Surgery for Type A Aortic Dissection in Albania

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1 Original Article 73 Copyright University of Medicine, Tirana AJMHS 2015; Vol. 46, Nr. 1: Surgery for Type A Aortic Dissection in Albania Ermal Likaj, Andi Kacani, Selman Dumani, Ali Refatllari Department of Cardiovascular Diseases, Faculty of Medicine, University of Medicine, Tirana and University Hospital Centre Mother Theresa, Tirana, Albania Abstract Introduction: The treatment of acute type A aortic dissection is surgically challenging and associated with high morbidity and mortality. We have started to perform this type of surgery only in the recent years. The aim of this study is to report short-term outcomes of this type of surgery in Albania. Methods: All 13 consecutive patients who underwent surgery for acute type A aortic dissection in a three year period from January 2011 to January 2014 were included. Patient, procedural and follow-up information was obtained from hospital records. Results: There were 9(64%) men and 4(36%) women included in the study, whose mean age was 54.7 ±7.9 years, ranging from 40 to 66. There were 4 postoperative deaths (30 %) among the patients in this study. The causes of death were: multi-organ failure (1 patient), stroke (1 patient), complications of uncontrollable bleeding (1 patient), and renal failure in another patient. One patient required re-exploration of the mediastinum for bleeding. Two patients required renal dialysis. One patient developed a deep sternal infection and sepsis. Conclusions: Acute type A aortic dissection in the current era is associated with a decreased operative mortality risk. We report that this type of surgery is performed in Albania with promising outcomes and we hope to improve these results in the future. Key Words: Albania, aorta, dissection, acute, disease outcomes. Address for correspondence: Ermal Likaj, Department of Heart and Blood-cells Diseases, Faculty of Medicine, University of Medicine, Tirana, Dibra Street No. 371, Tirana, Albania. Tel likajermal@gmail.com

2 Likaj E. et al. Surgery for Type A Aortic Dissection in Albania 74 INTRODUCTION The treatment of acute type A aortic dissection is surgically challenging and associated with high morbidity and mortality. The aim of the cardiac surgeons in dealing with this lifethreatening condition is to preserve the life of the patient. In Albania, this type of complex surgery has been performed recently (since 2009). In this study, we review our experience with the surgery for acute type A aortic dissection, describe the applied operative techniques and short-term outcome. METHODS Patient population All patients who had surgery for acute type A aortic dissection at the University Hospital Centre of Tirana from January 2011 to January 2014 were included into this study. Patient, procedural and follow-up information was obtained from hospital records. We found 13 consecutive patients operated for acute type A aortic dissection. Diagnosis was made by echocardiography and computed tomographic (CT) scan in all the patients. Eight patients had a normal aortic valve and five patients had important aortic insufficiency. Figure 1. Cardiac tamponade after acute dissection and aortic rupture

3 75 Likaj E. et al. Surgery for Type A Aortic Dissection in Albania Operative Techniques In our hospital, the traditionally performed surgery for acute type A aortic dissection is placing the patient on cardiopulmonary bypass and replacing the ascending aorta during aortic cross-clamping; retrograde femoral perfusion was used most of the times that the patient was on bypass. Cardiopulmonary bypass was established by initial femoral/axillary artery and right atrial cannulation in all patients. In all patients, the ascending aorta was clamped, resected and replaced with a tubular Dacron graft. In addition, partial or complete replacement of the transverse arch was performed in 5 patients under circulatory arrest with retrograde and/or anterograde cerebral perfusion. The aortic root was replaced or repaired depending on the pathology of the aortic valve. In the patients without a tear in the transverse arch, the ascending aorta was transected just below the origin of the innominate artery, and was replaced with a tubular Dacron graft. In patients with an intimal tear in the arch (4 patients) or proximal descending thoracic aorta (1 patient), the transverse arch was replaced. Figure 2. Right coronary dissection in acute aortic dissection: a rare complication

4 Likaj E. et al. Surgery for Type A Aortic Dissection in Albania 76 RESULTS There were 9(64%) men and 4(36%) women included in the study, whose mean age was 54.7 ±7.9 years, ranging from 40 to 66. One patient was in cardiogenic shock, one was mentally obtunded and two patients had signs of peripheral ischemia. No patient had Marfan syndrome or previous cardiac surgery. Preoperative coronary angiography was not performed, but 2 patients were known to have pre-operative myocardial ischemia. Patients were followed from 2 months to 3 years, with a mean follow up of months. None of the patients of this group was lost to follow-up. There were no late deaths and all 9 hospital survivors are alive up to date. No long-term complications or repeated surgery are documented in this patient population. There were 4 postoperative deaths (30 %) among the patients in this study. The causes of death were: multi-organ failure (1 patient), stroke (1 patient), complications of uncontrollable bleeding (1 patient), and renal failure in another patient. One patient required re-exploration of the mediastinum for bleeding. Two patients required renal dialysis. One patient developed a deep sternal infection and sepsis. Table 1. Pre-operative conditions of patients Condition Number of patient N(%) Hypertension 13(100) Marfan Syndrome 0(0) Previous cardiac operation 0(0) Cardiogenic shock 1(7) Myocardial ischemia 2(7) Neurologic disorders 1(7) Peripheral ischemia 2(14) Aortic regurgitation 5(38)

5 77 Likaj E. et al. Surgery for Type A Aortic Dissection in Albania Table 2. Surgical data SURGICAL TECHNIQUES DATA Cross clamp time ±51.7 min Cardiopulmonary bypass time ±84.2 min Ascending aorta replacement 13 pts * Arch replacement 5 pts Aortic valve procedure Isolated replacement Aortic valve repair Modified Bentall procedure 1 pts 1 pts 2 pts Initial cannuation Femoral artery Axillary artery 10 pts 3 pts BioGlue application 5 pts Surgical approach-median sternotomy 13 ts *patients Table 3. Circulatory arrest data Selective anterograde cerebral perfusion body temperature 25º C mean time 48.2 ± 35.5 min bilateral unilateral Retrograde cerebral perfusion body temperature 18º C mean time 37 ± 8.8 min 5 patients 3 patients 2 patients 3 patients Table 4. Mortality data IMMEDIATE MORTALITY Intra-operative deaths 0 Post-operative deaths Stroke Multi-organ failure Renal failure Bleeding 4 pts 1 pt 1 pt 1 pt 1 pt OVERALL HOSPITAL MORTALITY 30%

6 Likaj E. et al. Surgery for Type A Aortic Dissection in Albania 78 Table 5. Postoperative complications Complication Number of patients Atrial fibrillation 3 Pericardial effusion 2 Renal Failure 2 Cerebral edema 1 Stroke 1 Sepsis 1 Mean hospital stay: intensive care 6 days, surgical ward 9 days Figure 3. CT scan in a patient operated for acute aortic dissection

7 79 Likaj E. et al. Surgery for Type A Aortic Dissection in Albania DISCUSSION Type A acute aortic dissection is the most common acute aortic condition requiring urgent surgical therapy. Spontaneous mortality is very high: 50% of the patients die within the first 48 hours (roughly 1% per hour mortality) (1). Despite improvement in diagnosis and surgical techniques, early mortality remains high, from 15% to 30%, and has been constant during the decades. Furthermore, many reports point out that surgical results depend on pre-operative conditions, as these are the main determinants of early outcome (2). Improved care, earlier recognition of dissection using improved imaging modalities, development of better quality vascular grafts, more effective hemostatic agents, and improvements in the safety of cardiopulmonary bypass are the reasons for the increased quality of surgical outcomes. There is no doubt that aggressive surgical treatment of type A acute aortic dissection has saved a large number of lives compared with medical therapy only as the natural history with medical therapy alone would predict a 90-day mortality rate in the range of 70% to 90% (3). More recent data, however, reveal a different prognosis, suggesting that optimized medical management may be considered acceptable in certain high-risk groups. In the IRAD (International Registry of Acute Aortic Dissections) survey (4), surgery was not performed in 28% of patients with type A dissection for different reasons, and 42% of these were discharged from the hospital after intensive medical treatment. Chan and coworkers (5) report in-hospital mortality rates of 55.9% in patients who did not receive surgery for clinical (advanced age and comorbidity) and social (family support and economic problems) conditions, and this mortality decreased to 42.9% after a learning period. Therefore, when the expected mortality is equal or higher than 58%, the possibilities for survival according to the IRAD survey and other reports, are similar for either surgery or medical treatment (2). In such cases, surgery is no longer mandatory, and a careful evaluation of the individual patient seems to be a more suitable strategy. The possible alternative strategies are intensive medical therapy, with or without invasive procedures (percutaneous fenestration and stenting), or delay of the surgery to decrease operative mortality risk. The goal of surgery in patients with acute type A aortic dissection is the resection of the ascending aorta to eliminate the risk for intra-pericardial rupture and prevent coronary artery dissection or aortic valvular insufficiency. More extended operative repair depends on the extent of dissection, the site of the primary entry tear, the presence of concomitant disease and the experience of the surgeon. The majority of patients who demonstrate root involvement with aortic dissection can be treated by obliteration of the false lumen by placement

8 Likaj E. et al. Surgery for Type A Aortic Dissection in Albania 80 of Teflon felt as a neomedia and preservation of the aortic valve by the technique of resuspension. In this approach, pledgetted sutures are placed at the commissural posts from within the aorta to outside the reconstructed aortic wall and the normal geometry is restored. Recently reported long-term outcomes, suggest that the incidence of re-operation remains gratifyingly low in most cases (6). Root preservation is contraindicated in the presence of root aneurysm (4.5 cm), severe leaflet pathology not amenable to repair, or the presence of dissection into the coronary ostia. Root replacement is typically performed with a modified Bentall procedure with either a mechanical composite conduit, a composite of a bioprosthetic root and Dacron ascending aortic graft, or by a valve leaflet sparing aortic root resection. The presence of aortic dissection into the arch aorta mandates a determination of the need for arch resection. Typically, if aortic dissection is present into the distal ascending aorta or beyond, adjunctive use of deep hypothermic circulatory arrest is indicated with its attendant increase in morbidity and mortality. Indications for resection of the arch aorta include the presence of a primary entry tear in the arch or the presence of an arch aneurysm (4.5 cm). In the absence of these factors, the distal anastomosis can be constructed with the placement of Teflon felt as a neomedia, and obliteration of the false lumen. With recent studies suggesting a relatively low incidence of re-operation, this approach is adequate for most patients (6). However, noting the temporal improvements in both early and late survival, we and others have taken a more aggressive stance by performing extended arch repairs for younger patients (ie, 65 years) and those with Marfan syndrome (7). This approach may potentially reduce the need for later arch resection in the re-operative setting. Regarding brain protection strategy, we can say that it is an essential component of the operative technique for open surgical repairs of the ascending aorta and/or the aortic arch. Moderate or profound hypothermia with periods of circulatory arrest and/or selective antegrade brain perfusion and/or retrograde brain perfusion are the common strategies for achieving brain protection. There is controversy regarding the ability of retrograde brain perfusion to support brain metabolic function and to improve neurologic outcomes, including transient postoperative neurologic dysfunction, stroke rates, and mortality (8-10). However, this technique can maintain brain hypothermia (11) and has been associated with improved outcomes in the centers where it is used as a primary neuroprotection strategy. Selective antegrade brain perfusion may be provided by direct cannulation of one or more of the brachiocephalic arteries. If unilateral cannulation is performed, success may depend

9 81 Likaj E. et al. Surgery for Type A Aortic Dissection in Albania on patency of the circle of Willis. Alternatively, unilateral direct or side-graft cannulation of the right axillary artery permits extracorporeal circulation and cooling without manipulation of the diseased thoracic aorta. Bilateral brachiocephalic artery cannulation has also been reported (12). The literature is insufficient to determine whether unilateral or bilateral perfusion or complete avoidance of circulatory arrest is associated with improved outcomes. A retrospective analysis by Svensson et al suggested that axillary artery perfusion via a prosthetic side-graft was associated with improved outcomes compared with femoral arterial cannulation (13). Finally, direct cannulation of the aortic replacement graft may be used to institute antegrade brain perfusion following a period of circulatory arrest. The variability of techniques among surgical centers makes direct comparison difficult; however, most studies with some type of antegrade arterial brain perfusion report outcomes that are comparable to or better than those using hypothermic circulatory arrest alone or retrograde brain perfusion (14,15). Furthermore, selective antegrade brain perfusion may reduce the period of brain ischemia and permit less profound hypothermia, which may be associated with good clinical outcomes (16, 17, 18, 19, 20). CONCLUSIONS Surgery for acute dissection of the ascending aorta and aortic arch has been performed with promising results at our clinic in Albania. Surgical techniques include all the spectrum of the routine procedures applied widely nowadays. Experience is necessary to improve the results in emergency surgery for acute aortic dissection. Acknowledgements: Not available Conflict of interest disclosure: Not available REFERENCES 1. Green GR, Kron IL. Aortic dissection. In: Cohn LH, Edmunds LH Jr, eds. Cardiac Surgery in the Adult. New York: McGraw- Hill; 2003: Trimarchi S, Nienaber CA, Rampoldi V, Myrmel T, Suzuki T, Mehta RH, et al. Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience. J Thorac Cardiovasc Surg 2005;129: Myrmel T, Lai DTM, Miller DG. Can the principles of evidence-based medicine be applied to the treatment of aortic dissections? Eur J Cardiothorac Surg 2004;25: Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL et al. The International Registry of Acute Aortic Dissection (IRAD). JAMA 2000;283: Chan SH, Liu PY, Lin LJ, Chen JH. Predictors of in-hospital mortality in patients with acute aortic dissection. Int J Cardiol 2005;105: Zierer A, Voeller RK, Hill KE, Kouchoukos NT, Damiano RJ, Moon MR. Aortic enlargement and late reoperation after repair

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