Protective Coronary Artery Bypass Grafting Improves Surgical Outcomes in Acute Type A Aortic Dissection With Coronary
Ling-Chen Huang1, Ze-Hua Shao1, Yang-Xue Sun1
1Department of Vascular Surgery, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College.
Insights
Protective coronary artery bypass grafting (CABG) in acute type A aortic dissection (ATAAD) with severe coronary involvement reduces serious adverse events. This approach is safe and effective, without impacting long-term survival.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Aortic Disease Management
Background:
- Acute type A aortic dissection (ATAAD) with coronary ostial involvement presents complex surgical challenges.
- Managing coronary involvement during ATAAD requires specific surgical strategies.
- This study evaluates two distinct surgical approaches for coronary involvement in ATAAD.
Purpose of the Study:
- To compare the outcomes of isolated coronary ostial reconstruction versus protective coronary artery bypass grafting (CABG) in ATAAD patients.
- To identify factors associated with serious adverse events in ATAAD management.
- To assess the safety and effectiveness of different surgical strategies for coronary involvement in ATAAD.
Main Methods:
- A cohort of 617 ATAAD patients with coronary involvement were analyzed between 2019 and 2023.
- Patients underwent either isolated coronary ostial reconstruction (n=507) or protective CABG (n=110) based on disease severity.
- Serious adverse events included operative mortality, need for mechanical support, or stroke; logistic regression was used for analysis.
Main Results:
- Overall operative mortality was 3.73%, with 7.13% experiencing serious adverse events.
- The protective CABG group demonstrated significantly lower procedural myocardial injury (2.73% vs 9.27%, P = .037).
- Protective CABG was associated with a reduced risk of serious adverse events (OR, 0.24; P = .028) and showed a trend toward fewer overall events (2.73% vs 8.09%, P = .076).
Conclusions:
- The institutional surgical protocol, including protective CABG, is safe and effective for ATAAD with coronary involvement.
- Protective CABG is linked to decreased serious adverse events without compromising survival.
- An aggressive use of protective CABG is supported for severe coronary involvement in ATAAD.
Background:
Acute type A aortic dissection (ATAAD) with coronary ostial involvement poses significant surgical challenges. We describe two surgical approaches to managing coronary involvement and assess their outcomes.
Methods:
Between January 2019 and December 2023, 617 acute type A aortic dissection patients with coronary involvement were enrolled. Based on our institutional surgical protocol, 507 patients underwent isolated coronary ostial reconstruction, whereas 110 received protective coronary artery bypass grafting (CABG) after coronary ostial reconstruction or closure in cases of severe coronary involvement (defined as Neri A with >50% ostial margin involvement, Neri B with distal entry, or Neri C). Serious adverse events were defined as operative mortality, mechanical support, or stroke. Logistic regression identified factors associated with serious adverse events.
Results:
Operative mortality occurred in 23 patients (3.73%), and 44 patients (7.13%) experienced serious adverse events. Despite more severe coronary involvement (P < .001) and coronary malperfusion (P < .001) at baseline, the protective CABG group showed significantly lower procedural myocardial injury (2.73% vs 9.27%, P = .037) and a trend toward fewer serious adverse events (2.73% vs 8.09%, P = .076). Logistic regression identified that protective CABG was associated with a reduced risk of serious adverse events (odds ratio, 0.24; 95% CI, 0.07-0.86; P = .028). The median follow-up was 25.95 months. Kaplan-Meier analysis revealed no significant difference in cumulative survival between the 2 groups (log-rank P = .70).
Conclusions:
Our institutional surgical protocol demonstrates safety and effectiveness. The protective CABG approach was associated with a reduced risk of serious adverse events without impacting overall survival, supporting its more aggressive use in acute type A aortic dissection with severe coronary involvement.
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