Abstract
Objective: An inverse relationship between volume and mortality in some cardiothoracic surgical procedures has been previously established, leading to suggestions that acute aortic dissection should not be operated in community or low volume heart centers. We therefore reviewed our experience to compare with published data. Methods: Retrospective review of 27 patients who underwent proximal aortic surgery by a single surgeon at an inner city community hospital between May 2004 and April 2015. 16 patients, mean age 51.7 ± 13.6 years old, 75.0% males underwent emergency surgery for acute Stanford type A aortic dissection, while 9 with root or ascending aortic aneurysm, mean age 50.3 ± 15.0 years old, 88.9% males had elective proximal aortic surgery. 2 patients with arch aneurysm were excluded. Results: Four (25.0%) patients with acute dissection were in Penn class A, 3 (18.7%) Penn B, 3 (18.7%) Penn C and 6 (37.5%) Penn B+C. 10 (62.5%) patients underwent emergency root replacement with 60.0% (6/10) mortality all related to malperfusion including 2 patients with bloody stools, while 6 (37.5%) underwent supracoronary graft replacement with 16.6% (1/6) mortality from cardiac tamponade. The 5-year survival was 89.0%. In patients with aortic aneurysm, 8 (88.9%) underwent elective root replacement and 1 (11.1%) supracoronary graft replacement with zero mortality. Conclusion: Supracoronary graft replacement is performed for the majority of uncomplicated acute type A dissections and can be undertaken by the average general cardiac surgeon with acceptable results. Visceral malperfusion especially when associated with bloody stools portends a poor prognosis, and aortic dissection should be excluded in any Marfan patient presenting with acute abdomen. Delaying intervention in attempting transfer to a tertiary hospital can potentially increase preoperative mortality, known to rise with each passing hour from onset of acute dissection. Patients presenting therefore to community hospitals should probably undergo surgery there to avoid complications associated with delay.
Highlights
Proximal acute aortic dissection remains one of the most dreaded emergencies in cardiothoracic surgery, often associated with comparatively higher mortality and morbidity than other commonly encountered pathologies in the specialty
Between May 2004 and April 2015, 27 patients operated by the author underwent proximal aortic surgery at an inner city community hospital. 16 patients presented with Acute Stanford Type A Aortic Dissection (AAAD) and 11 patients with root, ascending and arch aneurysm
All the deaths occurred in patients with more complicated dissection according to the Penn classification. 2 patients presenting with signs of bowel ischemia and bloody stools died within 24 - 48 hours post operatively from refractory acidosis after aortic root replacement
Summary
Proximal acute aortic dissection remains one of the most dreaded emergencies in cardiothoracic surgery, often associated with comparatively higher mortality and morbidity than other commonly encountered pathologies in the specialty. These patients not infrequently present at night to community hospital based heart programs, some of whom may have limited experience with proximal aortic surgery. The surgeon at the community hospital may be in a dilemma on whether to operate locally or attempt finding a specialized tertiary hospital that is willing to accept the patient. Recent advances in surgical techniques, cerebral protection strategies and the advent of hybrid endovascular aortic repairs for complicated dissections have all contributed to an overall improvement in survival over the last decade even in the hands of less experienced aortic surgeons
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