Asian Cardiovasc Thorac Ann 2001;9:93-96
© 2001 Asia Publishing EXchange Pte Ltd
Acute Type A Aortic Dissection. Influence of Early Management on Results
Ahmad El-Bishry, MD,
Najib Al-Khaja, MD, PhD,
Hans Krebber, MD,
Mohamed El Fiki, MD1,,
Mohamed Abdel Aziz, MD,
Hosam Aboul Enein, MD,
Mohamed Saeed, MD,
Ismail Sallam, MD1,
Department of Surgery
Aortic Surgery Centre
Cairo University
Cairo, Egypt
1 Department of Cardiovascular Surgery
Naser Institute
Cairo, Egypt
|
|
|
For reprint information contact: Najib Al-Khaja, MD, PhD Tel: 971 4 271 4444 Fax: 971 4 271 9340 email: drnajib{at}emirates.net.ae Department of Cardiothoracic Surgery, Dubai Hospital, P.O. Box 7272, Dubai, UAE.
|
 |
Abstract
|
|---|
One hundred and six patients were operated upon for acute type A aortic dissection in 7 years between February 1992 and May 1999. There were 102 males and 4 females, aged 18 to 83 years with a mean of 59 ± 14 years. All patients underwent surgery within 14 hours of diagnosis. The ascending aorta was replaced with a Dacron graft in 103 patients; in the other 3 cases, the repair extended to the aortic arch. The aortic valve was preserved by resuspension in all except 4 patients, 3 of whom had Marfan's syndrome. There were 9 (8.5%) deaths, all due to respiratory and multiorgan failure. Nine patients (8.5%) needed hemodialysis; only one of these required permanent dialysis. Ten patients (9.4%) had transient neurological disorders, 2 others (1.9%) suffered permanent hemiplegia. Three patients (2.8%) underwent reoperation for bleeding. Tracheostomy for prolonged respiratory assistance was required in 6 patients (5.7%), of whom 1 died from respiratory failure. Early surgical intervention could be performed with low morbidity and mortality.
|
Introduction
|
|---|
Type A aortic dissection is fatal if not treated early. Approximately 50% of patients die within 48 hours of onset, with an attrition rate of 1% per hour; 70% die within one week and only 10% remain alive by the end of one year.1,2 Surgical treatment is technically demanding and despite improving results over recent decades, it still carries a considerable morbidity and mortality.3,4 A number of techniques have been developed to improve the outcome.5–9 The introduction of surgical glue has contributed to better results, and aortic valve preservation has reduced the morbidity associated with replacement of the valve with a prosthesis.10–14 However, the nature of the disease, the risk factors, and the duration between the onset of dissection and the surgical intervention all play important roles in the final outcome.15 The results of early surgical intervention in 106 patients with acute type A aortic dissection were reviewed retrospectively.
|
Patients and Methods
|
|---|
One hundred and six patients were operated upon for acute type A aortic dissection in 7 years (February 1992 to May 1999) at Naser Institute, Cairo, and the Aortic Surgery Center, Cairo University. There were 102 males and 4 females; their ages ranged from 18 to 83 years with a mean of 59 ± 14 years. The operation was performed as soon as possible after the diagnosis was made, in a range of 3 to 14 hours after the onset of dissection. Patients treated for chronic dissection were excluded from the study. The ascending aorta was involved in all cases, and there was involvement of the proximal arch of aorta in 3 patients (2.8%). Preoperative clinical details are given in Table 1
. Ten patients (9.4%) were in shock, generally related to cardiac tamponade, 10 had one established femoral pulse (3 patients had clinical ischemia of one lower limb). Early in the study, diagnosis was made by computed tomography but recently, trans-esophageal echocardiography has become the diagnostic method of choice.
Esophageal and rectal temperatures, transesophageal echocardiography, and electroencephalogram monitoring were carried out perioperatively. A femoral artery cannula was inserted and the chest was opened via a median sternotomy incision. The venae cavae were cannulated, a left atrial vent was set up, cardiopulmonary bypass was started, and the patient was cooled. The mid portion of the ascending aorta was clamped and the aorta was opened vertically to visualize the inside of the dissecting aorta. The lower stump of the aorta was cut transversely; blood cardioplegia was given directly into the coronary ostia. The aortic valve was examined, 3 Teflon-pledgeted 2/0 polypropylene sutures were inserted into the 3 aortic commissures, and the valve was tested for competence. The two layers of the dissection were glued together using gelatin-resorcine-formol (GRF) glue (Cardial SA; Filiale de C.R. Bard, Inc., Saint-Etienne, France). Approximately 3 minutes were needed for polymerization before a solid stump was ready for tight anastomosis. The edges of the two layers were oversewn with a continuous 4/0 polypropylene suture in 2 layers (Figure 1). A Dacron graft was anastomosed to the proximal stump by means of 3/0 polypropylene continuous sutures starting pos-teriorly, then the anastomosis was completed anteriorly in two layers. After completion of the proximal anastomosis, a second layer of GRF glue was applied to the suture and left for 3 minutes to polymerize and solidify.
View larger version (28K):
[in this window]
[in a new window]
|
Figure 1. The middle part of the ascending aorta is cut transversely and removed. Reconstruction of the proximal stump is carried out using gelatin-resorcine-formol glue, and the two edges of the stump are oversewn with a continuous suture of 4/0 polypropylene, in two layers. The distal stump is crossclamped.
|
|
When the nasopharyngeal temperature dropped to 18°C, circulation was stopped, the aortic crossclamp was opened, the heart was drained, and retrograde cerebral perfusion via the superior vena cava was started, keeping the central venous pressure around 20 mm Hg. The top end of the Dacron graft was clamped and blood cardioplegia was given through a side arm in the graft. The distal stump of the aorta was cut transversely, the 2 dissecting cylinders were glued with GRF, and continuous 4/0 polypropylene was used to suture the two layers (Figure 2A). The top end of the Dacron graft was cut distally, beveled, and sutured to the distal stump in a similar fashion to the proximal stump (Figure 2B). The graft was filled retro-gradely and clearing was performed through the side arm in the Dacron graft. Once the graft was de-aired, the retrograde circulation was stopped, and antegrade cardio-pulmonary bypass was started with rewarming. The side arm was then ligated and cut. In 3 cases where the intimal tear was in the aortic arch, the arch was either totally or partially replaced to resect the tear. In patients with Marfan's syndrome, aortic root replacement was per-formed using valved conduit and separate coronary ostia.
View larger version (54K):
[in this window]
[in a new window]
|
Figure 2. (A) The proximal stump is reconstructed and the aortic valve is tightened by means of 3 Teflon-pledgeted 2/0 polypropylene sutures in the 3 commissures. The aortic clamp is opened and the distal stump is reconstructed in the same fashion as the proximal one. (B) The ascending aorta after complete reconstruction using a Dacron graft.
|
|
Patients were followed up for 2 months postoperatively. Initially, this was during the hospital stay that ranged from 10 to 14 days in most cases, and up to 40 days in 21 patients (19.8%) who required extended medical care. Patients were examined in the outpatient clinic one month after discharge and then consigned back to the referring cardiologist for further follow-up. In addition to routine blood tests, electrocardiograms, and chest radiography, all patients had an echocardiographic study either before discharge or in the outpatient clinic.
|
Results
|
|---|
The duration of cardiopulmonary bypass ranged from 106 to 182 minutes (mean, 129 minutes), the duration of the initial crossclamping ranged from 17 to 37 minutes (mean, 24 minutes), and the circulatory arrest time was 18 to 66 minutes (mean, 29 minutes). The mean awakening time was 8 ± 4 hours. Postoperative morbidity and mortality are summarized in Table 2. Postoperative blood loss ranged from 120 to 960 mL (mean, 390 mL). Three patients underwent reoperation for excessive bleeding within 3 hours after the initial surgery, all did well later. Nine patients who had some renal impairment pre-operatively, required hemodialysis postoperatively, but only one needed permanent dialysis. The 10 patients with transient neurological disorders recovered and the 2 who had permanent hemiplegia survived and were discharged on a physiotherapy regime. Of the 6 patients who needed a tracheostomy, one eventually died from multiorgan failure. No intraoperative death occurred. Within 30 days of operation, there were 6 deaths; all were due to respiratory and multiorgan failure. There were 3 further hospital deaths: one patient died from heart failure at 48 days and 2 from respiratory failure at 52 and 58 days after surgery, respectively.
|
Discussion
|
|---|
Surgical treatment of acute type A aortic dissection is technically difficult and associated with considerable morbidity and mortality.3–9,15,16 The use of GFR in construction of a solid stump proximally and distally that can take the graft with no sequelae of bleeding or dissection, is important to the success of the procedure. Our experience with GRF glue was very encouraging and supported the findings of others that postoperative bleeding was surgically acceptable, with only 3 patients requiring reoperation for bleeding.10–12 Preserving the native aortic valve (in the majority of cases, the aortic valve is healthy) is an important factor in reducing complications by decreasing surgical time and later avoiding the potential hazards of a prosthetic valve.13
The hospital mortality of 8.5% was considered to be low. This was attributed to several factors including rapid surgical intervention before vital organs deteriorated. Bachet and colleagues11 found that patients below 65 years with isolated replacement of the ascending aorta had a mortality rate of less than 10%. Most of our patients were below 65 years and required isolated ascending aortic replacement. The experience of the surgical team may also have played a role in the outcome.
This study reports the short-term outcome but we will continue to monitor the long-term outcome of these patients. Although acute type A aortic dissection is a fatal condition, with our current technique, early surgical intervention could be performed with low morbidity and mortality.
|
References
|
|---|
-
Massimo CG, Presenti LF, Favi PP, Ponzalli M, Marranci P, Crisci C, et al. Excision of the aortic wall in the surgical treatment of acute type-A aortic dissection. Ann Thorac Surg 1990;50:274–6.[Abstract]
-
Miller DC. Replacement of the transverse aortic arch during emergency operation for type A acute aortic dissection [letter]. J Thorac Cardiovasc Surg 1989;98:310–3.[Medline]
-
Crawford ES, Svensson LG, Coselli JS, Safi HJ, Hess KR. Aortic dissection and dissecting aortic aneurysms. Ann Surg 1988;208:254–73.[Medline]
-
Ergin MA, McCullough J, Galla JD, Lansman SL, Griepp RB. Radical replacement of the aortic root in acute type A dissection: indications and outcome. Eur J Cardiothorac Surg 1996;10:840–4.[Abstract]
-
Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968;23: 338–9.[Abstract/Free Full Text]
-
Borst HG, Laas J, Haverich A. A new look at acute type-A dissection of the aorta. Eur J Cardiothorac Surg 1987; 1:186–9.[Abstract]
-
Ubranski PP. Replacement of the ascending aorta and aortic valve with a valved stentless composite graft. Ann Thorac Surg 1999;67:1501–2.[Abstract/Free Full Text]
-
Westaby S, Parry A, Giannopoulos N, Pillai R. Replacement of the thoracic aorta with collagen-impregnated woven Dacron grafts. J Thorac Cardiovasc Surg 1993;106: 427–33.[Abstract]
-
Liu DW, Lin PJ, Chang CH. Treatment of acute type A aortic dissection with intraluminal sutureless prosthesis. Ann Thorac Surg 1994;57:987–91.[Abstract]
-
Fabiani JN, Jebara VA, DeLoche A, Carpentier A. Use of glue without graft replacement for type A dissections: a new surgical technique. Ann Thorac Surg 1990;50:143–5.[Abstract]
-
Bachet J, Goudot B, Teodori G, Brodaty D, Dubois C, De Lentdecker P, et al. Surgery of type A acute aortic dissection with Gelatine-Resorcine-Formol biological glue: a twelve-year experience. J Cardiovasc Surg (Torino) 1990; 31:263–73.[Medline]
-
Séguin JR, Frapier JM, Colson P, Chaptal PA. Fibrin sealant improves results of type A acute aortic dissections. Ann Thorac Surg 1991;52:745–8.[Abstract]
-
Westaby S, Katsumata T, Freitas E. Aortic valve conservation in acute type A dissection. Ann Thorac Surg 1997;64:1108–12.[Abstract/Free Full Text]
-
Schäfers H-J, Fries R, Langer F, Nikoloudakis N, Graeter T, Grundmann U. Valve-preserving replacement of the ascending aorta: remodeling versus reimplantation. J Thorac Cardiovasc Surg 1998;116:990–6.[Abstract/Free Full Text]
-
Rene P, Von Segesser LK. Aortic dissection. Lancet 1997;349:1461–4.[Medline]
-
Bachet JE, Termignon JL, Dreyfus G, Goudot B, Martinelli L, Piquois A, et al. Aortic dissection. Prevalence, cause, and results of late reoperations. J Thorac Cardiovasc Surg 1994;108:199–206.[Abstract/Free Full Text]
TOP
Abstract
Introduction
