976
B.D. Conway et al. / Interactive CardioVascular and Thoracic Surgery
short- and long-term outcomes following repair of acute type A aortic dissection. In this study, we examined an unselected cohort of patients from four academic institutions. This study is among the first to compare early clinical outcomes and 5-year actuarial survival between patients repaired during 2000–2005 and those who had repair during 2006–2010. Surgical era affected early clinical outcomes and survival following acute type A aortic dissection repair in our analysis. Over time, operative mortality decreased and late survival improved, correspondingly with increasing use of antegrade cerebral perfusion and axillary arterial cannulation. Based on the results of our study, advancements in surgical techniques and postoperative management have significantly improved outcomes for patients with type A aortic dissection in the current era, compared with earlier years.
Study limitations Inherent limitations of a retrospective multi-institution investigation inevitably affected our study. Specifically, possible changes in the referral pattern (with earlier referral and expedient surgical repair) may be possible causes of improved outcomes in the second era; however, these were not evaluated because of the retrospective nature of the study. Bias may have also been introduced into the analysis because nine surgeons from four institutions performed the procedures. The small sample size precluded use of more appropriate and robust statistical techniques, such as propensity score matching to adjust for the differences in preoperative characteristics, as well as selection or time (improvement of technology overtime) bias between groups. Another limitation is that only patients who underwent operations for repair of type A dissection were included. Patients who died before operation, before or during transfer or evaluation were not included. Therefore, generalizing our results to all patients with type A aortic dissection is not possible. Further study of reoperations of the remaining dissected aorta, the causes of early or late mortality and the fate of the false lumen were outside the scope of our analysis. In future, these should be the focus for evaluating long-term outcomes of acute type A aortic dissection repair.
CONCLUSIONS Different surgical eras have prodigiously impacted the postoperative outcomes and survival in patients presenting with acute type A aortic dissection. Our findings suggest that surgical repair of type A aortic dissection in the modern era is associated with far greater survival compared with those repaired earlier. Conflict of interest: none declared.
REFERENCES [1] Svensson LG, Crawford ES. Cardiovascular and Vascular Disease of the Aorta. Philadelphia: W.B. Saunders Co., 1997;1–6. [2] Hirst AE Jr, Johns VJ Jr, Kime SW Jr. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine (Baltimore) 1958;37:217–79. [3] Kouchoukos NT, Dougenis D. Surgery of the thoracic aorta. N Engl J Med 1997;336:1876–88. [4] Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL et al. The International Registry of Acute Aortic Dissection (IRAD)—new insights into an old disease. JAMA 2000;283:897–903. [5] Bavaria JE, Brinster DR, Gorman RC, Woo YJ, Gleason T, Pochettino A. Advances in the treatment of acute type A dissection: an integrated approach. Ann Thorac Surg 2002;74:S1848–52; discussion S57–63.
[6] Bavaria JE, Pochettino A, Brinster DR, Gorman RC, McGarvey ML, Gorman JH et al. New paradigms and improved results for the surgical treatment of acute type A dissection. Ann Surg 2001;234:336–42; discussion 42–3. [7] Tolenaar JL, van Bogerijen GH, Eagle KA, Trimarchi S. Update in the management of aortic dissection. Curr Treat Options Cardiovasc Med 2013;15: 200–13. [8] Fann JI, Smith JA, Miller DC, Mitchell RS, Moore KA, Grunkemeier G et al. Surgical management of aortic dissection during a 30-year period. Circulation 1995;92:II113–21. [9] Blackstone EH, Naftel DC, Turner MJ. The decomposition of time-varying hazard into phases, each incorporating a separate stream of concomitant information. J Am Stat Assoc 1986;81:615–24. [10] Lytle BW, Mahfood SS, Cosgrove DM, Loop FD. Replacement of the ascending aorta. Early and late results. J Thorac Cardiovasc Surg 1990;99: 651–7; discussion 7–8. [11] Laas J, Jurmann MJ, Heinemann M, Borst HG. Advances in aortic arch surgery. Ann Thorac Surg 1992;53:227–32. [12] Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen-year experience with aortic root replacement. Results of 172 operations. Ann Surg 1991;214:308–18; discussion 18–20. [13] Crawford ES, Kirklin JW, Naftel DC, Svensson LG, Coselli JS, Safi HJ. Surgery for acute dissection of ascending aorta. Should the arch be included? J Thorac Cardiovasc Surg 1992;104:46–59. [14] Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results. Circulation 1990;82:IV24–38. [15] Miller DC, Mitchell RS, Oyer PE, Stinson EB, Jamieson SW, Shumway NE. Independent determinants of operative mortality for patients with aortic dissections. Circulation 1984;70:I153–64. [16] Pagni S, Ganzel BL, Trivedi JR, Singh R, Mascio CE, Austin EH et al. Early and midterm outcomes following surgery for acute type A aortic dissection. J Card Surg 2013;28:543–9. [17] Klodell CT, Karimi A, Beaver TM, Hess PJ, Martin TD. Outcomes for acute type A aortic dissection: effects of previous cardiac surgery. Ann Thorac Surg 2012;93:1206–12; discussion 12–4. [18] Campbell-Lloyd AJ, Mundy J, Pinto N, Wood A, Beller E, Strahan S et al. Contemporary results following surgical repair of acute type A aortic dissection (AAAD): a single centre experience. Heart Lung Circ 2010;19:665–72. [19] Mehta RH, Suzuki T, Hagan PG, Bossone E, Gilon D, Llovet A et al. Predicting death in patients with acute type A aortic dissection. Circulation 2002;105: 200–6. [20] Nienaber CA, Fattori R, Mehta RH, Richartz BM, Evangelista A, Petzsch M et al. Gender-related differences in acute aortic dissection. Circulation 2004;109:3014–21. [21] Ehrlich MP, Hagl C, McCullough JN, Zhang N, Shiang H, Bodian C et al. Retrograde cerebral perfusion provides negligible flow through brain capillaries in the pig. J Thorac Cardiovasc Surg 2001;122:331–8. [22] Anttila V, Pokela M, Kiviluoma K, Makiranta M, Hirvonen J, Juvonen T. Is maintained cranial hypothermia the only factor leading to improved outcome after retrograde cerebral perfusion? An experimental study with a chronic porcine model. J Thorac Cardiovasc Surg 2000;119:1021–9. [23] Dossche KM, Schepens MA, Morshuis WJ, Muysoms FE, Langemeijer JJ, Vermeulen FE. Antegrade selective cerebral perfusion in operations on the proximal thoracic aorta. Ann Thorac Surg 1999;67:1904–10; discussion 19–21. [24] Harrington DK, Walker AS, Kaukuntla H, Bracewell RM, Clutton-Brock TH, Faroqui M et al. Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial. Circulation 2004;110:II231–6. [25] Haldenwang PL, Bechtel M, Moustafine V, Buchwald D, Wippermann J, Wahlers T et al. State of the art in neuroprotection during acute type A aortic dissection repair. Perfusion 2012;27:119–26.
eComment. Acute type A aortic dissection repair in the current era Authors: Leo A. Bockeria and Sergey V. Rychin Bakoulev Center for Cardiovascular Surgery, Moscow, Russia doi: 10.1093/icvts/ivu358 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Acute type A aortic dissection is common life-threatening condition with high mortality in the absence of emergent surgical intervention. Despite advancements in
aortic surgery over the past decade, perioperative mortality after acute type A aortic dissection has remained high, ranging from 10-25% [2]. We read with a great interest the report by Conway BD et al [1]. The authors present the experience of 251 operations in patients with acute aortic dissection type A with a hospital mortality of 12% in recent years. We want to congratulate them on the excellent results, the reduction of hospital mortality from 24% to 12% in a short period of time (5 years) is impressive. Our Scientific Centre has dealt with the problem of surgical treatment in patients with acute type A aortic dissection since 1983. Up to 2000, operations were performed in only 34 patients with in-hospital mortality of 29%. The following years were marked by an increase in the number of operations and a decrease in hospital mortality: Between 2000 and 2005, 57 operations with a mortality of 19.2% were carried out. Between 2006 and 2014, 86 operations with mortality of 12.5% were recorded. We agree that the decline in mortality documented in the recent years could be attributed to the advances in diagnostics, surgical repair techniques and postoperative management. Since 2004, subclavian arterial perfusion has also been our preferred method. We agree that subclavian artery cannulation is a useful technique that may circumvent several technical problems related to aortic dissection, while also offering a convenient way to implement antegrade cerebral perfusion during circulatory arrest. However, the operation in deep hypothermia (15-18°C), as presented in this article, is, in our opinion, not justified if the time of cardiac arrest does not exceed 90 min. This increases the total cardiopulmonary bypass time, increases blood loss and worsens outcomes. Recently, in an experimental study in pigs, Salazar et al. [3] compared two levels of perfusate temperature: 18 and 25°C. They concluded ’that systemic circulatory arrest with selective cerebral perfusion (SCP) at 25°C can be safely performed while providing comparable cerebral and end-organ protection to that of 18°C with SCP’. Our
977
clinical data support that. In recent years, we have a low incidence of neurological complications and multiple organ failure in the postoperative period. So, as pointed out by several authors [4], we are convinced that right axillary artery cannulation associated with selective ACP at moderate hypothermia is presently the best possible method for treating acute type A dissection, regardless of the aortic repair itself. Conflict of interest: none declared. References [1] Conway BD, Stamou SC, Kouchoukos NT, Lobdell KW, Khabbaz KR, Murphy E et al. Improved clinical outcomes and surgical following repair of acute type A aortic dissection in the current era. Interact CardioVasc Thorac Surg 201419:971–7. [2] Rampoldi V, Trimarchi S, Eagle KA, Nienaber CA, Oh JK, Bossone E et al. Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score. Ann Thorac Surg 2007;83:55–61. [3] Salazar J, Coleman R, Griffith S, McNeil J, Young H, Calhoon J et al. Brain preservation with selective cerebral perfusion for operations requiring circulatory arrest: protection at 25 degrees C is similar to 18 degrees C with shorter operating times. Eur J Cardiothorac Surg 2009;36:524–31. [4] Halkos ME, Kerendi F, Myung R, Kilgo P, Puskas JD, Chen EP. Selective antegrade cerebral perfusion via right axillary artery cannulation reduces morbidity and mortality after proximal aortic surgery. J Thorac Cardiovasc Surg 2009;138:1081–9.
ORIGINAL ARTICLE
B.D. Conway et al. / Interactive CardioVascular and Thoracic Surgery
B.D. Conway et al. / Interactive CardioVascular and Thoracic Surgery
short- and long-term outcomes following repair of acute type A aortic dissection. In this study, we examined an unselected cohort of patients from four academic institutions. This study is among the first to compare early clinical outcomes and 5-year actuarial survival between patients repaired during 2000–2005 and those who had repair during 2006–2010. Surgical era affected early clinical outcomes and survival following acute type A aortic dissection repair in our analysis. Over time, operative mortality decreased and late survival improved, correspondingly with increasing use of antegrade cerebral perfusion and axillary arterial cannulation. Based on the results of our study, advancements in surgical techniques and postoperative management have significantly improved outcomes for patients with type A aortic dissection in the current era, compared with earlier years.
Study limitations Inherent limitations of a retrospective multi-institution investigation inevitably affected our study. Specifically, possible changes in the referral pattern (with earlier referral and expedient surgical repair) may be possible causes of improved outcomes in the second era; however, these were not evaluated because of the retrospective nature of the study. Bias may have also been introduced into the analysis because nine surgeons from four institutions performed the procedures. The small sample size precluded use of more appropriate and robust statistical techniques, such as propensity score matching to adjust for the differences in preoperative characteristics, as well as selection or time (improvement of technology overtime) bias between groups. Another limitation is that only patients who underwent operations for repair of type A dissection were included. Patients who died before operation, before or during transfer or evaluation were not included. Therefore, generalizing our results to all patients with type A aortic dissection is not possible. Further study of reoperations of the remaining dissected aorta, the causes of early or late mortality and the fate of the false lumen were outside the scope of our analysis. In future, these should be the focus for evaluating long-term outcomes of acute type A aortic dissection repair.
CONCLUSIONS Different surgical eras have prodigiously impacted the postoperative outcomes and survival in patients presenting with acute type A aortic dissection. Our findings suggest that surgical repair of type A aortic dissection in the modern era is associated with far greater survival compared with those repaired earlier. Conflict of interest: none declared.
REFERENCES [1] Svensson LG, Crawford ES. Cardiovascular and Vascular Disease of the Aorta. Philadelphia: W.B. Saunders Co., 1997;1–6. [2] Hirst AE Jr, Johns VJ Jr, Kime SW Jr. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine (Baltimore) 1958;37:217–79. [3] Kouchoukos NT, Dougenis D. Surgery of the thoracic aorta. N Engl J Med 1997;336:1876–88. [4] Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL et al. The International Registry of Acute Aortic Dissection (IRAD)—new insights into an old disease. JAMA 2000;283:897–903. [5] Bavaria JE, Brinster DR, Gorman RC, Woo YJ, Gleason T, Pochettino A. Advances in the treatment of acute type A dissection: an integrated approach. Ann Thorac Surg 2002;74:S1848–52; discussion S57–63.
[6] Bavaria JE, Pochettino A, Brinster DR, Gorman RC, McGarvey ML, Gorman JH et al. New paradigms and improved results for the surgical treatment of acute type A dissection. Ann Surg 2001;234:336–42; discussion 42–3. [7] Tolenaar JL, van Bogerijen GH, Eagle KA, Trimarchi S. Update in the management of aortic dissection. Curr Treat Options Cardiovasc Med 2013;15: 200–13. [8] Fann JI, Smith JA, Miller DC, Mitchell RS, Moore KA, Grunkemeier G et al. Surgical management of aortic dissection during a 30-year period. Circulation 1995;92:II113–21. [9] Blackstone EH, Naftel DC, Turner MJ. The decomposition of time-varying hazard into phases, each incorporating a separate stream of concomitant information. J Am Stat Assoc 1986;81:615–24. [10] Lytle BW, Mahfood SS, Cosgrove DM, Loop FD. Replacement of the ascending aorta. Early and late results. J Thorac Cardiovasc Surg 1990;99: 651–7; discussion 7–8. [11] Laas J, Jurmann MJ, Heinemann M, Borst HG. Advances in aortic arch surgery. Ann Thorac Surg 1992;53:227–32. [12] Kouchoukos NT, Wareing TH, Murphy SF, Perrillo JB. Sixteen-year experience with aortic root replacement. Results of 172 operations. Ann Surg 1991;214:308–18; discussion 18–20. [13] Crawford ES, Kirklin JW, Naftel DC, Svensson LG, Coselli JS, Safi HJ. Surgery for acute dissection of ascending aorta. Should the arch be included? J Thorac Cardiovasc Surg 1992;104:46–59. [14] Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Dissection of the aorta and dissecting aortic aneurysms. Improving early and long-term surgical results. Circulation 1990;82:IV24–38. [15] Miller DC, Mitchell RS, Oyer PE, Stinson EB, Jamieson SW, Shumway NE. Independent determinants of operative mortality for patients with aortic dissections. Circulation 1984;70:I153–64. [16] Pagni S, Ganzel BL, Trivedi JR, Singh R, Mascio CE, Austin EH et al. Early and midterm outcomes following surgery for acute type A aortic dissection. J Card Surg 2013;28:543–9. [17] Klodell CT, Karimi A, Beaver TM, Hess PJ, Martin TD. Outcomes for acute type A aortic dissection: effects of previous cardiac surgery. Ann Thorac Surg 2012;93:1206–12; discussion 12–4. [18] Campbell-Lloyd AJ, Mundy J, Pinto N, Wood A, Beller E, Strahan S et al. Contemporary results following surgical repair of acute type A aortic dissection (AAAD): a single centre experience. Heart Lung Circ 2010;19:665–72. [19] Mehta RH, Suzuki T, Hagan PG, Bossone E, Gilon D, Llovet A et al. Predicting death in patients with acute type A aortic dissection. Circulation 2002;105: 200–6. [20] Nienaber CA, Fattori R, Mehta RH, Richartz BM, Evangelista A, Petzsch M et al. Gender-related differences in acute aortic dissection. Circulation 2004;109:3014–21. [21] Ehrlich MP, Hagl C, McCullough JN, Zhang N, Shiang H, Bodian C et al. Retrograde cerebral perfusion provides negligible flow through brain capillaries in the pig. J Thorac Cardiovasc Surg 2001;122:331–8. [22] Anttila V, Pokela M, Kiviluoma K, Makiranta M, Hirvonen J, Juvonen T. Is maintained cranial hypothermia the only factor leading to improved outcome after retrograde cerebral perfusion? An experimental study with a chronic porcine model. J Thorac Cardiovasc Surg 2000;119:1021–9. [23] Dossche KM, Schepens MA, Morshuis WJ, Muysoms FE, Langemeijer JJ, Vermeulen FE. Antegrade selective cerebral perfusion in operations on the proximal thoracic aorta. Ann Thorac Surg 1999;67:1904–10; discussion 19–21. [24] Harrington DK, Walker AS, Kaukuntla H, Bracewell RM, Clutton-Brock TH, Faroqui M et al. Selective antegrade cerebral perfusion attenuates brain metabolic deficit in aortic arch surgery: a prospective randomized trial. Circulation 2004;110:II231–6. [25] Haldenwang PL, Bechtel M, Moustafine V, Buchwald D, Wippermann J, Wahlers T et al. State of the art in neuroprotection during acute type A aortic dissection repair. Perfusion 2012;27:119–26.
eComment. Acute type A aortic dissection repair in the current era Authors: Leo A. Bockeria and Sergey V. Rychin Bakoulev Center for Cardiovascular Surgery, Moscow, Russia doi: 10.1093/icvts/ivu358 © The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. Acute type A aortic dissection is common life-threatening condition with high mortality in the absence of emergent surgical intervention. Despite advancements in
aortic surgery over the past decade, perioperative mortality after acute type A aortic dissection has remained high, ranging from 10-25% [2]. We read with a great interest the report by Conway BD et al [1]. The authors present the experience of 251 operations in patients with acute aortic dissection type A with a hospital mortality of 12% in recent years. We want to congratulate them on the excellent results, the reduction of hospital mortality from 24% to 12% in a short period of time (5 years) is impressive. Our Scientific Centre has dealt with the problem of surgical treatment in patients with acute type A aortic dissection since 1983. Up to 2000, operations were performed in only 34 patients with in-hospital mortality of 29%. The following years were marked by an increase in the number of operations and a decrease in hospital mortality: Between 2000 and 2005, 57 operations with a mortality of 19.2% were carried out. Between 2006 and 2014, 86 operations with mortality of 12.5% were recorded. We agree that the decline in mortality documented in the recent years could be attributed to the advances in diagnostics, surgical repair techniques and postoperative management. Since 2004, subclavian arterial perfusion has also been our preferred method. We agree that subclavian artery cannulation is a useful technique that may circumvent several technical problems related to aortic dissection, while also offering a convenient way to implement antegrade cerebral perfusion during circulatory arrest. However, the operation in deep hypothermia (15-18°C), as presented in this article, is, in our opinion, not justified if the time of cardiac arrest does not exceed 90 min. This increases the total cardiopulmonary bypass time, increases blood loss and worsens outcomes. Recently, in an experimental study in pigs, Salazar et al. [3] compared two levels of perfusate temperature: 18 and 25°C. They concluded ’that systemic circulatory arrest with selective cerebral perfusion (SCP) at 25°C can be safely performed while providing comparable cerebral and end-organ protection to that of 18°C with SCP’. Our
977
clinical data support that. In recent years, we have a low incidence of neurological complications and multiple organ failure in the postoperative period. So, as pointed out by several authors [4], we are convinced that right axillary artery cannulation associated with selective ACP at moderate hypothermia is presently the best possible method for treating acute type A dissection, regardless of the aortic repair itself. Conflict of interest: none declared. References [1] Conway BD, Stamou SC, Kouchoukos NT, Lobdell KW, Khabbaz KR, Murphy E et al. Improved clinical outcomes and surgical following repair of acute type A aortic dissection in the current era. Interact CardioVasc Thorac Surg 201419:971–7. [2] Rampoldi V, Trimarchi S, Eagle KA, Nienaber CA, Oh JK, Bossone E et al. Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score. Ann Thorac Surg 2007;83:55–61. [3] Salazar J, Coleman R, Griffith S, McNeil J, Young H, Calhoon J et al. Brain preservation with selective cerebral perfusion for operations requiring circulatory arrest: protection at 25 degrees C is similar to 18 degrees C with shorter operating times. Eur J Cardiothorac Surg 2009;36:524–31. [4] Halkos ME, Kerendi F, Myung R, Kilgo P, Puskas JD, Chen EP. Selective antegrade cerebral perfusion via right axillary artery cannulation reduces morbidity and mortality after proximal aortic surgery. J Thorac Cardiovasc Surg 2009;138:1081–9.
ORIGINAL ARTICLE
B.D. Conway et al. / Interactive CardioVascular and Thoracic Surgery
