Technical Improvements and Individualized Operations Result in Favorable Outcome in Patients with Acute Aortic Dissection Type A

Abstract

Introduction: During the last 2 decades, outcome for patients operated for acute aortic dissections type A (AADA) improved. We analyzed our own institutional results over a 25-year period aimed to identify factors that are responsible for this improvement. Methods: In total, 407 patients were operated for AADA between 1988 and 2012 (132 female, 284 male, mean age 58 years). The cohort was divided in 6 consecutive time clusters. Thirty-day mortality, long-term survival, incidence of neurological complications and cardiovascular events were analyzed. Risk factors for 30-day and long term mortality were evaluated with univariate and multivariate regression analysis. Results: Overall 30-day mortality was 20.8%, highest in cluster III (1997–2000, 32%) and lowest in cluster V (2005–2008, 9.6%, p = 0.002). The David-operation was performed more frequently over the course of time (p = 0.008, cluster III versus V). Cannulation of the femoral artery was rarer (p = 0.009) and selective antegrade cerebral perfusion (SAP) and total arch replacement was more frequently applied (both p< 0.001) in cluster V, but bleeding volume (p = 0.01) and aortic clamp time (p< 0.001) increased. Introduction of moderate hypothermia combined with SAP and use of frozen elephant (since cluster V) trunk did not influence outcome significantly. Estimated five-year survival was 59.3%. Valve sparing techniques presented superior 5-year survival compared with composite implantation (p = 0.032). Furthermore, total arch replacement was not inferior to partial arch replacement regarding 30-day mortality (p = 0.816) and 5-year survival (p = 0.779). Important risk factors for 30-day mortality were neurological complication, previous thoracic surgery, cardiocirculatory arrest, bypass- and aortic clamp times. Cardiocirculatory arrest per se was revealed as risk factor for long term survival. Conclusions: By introduction of advanced intraoperative cerebral protection techniques, more aggressive arch surgery and aortic valve preserving techniques survival improved in patients with AADA. Improvement of outcome was observed despite longer aortic clamp time. In AADA patients individualized planning of surgical treatment is as important as quick surgery.