Root Replacement Surgery Versus More Conservative Management During Type A Acute Aortic Dissection Repair

• DOI: 10.1016/j.athoracsur.2014.06.070
• Publication Date: 2014-10-04T14:34:26Z
• Authors: Marco Di Eusanio; Santi Trimarchi; Mark D. Peterson; Truls Myrmel; G. Chad Hughes; Amit Korach; Thoralf M. Sundt; Roberto Di Bartol...; Kevin Greason; Ali Khoynezhad; Jehangir J. Appoo; Gianluca Folesani; Carlo De Vincentiis; Daniel G. Montgomery; Eric M. Isselbacher; Kim A. Eagle; Christoph A. Nien...; Himanshu J. Patel
• Keywords: Male; Reoperation; Canada; Aorta, Thoracic; Kaplan-Meier Estimate; Blood Vessel Prosthesis Implantation; 03 medical and health sciences; 0302 clinical medicine; Risk Factors; Odds Ratio; Humans; Hospital Mortality; Aged; Proportional Hazards Models; Retrospective Studies; Aortic Aneurysm, Thoracic; Aged; Aneurysm, Dissecting; Aorta, Thoracic; Aortic Aneurysm, Thoracic; Blood Vessel Prosthesis Implantation; Canada; Europe; Female; Hospital Mortality; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Odds Ratio; Proportional Hazards Models; Reoperation; Retrospective Studies; Risk Factors; Survival Rate; Treatment Outcome; United States; Cardiology and Cardiovascular Medicine; Surgery; Pulmonary and Respiratory Medicine; Medicine (all); Middle Aged; 3. Good health; Europe; Survival Rate; Aortic Dissection; Treatment Outcome; Female

Aortic root management in type A acute aortic dissection is controversial. This study compared outcomes of root replacement (RR) interventions versus more conservative root (CR) management.Of 1,995 type A acute aortic dissection patients enrolled in the International Registry of Acute Aortic Dissection, 699 (35%) underwent RR interventions and 1,296 (65%) underwent CR management. Independent predictors of hospital and 3-year survival were identified using multivariable logistic and Cox regression models.Compared with CR patients, RR patients were younger (56.9 versus 62.3 years; p = 0.023) and more likely to present with larger root diameter (4.7 cm versus 4.0 cm; p < 0.001), Marfan syndrome (8.7% versus 2.5%; p < 0.001), aortic insufficiency (64.0% versus 50.3%; p < 0.001), and hypotension, shock, or tamponade (33.0% versus 26.5%; p = 0.003). Root replacement management did not increase hospital mortality (propensity score-adjusted odds ratio, 1.14; p = 0.674). On Kaplan-Meier analysis, 3-year survival (RR, 92.5% ± 1.7% versus CR, 91.6% ± 1.3%; log-rank p = 0.623) and freedom from aortic root reintervention (RR, 99.2% ± 0.1% versus CR, 99.3% ± 0.1%; log-rank p = 0.770) were similar. Only 2 patients (1 per group) underwent follow-up root reintervention. Propensity score-adjusted Cox regression excluded a relationship between root treatment and follow-up survival (hazard ratio, 1.5; 95% confidence interval, 0.502 to 5.010; p = 0.432).In type A acute aortic dissection patients more-extensive RR interventions are not associated with increased hospital mortality. This supports such an approach in young patients and patients with connective tissue diseases and bicuspid aortic valves. Excellent midterm survival and freedom from root reintervention in both groups suggest stable behavior of the nonreplaced aortic sinuses at 3 years. Thus, pending studies with longer follow-up, the use of aggressive RR techniques can be determined by patient-specific and dissection-related factors.