Acute Type A Aortic Dissection. Influence of Early Management by bam81679

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									  Acute Type A Aortic Dissection. Influence of Early Management on Results
Ahmad El-Bishry, Najib Al-Khaja, Hans Krebber, Mohamed El Fiki, Mohamed Abdel
         Aziz, Hosam Aboul Enein, Mohamed Saeed and Ismail Sallam
                  Asian Cardiovasc Thorac Ann 2001;9:93-96


                    This information is current as of May 11, 2010



  The online version of this article, along with updated information and services, is
                         located on the World Wide Web at:
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The Asian Cardiovascular & Thoracic Annals is the official journal of The Asian Society for
Cardiovascular Surgery and affiliated journal of The Association of Thoracic and Cardiovascular
Surgeons of Asia.




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El-Bishry CONTRIBUTION TYPE A AORTIC DISSECTION. INFLUENCE OF EARLY MANAGEMENT ON RESULTS
ORIGINAL           ACUTE


ACUTE TYPE A AORTIC DISSECTION.
INFLUENCE OF EARLY MANAGEMENT
ON RESULTS
Ahmad El-Bishry, MD, Najib Al-Khaja, MD, PhD,
Hans Krebber, MD, Mohamed El Fiki, MD1,
Mohamed Abdel Aziz, MD, Hosam Aboul Enein, MD,
Mohamed Saeed, MD, Ismail Sallam, MD1
Department of Surgery
Aortic Surgery Centre
Cairo University
Cairo, Egypt
1Department of Cardiovascular Surgery

Naser Institute
Cairo, Egypt

              ABSTRACT
              One hundred and six patients were operated upon for acute type A aortic dissection
              in 7 years between February 1992 and May 1999. There were 102 males and 4
              females, aged 18 to 83 years with a mean of 59 ± 14 years. All patients underwent
              surgery within 14 hours of diagnosis. The ascending aorta was replaced with a
              Dacron graft in 103 patients; in the other 3 cases, the repair extended to the aortic
              arch. The aortic valve was preserved by resuspension in all except 4 patients, 3
              of whom had Marfan’s syndrome. There were 9 (8.5%) deaths, all due to respiratory
              and multiorgan failure. Nine patients (8.5%) needed hemodialysis; only one of
              these required permanent dialysis. Ten patients (9.4%) had transient neurological
              disorders, 2 others (1.9%) suffered permanent hemiplegia. Three patients (2.8%)
              underwent reoperation for bleeding. Tracheostomy for prolonged respiratory
              assistance was required in 6 patients (5.7%), of whom 1 died from respiratory
              failure. Early surgical intervention could be performed with low morbidity and
              mortality.

                                                                     (Asian Cardiovasc Thorac Ann 2001;9:93–6)


INTRODUCTION                                                        has reduced the morbidity associated with replacement of
Type A aortic dissection is fatal if not treated early.             the valve with a prosthesis.10–14 However, the nature of
Approximately 50% of patients die within 48 hours of                the disease, the risk factors, and the duration between the
onset, with an attrition rate of 1% per hour; 70% die               onset of dissection and the surgical intervention all play
within one week and only 10% remain alive by the end                important roles in the final outcome.15 The results of
of one year.1,2 Surgical treatment is technically demanding         early surgical intervention in 106 patients with acute type
and despite improving results over recent decades, it still         A aortic dissection were reviewed retrospectively.
carries a considerable morbidity and mortality.3,4 A number
of techniques have been developed to improve the                    PATIENTS AND METHODS
outcome. 5–9 The introduction of surgical glue has                  One hundred and six patients were operated upon for
contributed to better results, and aortic valve preservation        acute type A aortic dissection in 7 years (February 1992



For reprint information contact:
Najib Al-Khaja, MD, PhD Tel: 971 4 271 4444 Fax: 971 4 271 9340 email: drnajib@emirates.net.ae
Department of Cardiothoracic Surgery, Dubai Hospital, P.O. Box 7272, Dubai, UAE.

2001, V OL . 9, N O. 2                                         93          A SIAN CARDIOVASCULAR & T HORACIC ANNALS
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ACUTE TYPE A AORTIC DISSECTION. INFLUENCE OF EARLY MANAGEMENT ON RESULTS                                                                 El-Bishry

to May 1999) at Naser Institute, Cairo, and the Aortic                          were carried out perioperatively. A femoral artery cannula
Surgery Center, Cairo University. There were 102 males                          was inserted and the chest was opened via a median
and 4 females; their ages ranged from 18 to 83 years with                       sternotomy incision. The venae cavae were cannulated,
a mean of 59 ± 14 years. The operation was performed                            a left atrial vent was set up, cardiopulmonary bypass was
as soon as possible after the diagnosis was made, in a                          started, and the patient was cooled. The mid portion of
range of 3 to 14 hours after the onset of dissection.                           the ascending aorta was clamped and the aorta was opened
Patients treated for chronic dissection were excluded from                      vertically to visualize the inside of the dissecting aorta.
the study. The ascending aorta was involved in all cases,                       The lower stump of the aorta was cut transversely; blood
and there was involvement of the proximal arch of aorta                         cardioplegia was given directly into the coronary ostia.
in 3 patients (2.8%). Preoperative clinical details are                         The aortic valve was examined, 3 Teflon-pledgeted 2/0
given in Table 1. Ten patients (9.4%) were in shock,                            polypropylene sutures were inserted into the 3 aortic
generally related to cardiac tamponade, 10 had one                              commissures, and the valve was tested for competence.
established femoral pulse (3 patients had clinical ischemia                     The two layers of the dissection were glued together
of one lower limb). Early in the study, diagnosis was                           using gelatin-resorcine-formol (GRF) glue (Cardial SA;
made by computed tomography but recently, trans-                                Filiale de C.R. Bard, Inc., Saint-Etienne, France).
esophageal echocardiography has become the diagnostic                           Approximately 3 minutes were needed for polymerization
method of choice.                                                               before a solid stump was ready for tight anastomosis. The
                                                                                edges of the two layers were oversewn with a continuous
Esophageal and rectal temperatures, transesophageal                             4/0 polypropylene suture in 2 layers (Figure 1). A Dacron
echocardiography, and electroencephalogram monitoring                           graft was anastomosed to the proximal stump by means


      Table 1. Clinical Characteristics of 106 Patients
Variable                                             No. of Patients
Male                                                       102
Female                                                       4
Hypertension                                                93
Marfan’s syndrome                                            3
New York Heart Association
  Class II                                                  44
  Class III                                                 52
  Class IV                                                  10
Entry site of dissection
  Ascending aorta                                          103
  Aortic arch                                                3
                                                                                    A




                                                                                    B

Figure 1. The middle part of the ascending aorta is cut transversely and        Figure 2. (A) The proximal stump is reconstructed and the aortic valve
removed. Reconstruction of the proximal stump is carried out using              is tightened by means of 3 Teflon-pledgeted 2/0 polypropylene sutures
gelatin-resorcine-formol glue, and the two edges of the stump are               in the 3 commissures. The aortic clamp is opened and the distal stump
oversewn with a continuous suture of 4/0 polypropylene, in two layers.          is reconstructed in the same fashion as the proximal one. (B) The
The distal stump is crossclamped.                                               ascending aorta after complete reconstruction using a Dacron graft.


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El-Bishry                     ACUTE TYPE A AORTIC DISSECTION. INFLUENCE OF EARLY MANAGEMENT ON RESULTS

                                                                     18 to 66 minutes (mean, 29 minutes). The mean awakening
      Table 2. Postoperative Morbidity and Mortality
                                                                     time was 8 ± 4 hours. Postoperative morbidity and
Complication                                 No. of Patients         mortality are summarized in Table 2. Postoperative blood
Reoperation for bleeding                       3 (2.8%)              loss ranged from 120 to 960 mL (mean, 390 mL). Three
Renal                                          9 (8.5%)              patients underwent reoperation for excessive bleeding
Neurological                                                         within 3 hours after the initial surgery, all did well later.
  Transient                                   10   (9.4%)            Nine patients who had some renal impairment pre-
  Permanent                                    2   (1.9%)            operatively, required hemodialysis postoperatively, but
Respiratory                                    6   (5.7%)            only one needed permanent dialysis. The 10 patients with
Death                                          9   (8.5%)            transient neurological disorders recovered and the 2 who
                                                                     had permanent hemiplegia survived and were discharged
                                                                     on a physiotherapy regime. Of the 6 patients who needed
of 3/0 polypropylene continuous sutures starting pos-                a tracheostomy, one eventually died from multiorgan
teriorly, then the anastomosis was completed anteriorly in           failure. No intraoperative death occurred. Within 30 days
two layers. After completion of the proximal anastomosis,            of operation, there were 6 deaths; all were due to
a second layer of GRF glue was applied to the suture and             respiratory and multiorgan failure. There were 3 further
left for 3 minutes to polymerize and solidify.                       hospital deaths: one patient died from heart failure at 48
                                                                     days and 2 from respiratory failure at 52 and 58 days after
When the nasopharyngeal temperature dropped to 18°C,                 surgery, respectively.
circulation was stopped, the aortic crossclamp was opened,
the heart was drained, and retrograde cerebral perfusion             DISCUSSION
via the superior vena cava was started, keeping the central          Surgical treatment of acute type A aortic dissection is
venous pressure around 20 mm Hg. The top end of the                  technically difficult and associated with considerable
Dacron graft was clamped and blood cardioplegia was                  morbidity and mortality.3–9,15,16 The use of GFR in
given through a side arm in the graft. The distal stump              construction of a solid stump proximally and distally that
of the aorta was cut transversely, the 2 dissecting cylinders        can take the graft with no sequelae of bleeding or
were glued with GRF, and continuous 4/0 polypropylene                dissection, is important to the success of the procedure.
was used to suture the two layers (Figure 2A). The top               Our experience with GRF glue was very encouraging and
end of the Dacron graft was cut distally, beveled, and               supported the findings of others that postoperative bleeding
sutured to the distal stump in a similar fashion to the              was surgically acceptable, with only 3 patients requiring
proximal stump (Figure 2B). The graft was filled retro-              reoperation for bleeding.10–12 Preserving the native aortic
gradely and clearing was performed through the side arm              valve (in the majority of cases, the aortic valve is healthy)
in the Dacron graft. Once the graft was de-aired, the                is an important factor in reducing complications by
retrograde circulation was stopped, and antegrade cardio-            decreasing surgical time and later avoiding the potential
pulmonary bypass was started with rewarming. The side                hazards of a prosthetic valve.13
arm was then ligated and cut. In 3 cases where the intimal
tear was in the aortic arch, the arch was either totally or          The hospital mortality of 8.5% was considered to be low.
partially replaced to resect the tear. In patients with              This was attributed to several factors including rapid
Marfan’s syndrome, aortic root replacement was per-                  surgical intervention before vital organs deteriorated.
formed using valved conduit and separate coronary ostia.             Bachet and colleagues11 found that patients below 65
                                                                     years with isolated replacement of the ascending aorta
Patients were followed up for 2 months postoperatively.              had a mortality rate of less than 10%. Most of our patients
Initially, this was during the hospital stay that ranged             were below 65 years and required isolated ascending
from 10 to 14 days in most cases, and up to 40 days in               aortic replacement. The experience of the surgical team
21 patients (19.8%) who required extended medical care.              may also have played a role in the outcome.
Patients were examined in the outpatient clinic one month
                                                                     This study reports the short-term outcome but we will
after discharge and then consigned back to the referring
                                                                     continue to monitor the long-term outcome of these
cardiologist for further follow-up. In addition to routine
                                                                     patients. Although acute type A aortic dissection is a fatal
blood tests, electrocardiograms, and chest radiography,
                                                                     condition, with our current technique, early surgical
all patients had an echocardiographic study either before
                                                                     intervention could be performed with low morbidity and
discharge or in the outpatient clinic.
                                                                     mortality.
RESULTS                                                              REFERENCES
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2001, V OL . 9, N O. 2                                          95          A SIAN CARDIOVASCULAR & T HORACIC ANNALS
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ACUTE TYPE A AORTIC DISSECTION. INFLUENCE OF EARLY MANAGEMENT ON RESULTS                                                      El-Bishry

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A SIAN CARDIOVASCULAR & T HORACIC ANNALS                           96                                          2001, V OL . 9, N O . 2
                                Downloaded from asianannals.ctsnetjournals.org by on May 11, 2010
  Acute Type A Aortic Dissection. Influence of Early Management on Results
Ahmad El-Bishry, Najib Al-Khaja, Hans Krebber, Mohamed El Fiki, Mohamed Abdel
         Aziz, Hosam Aboul Enein, Mohamed Saeed and Ismail Sallam
                  Asian Cardiovasc Thorac Ann 2001;9:93-96
                    This information is current as of May 11, 2010

Updated Information               including high-resolution figures, can be found at:
& Services                        http://asianannals.ctsnetjournals.org/cgi/content/full/9/2/93
References                        This article cites 16 articles, 12 of which you can access for free at:

                                  http://asianannals.ctsnetjournals.org/cgi/content/full/9/2/93#BIBL
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