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Published on: December 11, 2017
Long-term outcomes after ascending aortic replacement and aortic root replacement for type A aortic dissection
Mikko Jormalainen1, Risto Kesävuori2, Peter Raivio1
1Division of Cardiac Surgery, Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
Insights
Supracoronary ascending aorta replacement offers similar long-term survival and reoperation rates compared to aortic root replacement for acute Stanford type A aortic dissection (TAAD). Both surgical approaches provide comparable clinical outcomes when stringent selection criteria are applied.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Aortic Dissection Research
Background:
- Acute Stanford type A aortic dissection (TAAD) is a life-threatening condition requiring prompt surgical intervention.
- Surgical strategies for TAAD often involve either ascending aortic replacement or aortic root replacement, with ongoing debate regarding optimal late outcomes.
Purpose of the Study:
- To compare the late clinical outcomes, specifically mortality and need for reoperation, between supracoronary ascending aorta replacement and aortic root replacement in patients with acute TAAD.
- To evaluate the efficacy of selective surgical strategies for proximal aortic reconstruction in TAAD.
Main Methods:
- A retrospective analysis of 309 patients who underwent surgery for acute TAAD between 2005 and 2018 at Helsinki University Hospital.
- Kaplan-Meier method for late mortality and competing risk method for proximal aortic reoperation were employed.
- Propensity score matching was used to compare outcomes between the two surgical groups.
Main Results:
- At 10 years, no significant difference in mortality was observed between aortic root replacement (33.8%) and ascending aortic replacement (35.2%) (P=0.806).
- Cumulative incidence of proximal aortic reoperation was similar, with 6.0% for aortic root replacement and 6.2% for ascending aortic replacement (P=0.65).
- In propensity score matched pairs, 10-year survival was comparable (34.4% vs. 36.2%, P=0.70), though reoperation rates showed a trend (7.0% vs. 13.0%, P=0.22).
Conclusions:
- Selective use of supracoronary ascending aorta replacement achieves late clinical outcomes comparable to aortic root replacement for acute TAAD.
- Stringent selection criteria for proximal aortic reconstruction are crucial for achieving similar outcomes between the two surgical approaches.
Objectives:
We investigated whether the selective use of supracoronary ascending aorta replacement achieves late outcomes comparable to those of aortic root replacement for acute Stanford type A aortic dissection (TAAD).
Methods:
Patients who underwent surgery for acute type A aortic dissection from 2005 to 2018 at the Helsinki University Hospital, Finland, were included in this analysis. Late mortality was evaluated with the Kaplan-Meier method and proximal aortic reoperation, i.e. operation on the aortic root or aortic valve, with the competing risk method.
Results:
Out of 309 patients, 216 underwent supracoronary ascending aortic replacement and 93 had aortic root replacement. At 10 years, mortality was 33.8% after aortic root replacement and 35.2% after ascending aortic replacement (P = 0.806, adjusted hazard ratio 1.25, 95% confidence interval, 0.77-2.02), and the cumulative incidence of proximal aortic reoperation was 6.0% in the aortic root replacement group and 6.2% in the ascending aortic replacement group (P = 0.65; adjusted subdistributional hazard ratio 0.53, 95% confidence interval 0.15-1.89). Among 71 propensity score matched pairs, 10-year survival was 34.4% after aortic root replacement and 36.2% after ascending aortic replacement surgery (P = 0.70). Cumulative incidence of proximal aortic reoperation was 7.0% after aortic root replacement and 13.0% after ascending aortic replacement surgery (P = 0.22). Among 102 patients with complete imaging data [mean follow-up, 4.7 (3.2) years], the estimated growth rate of the aortic root diameter was 0.22 mm/year, that of its area 7.19 mm2/year and that of its perimeter 0.43 mm/year.
Conclusions:
When stringent selection criteria were used to determine the extent of proximal aortic reconstruction, aortic root replacement and ascending aortic replacement for type A aortic dissection achieved comparable clinical outcomes.
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