Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection

Fernando Fleischman, Ramsey S. Elsayed, Robbin G. Cohen, James M. Tatum, S. Ram Kumar, Kayvan Kazerouni, Wendy J. Mack, Mark L. Barr, Mark J. Cunningham, Amy E. Hackmann, Craig J. Baker, Vaughn A. Starnes, Michael E. Bowdish

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Background Controversy exists regarding the optimal extent of repair for type A aortic dissection. Our approach is to replace the ascending aorta, and only replace the aortic root or arch when intimal tears are present in those areas. We examined intermediate outcomes with this approach to acute type A aortic dissection repair. Methods Between March 2005 and October 2016, 195 patients underwent repair of acute type A aortic dissection. Repair was categorized by site of proximal and distal anastomosis and extent of repair. Mean follow-up was 31.0 ± 30.9 months. Kaplan-Meier analysis was used to assess survival. Multiple variable Cox proportional hazards modeling was utilized to identify factors associated with overall mortality. Results Overall survival was 85.1%, 83.9%, 79.1%, and 74.4% at 6, 12, 36, and 60 months, respectively. Eight patients required reintervention. The cumulative incidence of aortic reintervention at 1 year with death as a competing outcome was 3.95%. Multiple variable regression analysis identified factors such as age, preoperative renal failure, concomitant thoracic endograft, postoperative myocardial infarction and sepsis, and need for extracorporeal membrane oxygenation as predictive of overall mortality. Neither proximal or distal extent of repair, nor need for reintervention affected overall survival (proximal: hazard ratio 1.63, 95% confidence interval: 0.75 to 3.51, p = 0.22; distal: hazard ratio 1.12, 95% confidence interval: 0.43 to 2.97, p = 0.81; reintervention: hazard ratio 0.03, 95% confidence interval: 0.002 to 0.490, p < 0.01). Conclusions A selective approach to root and arch repair in acute type A aortic dissection is safe. If aortic reintervention is needed, survival does not appear to be affected.

Original languageEnglish (US)
Pages (from-to)505-512
Number of pages8
JournalAnnals of Thoracic Surgery
Volume105
Issue number2
DOIs
StatePublished - Feb 2018
Externally publishedYes

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Thoracic Aorta
Dissection
Survival
Confidence Intervals
Tunica Intima
Extracorporeal Membrane Oxygenation
Mortality
Kaplan-Meier Estimate
Renal Insufficiency
Aorta
Sepsis
Thorax
Myocardial Infarction
Regression Analysis
Incidence

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine

Cite this

Fleischman, F., Elsayed, R. S., Cohen, R. G., Tatum, J. M., Kumar, S. R., Kazerouni, K., ... Bowdish, M. E. (2018). Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection. Annals of Thoracic Surgery, 105(2), 505-512. https://doi.org/10.1016/j.athoracsur.2017.07.016

Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection. / Fleischman, Fernando; Elsayed, Ramsey S.; Cohen, Robbin G.; Tatum, James M.; Kumar, S. Ram; Kazerouni, Kayvan; Mack, Wendy J.; Barr, Mark L.; Cunningham, Mark J.; Hackmann, Amy E.; Baker, Craig J.; Starnes, Vaughn A.; Bowdish, Michael E.

In: Annals of Thoracic Surgery, Vol. 105, No. 2, 02.2018, p. 505-512.

Research output: Contribution to journalArticle

Fleischman, F, Elsayed, RS, Cohen, RG, Tatum, JM, Kumar, SR, Kazerouni, K, Mack, WJ, Barr, ML, Cunningham, MJ, Hackmann, AE, Baker, CJ, Starnes, VA & Bowdish, ME 2018, 'Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection', Annals of Thoracic Surgery, vol. 105, no. 2, pp. 505-512. https://doi.org/10.1016/j.athoracsur.2017.07.016
Fleischman, Fernando ; Elsayed, Ramsey S. ; Cohen, Robbin G. ; Tatum, James M. ; Kumar, S. Ram ; Kazerouni, Kayvan ; Mack, Wendy J. ; Barr, Mark L. ; Cunningham, Mark J. ; Hackmann, Amy E. ; Baker, Craig J. ; Starnes, Vaughn A. ; Bowdish, Michael E. / Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection. In: Annals of Thoracic Surgery. 2018 ; Vol. 105, No. 2. pp. 505-512.
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abstract = "Background Controversy exists regarding the optimal extent of repair for type A aortic dissection. Our approach is to replace the ascending aorta, and only replace the aortic root or arch when intimal tears are present in those areas. We examined intermediate outcomes with this approach to acute type A aortic dissection repair. Methods Between March 2005 and October 2016, 195 patients underwent repair of acute type A aortic dissection. Repair was categorized by site of proximal and distal anastomosis and extent of repair. Mean follow-up was 31.0 ± 30.9 months. Kaplan-Meier analysis was used to assess survival. Multiple variable Cox proportional hazards modeling was utilized to identify factors associated with overall mortality. Results Overall survival was 85.1{\%}, 83.9{\%}, 79.1{\%}, and 74.4{\%} at 6, 12, 36, and 60 months, respectively. Eight patients required reintervention. The cumulative incidence of aortic reintervention at 1 year with death as a competing outcome was 3.95{\%}. Multiple variable regression analysis identified factors such as age, preoperative renal failure, concomitant thoracic endograft, postoperative myocardial infarction and sepsis, and need for extracorporeal membrane oxygenation as predictive of overall mortality. Neither proximal or distal extent of repair, nor need for reintervention affected overall survival (proximal: hazard ratio 1.63, 95{\%} confidence interval: 0.75 to 3.51, p = 0.22; distal: hazard ratio 1.12, 95{\%} confidence interval: 0.43 to 2.97, p = 0.81; reintervention: hazard ratio 0.03, 95{\%} confidence interval: 0.002 to 0.490, p < 0.01). Conclusions A selective approach to root and arch repair in acute type A aortic dissection is safe. If aortic reintervention is needed, survival does not appear to be affected.",
author = "Fernando Fleischman and Elsayed, {Ramsey S.} and Cohen, {Robbin G.} and Tatum, {James M.} and Kumar, {S. Ram} and Kayvan Kazerouni and Mack, {Wendy J.} and Barr, {Mark L.} and Cunningham, {Mark J.} and Hackmann, {Amy E.} and Baker, {Craig J.} and Starnes, {Vaughn A.} and Bowdish, {Michael E.}",
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T1 - Selective Aortic Arch and Root Replacement in Repair of Acute Type A Aortic Dissection

AU - Fleischman, Fernando

AU - Elsayed, Ramsey S.

AU - Cohen, Robbin G.

AU - Tatum, James M.

AU - Kumar, S. Ram

AU - Kazerouni, Kayvan

AU - Mack, Wendy J.

AU - Barr, Mark L.

AU - Cunningham, Mark J.

AU - Hackmann, Amy E.

AU - Baker, Craig J.

AU - Starnes, Vaughn A.

AU - Bowdish, Michael E.

PY - 2018/2

Y1 - 2018/2

N2 - Background Controversy exists regarding the optimal extent of repair for type A aortic dissection. Our approach is to replace the ascending aorta, and only replace the aortic root or arch when intimal tears are present in those areas. We examined intermediate outcomes with this approach to acute type A aortic dissection repair. Methods Between March 2005 and October 2016, 195 patients underwent repair of acute type A aortic dissection. Repair was categorized by site of proximal and distal anastomosis and extent of repair. Mean follow-up was 31.0 ± 30.9 months. Kaplan-Meier analysis was used to assess survival. Multiple variable Cox proportional hazards modeling was utilized to identify factors associated with overall mortality. Results Overall survival was 85.1%, 83.9%, 79.1%, and 74.4% at 6, 12, 36, and 60 months, respectively. Eight patients required reintervention. The cumulative incidence of aortic reintervention at 1 year with death as a competing outcome was 3.95%. Multiple variable regression analysis identified factors such as age, preoperative renal failure, concomitant thoracic endograft, postoperative myocardial infarction and sepsis, and need for extracorporeal membrane oxygenation as predictive of overall mortality. Neither proximal or distal extent of repair, nor need for reintervention affected overall survival (proximal: hazard ratio 1.63, 95% confidence interval: 0.75 to 3.51, p = 0.22; distal: hazard ratio 1.12, 95% confidence interval: 0.43 to 2.97, p = 0.81; reintervention: hazard ratio 0.03, 95% confidence interval: 0.002 to 0.490, p < 0.01). Conclusions A selective approach to root and arch repair in acute type A aortic dissection is safe. If aortic reintervention is needed, survival does not appear to be affected.

AB - Background Controversy exists regarding the optimal extent of repair for type A aortic dissection. Our approach is to replace the ascending aorta, and only replace the aortic root or arch when intimal tears are present in those areas. We examined intermediate outcomes with this approach to acute type A aortic dissection repair. Methods Between March 2005 and October 2016, 195 patients underwent repair of acute type A aortic dissection. Repair was categorized by site of proximal and distal anastomosis and extent of repair. Mean follow-up was 31.0 ± 30.9 months. Kaplan-Meier analysis was used to assess survival. Multiple variable Cox proportional hazards modeling was utilized to identify factors associated with overall mortality. Results Overall survival was 85.1%, 83.9%, 79.1%, and 74.4% at 6, 12, 36, and 60 months, respectively. Eight patients required reintervention. The cumulative incidence of aortic reintervention at 1 year with death as a competing outcome was 3.95%. Multiple variable regression analysis identified factors such as age, preoperative renal failure, concomitant thoracic endograft, postoperative myocardial infarction and sepsis, and need for extracorporeal membrane oxygenation as predictive of overall mortality. Neither proximal or distal extent of repair, nor need for reintervention affected overall survival (proximal: hazard ratio 1.63, 95% confidence interval: 0.75 to 3.51, p = 0.22; distal: hazard ratio 1.12, 95% confidence interval: 0.43 to 2.97, p = 0.81; reintervention: hazard ratio 0.03, 95% confidence interval: 0.002 to 0.490, p < 0.01). Conclusions A selective approach to root and arch repair in acute type A aortic dissection is safe. If aortic reintervention is needed, survival does not appear to be affected.

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