Should a reimplantation valve sparing procedure be done systematically in type A aortic dissection?

Abstract

To evaluate the risks and benefits of a systematic reimplantation valve sparing procedure in the surgical treatment of type A aortic dissection (TAAD). From February December 2005, 15 consecutive patients (mean age 61+/-12 years) who underwent surgery for TAAD were analyzed prospectively. Eleven had a preoperative CT-scan and all had an echography. Eight patients presented with a preoperative aortic insufficiency>2/4 and seven had an ascending aortic aneurysm over 50mm. In 11 cases, arterial cannulation was performed directly into the ascending aorta. Surgical technique included complete resection and replacement of the ascending aorta using a reimplantation valve sparing technique (David), associated in 12 patients with an arch replacement, under mild (29.7+/-3.0 degrees C) hypothermia and cerebral selective antegrade perfusion. Aortic clamping, cerebral perfusion and cardiopulmonary bypass (CPB) times were respectively 93+/-29, 18+/-9, and 131+/-38min. Mean bleeding at 24h was 1165+/-846ml. Troponin I level at 24h was 21+/-30 microg/l. One patient had a right coronary artery bypass for a chronically occluded coronary. Another had a triple arterial revascularisation for pre-existing coronary dissection. One patient presented with a postoperative regressive right hemiparesia (normal CT-scan). Two patients underwent revision for bleeding (one was undergoing treatment by clopidogrel). One patient had at day 7 an implantation of a covered stentgraft on the descending aorta for a concomitant penetrating aortic ulcer. One patient died suddenly on POD 7 during a tracheal aspiration. Intubation and ICU times were respectively 9.5+/-16.3 and 16.2+/-20.9 days. Four patients with severe preoperative co morbidities had long intubations. Echographic and CT-scan control, done in postoperative and after a mean follow up of 11.0+/-4.8 months, did not show any residual aortic insufficiency (actuarial survival rate at 2 years of 93.3%). A reimplantation valve sparing procedure in the TAAD seems to be reliable and should be proposed systematically without emphasizing perioperative morbidity.