Remodeling of the Remnant Aorta after Acute Type A Aortic Dissection Surgery

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1 Remodeling of the Remnant Aorta after Acute Type A Aortic Dissection Surgery Are Young Patients More Likely to Develop Adverse Aortic Remodeling of the Remnant Aorta Over Time? Suk Jung Choo¹, Jihoon Kim¹, Sun Kyun Ro², Joon Bum Kim¹, Sung-Ho Jung¹, Cheol Hyun Chung¹, Jae Won Lee¹ 1 Thoracic and Cardiovascular Surgery, Asan Medical Center, College of Medicine, University of Ulsan, Seoul, Korea; 2 Thoracic and Cardiovascular Surgery, Hanyang University Guri Hospital, Hanyang University College of Medicine, Gyeonggi-do, Korea 1

2 Background Adverse aortic remodeling after acute type A aortic dissection in younger ages may be more extensive in its course than in advanced age 2

3 Study design - Pre/Post op CT

4 Method The aortic index segments analyzed in the study were the remnant aortic sinus, aortic arch, and proximal descending aorta 4

5 Enrollment: Jan Dec Acute type A aortic dissection Ascending and/or hemiarch replacement 162 Pre- and postoperative chest CT (+) 124 F/U > 1 month 76.5% 5

6 Method The patients were divided into two groups according to age Group A Age < 50 yrs Group B Age 50 yrs n Mean age (yrs) 42.9 ± ± 7.4 6

7 Patient demographics and clinical characteristics Characteristics Group A (n = 29) Group B (n = 95) P value Age (y) 42.9 ± ± 7.4 NA Male gender 18 (62.1) 38 (40.0).037 Risk Factors DM 1 (3.4) 3 (3.2) >.999 Hypertension 10 (34.5) 58 (61.1).012 COPD 0 (0.0) 2 (2.1) >.999 Renal failure 0 (0.0) 1 (1.1) >.999 CVD 1 (3.4) 5 (5.3) >.999 Marfan syndrome 3 (10.3) 1 (1.1).040 Bicuspid aortic valve 2 (6.9) 1 (1.1).136 COPD, Chronic obstructive pulmonary disease; CVD, cerebrovascular disease; DM, diabetes mellitus; IMH, intramural hematoma; NA, Not applicable. 7 *Chi-square statistic for overall difference.

8 Patient demographics and clinical characteristics Characteristics Group A (n = 29) Group B (n = 95) P value Dissection Characteristics.158 * DeBakey I 29 (100.0) 84 (88.4).066 DeBakey II 0 (0.0) 2 (2.1) >.999 IMH (All DeBakey I) 0 (0.0) 9 (9.5).115 Malperfusion Cerebral 1 (3.4) 4 (4.2) >.999 Visceral 1 (3.4) 1 (1.1).415 Peripheral 2 (6.9) 5 (5.3).665 Previous cardiac or aortic surgery 0 (0.0) 1 (1.1) >.999 COPD, Chronic obstructive pulmonary disease; CVD, cerebrovascular disease; DM, diabetes mellitus; IMH, intramural hematoma; NA, Not applicable. 8 *Chi-square statistic for overall difference.

9 Operative data Tear site location Variable Group A (n = 29) Group B (n = 95) P value.007 * Ascending aorta 14 (48.3) 53 (55.8).477 Aortic arch 3 (10.3) 16 (16.8).559 Descending thoracic aorta 2 (6.9) 4 (4.2).624 Combined 4 (13.8) 5 (5.3).212 Unidentified or unrecorded 6 (20.7) 17 (17.9).735 Tear site exclusion 18 (62.1) 74 (77.9).088 Aorta replacement.771 * Ascending 5 (17.2) 14 (14.7).771 Ascending+hemiarch 24 (82.8) 81 (85.3).771 ACC, Aortic cross-clamp; ACP, antegrade cerebral perfusion; AVP, aortic valvuloplasty; CABG, coronary artery bypass grafting; CPB, cardiopulmonary bypass; Fem-fem bypass, femorofemoral bypass grafting; RCP, retrograde cerebral perfusion; TCA, total circulatory arrest *Chi-square statistic for overall difference. 9

10 Operative data Variable Group A Group B P (n = 29) (n = 95) value Concomitant surgery.931 * AVP 4 (13.8) 16 (16.8) >.999 CABG 2 (6.9) 3 (3.2).665 Fem-fem bypass 1 (3.4) 4 (4.2) >.999 Others 0 (0.0) 3 (3.2) >.999 Cardiopulmonary bypass CPB time (min) ± ± ACC time (min) ± ± Low body arrest time (min) 25.0 ± ± TCA 0 (0) 6 (6.3).334 RCP 17 (58.6) 49 (51.6).506 ACP 12 (41.4) 40 (42.1).945 Target temperature ( ) 18.1 ± ± ACC, Aortic cross-clamp; ACP, antegrade cerebral perfusion; AVP, aortic valvuloplasty; CABG, coronary artery bypass grafting; CPB, cardiopulmonary bypass; Fem-fem bypass, femorofemoral bypass grafting; RCP, retrograde cerebral perfusion; TCA, total circulatory arrest *Chi-square statistic for overall difference. 10

11 Early outcomes and complications Variable Group A (n = 29) Group B (n = 95) P value Neurologic deficits 2 (6.9) 6 (6.3) >.999 Pneumonia 4 (13.8) 13 (13.7) >.999 Renal failure 3 (10.3) 22 (23.2).132 Duration of mechanical ventilation (d) 2.6 ± ± ICU stay (d) 5.6 ± ± Hospital stay (d) 16.4 ± ± In-hospital mortality 1 (3.4) 1 (1.1).415 Aortic reoperation 3 (10.3) 5 (5.3).388 * Root remodeling 0 (0.0) 1 (1.1) Bentall operation 1 (3.4) 0 (0.0) Replacement of total arch 0 (0.0) 1 (1.1) Replacement of DTA 1 (3.4) 1 (1.1) Replacement of TAA 1 (3.4) 1 (1.1) Replacement of total arch and TAA 0 (0.0) 1 (1.1) DTA, Descending thoracic aorta; ICU, intensive care unit; TAA, thoracoabdominal aorta. *Chi-square statistic for overall difference. 11

12 CT follow up period Overall CT follow up period Median: 36.4 (IQR ) months Young age Median: 33.4 (IQR ) months Old age Median: 27.7 (IQR ) months Mean 53.4 ± 40.9 vs 40.8 ± 32.3 P =

13 Size changes of the remnant aorta on the computed tomography scans (mm) Group A (n = 29) Group B (n = 95) Preoperative CT scan Latest CT scan P value Location Preoperative CT scan Latest CT scan P value 41.8 ± ± Aortic sinus 40.5 ± ± ± ± Aortic arch 38.5 ± ± ± ± Proximal DTA 37.6 ± ± CT, Computed tomography; DTA, descending thoracic aorta. 13

14 Size changes of the remnant aorta on the computed tomography scans (mm) Location Group A (n = 29) Group B (n = 95) P value Aortic sinus 41.8 ± ± Preoperative CT scan Aortic arch 36.5 ± ± Proximal DTA 36.4 ± ± Aortic sinus 44.1 ± ± Latest CT scan Aortic arch 41.3 ± ± Proximal DTA 43.0 ± ± CT, Computed tomography; DTA, descending thoracic aorta. 14

15 Association between age and aortic expansion rates developed by linear regression models 15

16 Overall Survival Curves 16

17 Finding summary All index segments of the non-operated remnant aorta in young patients showed significant dilatation over time after acute type A aortic dissection surgery whereas in the older patients only the descending thoracic aorta appeared to significantly dilate 17

18 Comments The results suggested a more extensive pattern of aortic remodeling in relatively younger patients Extensive surgery should be performed on a need basis- albeit more proactively Close and frequent monitoring Optimal medical treatment should be ensured 18

19 Limitations Retrospective study How young is young? Measurement error- One observer (JK) blinded to patient-identifying information performed the image analysis F/U period relatively short follow up Etiology? Biopsy studies? 19

20 Thank you for your attention 20

21 Q & A 21

22 Acute AD Type A < 50 y/o (n=83) 50 y/o (n=188) P value Bentall procedure 16 (19.3) 3 (1.6) <.001 Root remodelling 1 (1.2) 4 (2.1) >.999 Total arch replacement 31 (37.3) 36 (19.1) <.002 Jan Dec

23 Cause of Death Group A Group B Cardiac tamponade 1 Unknown 2 Tracheostomy obstruction Malignancy 3 Sepsis 1 Unknown 2 n 1 23

24 Impact of age on late aortic expansion determined by linear regression analyses R 2 Unadjusted Adjusted* Beta Standard P coefficient error value** R 2 Beta Standard P coefficient error value** Aortic sinus (0.092) (0.020) Aortic arch (0.028) (0.070) Proximal DTA (0.101) (0.892) DTA, descending thoracic aorta. *Multivariable linear regression analyses were performed. Covariates for multivariable models in addition to age were as follows (selected from univariable analyses that had p values of less than 0.20): (1) Aortic sinus: preoperative sinus diameter, root involvement of aortic dissection; (2) Arch: preoperative arch diameter; (3) Descending aorta: preoperative descending aortic diameter, intramural hematoma and distal extent of aortic dissection. ** Statistical models were further validated by 1000 bootstrap samples (P values in parentheses). 24

25 Image analysis 25

26 Conclusion Aorta tends to dilate in a more extensive fashion in young patients after acute AD surgery Extensive surgery should be performed on a need basis- albeit more proactively Close and frequent monitoring Optimal medical treatment should be ensured 26

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