Acute type A aortic dissection: 18 years of experience in one center (Hospital 12 de Octubre)

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1 doi: /icvts Interctive CrdioVsculr nd Thorcic Surgery 9 (2009) Institutionl report - Vsculr thorcic Acute type A ortic dissection: 18 yers of experience in one center (Hospitl 12 de Octure) Alerto Fortez *, Crlos Mrtín, Jorge Centeno, Mrí Jesús López, Enrique Pérez, Jvier de Diego, Violet Sánchez, José Cortin Deprtment of Crdic Surgery, Hospitl Universitrio 12 de Octure, Mdrid, Spin Deprtment of Crdiology, Hospitl Universitrio 12 de Octure, Mdrid, Spin Received 3 Ferury 2009; received in revised form 19 April 2009; ccepted 20 April 2009 Astrct Here, we review our experience in cute type A ortic dissection nlyzing the role of ntegrde rin protection. A totl of 105 ptients underwent surgery for cute type A ortic dissection etween Mrch 1990 nd Octoer An open technique with deep hypothermi ws used in 81 ptients. Deep hypothermi lone ws induced in 32 ptients; in comintion with retrogrde cererl perfusion in 26 ptients nd in comintion with ntegrde cererl perfusion (ACP) in the finl 23 ptients. The overll hospitl mortlity rte ws 15%. Hospitl mortlity risk fctors were ge G70 yers nd preopertive shock (P-0.05). Hospitl mortlity ws reduced to 9% in the lst 23 consecutive ptients in whom ACP ws ccomplished (Ps0.05). Survivl rte fter 1, 5, 10 nd 15 yers of follow-up ws 97.6"1.7%, 84.3"4.4%, 60.7"7.5% nd 57.1"7.8%, respectively. The only lte deth risk predictor ws the non-use of ACP (P-0.05). Surgery for cute ortic dissection provides excellent results. ACP vi the xillry rtery improves the prognosis for these ptients nd should e the rin protection method of choice Pulished y Europen Assocition for Crdio-Thorcic Surgery. All rights reserved. Keywords: Aort; Aortic dissection; Cererl protection; Surgery compliction; Neurologic injury 1. Introduction Despite new dvnces, cute type A ortic dissection is still ssocited with high moridity nd mortlity rtes. At present, hospitl mortlity is reported etween 15% nd 35%, with 5-yer survivl rte of 65 75% w1 4x. The high incidence (10 20%) of postopertive neurologicl complictions in these ptients hs een ssocited with indequte rin protection during circultory rrest, emolic ccidents ndyor cererl mlperfusion due to preferentil flow to the flse lumen during perfusion. In recent yers, the introduction of new rin protection techniques, such s ntegrde cererl perfusion (ACP) nd cnnultion of xillry rtery, hs considerly reduced the incidence of this compliction w5 8x. The im of this retrospective study is to consider our experience in cute type A ortic dissection in terms of hospitl mortlity, reopertion nd long-term survivl. 2. Mterils nd methods A totl of ptients (85 men nd 20 women) underwent surgery in our hospitl for cute type A ortic dissection from Mrch 1990 to Octoer Specil mention to Dr. J.J. Rufilnchs (Chief Division of Crdic Surgery from ). *Corresponding uthor. CyAgsti n C, 28041, Mdrid, Spin. Tel.: q ; fx: q E-mil ddress: pfortez@yhoo.es (A. Fortez) Pulished y Europen Assocition for Crdio-Thorcic Surgery The men ge ws 59"8 yers. The dignosis ws confirmed using ortogrphy in the initil experience (17%) nd trnsthorcic echocrdiogrphy (77%), trnsesophgel echocrdiogrphy (67%) ndyor thorcodominl scn (66%) lter on. A totl of 98 ptients (93%) underwent emergency surgery (-24 h) nd the reminder underwent urgent surgery (within 72 h of dignosis). Imging tests showed ortic regurgittion in 87 ptients (52% severe). The preopertive clinicl nd demogrphic chrcteristics of the ptients re given in Tle Surgicl technique Initilly, the inclusion method ws used with simple ortic cross-clmping. Open distl nstomosis ws introduced in 1994 nd this is currently the method of choice. Arteril cnnultion ws performed on femorl rtery (76%), xillry rtery (20%) or ortic rch (4%), nd venous dringe on the right trium (86%) or femorl vein (14%). The scending ort ws clmped nd crdioplegic solution (5 10 mlykg) ws infused into the coronry sinus t pressure round 40 mmhg. A longitudinl opening ws mde in the scending ort with suprcoronry circumferentil trnsection; the rupture of the intim ws locted nd the morphology nd functionlity of the ortic vlve ws exmined. The esophgel nd ldder tempertures were monitored nd cooling ws interrupted when the ldder

2 Tle 1 Preopertive chrcteristics of ptients (ns105) A. Fortez et l. / Interctive CrdioVsculr nd Thorcic Surgery 9 (2009) n (%) NYHA IIIyIV 47 (45%) Prior AMI 9 (9%) Previous crdic surgery 7 (7%) Aortic regurgittion 89 (85%) Smoking 54 (51%) Dietes mellitus 8 (8%) HTA 78 (74%) Hypercholesterolemi 26 (25%) Renl dysfunction 16 (15%) Chron. pulmon. emphysem 18 (17%) Neurologicl dysfunction c 7 (7%) Peripherl rteriopthy 7 (7%) Mrfn 4 (4%) Ventriculr dysfunction d 8 (8%) Crdiogenic shock 17 (16%) c Current or previous; preopertive cretinine vlues )1.5 mgydl; history d of trnsitory ischemic ttck or stroke; left ventricle ejection frction -40%. temperture reched 18 8C. The pthologicl segment of ort ws resected nd replced with Hemshield Dcron grft (Boston Scientific, Ntick, MA, USA), reinforcing the ntive ort with geltine-resorcine-formldehyde (Lortories Crdil, Sint-Etienne, Frnce). Isolted scending ortic replcement ws performed in 66 ptients, involving the hemirch in 26 nd the whole ortic rch in 13. Elephnt trunk technique ws dded in six ptients. The ortic vlve ws preserved in 64 ptients nd it ws replced in 38. A proximl rupture ws locted in 88 ptients. The men CPB durtion ws 183"56 min. The men ortic clmp time ws 113"38 min nd the men circultory rrest time ws 37"23 min. During circultory rrest, the rin protection method used ws deep hypothermi. It ws comined with retrogrde cererl perfusion in 26 ptients ( mlymin) nd with ACP vi the right xillry rtery in the lst 23 ptients (10 15 mlykgy min) Follow-up All the surviving ptients were required to hve seril computed tomogrphy (CT) to ssess the distl ort. Clinicl dt were otined y mens of personl ndyor telephone interviews with ptients, their fmily nd primry cre physicins. These dt included informtion on postopertive moridityymortlity nd ny reopertions performed. A totl of 85 ptients were ville for followup Sttisticl nlysis The SPSS sttisticl pckge (version for Windows SPSS, Chicgo, IL, USA) ws used for ll nlyses. Univrite nlysis ws crried out on the periopertive vriles to determine the sttisticlly significnt risk fctors (P-0.05) for hospitl mortlity, reopertion nd mortlity during follow-up. Univrite nlysis ws followed y logistic regression or Cox regression nlysis to determine the independent risk fctors. Kpln Meier survivl curves were developed to estimte ptients free of reopertion nd survivl in terms of time. 3. Results 3.1. Hospitl mortlity Hospitl mortlity ws 15% (16y105). Six ptients died s result of intropertive hemorrhge, four due to low crdic output, two from neurologicl dmge, two from sepsis nd two from postopertive multiple orgn filure. The complictions oserved during the postopertive period re shown in Tle 2. Univrite nlysis showed dvnced ge (G70 yers), left ventriculr dysfunction, preopertive crdiogenic shock, CPB time )200 min, clmp time )130 min nd postopertive stroke s risk fctors for hospitl mortlity. Multivrite nlysis identified dvnced ge (G70 yers) nd preopertive crdiogenic shock s risk fctors for hospitl mortlity (Ps0.043; RRs2.77 nd Ps0.025; RRs2.6, respectively) Neurologicl complictions Ptients were grouped ccording to whether or not circultory rrest ws introduced nd those who hd received it were clssified to the different methods of rin protection used. Mortlity nd postopertive neurologicl complictions were clculted in ech of these groups. No sttisticl significnce ws oserved (Tle 3) Follow-up Postopertive follow-up ws possile in 95% of the ptients (medin 67 months, rnge months). After dischrge from hospitl, 70% of the ptients (62y89) hd t lest one CT scn. Of the 27 surviving ptients who did not undergo CT, 17 declined to hve the imging test, four were lost to follow-up nd six ptients died during the follow-up period. Tomogrphic nlysis showed flse lumen in the distl ort remining permele in 71% of the ptients, lthough progressive diltion of the thorcic nd or dominl ort ws oserved in only 17%. 4. Reopertion Reopertion ws not required fter 1, 5, 10 nd 15 yers in 98.4"16%, 92.8"3.5%, 81.8"6% nd 42.7"13.3% of the Tle 2 Postopertive complictions Respirtory infection Reopertion due to leeding TND Stroke Superficil wound infection Medistinitis AV Blockge (permnent PM) Sepsis Peripherl mlperfusion Renl filure Other ptients 11 ptients 15 ptients 10 ptients 4 ptients 2 ptients 2 ptients 2 ptients 3 ptients 4 ptients 4 ptients Temporry neurologicl dysfunction (TND): gittion, confusion, delirium, mnesi, postopertive Prkinson like symptoms, totlly resolved on dischrge from hospitl. Discovery of cute lesion in crnil CT nd or persistent neurologicl deficit. New Ides Cse Report Protocol Institutionl Report Negtive Results Follow-up Pper Best Evidence Topic Proposl for Bilout Procedure Work in Progress Report Stte-of-the-rt Brief Communiction Nomenclture

3 428 A. Fortez et l. / Interctive CrdioVsculr nd Thorcic Surgery 9 (2009) ptients, respectively (Fig. 1). Cox regression nlysis pointed to severe preopertive ortic regurgittion nd preservtion of the ortic vlve s independent reopertion risk fctors (Ps0.043; RRs2.8 nd Ps0.037; RRs4.1, respectively). Determinnt fctors in univrite nlysis re shown in Tle 4. During follow-up period, 13 ptients (14.6%) were reoperted for the following resons: severe ortic insufficiency nd diltion of the scending ort in five ptients, severe ortic insufficiency nd redissection of the scending ort in three, isolted severe ortic insufficiency in one, severe ortic nd mitrl insufficiency in one, mitroortic endocrditis in one, ortoronchil flse neurysm in one nd fistul etween scending ort nd the right trium in one ptient. No ptient ws reoperted for pthology in descending thorcic ort. The hospitl mortlity rte ws 23% (3y13 ptients). Tle 3 Neurologicl complictions nd mortlity with the different rin protective methods used Stroke TND Mortlity Without circultory rrest (ns24) 3 (12.5%) 5 (21%) 4 (17%) Circultory rrest Isolte deep hypothermi (ns32) 2 (6.2%) 3 (9.3%) 4 (12.5%) Retrogrde perfusion (ns26) 3 (11.5%) 5 (19.2%) 6 (23%) Antegrde perfusion (ns23) 2 (8.6%) 2 (8.6%) 2 (8.6%) P-vlue TND, temporry neurologicl dysfunction Long-term survivl Mortlity rte ws 25% (22y89). The cturil survivl rte ws 97.6"1.7%, 84.3"4.4%, 60.7"7.5% nd 57.1" 7.8% fter 1, 5, 10 nd 15 yers, respectively (Fig. 2). Ten ptients died s result of crdic disese, two due to intropertive hemorrhge, two due to neurologicl dmge, two from neoplsi, two from sudden rupture of thorcic ort nd four from n unknown cuse. Determinnts fctors of follow-up mortlity re shown in Tle 5. Multivrite nlysis showed the non-use of ntegrde rin protection to e the only significnt independent mortlity predictor during the follow-up period (Cox regression) (Ps0.02; RRs3.2). 5. Discussion Acute type A ortic dissection is criticl sitution requiring emergency surgicl intervention in the mjority of cses. Siegl w9x estimted tht mortlity risk in untreted ptients increses y 1% per hour during the first 48 h, reching 70% fter week. According to dt provided y the Interntionl Registry of Acute Aortic Dissection (IRAD), mortlity rte for ptients treted conservtively is 58%, the compred to glol surgicl mortlity of 24% w1, 10, 11x. Although recent yers hve rought importnt dvnces in dignostic nd surgicl techniques, there re mrked Fig. 1. Freedom from reopertion curve. Tle 4 Univrite nlysis in hospitl survivl ptients (determinnt fctors) Vriles Reopertion n (%) P-vlue Severe ortic regurgittion (42y89) 10y42 (24%) Aortic vlve spring (58y89) 13y58 (22%) Fig. 2. Survivl during follow-up curve. Tle 5 Follow-up mortlity. Univrite nlysis (determinnt fctors) Vriles Mortlity n (%) P-vlue Age )70 yers (17y89) 8y17 (47%) Inclusion technique (17y89) 8y17 (47%) Non-use of ACP (68y89) 22y68 (32%) Postopertive TND (15y89) 8y15 (53%) 0.034

4 A. Fortez et l. / Interctive CrdioVsculr nd Thorcic Surgery 9 (2009) vritions in hospitl mortlity, with rnge etween 15% nd 30% w1, 10 12x. Predictor fctors of hospitl mortlity in cute type A ortic dissection re similr in the mjority of the rticles pulished w2, 12x. According to IRAD dt w1x, independent mortlity fctors re dvnced ge, hypotensionyshock, previous crdiopthy nd preopertive renl, mesenteric or myocrdil ischemi. In our experience, the only independent hospitl mortlity predictors were dvnced ge (G70 yers) nd preopertive crdiogenic shock. Postopertive neurologicl complictions re frequent cuse of moridityymortlity in ortic dissection, the estimted incidence eing etween 10% nd 20% w3x. Ergin et l. w5x suggest tht postopertive stroke is cused minly y emolic incidents relted possily to retrogrde perfusion from the femorl rtery, nd not directly to the method of rin protection used, while temporry neurologicl dysfunction (TND) could e linked to indequte rin protection. ACP hs een ssocited with significnt reduction in TND in vrious recent reviews w6, 13x, lthough its role is not so pprent in the reduction of stroke. Neurologicl dmge in ortic dissection is multifctoril nd my e cused y prolonged circultory rrest, emolic incidents ndyor y syndrome of cererl mlperfusion due to preferentil flow to the flse lumen. Cnnultion of the xillry reduces the risk of mlperfusion nd it lso reduces the emoliztion of thromi from the dominl nd thorcic ort w7, 8x. In our experience, ACP vi the xillry rtery reduced the incidence of TND to 8.6% nd the incidence of hospitl mortlity to 9% in the lst 23 ptients, suggesting its protective role ginst neurologicl complictions nd ssocited moridityy mortlity. Acute preopertive ortic regurgittion nd preservtion of the ortic vlve were the determining fctors for lte ortic reopertion. According to these dt nd supported y other reports, n ggressive pproch on the ortic root in the initil surgery (Bentll procedure) could e justified w4x. Estrer et l. w14x, on the other hnd, oserved n cceptle durility of the ortic vlve fter preservtion, indicting tht potentil reopertion should not dictte the initil procedure. On dischrge from hospitl, only 8 (13%) of the 62 surviving ptients who hd undergone CT during the follow-up period showed progressive diltion in other res of the ort requiring surgery one ptient with ortoronchil flse neurysm, one with fistul etween scending ort nd the right trium, two ptients with dominl ortic neurysm, two with thorco-dominl neurysm nd two with descending thorcic ort neurysm. Two of these ptients were operted, two declined reintervention nd the reminder presented high comoridity which mde the procedure non-indicted. This low rte of reopertion of the distl ort is proly due to the high percentge of primry ruptures of the intim identified during the intervention. Thus, vrious uthors report tht not resecting the re of rupture in the initil surgery is the principl fctor for lte reopertion due to diltion of the thorcic or dominl ort w4, 14x. Acturil survivl curve fter dischrge from hospitl shows similr shpe thn those descried y other uthors w3, 4x. Non-use of ntegrde rin protection ws found to e predictor of lte mortlity, showing tht lthough ntegrde perfusion did not significntly lter the initil postopertive results, it is of mjor importnce with regrd to lte survivl. This finding shows tht mintining correct cererl nd neurologicl function hs direct effect on survivl. Pompilio et l. w15x determined the effect of periopertive neurologicl incidents on lte mortlity, i.e., the ptients who survived neurologicl dmge while in hospitl, presented lower long-term survivl rte. This could e explined y these ptients high-risk of contrcting ronchopneumoni, new neurologicl incidents nd other complictions ssocited with their limited functionl cpcity w2x Limittions This rticle is suject to ll the limittions of nonrndomized retrospective study. The low incidence of this pthology entils smll numer of ptients operted, limiting the sttisticl power of these findings. Only 70% of the ptients hd follow-up CT scn, proly ecuse our hospitl supports high mrginl popultion. Becuse the review covered long period (18 yers), the three methods of rin protection were not in use t the sme time, with the sttisticl significnce of this issue eing unknown. 6. Conclusions Short- nd long-term results of cute ortic dissection re cceptle. ACP vi the xillry rtery hs modified the concept of circultory rrest nd seems to improve longterm prognosis of these ptients. We feel it should e the method of choice for rin protection in cute ortic dissection when the supr-ortic vessels re not ffected. 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