Long-term results of aggressive hemiarch replacement in 534 patients with type A aortic dissection

Objective: To present the outcomes of routinely performed hemiarch replacement in patients with acute type A aortic dissection. Methods: From 1993 to 2013, among 629 patients with acute type A dissection, 534 patients (85%) underwent hemiarch, 63 patients (10%) underwent hemiarch and antegrade thoracic stent grafting, 26 patients (4%) underwent total arch, and 6 patients (1%) underwent isolated ascending replacement. Patients with hemiarch replacement comprised the study population. Median follow-up was 4.1 years (first quartile, 1.9; third quartile, 7.8) (2462 patient years). Results: In-hospital mortality was 12% (66 out of 534 patients). Survival was 80% +/- 2%, 68% +/- 3%, and 51% +/- 3%, and 84% +/- 3%, 65% +/- 4%, and 41% +/- 6% in DeBakey type I and II patients at 1, 5, and 10 years, respectively (log rank P = .375). Freedom from distal aortic reintervention was 97% +/- 1%, 90% +/- 2%, and 85% +/- 3% and 99% +/- 1%, 97% +/- 2%, and 90% +/- 5% in DeBakey type I and II patients at 1, 5, and 10 years, respectively (log rank P = .046). Seven patients (1.3%) required reintervention for aortic arch aneurysm and 25 patients (5%) required reintervention for descending aortopathy. The success rate for distal reintervention performed electively or urgently was 92% (24 out of 26 patients). Marfan syndrome (odds ratio, 3.43; P = .046) and DeBakey type I dissection (odds ratio, 2.49; P = .048) were independent predictors of distal aortic reintervention. Conclusions: Aggressive hemiarch replacement in acute type A dissection can be performed with low mortality and low aortic arch reoperation rate. Resection of all dissected aortic wall tissue decreases, but does not eliminate, the risk of later adverse aortic events.