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Type A aortic dissection after nonaortic cardiac surgery
Olaf Stanger1, Thomas Schachner, Brigitta Gahl
1Department of Cardiovascular Surgery, University Hospital Berne (Inselspital), Berne, Switzerland (O.S., B.G., L.E., T.C.); Clinic of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (T.S.); University Clinic of Cardiac Surgery, Medical University Graz, Graz, Austria (P.O.); Department of Cardiovascular Surgery, Hietzing Hospital, Vienna, Austria (M.T.); Department of Cardiothoracic Surgery, The Liverpool Heart and Chest Hospital, Liverpool, UK (D.H., M.F.); Department of Cardiac Surgery, Vienna Medical University, Vienna, Austria (D.W.); University Cardiovascular Centre Freiburg-Bad Krotzingen, Freiburg, Germany (M.S., B.R.); Department of Histopathology, Royal Brompton and Harefield NHS Foundation Trust, London, UK (M.N.S.); Department of Cardiac Surgery, Oxford University NHS Hospitals, Oxford, UK (M.P.); Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH (J.B.); and Department of Cardiothoracic Surgery, Royal Brompton Hospital, London, UK (J.P.).
Insights
Previous cardiac surgery, especially coronary artery bypass grafting (CABG), increases operative mortality for type A aortic dissection (AAD). Preoperative angiography and managing coronary disease improve outcomes in these high-risk patients.
Area of Science:
- Cardiovascular Surgery
- Aortic Diseases
- Surgical Outcomes
Background:
- Cardiac surgery involving cardiopulmonary bypass can lead to type A aortic dissection (AAD) due to aortic manipulation.
- Pre-existing aortic wall pathology, particularly medial degeneration, contributes to AAD at sites of surgical trauma.
Purpose of the Study:
- To investigate the impact of prior cardiac surgery, specifically coronary artery bypass grafting (CABG), on operative mortality in patients undergoing repair for type A aortic dissection (AAD).
- To identify factors influencing outcomes in patients with AAD following previous cardiac surgery.
Main Methods:
- Retrospective analysis of 103 patients who underwent surgical repair for AAD after nonaortic cardiac surgery.
- Logistic regression modeling was used to assess the association between prior CABG and operative mortality.
- Analysis of intimal tear locations, aortic diameters, and histological findings in resected tissues.
Main Results:
- Patients with prior CABG had significantly higher operative mortality for AAD repair compared to non-CABG patients (OR 2.90).
- In late AAD cases, mortality was highest in patients lacking preoperative coronary angiography and proper management of coronary/graft disease (OR 5.36).
- Intimal tears were predominantly at sites of previous surgical trauma, and dissected aortas often showed medial degeneration.
Conclusions:
- Preexisting aortic pathology, exacerbated by mechanical trauma during cardiac surgery, predisposes to AAD.
- Prior CABG is a significant risk factor for increased operative mortality in AAD repair.
- Preoperative coronary angiography and management of coronary/graft disease are crucial for improving outcomes in patients with AAD after CABG.
Background:
Cardiac surgery with cardiopulmonary bypass is associated with mechanical manipulation of the ascending aorta that occasionally leads to type A aortic dissection (AAD).
Methods And Results:
One hundred three patients with surgical repair for AAD following nonaortic cardiac surgery were identified. With the use of logistic regression modeling, coronary artery bypass surgery (CABG), either isolated or combined with another procedure in the initial operation, was associated with significantly higher operative mortality in comparison with patients with non-CABG procedures at the time of AAD repair both for all patients (odds ratio, 2.90; 95% confidence interval, 1.09-7.72; P=0.033) and for patients with acute and chronic AAD≥30 days after the initial operation (odds ratio, 3.62; 95% confidence interval, 1.13-11.54; P=0.03). In patients who developed AAD late after the initial operation, operative mortality was highest in patients without preoperative coronary angiography and appropriate management of their native coronary artery disease and graft disease (odds ratio, 5.36; 95% confidence interval, 1.68-17.0; P=0.002). Nearly all the intimal dissection tears were located at sites of previous surgical trauma. Most of the ascending aortas that had dissected initially had a diameter≥40 mm with histological evidence of medial degeneration in resected tissue samples.
Conclusions:
In patients who have undergone previous cardiac surgery, preexisting aortic wall pathology contributes to AAD with typical intimal damage at sites of mechanical trauma. The operative mortality was the highest in patients with previous CABG in comparison with patients with non-CABG procedures. Preoperative coronary angiography and operative management of native coronary and graft disease were significantly associated with outcome in patients with previous CABG.
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