Proximal Reoperation Research Articles

Indications and outcomes of second aortic procedures after acute type A dissection repair.

Aortic arch or aortic root replacement is not performed in all cases of acute type A aortic dissection (ATAD), and a second aortic procedure will become necessary over time for some patients. Indications and outcomes, of second aortic procedures have not been studied extensively. Characteristics and in-hospital outcomes of all patients undergoing surgical repair for type A acute aortic dissection were analysed and patients needing second aortic procedure during follow-up were identified. The latter group was divided in 2 subgroups: on-pump includes patients operated on using cardiopulmonary bypass and off-pump without cardiopulmonary bypass. A total of 638 patients underwent surgery for ATAD; 8% required a second aortic procedure. The most frequent indication for the second aortic procedure was dehiscence of suture lines (44%), followed by arch dilatation (24%). In-hospital mortality was 12%. Isolated ascending aorta replacement at the first surgery was associated with higher incidence of second aortic procedure (P = 0.006). Most patients in the on-pump group underwent a proximal reoperation (75%), with a mortality rate of 14.2%. In-hospital mortality of patients in the off-pump group was 7.7%. Long-term survival analysis showed no difference between groups (P = 0,526), Off-pump patients have greater likelihood of a second intervention during follow-up (P = 0.004). Extended aortic root surgery and customized aortic arch repair in ATAD could be reasonable to reduce the incidence and mortality of high-risk second aortic procedures.

Type A acute aortic dissection with ≥40-mm aortic root: results of conservative and replacement strategies at long-term follow-up.

We evaluated the long-term results of aortic root (AR) preservation and replacement in patients operated on for acute type A aortic dissection. Out of 302 patients discharged after repair of acute aortic dissection (1977-2019), 124 patients had an AR ≥40 mm, which was preserved in 84 (68%, group A) patients and replaced in 40 (32%, group B) patients. Group B patients were younger (mean age 57 ± 12 vs 62 ± 11 years, P = 0.07), with a mean AR of 47 vs 43 mm and ≥moderate aortic insufficiency in 65% vs 30%. Survival, causes of death and reoperations were analysed at mean follow-up of 9 ± 8 years (6 months to 40 years). Actuarial survival of discharged patients at 5, 10 and 15 years was 97% (0.89-0.99), 78% (0.67-0.90) and 75% (0.64-0.88) in group A, and 85% (0.71-0.95), 62% (0.44-0.78) and 57% (0.39-0.76) in group B (log-rank test P = 0.2). Nine patients in group A (7 patients for aortic insufficiency and dilatation of the root and 2 patients for pseudoaneurysm) and 1 patient of group B (pseudoaneurysm of the right coronary button) required proximal reoperation without deaths. At 5, 10 and 15 years, the cumulative incidence of proximal aortic reoperations was 5%, 9% and 25% in group A, and 0%, 3% and 3% in group B (P = 0.02). At multivariable analysis AR >45 mm [hazard ratio (HR) 6.8, P = 0.026] and age (HR 0.9, P = 0.016) were independently associated with proximal reoperation. AR preservation in acute type A dissection showed acceptable long-term outcomes. Nevertheless, a more aggressive approach appears a valid option, especially in patients with AR diameter >45 mm.

Aortic Root Remodeling in Acute Aortic Dissection.

To evaluate the long-term results of remodeling in acute aortic dissection type A (AADA) to define operative risk and root and valve stability. Between October 1995 and December 2018, a total of 352 patients were treated surgically for AADA. Of these, 90 patients with AADA (<2 weeks from onset; age: 57 ± 15 years; 70 males) with a root diameter of >43 to 45 mm (depending on patient size) (48 ± 4.1 mm) underwent aortic root remodeling and were analyzed further. As the control group, we chose the patients with normally sized aortic roots who had been treated by tubular replacement only (n = 227). Other procedures were performed in 35 cases. Early mortality was 9% in the remodeling group versus 15% in the tubular ascending aortic replacement (TAR). Actuarial survival at 10 and 15 years was 68 ± 5% and 58.3 ± 6.4%, respectively, in the root remodeling group versus 68 ± 4% and 66 ± 4% in the TAR group (p = 0.99). Freedom from reoperation on the aortic valve or root was 95 ± 3% at 10 years and at 89 ± 6% at 15 years. Freedom from proximal reoperation after TAR at 10 and 15 years was 93 ± 3% and 91 ± 3% (n = 31 patients at risk), respectively, not statistically different from that after remodeling (p = 0.75). The long-term stability of aortic root remodeling for enlarged roots with AADA was comparable to TAR preserving a normal aortic root.

Surgical Management and Outcomes of the Aortic Root in Acute Type A Aortic Dissection

This study evaluated the short- and middle-term outcomes of different aortic root managements in the setting of acute type A aortic dissection (ATAAD): aortic root repair (ARR group), untouched aortic root (UAR group), and Bentall procedure (Bentall group). The study enrolled 673 patients (512 men; age 48.8 ± 11.2 years) between 2010 and 2015. Survival, aortic growth, reintervention, and valve function were compared between the 3 groups. The ages were 50.6 ± 9.9, 49.8 ± 12.2, and 44.0 ± 12.0 years for ARR, UAR, and Bentall groups, respectively (P < .01). The mean follow-up time was 3.0 years (range, 0.5-6.8 years). The aortic root diameters in the groups were 39.0 ± 5.1 mm in ARR, 38.2 ± 4.4 mm in UAR, and 50.3 ± 6.2 mm in Bentall (P < .01). The overall 30-day mortality was 11.7% (79 of 673). There was no difference in 30-day mortality between the 3 groups (P= .58). The estimated aortic root growth rate was 0.60 ± 0.17 mm/y for ARR and 0.50 ± 0.14 mm/y for UAR. During follow-up, 28 patients (4.1%) died. Differences in 5-year survival between the 3 groups did not reach statistical significance (P= .82). Aortic insufficiency greater than grade 2+ developed in 15 patients (2.2%). There was no significant difference between ARR and UAR in freedom from aortic insufficiency greater than grade 2+ (P= .56). None of the patients experienced new dissection or underwent proximal reoperation during the follow-up period. Conservative techniques (ARR and UAR) and aggressive root replacement can both be performed with excellent short- and middle-term outcomes in ATAAD. Thus, an individualized approach in managing the aortic root for ATAAD is recommended based on the patient's general condition, root pathology, and the surgeon's preference.

Contemporary outcomes of composite aortic root replacement in elderly patients.

We investigated the clinical and haemodynamic outcomes in elderly patients undergoing composite aortic root replacement. Between 2005 and 2017, 135 patients underwent aortic root surgery at our hospital. Of these 135 patients, 47 patients aged ≥65 years were included in this study. Pathologies included aneurysms in 31, chronic aortic dissection in 6, acute aortic dissection in 4 and other causes in 6 patients. A bioprosthesis was used in 27 and a mechanical valve in 20 patients. The mean age was 71.0 ± 4.3 years. The mean follow-up period was 61 ± 35 months. Follow-up echocardiographic data (average 48 months after surgery) were collected in 35 patients (74%). The in-hospital mortality rate was 2.1% (1 patient). Seven late deaths occurred during follow-up. The 1-, 5- and 8-year overall survival was 93.6%, 82.9% and 82.9%, respectively. Infective endocarditis, Marfan syndrome and diabetes were independent predictors of poorer survival. During the follow-up, thromboembolism occurred in 1 patient, major bleeding events in 5 patients, or proximal reoperation for prosthetic valve endocarditis in 1 patient. The type of valve, mechanical or biological valve, did not affect late mortality and morbidity. Follow-up echocardiography revealed significantly improved left ventricular ejection fraction compared with that at discharge. Composite aortic root replacement provided satisfactory midterm outcomes in patients aged ≥65 years. Further studies with a longer follow-up are warranted to evaluate late valve-related events.

Low rate of reoperations after acute type A aortic dissection repair from The Nordic Consortium Registry

ObjectivesTo describe the relationship between the extent of primary aortic repair and the incidence of reoperations after surgery for type A aortic dissection. MethodsA retrospective cohort of 1159 patients treated for type A aortic dissection at eight Nordic low- to medium-sized cardiothoracic centers from 2005 to 2014. Data were gathered from patient records and national registries. Patients were separately divided into 3 groups according to the distal anastomoses technique (ascending aorta [n = 791], hemiarch [n = 247], and total arch [n = 66]), and into 2 groups for proximal repair (aortic root replacement [n = 285] and supracoronary repair [n = 832]). Freedom from reoperation was estimated with cumulative incidence survival and Fine-Gray competing risk regression model was used to identify independent risk factors for reoperation. ResultsThe median follow-up was 2.7 years (range, 0-10 years). Altogether 51 out of 911 patients underwent reoperation. Freedom from distal reoperation at 5 years was 96.9%, with no significant difference between the groups (P = .22). Freedom from proximal reoperation at 5 years was 97.8%, with no difference between the groups (P = .84). Neither DeBakey classification nor the extent of proximal or distal repair predicted freedom from a later reoperation. The only independent risk factor associated with a later proximal reoperation was a history of connective tissue disease. ConclusionsType A aortic dissection repair in low- to medium-volume centers was associated with a low reoperation rate and satisfactory midterm survival. The extent of the primary repair had no significant influence on reoperation rate or midterm survival.

Aortic root remodeling leads to good valve stability in acute aortic dissection and preexistent root dilatation

ObjectivesTo evaluate the long-term results of aortic root remodeling in the setting of acute aortic dissection type A (AADA). MethodsBetween October 1995 and May 2013, a total of 215 patients were treated surgically for AADA. Of these, 59 patients with AADA (<2 weeks from onset, age 56 ± 16 years, 53 males) with a root diameter of ≥43 to 45 mm (depending on patient size) underwent aortic root remodeling and were analyzed further. Reimplantation was performed in 7 patients; root replacement with a mechanical composite graft, in 16 patients; root replacement with a stentless biological prosthesis, in 10 patients; and tubular ascending aortic replacement, in 133 patients. ResultsReexploration for bleeding was performed in 10 patients (17%; 8% since 2007). Early mortality was 6.8%; no patient died after 2002. Actuarial survival at 10 years was 72% ± 6%. One patient underwent aortic valve replacement for recurrent cusp prolapse at 1 year after surgery. In this operation, cusp configuration was assessed by eyeballing until 2003. The rate of freedom from proximal reoperation at 10 years was 98% ± 2%. Using a Cox proportional hazards model, no independent predictors for survival and reoperation after remodeling were found. Advanced age and concomitant coronary artery bypass grafting were identified as independent predictors for survival in all 215 patients with AADA. ConclusionsRoot remodeling allows for stable valve preservation in patients with AADA and preexistent root dilatation.

Late echocardiographic study of aortic valve and aortic root after surgery for type a acute aortic dissection

Objective:In case of concomitant aortic regurgitation (AR) valve, sparing operation is considered the first choice in selected patients. The aim of this retrospective clinical and echocardiographic study was to evaluate the long-term survival results of conservative approach and the determinants of recurrent AR.Methods:From 2000 to 2011, fifty patients (median: 63 years and interquartile range: 53–72) underwent an aortic valve-sparing procedure for acute aortic dissection, and discharged alive. The long-term clinical and echocardiographic outcome was analyzed.Results:Late all-causes mortality was 18% (nine patients) at a median follow-up of 55.8 months. Ten patients (20%) underwent re-operations, five of them for aortic valve/root recurrent disease; freedom from proximal re-operation was 90%. Two-third of the patients had a preoperative AR grade <3; a non-negligible number of patients with acute significant AR (23% with grade ≥3) at the time of surgery underwent conservative aortic valve surgery. At a median echocardiographic follow-up of 50.5 months, we found no significant correlation between late recurrent AR and AR grade at the time of surgery and the aortic root diameter. Late recurrent AR grade was significantly higher in patients who underwent aortic commissures and cusps resuspension than those who underwent lone ascending aorta replacement (2.29 ± 1.05 vs. 1.58 ± 1.03, P = 0.028).Conclusions:Preoperative AR and late aortic root diameter were not the predictors of late AR. Late AR is higher in patients who underwent aortic commissures and cusps resuspension compared to the only replacement of the ascending aorta.

Bicuspid Aortic Valve Resuspension in Acute Type A Aortic Dissection Patients

There are no data on the fate of the preserved bicuspid aortic valve (BAV) in patients with acute type A aortic dissection. We investigated surgical outcomes in BAV patients who had undergone aortic valve resuspension versus replacement for dissection type A. Among 1,500 consecutive patients operated on for acute type A dissection between 1993 and 2013 at 3 tertiary centers, 66 had BAV (68% males, median age 60 ± 15 years). Thirteen BAV resuspension patients were compared with 53 BAV replacement patients. Median follow-up was 5.0 ± 4.7 years. The ages of both groups were similar (resuspension 62 ± 13 vs replacement 57 ± 15 years, p = 0.62), and both presented similar risk-factor profiles. Moderate-to-severe aortic valve regurgitation was observed in 15% of the resuspension and 45% of the replacement patients (p = 0.06). Resuspension patients required shorter cardiopulmonary bypass and cross-clamp times (153 ± 48 vs 224 ± 76 min, p < 0.01; 106 ± 33 vs 172 ± 57 min, p < 0.01, respectively). In-hospital mortality was observed in 15.4% of the resuspension and 15.1% of the replacement patients (p = 1). One replacement patient underwent a proximal reoperation. The resuspension group experienced no severe aortic regurgitation, nor any need for proximal reintervention. Overall survival was 68% ± 13% vs 65% ± 7% at 5 years in resuspension and replacement groups, respectively (log- rank, p = 0.97). The BAV resuspension in type A dissection patients showed good short- and mid-term results. It is doable with acceptable results, and full root replacement is not always necessary.

Proximal Redo after Acute Type A Aortic Dissection: Early Results form a Multicenter Experience

Objectives: The aim of this European multicenter-experience was to report on surgical outcomes in terms of mortality and complications of proximal reoperation after intial repair of acute typ A dissection (AAD). Methods: Between May 1998 and January 2014, 71 isolated proximal aortic re-operation (mean time from the first procedure was 3.67 years, range 0.15–16.6) were performed in 66 patients (mean age 60.8 ± 12.4 years, males 50). Proximal causes for re-operation were aortic root aneurysm in 17, root re-dissection in 13, aortic valve insufficiency in 24 and proximal anastomic pseudoaneurysm in 19 patients. Result: The most frequent proximal procedure during redo was the composite aortic root replacement (Bentall procedure) (40 operations, 56.35%), followed by isolated aortic valve replacement (13 pts., 18,31%) and ascending aorta replacement (9 pts., 12,68%). David procedure was performed in 4 patients (5.63%). In-hospital mortality was 14% (10 pts.), of them 7 deaths were reported after emergency operations and 3 in elective or urgent setting. Causes of deaths were cardiac in 5, neurological in 2, MOF in 3. Major adverse event included low output syndrome in 7, neurological complications in 7, acute renal failure 7 and bleeding complications in 10 patients and lung failure in 5 patients. Conclusion: Proximal re-operations can be performed with acceptable in-hospital results. Thus conservative approach of the proximal aorta for AAD should not be considered a concern for late reoperations. Strict follow-up after AAD is mandatory to avoid emergency re-operations.

190 * REDO AFTER ACUTE TYPE A AORTIC DISSECTION: EARLY RESULTS FROM A MULTICENTRE REAL-WORLD EXPERIENCE

Objectives: To provide early results of repetitive surgical procedures after first operation for acute type A aortic dissection (AAD) and to identify risk factors for mortality. Methods: Between May 1998 and January 2014, 117 aortic reoperations after initial operation for AAD (mean time from the first procedure was 3.98 years, range 0.1–20.87) were performed in 110 patients (mean age 59.8 ± 12.6 years) in 7 real-world institutions. Proximal causes for reoperation were aortic root aneurysm in 20, root re-dissection in 17, aortic valve insufficiency in 27 and proximal anastomotic pseudoaneurysm in 26 patients. Distal causes were arch re-dissection in 18, arch dilatation in 15, anastomotic pseudoaneurysm in 25 patients. Results: A total of 74 isolated proximal, 30 isolated distal and 13 combined procedures were performed. There were 23 (19.66%) in-hospital deaths (elective/urgent 11.11%, emergency 66.67%). Causes of death were cardiac in 8, neurological in 3, multiorgan failure in 5, sepsis in 2, bleeding in 3 and lung failure in 2 patients. Multivariate logistic regression analyses revealed that risk factors for mortality were emergency operation (P < 0.0001), previous distal procedure (P = 0.04) and new elephant trunk procedure (P = 0.03). New proximal procedures were not found to be risk factors for early mortality (P = 0.15). Conclusion: This multicentre experience shows that redo surgery after AAD operations remains a challenging procedure especially in emergency settings and after surgery of the distal aorta. Proximal reoperation does not affect mortality; therefore initial aortic root preservation for AAD should not be considered a concern for late reoperations.

Low incidence of late pseudoaneurysm and reoperation after conventional repair of acute type a aortic dissection.

Suture line dehiscence and pseudoaneurysm formation is one of the leading causes of late reoperation after surgical repair of acute type A aortic dissection (AAD). A sandwich technique can affect the need of reoperation. We sought to assess the late outcomes (mortality and reoperation) of a modified reinforced sandwich technique in conventional AAD repair. Retrospective review of 63 consecutive patients undergoing AAD repair between 2003 and 2013. Aortic anastomosis was performed with a modified reinforced sandwich technique using Hemashield strips and two-layer polypropylene continuous and interrupted mattress sutures. Marfan syndrome was diagnosed in five (8%) and bicuspid aortic valve in three patients (5%). Twenty-one patients (33%) had preoperative cardiogenic shock necessitating inotropic support. Replacement of the ascending aorta with aortic valve preservation was performed in 58 (92%) and hemiarch replacement in five patients (8%). Four patients died during initial hospitalization, yielding a hospital mortality of 6%. Median follow-up duration was 73 months (range, 1-124). Kaplan-Meier survival rates were 94 ± 3%, 84 ± 5%, and 59 ± 11% at 1, 5, and 10 years. One patient (1.7%) required proximal reoperation 44 months after AAD repair because of progressive dilatation of the aortic root. No patient had severe aortic regurgitation or pseudoaneurysm after AAD repair. Actuarial freedom from reoperation at 1, 5, and 10 years was 100%, 97%, and 97%. A reinforced sandwich technique was a good technique resulting in a low incidence of late reoperation and pseudoaneurysm formation.

Long-Term Results of Neomedia Sinus Valsalva Repair in 489 Patients With Type A Aortic Dissection

Acute type A aortic dissection frequently occurs in patients with normally sized aortic roots. The aim of this investigation was to describe the durability of aortic valve resuspension and root repair with a novel technique of reconstruction in type A dissection. From 1993 to 2013, among 629 patients operated on for acute type A dissection 489 (62% male, median age 62 years (53; 73) underwent aortic valve resuspension and reinforcement of the sinus of Valsalva with a Teflon felt neomedia. The median follow-up time was 4.1 years (1.3; 6.8) (2075 patient-years). In-hospital mortality was 11% (56/489). Survival was 69%±2%, 50%±3%, and 36%±5% at 5, 10, and 15 years, respectively. Freedom from moderate or severe aortic regurgitation was not influenced by the aortic regurgitation grade at the initial operation (p=0.131). Freedom from proximal aortic reoperation was 96%±1%, 92%±2%, and 89%±4% at 5, 10, and 15 years, respectively. Seventeen patients (3%) required proximal reoperation: 10 for aortic regurgitation, including 3 with concomitant pseudoaneurysm and 2 with root aneurysm; 6 for pseudoaneurysm; and 1 for graft infection. Aortic root neomedia reconstruction and valve resuspension can be successfully performed in the majority of patients with type A dissection. The in-hospital mortality is low, and the results are durable.

Mortality and reoperations in survivors operated on for acute type A aortic dissection and implications for catheter-based or hybrid interventions

This study investigated late outcomes (mortality, reoperations) and their associated predictors after operations for acute type A aortic dissection. The role catheter-based and hybrid interventions is discussed. All hospital survivors operated on for acute type A aortic dissection from 1990 through 2009 were reviewed, with cross-sectional follow-up. Mortality (overall and aortic) and freedom from reoperations (proximal and distal) were estimated using actuarial methods. Preoperative, intraoperative, and postoperative variables (n = 44) associated with late outcomes were analyzed with univariable and multivariable (Cox) statistical methods. Of 360 operated-on patients, 291 hospital survivors (81%) were monitored for a median of 5.5 years (1864 patient-years). Total late mortality was 30% (n = 86), with estimated (standard error) survival of 82% (3%), 64% (4%), and 48% (6%) at 5, 10, and 15 years, respectively. Aortic events accounted for at least 27% (up to 42% including unknown causes) of late deaths. In Cox analysis, variables independently related (hazard ratios [95% confidence limits]) to late mortality were increased age (1.6 per 10 years [1.3, 2.0]), earlier operation (<2005; 2.3 [1.2, 4.6]), permanent neurologic damage (2.6 [1.6, 4.2]), and respiratory insufficiency (3.4 [1.8, 6.4]). Thirty-four patients underwent 46 reoperations, 21 on the proximal and 25 on the distal aorta, up to 19 years after the primary operation; respective in-hospital reoperative mortality was 14% and 12%. Estimated freedom (standard error) from aortic reoperation was 95% (2%), 87% (4%), and 61% (5%) at 5, 10, and 15 years, respectively. In multivariable Cox analysis (hazard ratios [95% confidence limits]), use of surgical adhesive at the primary operation (4.2 [1.6, 11]) and temporary neurologic damage (3.2l [1.2, 8.9]) were independently related to proximal reoperation, and DeBakey type I dissection (10.5 [1.4, 80]) was related to late distal reoperation. Catheter-based (endovascular, percutaneous) or hybrid procedures were not used in any patients but could have been used in up to 74% of reoperations, including in four of six of those that resulted in in-hospital death and putatively in 10 of 17 patients who sustained lethal aortic events without reoperation. Despite close follow-up, aortic-related death after a successful operation for acute type A aortic dissection is prevalent, and overall mortality remains substantial. Reoperations are not uncommon, may be indicated very late as well as repeatedly in the same patient, and are associated with a significant mortality. Increased use of applicable but seemingly under-used catheter-based or hybrid treatment approaches could benefit this growing patient population by offering repeat intervention to more patients and as substitute for reoperative open surgery in selected cases.

Fate of the preserved aortic root after treatment of acute type A aortic dissection: 23-year follow-up

The objective of this study was to examine the fate of the native aortic root after replacement of the ascending aorta to treat acute type A aortic dissection. Between June 1985 and January 2010, 319 consecutive patients (mean age, 63 ± 11 years) with acute type A aortic dissection underwent replacement of the ascending aorta with preservation of the aortic root. The aortic valve was also replaced in 21 of these patients (7%). The intervention was extended to the aortic arch in 210 patients (66%), of whom 173 (54%) underwent hemiarch replacement, and 37 (12%), total arch replacement. There were 109 (34%) in-hospital deaths. Of the 210 discharged patients, survival was 95%, 58%, and 27% at 1, 10, and 23 years, respectively. Freedom from reoperation on the proximal aorta was reported by 97%, 92%, and 82% patients at 5, 10, and 23 years, respectively. Twelve patients were reoperated for aortic root dilatation and 2 died during reoperation. Univariate and multivariate Cox regression analyses revealed that significant risk factors for proximal reoperation were age <60 years (P=.005; relative risk, 1.94) and Marfan syndrome (P=.011; relative risk, 2.76). At follow-up, 15 patients (11%) had an aortic root diameter of >45 mm, but they were not reoperated. For acute type A aortic dissection, replacement of the ascending aorta with root preservation shows long-term effectiveness with low reoperation and aortic root dilatation rates.

Aortic root conservative repair of acute type A aortic dissection involving the aortic root: Fate of the aortic root and aortic valve function

Despite many studies about aortic valve function and aortic root geometry after conservative aortic root repair of acute type A aortic dissection, the results are not always consistent or conclusive. This study aims to evaluate aortic root diameter and aortic valve function after surgery for acute type A aortic dissection involving the aortic root. A retrospective review was performed of 196 consecutive patients (age, 56.9 ± 11.4 years; 96 men) who underwent conservative aortic root repair including sinotubular junction resuspension for the management of acute type A aortic dissection involving the aortic root. The 30-day mortality rate was 5.1% (n=10). During a median follow-up period of 45.3 ± 36.4 months, there were 28 deaths and 11 cases of aortic reoperation (proximal reoperation in 1 and distal reoperation in 10). Of the 6-month survivors (n=177, 90.3%), echocardiography and computed tomography were performed in the late period (>6 months) on 115 (65.0%) and 138 (78.0%), respectively. Significant aortic regurgitation (greater than grade 2+) or root dilatation (>45 mm) was observed in 5 and 19 patients, respectively. Freedom from aortic regurgitation (greater than grade 2+) or root dilatation (>45 mm) at 5 years was 84.6% ± 3.9%. On the Cox regression analysis, the maximal aortic root diameter at initial presentation was the only significant predictor of aortic regurgitation and aortic root dilatation (hazard ratio, 1.10; 95% confidence interval, 1.02-1.19; P=.014). Conservative aortic root repair of acute type A aortic dissection demonstrates acceptable long-term clinical outcomes. However, more aggressive approaches should be considered for patients who have aortic root dilatation because of the risk of developing a root aneurysm after surgery.

Reoperation After Surgical Correction of Acute Type A Aortic Dissection: Risk Factor Analysis

Aortic dissection is an evolving process that may require one or several reoperations after its initial repair. We conducted a study to evaluate risk factors and define the incidence and locations of reoperations after surgical correction of acute type A aortic dissection (AAD). Between 1998 and 2008, 250 consecutive patients (mean age 62.5±12.4 years) underwent surgery for AAD at our institution. Replacement of the ascending aorta was done in 173 cases, composite graft replacement in 61 cases, separate aortic valve and ascending aorta replacement in 2 cases, and arch replacement required by distal repair in 14 cases. Mean follow-up time was 4.7±5.6 years. Freedom from reoperation was 99%, 82%, and 79% at 1, 5, and 10 years, respectively. Twenty-five patients required 25 reoperations at a mean interval of 4.7 years after initial surgery for the correction of AAD. Reoperations included 21 procedures on the proximal aorta (ascending aorta, aortic root, or valve) and 4 procedures on the distal aorta (arch or descending aorta). Cox regression analysis identified the use of gelatin-resorcinol-formaldehyde (GRF) glue (p=0.0270), and nonreplacement of the aortic root at the time of initial AAD repair (p=0.0004), as a significant risk factor for proximal reoperation, and a patent false lumen (p=0.0107) as a significant risk factor for distal reoperation. A patent false lumen, the use of GRF glue, and aortic root preservation at initial operation influence the risk for surgical correction in patients undergoing surgery for AAD. These patients need long-term follow-up.

Towards safer reoperations: special aspects in aortic dissection☆

Surgical treatment of acute aortic dissection has been largely standardized, but some patients develop late complications that require repeat surgery. The 10-year freedom from proximal and distal reoperation is approximately 70-80%, and the risk of proximal reoperation is approximately 10%. Aggressive resection of the aortic root has not been proven to eliminate the need for proximal reoperation, but it appears reasonable for pre-existent root dilatation. The coronary button technique has resulted in greater freedom from death and reoperation and thus appears advisable. The risk of distal reoperations seems generally lower than that of proximal operations (0-4%). Routine extension of replacement into the total arch in the initial operation is associated with increased risk, and it appears not to decrease the probability of reoperation. Aggressive replacement of the total arch may be justified only for connective tissue disease. The choice of thoracic incision is important for aortic reoperations. A median sternotomy provides excellent exposure to the proximal aorta. A posterolateral thoracotomy allows good exposure for distal arch or descending aorta but may be associated with pain-related pulmonary impairment. A bilateral thoracotomy gives easy access for arch and descending aorta but is associated with the highest degree of respiratory impairment. We use a median sternotomy in most instances and choose a bilateral thoracotomy for complex aortic pathology. A posterolateral thoracotomy seems preferable for most distal arch and/or descending aortic replacements. Since femoral arterial cannulation can contribute to an increased incidence of neurological complication, cannulation of the axillary artery appears advisable. We prefer implantation of a Dacron graft and to cannulate the graft. If the aorta is adjacent to the sternum, the patient is placed on cardiopulmonary bypass (CPB) before repeat sternotomy. The patient is cooled to a nasopharyngeal temperature of 28-30 degrees C and at the time of sternotomy CPB is temporarily interrupted. We have not yet had to use transapical venting. Using these approaches we have been able to maintain a procedure-related mortality of 4%, which is not different from primary operations on an aneurysmatic aorta.

Fate of the Residual Distal and Proximal Aorta After Acute Type A Dissection Repair Using a Contemporary Surgical Reconstruction Algorithm

In this study, we evaluated the long-term results of our contemporary, standardized surgical management algorithm for repair of acute type A aortic dissections. Prior reports have analyzed heterogeneous techniques and populations. From 1993 to 2004, 221 consecutive patients underwent repair of acute type A aortic dissection at our aortic center. Hemiarch repair was performed in 97.7% (216 of 221), and total arch in 2.3% (5 of 221). Of these, 72.9% (161 of 221) underwent aortic valve resuspension, and 27.1% (60 of 221) had aortic root replacement. In-hospital mortality for a primary operation was 12.7% (28 of 221). Actuarial survival was 79.2% at 1 year, 62.8% at 5 years, and 46.3% at 10 years. Significant risk factors for decreased survival included prior stroke, cerebral malperfusion, and length of cardiopulmonary bypass. Freedom from proximal reoperation after aortic valve resuspension was 94.6% at 5 years and 76.8% at 10 years, with cardiac malperfusion as the main risk factor. Freedom from distal reoperation was 87.6% at 5 years and 76.4% at 10 years, with Marfan syndrome, age, and extent of dissection as significant risk factors for reoperation. In-hospital mortality was 18.2% (2 of 11) after proximal reoperation and 31.2% (5 of 16) after distal reoperation. We report improved long-term durability of our proximal root repair, with cardiac malperfusion as a significant risk factor. Marfan disease, younger age, and DeBakey type I dissection are risk factors for distal reoperation. To further improve long-term outcome, means to prevent progression of distal aortic disease need to be developed.

Proximal Reoperations After Repaired Acute Type A Aortic Dissection

Concerned with the associated risks of proximal reoperation, some have proposed an aggressive approach of aortic root replacement during emergent repair of acute type A aortic dissection. Because few data exist regarding late reoperations, we report outcomes of proximal reoperation after repaired type A aortic dissection. Between January 1991 and March 2006, 63 patients underwent reoperation after previous repair for acute type A aortic dissection. Procedures performed at reoperation included ascending (94%, 59 of 63), total arch (62%, 39 of 63), elephant trunk (56%, 35 of 63), aortic valve replacement (38%, 24 of 63), aortic root (27%, 17 of 63), and coronary artery bypass graft (8%, 5 of 63). Preoperative, operative, and postoperative variables were analyzed retrospectively with regard to early and late mortality. Thirty-day mortality was 11.1% (7 of 63). No strokes occurred. Incidence of renal failure, respiratory failure, and bleeding was 6% (4 of 63), 23% (15 of 63), and 6% (4 of 63), respectively. Mean time from initial repair to reoperation was 69 months (range, 1 to 258). Procedure performed (root versus ascending/resuspension) at initial repair did not affect the time to reoperation (p > 0.05). Median follow-up was 40 months; and 1-, 5-, and 10-year survival was 82%, 74%, and 62%, respectively. Multivariate predictors of late mortality were prior coronary artery bypass graft surgery (odds ratio = 6.5, p < 0.003), bypass time (odds ratio = 3.6, p < 0.02), and renal dysfunction (odds ratio = 3.7, p < 0.05). Proximal reoperations for repaired acute type A aortic dissection can be performed with acceptable early and late mortality. The concern for proximal reoperation should not dictate the initial procedure choice during acute type A aortic dissection. Continued clinical and radiographic surveillance of repaired type A aortic dissection is warranted.