Surgical management and long-term outcomes for acute ascending aortic dissection
Received 2 May 2008; received in revised form 6 November 2008; accepted 4 January 2009. published online 01 June 2009.
Objective
We sought to assess early and late survival and cardiovascular-specific mortality after surgical repair of acute ascending aortic dissection and the effect of differences in surgical technique, patient characteristics, and preoperative diagnostic testing.
Methods
Between 1979 and 2003, 195 consecutive patients underwent repair for acute ascending aortic dissection within 2 weeks of the onset of symptoms. Mean follow-up was 7.0 ± 5.9 years (range, 0–26 years) and was 100% complete.
Results
Patients were aged 62 ± 15 years on average and were mostly male (66%) and hypertensive (69%). Risk of death early and late after the operation decreased over the study period, with hospital mortality decreasing from 21% to 4% when comparing the first and most recent quartiles (P = .007, χ2 test for trend). At 1, 5, 10, and 20 years postoperatively, survival was 84%, 69%, 55%, and 30%, respectively, and freedom from cardiovascular death was 86%, 80%, 71%, and 51%, respectively. Additional independent risk factors for death were older age (P < .001), renal dysfunction (P < .003), syncope (P = .007), and peripheral vascular disease (P = .006). During the study period, echocardiographic and computed tomographic diagnostic imaging replaced routine aortic angiographic analysis, and operative techniques involved more frequent use of open distal anastomoses, retrograde cerebral perfusion, earlier restoration of antegrade perfusion, and a conservative approach to aortic arch repair. Freedom from reoperation on the aorta or aortic valve was 93% and 84% at 5 and 10 years, respectively.
Conclusions
Early and late survival after repair of acute ascending aortic dissection has improved progressively over 25 years in association with noticeable changes in preoperative and intraoperative management. Aortic reoperations were infrequent during follow-up.
aDivision of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
bDivision of Cardiology, Massachusetts General Hospital, Boston, Mass
cDepartment of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
Address for reprints: Arvind K. Agnihotri, MD, Department of Cardiothoracic Surgery, Massachusetts General Hospital, 55 Fruit St, COX 630, Boston, MA 02114.
Disclosures: Salary support (to L.M.S.) was provided by a fellowship award from the Canadian Institutes of Health Research's Clinical Research Initiative and the Rosetti Fund (Massachusetts General Hospital, Boston, Massachusetts).
ABSTRACT