Surgery of Acute Type A Dissection: What Have We Learned during the Past 25 Years?

(*1:Institut Mutualiste Montsouris, Boulevard Jourdan, 75014 Paris, France, *2:Hopital Foch, Suresnes, France, *3:Centre Cardiologique du Nord, Saint-Denis, France, *4:Clinique de la Roseraie, Aubervilliers, France)

*1 Jean Bachet *2 Bertrand Goudot *2 Gilles Dreyfus
*3 Denis Brodaty *2 Claude Dubois *2 Philippe Delentdecker
*2 Feirouze Teimouri *4 Daniel Guilmet
@Every acute dissection involving the ascending aorta (Stanford type A) must undergo emergency surgical repair. However, the surgical techniques must vary according to the clinical presentation of the patients or the anatomical patterns observed. Furthermore, surgery is generally difficult because of the poor condition of the aortic tissues. To reduce those difficulties many technical artifacts have been described. In 1977, we have proposed the use of Gelatin-Resorcin-Formalin (GRF) biological glue to reinforce the suture areas.
@From January 1977 to July 1999, 212 patients (152 males and 60 females) aged from 15 to 80 years (mean age: 54{11 years) underwent an emergency operation for type A aortic dissection. One hundred seventy-eight patients (84%) were operated on within 4 h after being referred to the hospital. Twenty-eight patients (13.2%) had Marfan's syndome. In 44 patients (20.7%), the aortic valve was replaced either independently (6 cases: 2.8%) or by means of a composite graft (38 cases: 17.9%). Because of the location of the intimal tear, the aortic replacement was extended to the transverse arch in 61 patients (28.7%).
@Hospital mortality amounts to 21.6% (46 patients), 25% in patients with arch replacement and 19.4% in patients without arch replacement (n.s). Analysis of hospital mortality demonstrates that the main causes of death were cardiac tamponade, neurologic disorders and visceral malperfusion. One hundred sixty-six patients were discharged and surveyed from 5 months to 22 years postoperatively (Mean follow-up: 85{66 months). During this period of time, 25 patients (15%) had to be reoperated on for a total of 33 reoperations. Seven patients (28%) died at reoperation. At univariate analysis, presence of Marfan's syndrome (p0.05) and absence of arch replacement (p0.02) were determinant risk factors for reoperation. Emergency (p0.01) and thoraco-abdominal replacement (p0.04) were determinant risk-factors of death at reoperation. The freedom from reoperation (Kaplan-Meier, CI: 95%) is: 96% (90-98), 87% (79-92), 80% (70-88), 66% (51-78) at 1, 5, 10, and 15 years, respectively.
@A total of 39 patients (24.3%) died during follow-up. Presence of Marfan's syndrome (p0.01), reoperation (p0.02), stroke (p0.05), cardiac failure (p0.05) were determinant risk factors of late mortality. The late survival rate (K-M. C. I.: 95%), including hospital mortality, is 71% (64-77), 66% (58-73), 56% (47-64), 46% (36-56), 37% (28-44) at 1, 10, 15, and 20 years respectively.
@During this experience extending over more than 23 years, the GRF glue has proved to be extremely useful, making the procedure much easier and safer. Nevertheless many factors appeared of importance in the pre, intra, and postoperative management of the patients. Cardiac tamponnade and visceral malperfusion must be properly diagnosed and treated. During aortic repair, the main intimal tear must be resected. The transverse arch must be checked and replaced whenever necessary. The aortic valve should be preserved whenever possible. During CPB, perfusing the aorta in the regular antegrade way seems to dramatically reduce the rate of malperfusion. The quality of the first emergency operation seems to have a major influence on the late results, especially concerning the rate of late reoperations and aortic ruptures. However, those late results depend also on the patient's basic condition, particularly in Marfan patients.
@Jpn. J. Cardiovasc. Surg. 29: 211-220 (2000)
@Invited Lecture at The 30th Annual Meeting of The Japanese Society for Cardiovascular Surgery, Tokyo, February 16-18, 2000.