. Patients who underwent conservative repair (group 1) were compared with those who underwent extensive repair (group 2) using univariable and multivariable analysis.

      Results

      From 1997 to 2019, 343 patients underwent ATAAD repair. Two hundred forty had conservative repair (root-sparing, hemiarch) whereas 103 had extensive repair (root replacement and/or total arch). Group 1 was older with more comorbidities such as hypertension, previous myocardial infarction, and renal dysfunction. Group 2 had more connective tissue disease (2.1% vs 12.6%; P < .01), aortic insufficiency, and longer intraoperative times. The incidence of individual postoperative complications was similar regardless of approach. A composite of major adverse events (operative mortality, myocardial infarction, stroke, dialysis, or tracheostomy) was higher in the conservative group (15.1% vs 5.9%; P = .03). Operative mortality was 5.6% and not different between groups. Ten-year survival was similar with either surgical approach. Ten-year cumulative risk of reintervention was greater in group 2 (5.6% vs 21% at 10 years; P < .01). In multivariable analysis, ejection fraction and diabetes were predictors of major adverse events but not extensive approach. Extensive approach was a predictor of late reoperation (odds ratio, 3.03 [95% confidence interval, 1.29-7.2]; P = .01).

      Conclusions

      A tailored conservative approach to ATAAD leads to favorable operative outcomes without compromising durability.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      AI (aortic insufficiency), ATAAD (acute type A aortic dissection), CI (confidence interval), CTD (connective tissue disease), CVG (composite valve graft), FET (frozen elephant trunk), IQR (interquartile range), MAE (major adverse events), MAPE (major adverse pulmonary events), OM (operative mortality), PND (permanent neurologic deficit), RCP (retrograde cerebral perfusion), SCI (spinal cord injury), TAR (total arch replacement), VSRR (valve-sparing root reimplantation)
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