Surgical management for type A aortic dissection: 38 cases experience in King Chulalongkorn Memorial Hospital: early result and longterm follow-up.

ABSTRACT

OBJECTIVE: The objective of the present study was to evaluate the outcome of operative treatment for type A aortic dissection during the past 8 year period. PATIENTS AND METHOD: From January 1992 to March 2000, 38 patients (24 men and 14 women) underwent operations for acute (n = 26) and chronic (n = 12) type A aortic dissection. Patient's age ranged from 24 to 82 years (mean age 56 years). Surgical procedures included supracoronary ascending aortic graft for normal sinuses and valve (n = 34) with valve resuspension for commissural detatchment (n = 2), composite valve and ascending aortic graft for abnormal sinuses and valve (n = 1), and valve replacement and supracoronary ascending aortic graft for normal sinuses and abnormal valve (n = 1). Resection was extended into the arch and descending aorta in chronic dissection if there was excessive dilatation of the arch and descending aorta (n = 3). In 28 patients, aortic graft replacement was accomplished by proximal and distal anastomoses during aortic cross-clamping just proximal to the innominate artery. In 10 patients, deep hypothermia and circulatory arrest was used for open distal anastomosis or for arch replacement. Simultaneous coronary artery bypass grafting was performed in 4 patients. Pre-operative risk factors and the condition of the patients were defined and post-operative morbidity and mortality were followed in the early and long term period. RESULTS: There were 2 post-operative deaths (5.2%); one patient died of acute renal failure, the other patient had intra-operative rupture of the heart chamber; both were operated on in the acute phase of dissection. Complications included sternal wound infection in one case, neurological complication in two cases, respiratory problems in three cases, pericardial effusion in one case and post-operative bleeding that required re-operation in five cases. There was no hospital mortality in the group that were operated on in the chronic phase of dissection. Patient follow-up ranged 2 months to 8 years, there were two late mortalities, both, from acute myocardial infarction (at 33 days and 2 years after surgery). Survival rate was 92 per cent and 86 per cent at 30 days and 2 years, respectively. CONCLUSION: The result of repair of type A dissection in both phases was good in our center. The operative mortality was 5.2 per cent. Predictive factors of mortality were pre-operative shock (p=0.021), tamponade (p=0.021) and operation in the acute phase of dissection (p=0.042). In chronic type A dissection, the operative mortality was zero. Coronary artery disease was the most common cause of late deaths. Intermediate term survival in the present series was satisfactory.