Acute type A aortic dissection: long-term results and reoperations

OBJECTIVES: The objective of this study was to report long-term results and incidence of reoperations after surgery for acute type A dissection. METHODS: All 232 consecutive patients who underwent surgery for acute type A aortic dissection from 1972 to April 2011 were included. Patient, procedural and follow-up information was obtained from hospital records. RESULTS: Mean age was 57.9 years (standard deviation 13.4 years), 64% were male. In 157 patients, the native aortic valve was preserved, 75 underwent aortic valve replacement (valved conduit 49, aortic allograft 16, mechanical prosthesis 8 and bioprosthesis 2). Thirty-, 60- and 90-day mortalities were 18.1% (n = 42), 19.8% (n = 46) and 21.6% (n = 50), and decreased over time. Thirty-day mortality in the period 2007-11 was 12.5%. During follow-up of hospital survivors (mean duration 7.2 years, range 0.2-25.7 years), 64 patients died. Risk factors for 30-day mortality were preoperative resuscitation and longer cardiopulmonary bypass time. The use of circulatory arrest and biological glue was associated with a lower 30-day mortality. Actuarial survival was 53.4% (95% confidence interval [CI] 45.8-61.0%) after 10 and 29.3% (95% CI 29.9-48.7%) after 15 years. Late survival was comparable for patients with preserved native valves versus patients with various types of valve replacement. Forty-three patients underwent 47 reoperations; for aortic valve insufficiency in 17 patients (12 native valve, 5 allograft), recurrent aortic dissections or aneurysms in 27 and other cardiac operations in 3. Actuarial freedom from aortic valve reoperation at 10 years was 85.6% for patients with a preserved native aortic valve, 84.8% after allograft implantation and 100% after prosthetic replacement (Tarone-Ware test P = 0.13). Aortic valve preservation in patients presenting with severe aortic insufficiency was associated with an increased risk of aortic valve reoperation. CONCLUSIONS: Acute type A dissection in the current era is associated with a decreasing acceptable operative mortality risk and has a satisfactory long-term survival for hospital survivors. These factors were both involved were associated with a lower 30-day mortality. A substantial proportion of patients will require reoperations on the aortic valve or the aorta.