International Journal of Cardiology 184 (2015) 285–290
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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Aortic root surgery improves long-term survival after acute type A aortic dissection☆ Ilir Hysi a, Francis Juthier a, Olivier Fabre b, Olivier Fouquet c, Natacha Rousse a, Carlo Banfi a, Claire Pinçon d, Alain Prat a, André Vincentelli a,⁎ a
Centre Hospitalier Régional et Universitaire de Lille, Lille 59035, Department of Cardiovascular Surgery, France Centre Hospitalier de Lens et Hôpital privé de Bois Bernard, Lens, Department of Cardiac surgery, France Centre Hospitalier Universitaire d'Angers, Angers 42000, Department of Cardiovascular and Thoracic surgery, France d Université Lille Nord de France, Lille 59000, UDSL, EA2694, Department of Biostatistics, France b c
a r t i c l e
i n f o
Article history: Received 18 September 2014 Accepted 14 February 2015 Available online 19 February 2015 Keywords: Aortic dissection Aortic root Outcomes Root reoperation
a b s t r a c t Objective: Our objective was to analyze the long term survival of patient operated on for acute type A aortic dissection. Methods: Between 1990 and 2010, 226 patients underwent emergency surgical operation for acute type A aortic dissection. We have followed the long-term outcomes. Results: 144 patients were operated on with a supracommissural replacement of the ascending aorta (SCR) and 82 with an aortic root surgery (ARS, including 77 Bentall procedures and 5 Tirone David operations). Aortic crossclamp was longer in ARS group (150.8 vs. 103.6 min, p b 0.0001). Overall in-hospital mortality was lower in ARS group (20% vs. 34%, p 0.03). Median follow-up was 11.6 years. 10-year survival was higher in ARS group (85.7% vs. 65.9%, p 0.03) and 10-year freedom from aortic root reoperation was significantly lower in ARS group (93.4% vs. 82.9%, p 0.02). In a multivariate analysis aortic root surgery was an independent protective factor for proximal reoperations OR 0.393, CI 95% [0.206–0.748], p = 0.005. Conclusions: Our study suggests that complete aortic root replacement in type A aortic dissection does not burden short-term outcomes, improves long-term survivals and decreases the rate of late reoperation. Whether this approach has to be preferred in younger patient has to be demonstrated in further studies. © 2015 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Surgical management of acute type A aortic dissection remains challenging. Perioperative results have been widely reported yet there is no full consensus in the literature regarding the choice of proximal repair surgical technique and it still may remain a decision made on surgeon's discretion or center's tradition. On one hand, the supracommissural replacement allows the preservation of the native aortic valve without an anticoagulant treatment, but on the other hand, the complete root replacement, a more demanding operation, may reduce later high risk proximal reoperations [1–3]. Whether a long term result might be influenced by perioperative proximal management has not yet been demonstrated. Aims of the present study were to evaluate early and late outcomes of a consecutive cohort of patient operated on in our center on an ☆ “All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation”. ⁎ Corresponding author at: Service de Chirurgie cardiaque, Hôpital Cardiologique, CHRU Lille, F59037 Lille, France. E-mail address: [email protected] (A. Vincentelli).
http://dx.doi.org/10.1016/j.ijcard.2015.02.020 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
emergency basis for an acute type A dissection. The primary endpoint was to determine whether perioperative proximal surgical strategy had improved late survival. The second endpoint was to evaluate the late mortality and the reoperations' rate. A composite endpoint so called event-free survival was made with the probability to be free from late death and proximal reoperation. 2. Patients and methods 2.1. Population This was a retrospective study of 226 consecutive patients operated on, in an emergency basis, for acute type A aortic dissection between January 1990 and December 2010. The whole cohort of patients had a mean age of 59.2 (±19.9) years and there was mostly male (66%). Patients were operated according two surgical strategies: supracommissural replacement (SCR n = 144 patients); or aortic root surgery with or without aortic valve replacement (ARS n = 82 patients, 77 Bentall and 5 Tirone David). The strategy regarding the surgical techniques was guided by perioperative findings and surgeon's
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Table 1 Preoperative characteristics among the two groups.
Table 2 Peroperative characteristics among the two groups.
SCR n = 144
ARS n = 82
SCR n = 144
ARS n = 82
Variable
n/mean (%/±σ)
n/mean (%/σ)
p value
Variable
n/mean (%/±σ)
n/mean (%/σ)
p value
Age BMI Female Type 1 dissection Marfan syndrome Bicuspid valve Hypertension Renal failure AoI ≥3 Cardiogenic shock Stroke Peripheral malperfusion Mesenteric Lower limb Prior cardiac surgery
62 (±11.4) years 26.3 (±4.0) kg/m2 54 (37%) 126 (87%) 0 (0%) 6 (4%) 110 (76%) 10 (6%) 10 (7%) 31 (21%) 21 (14%) 12 (8%) 2 (1%) 10 (6%) 0 (0%)
54.4 (±14.2) years 27.3 (±5.0) kg/m2 23 (28%) 65 (79%) 12 (14%) 6 (7%) 54 (65%) 2 (2%) 21 (25%) 9 (11%) 8 (9%) 5 (6%) 0 (0%) 5 (6%) 2 (2%)
0.00001 0.13 0.15 0.10 0.0001 0.36 0.09 0.22 0.0001 0.046 0.30 0.54
Axillary cannulation Femoral cannulation Pericardial effusion Open distal anastomosis Hemiarch Complete arch Frozen elephant trunk AC AC timea Circulatory arrest timea Cross-clamp time CPB time
26 (18%) 107 (74%) 88 (61%) 109 (75%) 64 (44%) 24 (16%) 6 (4%) 100 (69%) 42.0 (±17.9) min 47.3 (±29.8) min 103.6 (±37.2) min 145.1 (±47.7) min
44 (53%) 34 (41%) 48 (58%) 53 (64%) 36 (43%) 14 (17%) 1 (1%) 49 (59%) 37.7 (±14.8) min 42.9 (±18.4) min 150.8 (±42.7) min 195.8 (±57.4) min
b0.00001 b0.00001 0.70 0.08 0.90 0.94 0.43 0.14 0.14 0.25 b0.00001 b0.00001
0.13
AC: antegrade cerebroplegia. a Analysis among patients having a circulatory arrest.
BMI: body mass index; AoI: aortic insufficiency.
habitudes. Preoperative data of the patients are summarized in Table 1. The study was approved by the Institutional Review Board of the French Society of Thoracic and Cardio-Vascular Surgery (CERCSFCTCV-2013-7-29-17-7-0-HyIl). 2.2. Surgical techniques According to surgeon's preferences, cardiopulmonary bypass (CPB) was established between the femoral or axillary artery and the right atrium or both vena cava. Since 1999 [4], the antegrade axillary arterial perfusion was more and more performed. The ARS group being more recent in our cohort, the antegrade axillary arterial perfusion was more frequent than the retrograde femoral arterial perfusion, in the latter group. Myocardial protection was achieved by antegrade and/or retrograde cold blood cardioplegia repeated every 30 min with a warm blood reperfusion. In case of ascending aorta replacement, the aortic wall was felt with surgical glue (Bioglue, Cryolife, Kennesaw, GA) and the aortic valve was resuspended in case of aortic regurgitation. Aortic root replacement was performed with a usual Bentall procedure. Biological Bentall was made with a pericardial valve sutured to a Dacron prosthesis and then anchored to the left ventricle orifice. In some cases a valve sparing procedure was performed according to the inclusion technique with a Gelweave Valsalva prosthesis (Gelweave Valsalva, Vascutek, Inchinnan, UK). In both groups distal open anastomosis was performed most of the time during a circulatory arrest with an antegrade cerebral perfusion at 28 °C. 2.3. Postoperative management After the surgical procedure, patients were monitored at the intensive care unit (ICU) for at least 48 h. In case of early visceral malfunction (kidney, liver) a CT scan was emergently performed to rule out any peripheral malperfusion syndrome. Before discharge, all patients had a thoraco-abdominal contrast-enhanced CT Scan, which served for the initial assessment of the distal aortic lesions. Furthermore, a 24-hour blood pressure Holter monitor was performed to guide the long-term antihypertensive treatment. 2.4. Follow-up All patients who survived the operation were followed up. Events were defined as death or aortic root reoperation. All patients had a
regular cardiac follow-up during the first year after surgery with CT scan at 6 months and/or 1 year. Operative mortality included all patients who died within 30 days of surgery and patients never leaving the hospital. Recent clinical data were collected by telephone interviews, from the patients or their attending physicians or cardiologists. Survival was defined as the time lapsed from the date of surgery until the date of death or the end of the follow-up termination time (right censoring) excluding postoperative mortality.
2.5. Statistical analysis Analyses were conducted using SAS software (SAS version 9.1, SAS Institute Inc., Cary, NC, USA). Continuous variables are expressed as mean +/− SD, and categorical variables are presented as absolute numbers and percentages. Characteristics of subjects according to the type of surgical operation for acute type A aortic dissection were compared with Chi-square or Fisher's exact tests as appropriate for categorical variables and with Mann–Whitney U test for continuous variables.
Table 3 Postoperative morbidity and mortality among the two groups. SCR n = 144
ARS n = 82
Variable
n/mean (%/±σ)
n/mean (%/σ)
p value
ICU stay Hospital stay Stroke Renal failure (dialysis) Myocardial infarction Peripheral malperfusion Mesenteric Lower limb Fenestration Respiratory failure Pace maker Tamponade Mediastinitis In-hospital mortality Hemorrhage Cardiogenic shock Multiorgan failure Stroke Pulmonary embolism Mesenteric malperfusion
7.1 (±12.1) days 15.6 (±14.4) days 31 (21%) 46 (31%) 3 (2%) 11 (7%) 7 (4%) 4 (2%) 5 (3%) 17 (11%) 3 (2%) 9 (6%) 2 (1%) 50 (34%) 13 (26%) 8 (16%) 12 (24%) 10 (20%) 1 (2%) 6 (12%)
6.8 (±9.3) days 16.4 (±10.6) days 10 (12%) 17 (20%) 6 (7%) 3 (3%) 2 (2%) 1 (1%) 6 (7%) 13 (15%) 1 (1%) 6 (7%) 1 (1%) 17 (20%) 4 (23%) 5 (29%) 5 (29%) 1 (5%) 1 (5%) 1 (5%)
0.81 0.63 0.08 0.07 0.08 0.23
ICU: intensive care unit.
0.21 0.39 1.00 0.76 1.00 0.03 0.99 0.29 0.51 0.26 0.45 0.66
I. Hysi et al. / International Journal of Cardiology 184 (2015) 285–290 Table 4 Univariate and multivariate Cox analysis of factors affecting in-hospital mortality. Univariate analysis Variable SCR Age (per year) Type 1 dissection Marfan syndrome Cardiogenic shock Axillary cannulation Open distal anastomosis Circulatory arrest Cross-clamp time (per min) CPB time (per min) Renal failure Before 3 days of follow-up After 3 days of follow-up Postoperative myocardial infarction Peripheral malperfusion
OR
CI 95%
p value
1.823 1.051 1.328 0.522 2.135 0.722 1.083 1.083 1.002 1.004
[1.051–3.161] [1.028–1.074] [0.661–2.892] [0.128–2.131] [1.254–3.636] [0.417–1.252] [0.631–1.859] [0.631–1.859] [0.996–1.007] [1.000–1.008]
0.03 b0.0001 0.39 0.36 0.005 0.25 0.77 0.77 0.52 0.07
0.588 7.023 6.560 3.284
[0.241–1.434] [3.449–14.304] [3.207–13.420] [1.673–6.449]
0.24 b0.0001 b0.0001 0.0006
Multivariate analysis Variable
OR
CI 95%
p value
Postoperative myocardial infarction Renal failure after 3 days of follow-up SCR Age (per year) CPB time (per min)
11.375 5.200 2.257 1.042 1.006
[4.808–26.912] [2.509–10.776] [1.165–4.373] [1.019–1.065] [1.001–1.010]
b0.0001 b0.0001 0.02 0.0004 0.01
Event-free survival curves were estimated using the Kaplan– Meier method and compared using the log-rank test. Median follow-up time was estimated with the reverse Kaplan–Meier method. Univariate followed by multivariate Cox analyses were performed to assess the prognostic value of the type of surgical operation for acute type A aortic dissection on postoperative survival, proximal reintervention free survival and freedom from proximal reintervention, first unadjusted then adjusted on potential confounding factors. The log-linearity assumption for continuous variables and the proportional hazard assumption were tested by Kolmogorov-type supremum tests as implemented in the PROC PHREG of the SAS software (SAS version 9.1, SAS Institute Inc.,
287
Cary, NC, USA). In case of violation of the former assumption, the continuous variable was dichotomized, the cut-off value being visually established; in case of violation of the latter assumption, a piecewise model was used to model the hazard ratio as a step function of time, the cut-off value being again visually established. In both cases, it was ensured that the Schwarz's Bayesian Criterion was minimal. A two-tailed type I error rate b0.05 was considered for statistical significance. 3. Results Table 1 resumes preoperative characteristics among the two groups. The proximal intimal tear of the aortic dissection was more frequently found in the ascending aorta in the ARS group (93% vs. 80%, p 0.006). Also, in the ARS group, coronary bypasses at the end of the CPB were more frequent (9% vs. 1%, p = 0.007). This was related to the dissecting process in all cases (dissection of the coronary ostium or artery). Table 2 illustrates the perioperative data between the groups. Overall in-hospital mortality in the cohort was 29% (67 patients) and it was higher in the SCR group. The specific causes of mortality were not different between the groups (Table 3). In a univariate analysis (Table 4), overall in-hospital mortality was significantly influenced by a series of factors such as SCR, age, cardiogenic shock and peripheral malperfusion. In multivariate analysis (Table 4) SCR, age, renal failure persistent after 3 days of followup and myocardial infarction were significant independent factors for early mortality. For the whole cohort, the mean duration of ICU and total hospital stay were 6.9 (±11.1) days and 15.8 (±13) days, respectively. Operative morbidity between the two groups was also comparable with regard to renal failure, myocardial infarction, prolonged mechanical ventilation, stroke, peripheral malperfusion and early reoperations (Table 3). 3.1. Survival Mean follow-up was 9.1 (± 0.5) years and median follow-up was 11.6 years (range 0 to 22.7 years). 5-, 10- and 15-year survivals were 87%, 72.5% and 69%, respectively (Fig. 1A). In the SCR group these
Fig. 1. A: Kaplan–Meier survival; B: Survival among the groups.
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survival rates were 83.8%, 65.9% and 62.6%, while in the ARS group they were 91.8%, 85.7% and 81.8%. Survival was higher in ARS group (logrank p = 0.03, Fig. 1B). 3.2. Aortic root reoperations During the follow-up of the 159 patients surviving the initial surgery, 17 surgical reoperations were required on the aortic root or valve. Fifteen reoperations were performed in the SCR group: recurrent dissection of the aortic root (n = 7), progressive dilatation of the aortic root with valve insufficiency (n = 7) and stenosis of the left main requiring bypass surgery (n = 1). In the ARS group two reoperations were performed: one for aortic insufficiency with commissural prolapse after a Tirone David and one for bioprosthesis degeneration in a biological Bentall. The operative mortality of these reoperations was 23% (n = 4). All four deaths were observed in the SCR group. The median duration between the index operation and the reoperation was 53.3 months (7.7–192.5 months). 3.3. Event-free survival (late death and proximal aorta reoperations) For the entire cohort, 5-, 10- and 15-year event-free survivals were 82.3%, 65.1% and 59.4%, respectively. In the SCR group event-free survival rates were 76.1%, 57.2% and 51.0%, while in the ARS group they were 91.8%, 79.6% and 75.6% (log-rank p = 0.008, Fig. 2A). In a multivariate analysis, aortic root surgery (Bentall or Tirone David) significantly improved event-free survival (Table 5). 3.4. Freedom from aortic root reoperation For the entire cohort, the 5-, 10- and 15-year freedom values from proximal reoperation were 92.9%, 87.1% and 83.7%, respectively. In the
Table 5 Multivariate Cox analysis of factors affecting event-free survival. Multivariate analysis Variable
OR
CI 95%
p value
ARS Sex: female Preoperative peripheral malperfusion
0.393 0.462 3.110
[0.206–0.748] [0.243–0.878] [1.203–8.040]
0.005 0.02 0.02
SCR group these rates were 88.2%, 82.9% and 78%, while in the ARS group they were 100%, 93.4% and 93.4% (log-rank p = 0.02, Fig. 2B). 4. Comment Simon Kupilik et al. [5] showed in vitro and in vivo that the supracommissural replacement of the aorta by a vascular prosthesis induced significant hemodynamic changes at the level of the aortic root by increasing parietal tension as a result of the rigidity of the adjacent vascular prosthesis. Ergin et al. [6] first proposed the complete replacement of the aortic root for acute type A aortic dissection as a surgical technique potentially reducing long-term reoperations. We have summarized in Table 6 the rate of proximal aorta reoperation as it was recently published. The rate of reoperation in the ARS groups was always b 10%. Only two studies have reported a mean follow-up of more than 9 years, one of these from Niclaus et al. [7] reported a rate of 23% of reoperation in the SCR group in selected young patients (b 40 years). In our study, with a median follow up of 11.6 years, we demonstrated that ARS with a Bentall or Tirone David procedure did not burdened perioperative results and was an independent significant protective factor of survival and freedom from late aortic root reoperation.
Fig. 2. A: Event-free survival among the groups; B: Freedom from proximal reoperation among the groups.
I. Hysi et al. / International Journal of Cardiology 184 (2015) 285–290 Table 6 Proximal reoperations' rates for acute type A aortic dissection in the recent literature. Author
SCR/ARS (n=)
Proximal reoperations SCR/ARS (%)
Mean follow-up (years)
Pessotto et al. [15] Sabik et al. [1] Gelsomino et al. [17] De Paulis et al. [2] Fujimatsu et al. [11] Niclauss et al. Consistre et al. [18] Malvindi et al. [19] Bekkers et al. [14] Present study
99/34 135/0 0/19 41/0 33/12 13/14 173/61 95/13 157/49 144/82
15/0 4/0 0/0 17/0 18/0 23/0 6/0 21/8 8/0 10/2
5 4.7 7.2 5 3 9.7 4.7 6.5 7.2 9.1
4.1. Operative mortality Mortality for acute type A aortic dissection varies between 15% and 30% [3]. It remains high with little changes through time, despite recent technical advances reflecting the severity of the disease itself. Fann et al. [8] reported, in a large series, a 26% 30-day mortality rate and one of the initial publications from the international registry of acute aortic dissection (IRAD) reported a 27% 30-day mortality rate [9]. Lately, data from the latter registry showed a 23% and a 63% 30-day mortality rate in patients with and without mesenteric malperfusion, respectively [10]. Fujimatsu et al. [11], who also divided their cohort into two groups (SCR vs. Bentall), did not find any significant difference in operative mortality. Similarly, Niclauss et al., [7] in a selected young population (b 40 years), found no significant difference in mortality between the two surgical techniques. ARS is usually considered as a more complex and demanding operation than SCR. In our study, surprisingly, we found a lower mortality rate in the ARS group. Despite longer times of cross-clamp and CPB in this group, postoperative complications including neurological complications or peripheral malperfusions were not different between the groups. Similarly, the ICU and hospital lengths of stay were also not significantly different. These results suggest that the occurrence of a complication is related to the gravity of the primary disease and not due to the surgical complexity of the procedure. Furthermore our findings suggested that a complete resection of the proximal diseased aorta did not burden immediate results. There is still debate about the value of an “age cut-off” for patients undergoing surgery for acute type A aortic dissection [12], however results from surgery remains superior to those from medical treatment until the age of 80 [13]. Nevertheless, the importance of age and its impact on operative mortality should not be underestimated. Like others before, we showed that it is an important prognostic factor per se; in our study every decade of age tenfold increased the mortality risk. We observed more right coronary artery bypasses in the ARS group, but without affecting in-hospital mortality. Although these coronary issues were all related to the dissecting process itself, this technical point represents the Achilles' heel of the Bentall procedure, especially during an acute aortic dissection.
289
our series has given patients a “near” normal lifespan after an acute aortic “accident”. In the absence of aortic root replacement, when there is no preoperative aortic regurgitation, 10% of patients will develop later significant aortic insufficiency, while among patients who have preoperative aortic regurgitation, 39% will develop severe postoperative aortic insufficiency [15]. Others [14,15] have reported that proximal reoperation rates were higher in patients with worse than mild grade preoperative aortic insufficiency. In our study, we did not observe the same link between aortic insufficiency and late proximal reoperations (data not shown). But most of the time in our practice ARS was preferred in case of significant preoperative aortic regurgitation (Table 1). This strategy has also probably contributed to the reduction of the number of late reoperations on the aortic root. Commonly, the false lumen remains circulating in 50–70% of patients. Gariboldi et al. [16] identified the Bentall procedure and anticoagulation treatment as risk factors for patency of the false lumen but its thrombosis after surgery remains unpredictable. Our study was not designed to analyze the influence of ARS on the patency of the aortic false lumen, but on the other hand the negative impact of a lifelong anticoagulation treatment could suggest the routine use of a bioprosthetic valve during Bentall procedures for acute type A aortic dissection even in young patients. Biological Bentall will avoid anticoagulant treatment. The absence of a mechanical valve will facilitate further TEVAR procedures and in case of early bioprosthesis degeneration a transapical TAVR with a valve-in-valve procedure could be proposed. 4.3. Limitations of our study The major limitation of our study is its retrospective nature and the absence of a clear surgical strategy regarding the aortic root. Furthermore the ARS group was more young and recent in our study as a consequence of evolution of our surgical strategy with time, thus it might has induced a bias in our analysis. 4.4. Conclusion Our study suggests the value of a complete aortic root replacement for acute type A aortic dissection. This aggressive surgical strategy has reduced the rate of late proximal reoperations with acceptable postoperative outcomes and whether it has to be systematically preferred in younger patient has to be demonstrated. Furthermore a wider use of biological Bentall or valve sparing operation in younger patient to avoid a lifetime anticoagulant treatment or to facilitate further endovascular procedure has also to be further studied. Funding None. Conflicts of interest None to declare.
4.2. Long-term survival and proximal reoperations References Bekkers et al. [14] reported a 15-year survival, which included operative mortality, of 37%. Notably, the authors noted that this late survival was comparable with the survival of an age-matched German cohort of patients undergoing an aortic valve replacement with a mechanical prosthesis. In our cohort, the 15-year survival, which excluded operative mortality, was 69% with a significant difference between the groups (SCR 62.6% vs. ARS 82.8%). ARS in
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International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Aortic root surgery improves long-term survival after acute type A aortic dissection☆ Ilir Hysi a, Francis Juthier a, Olivier Fabre b, Olivier Fouquet c, Natacha Rousse a, Carlo Banfi a, Claire Pinçon d, Alain Prat a, André Vincentelli a,⁎ a
Centre Hospitalier Régional et Universitaire de Lille, Lille 59035, Department of Cardiovascular Surgery, France Centre Hospitalier de Lens et Hôpital privé de Bois Bernard, Lens, Department of Cardiac surgery, France Centre Hospitalier Universitaire d'Angers, Angers 42000, Department of Cardiovascular and Thoracic surgery, France d Université Lille Nord de France, Lille 59000, UDSL, EA2694, Department of Biostatistics, France b c
a r t i c l e
i n f o
Article history: Received 18 September 2014 Accepted 14 February 2015 Available online 19 February 2015 Keywords: Aortic dissection Aortic root Outcomes Root reoperation
a b s t r a c t Objective: Our objective was to analyze the long term survival of patient operated on for acute type A aortic dissection. Methods: Between 1990 and 2010, 226 patients underwent emergency surgical operation for acute type A aortic dissection. We have followed the long-term outcomes. Results: 144 patients were operated on with a supracommissural replacement of the ascending aorta (SCR) and 82 with an aortic root surgery (ARS, including 77 Bentall procedures and 5 Tirone David operations). Aortic crossclamp was longer in ARS group (150.8 vs. 103.6 min, p b 0.0001). Overall in-hospital mortality was lower in ARS group (20% vs. 34%, p 0.03). Median follow-up was 11.6 years. 10-year survival was higher in ARS group (85.7% vs. 65.9%, p 0.03) and 10-year freedom from aortic root reoperation was significantly lower in ARS group (93.4% vs. 82.9%, p 0.02). In a multivariate analysis aortic root surgery was an independent protective factor for proximal reoperations OR 0.393, CI 95% [0.206–0.748], p = 0.005. Conclusions: Our study suggests that complete aortic root replacement in type A aortic dissection does not burden short-term outcomes, improves long-term survivals and decreases the rate of late reoperation. Whether this approach has to be preferred in younger patient has to be demonstrated in further studies. © 2015 Elsevier Ireland Ltd. All rights reserved.
1. Introduction Surgical management of acute type A aortic dissection remains challenging. Perioperative results have been widely reported yet there is no full consensus in the literature regarding the choice of proximal repair surgical technique and it still may remain a decision made on surgeon's discretion or center's tradition. On one hand, the supracommissural replacement allows the preservation of the native aortic valve without an anticoagulant treatment, but on the other hand, the complete root replacement, a more demanding operation, may reduce later high risk proximal reoperations [1–3]. Whether a long term result might be influenced by perioperative proximal management has not yet been demonstrated. Aims of the present study were to evaluate early and late outcomes of a consecutive cohort of patient operated on in our center on an ☆ “All authors take responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation”. ⁎ Corresponding author at: Service de Chirurgie cardiaque, Hôpital Cardiologique, CHRU Lille, F59037 Lille, France. E-mail address: [email protected] (A. Vincentelli).
http://dx.doi.org/10.1016/j.ijcard.2015.02.020 0167-5273/© 2015 Elsevier Ireland Ltd. All rights reserved.
emergency basis for an acute type A dissection. The primary endpoint was to determine whether perioperative proximal surgical strategy had improved late survival. The second endpoint was to evaluate the late mortality and the reoperations' rate. A composite endpoint so called event-free survival was made with the probability to be free from late death and proximal reoperation. 2. Patients and methods 2.1. Population This was a retrospective study of 226 consecutive patients operated on, in an emergency basis, for acute type A aortic dissection between January 1990 and December 2010. The whole cohort of patients had a mean age of 59.2 (±19.9) years and there was mostly male (66%). Patients were operated according two surgical strategies: supracommissural replacement (SCR n = 144 patients); or aortic root surgery with or without aortic valve replacement (ARS n = 82 patients, 77 Bentall and 5 Tirone David). The strategy regarding the surgical techniques was guided by perioperative findings and surgeon's
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Table 1 Preoperative characteristics among the two groups.
Table 2 Peroperative characteristics among the two groups.
SCR n = 144
ARS n = 82
SCR n = 144
ARS n = 82
Variable
n/mean (%/±σ)
n/mean (%/σ)
p value
Variable
n/mean (%/±σ)
n/mean (%/σ)
p value
Age BMI Female Type 1 dissection Marfan syndrome Bicuspid valve Hypertension Renal failure AoI ≥3 Cardiogenic shock Stroke Peripheral malperfusion Mesenteric Lower limb Prior cardiac surgery
62 (±11.4) years 26.3 (±4.0) kg/m2 54 (37%) 126 (87%) 0 (0%) 6 (4%) 110 (76%) 10 (6%) 10 (7%) 31 (21%) 21 (14%) 12 (8%) 2 (1%) 10 (6%) 0 (0%)
54.4 (±14.2) years 27.3 (±5.0) kg/m2 23 (28%) 65 (79%) 12 (14%) 6 (7%) 54 (65%) 2 (2%) 21 (25%) 9 (11%) 8 (9%) 5 (6%) 0 (0%) 5 (6%) 2 (2%)
0.00001 0.13 0.15 0.10 0.0001 0.36 0.09 0.22 0.0001 0.046 0.30 0.54
Axillary cannulation Femoral cannulation Pericardial effusion Open distal anastomosis Hemiarch Complete arch Frozen elephant trunk AC AC timea Circulatory arrest timea Cross-clamp time CPB time
26 (18%) 107 (74%) 88 (61%) 109 (75%) 64 (44%) 24 (16%) 6 (4%) 100 (69%) 42.0 (±17.9) min 47.3 (±29.8) min 103.6 (±37.2) min 145.1 (±47.7) min
44 (53%) 34 (41%) 48 (58%) 53 (64%) 36 (43%) 14 (17%) 1 (1%) 49 (59%) 37.7 (±14.8) min 42.9 (±18.4) min 150.8 (±42.7) min 195.8 (±57.4) min
b0.00001 b0.00001 0.70 0.08 0.90 0.94 0.43 0.14 0.14 0.25 b0.00001 b0.00001
0.13
AC: antegrade cerebroplegia. a Analysis among patients having a circulatory arrest.
BMI: body mass index; AoI: aortic insufficiency.
habitudes. Preoperative data of the patients are summarized in Table 1. The study was approved by the Institutional Review Board of the French Society of Thoracic and Cardio-Vascular Surgery (CERCSFCTCV-2013-7-29-17-7-0-HyIl). 2.2. Surgical techniques According to surgeon's preferences, cardiopulmonary bypass (CPB) was established between the femoral or axillary artery and the right atrium or both vena cava. Since 1999 [4], the antegrade axillary arterial perfusion was more and more performed. The ARS group being more recent in our cohort, the antegrade axillary arterial perfusion was more frequent than the retrograde femoral arterial perfusion, in the latter group. Myocardial protection was achieved by antegrade and/or retrograde cold blood cardioplegia repeated every 30 min with a warm blood reperfusion. In case of ascending aorta replacement, the aortic wall was felt with surgical glue (Bioglue, Cryolife, Kennesaw, GA) and the aortic valve was resuspended in case of aortic regurgitation. Aortic root replacement was performed with a usual Bentall procedure. Biological Bentall was made with a pericardial valve sutured to a Dacron prosthesis and then anchored to the left ventricle orifice. In some cases a valve sparing procedure was performed according to the inclusion technique with a Gelweave Valsalva prosthesis (Gelweave Valsalva, Vascutek, Inchinnan, UK). In both groups distal open anastomosis was performed most of the time during a circulatory arrest with an antegrade cerebral perfusion at 28 °C. 2.3. Postoperative management After the surgical procedure, patients were monitored at the intensive care unit (ICU) for at least 48 h. In case of early visceral malfunction (kidney, liver) a CT scan was emergently performed to rule out any peripheral malperfusion syndrome. Before discharge, all patients had a thoraco-abdominal contrast-enhanced CT Scan, which served for the initial assessment of the distal aortic lesions. Furthermore, a 24-hour blood pressure Holter monitor was performed to guide the long-term antihypertensive treatment. 2.4. Follow-up All patients who survived the operation were followed up. Events were defined as death or aortic root reoperation. All patients had a
regular cardiac follow-up during the first year after surgery with CT scan at 6 months and/or 1 year. Operative mortality included all patients who died within 30 days of surgery and patients never leaving the hospital. Recent clinical data were collected by telephone interviews, from the patients or their attending physicians or cardiologists. Survival was defined as the time lapsed from the date of surgery until the date of death or the end of the follow-up termination time (right censoring) excluding postoperative mortality.
2.5. Statistical analysis Analyses were conducted using SAS software (SAS version 9.1, SAS Institute Inc., Cary, NC, USA). Continuous variables are expressed as mean +/− SD, and categorical variables are presented as absolute numbers and percentages. Characteristics of subjects according to the type of surgical operation for acute type A aortic dissection were compared with Chi-square or Fisher's exact tests as appropriate for categorical variables and with Mann–Whitney U test for continuous variables.
Table 3 Postoperative morbidity and mortality among the two groups. SCR n = 144
ARS n = 82
Variable
n/mean (%/±σ)
n/mean (%/σ)
p value
ICU stay Hospital stay Stroke Renal failure (dialysis) Myocardial infarction Peripheral malperfusion Mesenteric Lower limb Fenestration Respiratory failure Pace maker Tamponade Mediastinitis In-hospital mortality Hemorrhage Cardiogenic shock Multiorgan failure Stroke Pulmonary embolism Mesenteric malperfusion
7.1 (±12.1) days 15.6 (±14.4) days 31 (21%) 46 (31%) 3 (2%) 11 (7%) 7 (4%) 4 (2%) 5 (3%) 17 (11%) 3 (2%) 9 (6%) 2 (1%) 50 (34%) 13 (26%) 8 (16%) 12 (24%) 10 (20%) 1 (2%) 6 (12%)
6.8 (±9.3) days 16.4 (±10.6) days 10 (12%) 17 (20%) 6 (7%) 3 (3%) 2 (2%) 1 (1%) 6 (7%) 13 (15%) 1 (1%) 6 (7%) 1 (1%) 17 (20%) 4 (23%) 5 (29%) 5 (29%) 1 (5%) 1 (5%) 1 (5%)
0.81 0.63 0.08 0.07 0.08 0.23
ICU: intensive care unit.
0.21 0.39 1.00 0.76 1.00 0.03 0.99 0.29 0.51 0.26 0.45 0.66
I. Hysi et al. / International Journal of Cardiology 184 (2015) 285–290 Table 4 Univariate and multivariate Cox analysis of factors affecting in-hospital mortality. Univariate analysis Variable SCR Age (per year) Type 1 dissection Marfan syndrome Cardiogenic shock Axillary cannulation Open distal anastomosis Circulatory arrest Cross-clamp time (per min) CPB time (per min) Renal failure Before 3 days of follow-up After 3 days of follow-up Postoperative myocardial infarction Peripheral malperfusion
OR
CI 95%
p value
1.823 1.051 1.328 0.522 2.135 0.722 1.083 1.083 1.002 1.004
[1.051–3.161] [1.028–1.074] [0.661–2.892] [0.128–2.131] [1.254–3.636] [0.417–1.252] [0.631–1.859] [0.631–1.859] [0.996–1.007] [1.000–1.008]
0.03 b0.0001 0.39 0.36 0.005 0.25 0.77 0.77 0.52 0.07
0.588 7.023 6.560 3.284
[0.241–1.434] [3.449–14.304] [3.207–13.420] [1.673–6.449]
0.24 b0.0001 b0.0001 0.0006
Multivariate analysis Variable
OR
CI 95%
p value
Postoperative myocardial infarction Renal failure after 3 days of follow-up SCR Age (per year) CPB time (per min)
11.375 5.200 2.257 1.042 1.006
[4.808–26.912] [2.509–10.776] [1.165–4.373] [1.019–1.065] [1.001–1.010]
b0.0001 b0.0001 0.02 0.0004 0.01
Event-free survival curves were estimated using the Kaplan– Meier method and compared using the log-rank test. Median follow-up time was estimated with the reverse Kaplan–Meier method. Univariate followed by multivariate Cox analyses were performed to assess the prognostic value of the type of surgical operation for acute type A aortic dissection on postoperative survival, proximal reintervention free survival and freedom from proximal reintervention, first unadjusted then adjusted on potential confounding factors. The log-linearity assumption for continuous variables and the proportional hazard assumption were tested by Kolmogorov-type supremum tests as implemented in the PROC PHREG of the SAS software (SAS version 9.1, SAS Institute Inc.,
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Cary, NC, USA). In case of violation of the former assumption, the continuous variable was dichotomized, the cut-off value being visually established; in case of violation of the latter assumption, a piecewise model was used to model the hazard ratio as a step function of time, the cut-off value being again visually established. In both cases, it was ensured that the Schwarz's Bayesian Criterion was minimal. A two-tailed type I error rate b0.05 was considered for statistical significance. 3. Results Table 1 resumes preoperative characteristics among the two groups. The proximal intimal tear of the aortic dissection was more frequently found in the ascending aorta in the ARS group (93% vs. 80%, p 0.006). Also, in the ARS group, coronary bypasses at the end of the CPB were more frequent (9% vs. 1%, p = 0.007). This was related to the dissecting process in all cases (dissection of the coronary ostium or artery). Table 2 illustrates the perioperative data between the groups. Overall in-hospital mortality in the cohort was 29% (67 patients) and it was higher in the SCR group. The specific causes of mortality were not different between the groups (Table 3). In a univariate analysis (Table 4), overall in-hospital mortality was significantly influenced by a series of factors such as SCR, age, cardiogenic shock and peripheral malperfusion. In multivariate analysis (Table 4) SCR, age, renal failure persistent after 3 days of followup and myocardial infarction were significant independent factors for early mortality. For the whole cohort, the mean duration of ICU and total hospital stay were 6.9 (±11.1) days and 15.8 (±13) days, respectively. Operative morbidity between the two groups was also comparable with regard to renal failure, myocardial infarction, prolonged mechanical ventilation, stroke, peripheral malperfusion and early reoperations (Table 3). 3.1. Survival Mean follow-up was 9.1 (± 0.5) years and median follow-up was 11.6 years (range 0 to 22.7 years). 5-, 10- and 15-year survivals were 87%, 72.5% and 69%, respectively (Fig. 1A). In the SCR group these
Fig. 1. A: Kaplan–Meier survival; B: Survival among the groups.
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survival rates were 83.8%, 65.9% and 62.6%, while in the ARS group they were 91.8%, 85.7% and 81.8%. Survival was higher in ARS group (logrank p = 0.03, Fig. 1B). 3.2. Aortic root reoperations During the follow-up of the 159 patients surviving the initial surgery, 17 surgical reoperations were required on the aortic root or valve. Fifteen reoperations were performed in the SCR group: recurrent dissection of the aortic root (n = 7), progressive dilatation of the aortic root with valve insufficiency (n = 7) and stenosis of the left main requiring bypass surgery (n = 1). In the ARS group two reoperations were performed: one for aortic insufficiency with commissural prolapse after a Tirone David and one for bioprosthesis degeneration in a biological Bentall. The operative mortality of these reoperations was 23% (n = 4). All four deaths were observed in the SCR group. The median duration between the index operation and the reoperation was 53.3 months (7.7–192.5 months). 3.3. Event-free survival (late death and proximal aorta reoperations) For the entire cohort, 5-, 10- and 15-year event-free survivals were 82.3%, 65.1% and 59.4%, respectively. In the SCR group event-free survival rates were 76.1%, 57.2% and 51.0%, while in the ARS group they were 91.8%, 79.6% and 75.6% (log-rank p = 0.008, Fig. 2A). In a multivariate analysis, aortic root surgery (Bentall or Tirone David) significantly improved event-free survival (Table 5). 3.4. Freedom from aortic root reoperation For the entire cohort, the 5-, 10- and 15-year freedom values from proximal reoperation were 92.9%, 87.1% and 83.7%, respectively. In the
Table 5 Multivariate Cox analysis of factors affecting event-free survival. Multivariate analysis Variable
OR
CI 95%
p value
ARS Sex: female Preoperative peripheral malperfusion
0.393 0.462 3.110
[0.206–0.748] [0.243–0.878] [1.203–8.040]
0.005 0.02 0.02
SCR group these rates were 88.2%, 82.9% and 78%, while in the ARS group they were 100%, 93.4% and 93.4% (log-rank p = 0.02, Fig. 2B). 4. Comment Simon Kupilik et al. [5] showed in vitro and in vivo that the supracommissural replacement of the aorta by a vascular prosthesis induced significant hemodynamic changes at the level of the aortic root by increasing parietal tension as a result of the rigidity of the adjacent vascular prosthesis. Ergin et al. [6] first proposed the complete replacement of the aortic root for acute type A aortic dissection as a surgical technique potentially reducing long-term reoperations. We have summarized in Table 6 the rate of proximal aorta reoperation as it was recently published. The rate of reoperation in the ARS groups was always b 10%. Only two studies have reported a mean follow-up of more than 9 years, one of these from Niclaus et al. [7] reported a rate of 23% of reoperation in the SCR group in selected young patients (b 40 years). In our study, with a median follow up of 11.6 years, we demonstrated that ARS with a Bentall or Tirone David procedure did not burdened perioperative results and was an independent significant protective factor of survival and freedom from late aortic root reoperation.
Fig. 2. A: Event-free survival among the groups; B: Freedom from proximal reoperation among the groups.
I. Hysi et al. / International Journal of Cardiology 184 (2015) 285–290 Table 6 Proximal reoperations' rates for acute type A aortic dissection in the recent literature. Author
SCR/ARS (n=)
Proximal reoperations SCR/ARS (%)
Mean follow-up (years)
Pessotto et al. [15] Sabik et al. [1] Gelsomino et al. [17] De Paulis et al. [2] Fujimatsu et al. [11] Niclauss et al. Consistre et al. [18] Malvindi et al. [19] Bekkers et al. [14] Present study
99/34 135/0 0/19 41/0 33/12 13/14 173/61 95/13 157/49 144/82
15/0 4/0 0/0 17/0 18/0 23/0 6/0 21/8 8/0 10/2
5 4.7 7.2 5 3 9.7 4.7 6.5 7.2 9.1
4.1. Operative mortality Mortality for acute type A aortic dissection varies between 15% and 30% [3]. It remains high with little changes through time, despite recent technical advances reflecting the severity of the disease itself. Fann et al. [8] reported, in a large series, a 26% 30-day mortality rate and one of the initial publications from the international registry of acute aortic dissection (IRAD) reported a 27% 30-day mortality rate [9]. Lately, data from the latter registry showed a 23% and a 63% 30-day mortality rate in patients with and without mesenteric malperfusion, respectively [10]. Fujimatsu et al. [11], who also divided their cohort into two groups (SCR vs. Bentall), did not find any significant difference in operative mortality. Similarly, Niclauss et al., [7] in a selected young population (b 40 years), found no significant difference in mortality between the two surgical techniques. ARS is usually considered as a more complex and demanding operation than SCR. In our study, surprisingly, we found a lower mortality rate in the ARS group. Despite longer times of cross-clamp and CPB in this group, postoperative complications including neurological complications or peripheral malperfusions were not different between the groups. Similarly, the ICU and hospital lengths of stay were also not significantly different. These results suggest that the occurrence of a complication is related to the gravity of the primary disease and not due to the surgical complexity of the procedure. Furthermore our findings suggested that a complete resection of the proximal diseased aorta did not burden immediate results. There is still debate about the value of an “age cut-off” for patients undergoing surgery for acute type A aortic dissection [12], however results from surgery remains superior to those from medical treatment until the age of 80 [13]. Nevertheless, the importance of age and its impact on operative mortality should not be underestimated. Like others before, we showed that it is an important prognostic factor per se; in our study every decade of age tenfold increased the mortality risk. We observed more right coronary artery bypasses in the ARS group, but without affecting in-hospital mortality. Although these coronary issues were all related to the dissecting process itself, this technical point represents the Achilles' heel of the Bentall procedure, especially during an acute aortic dissection.
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our series has given patients a “near” normal lifespan after an acute aortic “accident”. In the absence of aortic root replacement, when there is no preoperative aortic regurgitation, 10% of patients will develop later significant aortic insufficiency, while among patients who have preoperative aortic regurgitation, 39% will develop severe postoperative aortic insufficiency [15]. Others [14,15] have reported that proximal reoperation rates were higher in patients with worse than mild grade preoperative aortic insufficiency. In our study, we did not observe the same link between aortic insufficiency and late proximal reoperations (data not shown). But most of the time in our practice ARS was preferred in case of significant preoperative aortic regurgitation (Table 1). This strategy has also probably contributed to the reduction of the number of late reoperations on the aortic root. Commonly, the false lumen remains circulating in 50–70% of patients. Gariboldi et al. [16] identified the Bentall procedure and anticoagulation treatment as risk factors for patency of the false lumen but its thrombosis after surgery remains unpredictable. Our study was not designed to analyze the influence of ARS on the patency of the aortic false lumen, but on the other hand the negative impact of a lifelong anticoagulation treatment could suggest the routine use of a bioprosthetic valve during Bentall procedures for acute type A aortic dissection even in young patients. Biological Bentall will avoid anticoagulant treatment. The absence of a mechanical valve will facilitate further TEVAR procedures and in case of early bioprosthesis degeneration a transapical TAVR with a valve-in-valve procedure could be proposed. 4.3. Limitations of our study The major limitation of our study is its retrospective nature and the absence of a clear surgical strategy regarding the aortic root. Furthermore the ARS group was more young and recent in our study as a consequence of evolution of our surgical strategy with time, thus it might has induced a bias in our analysis. 4.4. Conclusion Our study suggests the value of a complete aortic root replacement for acute type A aortic dissection. This aggressive surgical strategy has reduced the rate of late proximal reoperations with acceptable postoperative outcomes and whether it has to be systematically preferred in younger patient has to be demonstrated. Furthermore a wider use of biological Bentall or valve sparing operation in younger patient to avoid a lifetime anticoagulant treatment or to facilitate further endovascular procedure has also to be further studied. Funding None. Conflicts of interest None to declare.
4.2. Long-term survival and proximal reoperations References Bekkers et al. [14] reported a 15-year survival, which included operative mortality, of 37%. Notably, the authors noted that this late survival was comparable with the survival of an age-matched German cohort of patients undergoing an aortic valve replacement with a mechanical prosthesis. In our cohort, the 15-year survival, which excluded operative mortality, was 69% with a significant difference between the groups (SCR 62.6% vs. ARS 82.8%). ARS in
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