Category: Long Term Survival Rates

Aortic Dissection Repair: Tight BP Control Avoids Late Reoperation

Importance of Blood Pressure Control After Repair of Acute Type A Aortic Dissection: 25-year Follow-up in 252 Patients
Spencer J Melby, MD*, Andreas Zierer, MD*, Michael K Pasque, MD*, Jennifer S Lawton, MD*, Hersh S Maniar, MD*, Nicholas T Kouchoukos, MD, Ralph J Damiano, Jr., MD, Marc R Moon, MD
Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO
Our aim was to evaluate factors which impacted outcome following repair of acute type A aortic dissection.
Over a 25-year period(1984-2009), 252 patients underwent repair of acute type A dissection by 26 surgeons. Mean late follow-up for reoperation or death was 6.9±5.9 years.
Operative mortality was 16%(41/252). Multivariate analysis identified one risk factor for operative death: branch-vessel malperfusion on presentation(p=0.003). For 211 operative survivors, 5, 10, and 20-year survival was 78%±3%, 59%±4%, and 24%±6%, respectively. Late death occurred earlier in patients with previous stroke(p=0.02) and chronic renal insufficiency(p=0.007) but was independent of operative approach(ascending versus hemiarch, cross-clamp versus circulatory arrest, AV repair versus replacement; p>0.20 for all). Risk factors for late reoperation included male gender(p=0.006), Marfan syndrome(p<0.001), elevated systolic blood pressure(SBP, p<0.001), and absence of beta-blocker therapy(p<0.001). Kaplan-Meier analysis demonstrated that at 10-year followup, patients who maintained SBP<120mmHg had improved freedom from reoperation(92%±5%) compared to those with 120-140mmHg(74%±7%) or SBP>140mmHg(49%±14%, p<0.001), and patients on beta-blocker therapy experienced 86%±5% freedom from reoperation compared to 57%±11% for those without beta-blockers(p<0.001). CONCLUSIONS: Operative survival was decreased in the presence of preoperative malperfusion. Long-term survival was dependent on underlying comorbidities but not operative approach. Reoperation was markedly increased in patients not on beta-blocker therapy, and decreased with better control of SBP. Strict control of hypertension with beta-blocker therapy for life is warranted in these patients. Operative mortality was 16% among 252 patients who underwent repair of acute type A aortic dissection at the hands of 26 surgeons at Barnes-Jewish Hospital in St. Louis during 1984-2009. Of 28 variables that were scrutinized in a multivariate analysis, only one proved to be an independent risk factor for operative mortality: branch vessel malperfusion at presentation, with an associated 2.5-fold increased risk, Dr. Spencer J. Melby reported at the annual meeting of the American Surgical Association. Some 27 of 211 operative survivors required 30 late reoperations. Four variables were independently predictive of late reoperation: male sex, Marfan syndrome, not being on a beta-blocker at last follow-up, and systolic blood pressure (SBP) greater than 120 mm Hg, according to Dr. Melby of Washington University in St. Louis. The rates of freedom from reoperation among patients on beta-blocker therapy at 10 and 15 years were 86% and 83%, respectively, compared with 57% and 37% in patients who were not on the medication. Patients who maintained their SBP below 120 mm Hg had 10- and 15-year rates of freedom from reoperation of 92%. Among those whose SBP was 120-140 mm Hg, the rates were 74% and 66%. In patients who maintained SBP in excess of 140 mm Hg, the 10- and 15-year rates of freedom from reoperation was 49% and 30%. In terms of perfusion techniques that were utilized in the initial repair, 35% of patients were placed on an aortic cross-clamp only, 30% had hypothermic cardiac arrest with retrograde cerebral perfusion, and 35% got hypothermic cardiac arrest without retrograde cerebral perfusion. Importantly, long-term survival was not related to operative approach. Late survival was decreased, however, in patients with previous stroke or chronic renal insufficiency. Discussant Dr. Thoralf M. Sundt III noted that although acute aortic dissection is an uncommon condition, it is nonetheless the most common fatal catastrophe of the aorta. Multiple studies over the years indicate that not much progress has been made in improving the high perioperative and long-term morbidity and mortality. “We don’t seem to be learning very much over time. It’s not getting better. So a study such as this one that can impact the long-term results in these patients is important,” said Dr. Sundt, chief of cardiac surgery at Massachusetts General Hospital, Boston. He particularly welcomed Dr. Melby’s emphasis on lifelong beta-blocker therapy. “It may seem a bit odd for surgeons to be focusing on pharmacologic treatment, but in fact aortic disease is really a disease that’s most often treated by surgeons. There are few medical vascular specialists, and so it really is important for us to follow these patients. This is a chronic condition, and we ought to adopt a posture towards that condition where we are responsible for caring for these patients over time,” according to the surgeon. Dr. Sundt noted that many surgeons have adopted as dogma that these repairs should be done under hypothermic circulatory arrest rather than cross-clamp. “Your group is bucking the trend,” he commented. Dr. Melby agreed that hypothermic cardiac arrest is “trendy.” Some surgeons at Barnes-Jewish use it routinely. But in the study, the risk of reoperation for bleeding was 17% in patients who were managed via hypothermic cardiac arrest, compared with 7% with cross-clamp. Cardiopulmonary bypass time was about 30 minutes shorter with the cross-clamp. “One of the conclusions of our paper is that because we found [that] long-term outcomes were independent of the technique, it’s safe to say that surgeons should treat this problem in the way they’re most comfortable,” he added. Dr. Melby said that he has no relevant financial interests.

Long Term Survival Rates for Aortic Dissection Survivors


Thanks to my good friend, Dr. Gabriele DiLouzzo, I am proud to share with you a recent newsletter that was produced by him at the Mount Sinai Aortic Center. This study was covering patients over a 7 year period there. It’s definitely worth reading. You can find it here.

Don’t forget you can also attend the Aortic Dissection Symposium coming up very soon in New York.

Best Regards,

Brian Tinsley

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