Aortic Surgery Symposium 2010

New York, NYApril, 2010

Department of Cardiothoracic and Vascular Surgery

The University of Texas Medical School at HoustonMemorial Hermann Heart & Vascular

Institute

AL Estrera, MD, CC Miller III, PhD, TK Lee, MD, T Kaneko, MD, JC Walkes, MD, H Safi, MD

Outcomes of Acute Type A Aortic Dissection After Previous Cardiac Surgery

Purpose

• Since few data exist, we report outcomes of acute type A aortic dissection (ATAAD) after previous cardiac surgery (PCS).

Methods

330 Acute Type A Aortic Dissection

Jan. 1991 – March 2009

Median age: 62 (21-91)

69%

31%

281 Primary (85%) 49 PCS (15%)

Variable

Previous Cardiac Surgery

Group

Number (%)n=49

Primary Group

Number (%)n=49

P-Value

Age 63+12.8 57.9+13.9 <.02

Male Gender 40 (82) 187 (67) <.04

Chest Pain 40 (82) 256 (91) .07

Back Pain 36 (73) 215 (77) .72

Leg Weakness 10 (20) 48 (17) .55

Stroke 1 (2) 29 (10) .07

Paraplegia 4 (8) 17 (6) .53

Hypotension 10 (20) 70 (25) .59

Tamponade 6 (all CABG) (12) 48 (17) .42

Myocardial Ischemia 5 (10) 25 (9) .79

Al (Mod Sev) 15 (30) 132 (47) <.05Time Interval (Admission-OR) Hours 46.4+63.3 37.1+73.1 .40

Aortic Size 5.7+1.4 5.0+0.8 .0001

PA Rupture/Fistula 2 (4) 0 (0) <.03

Preoperative Variables in Acute Type A Aortic Dissection with/without PCS

Mean Interval 56 ± 77 monthsInterval range 3d - 370 months

Interval

2 pts: 2 previous sternotomies2 pts: 2 previous sternotomies

Previous Cardiac Surgery

Procedures (Re-Op)Procedures (Re-Op)

Aortic Root

8%

Ascending

100%

Prox Arch

94%

CABG 16%

Total Arch

10%

ET1 4%

Variable

Previous Cardiac Surgery

Number (%)n=49

No Previous Cardiac Surgery

Number (%)n=281 P-Value

MI 4 (8) 15 (5) .50

CVA/Coma 5 (10) 7 (2.5) <.03

TND 12 (24) 28 (10) <.007

Bleed 2 (4) 24 (8.5) .39

Renal Failure (Dialysis) 6 (12) 28 (9.9) .55

Repiratory Failure (Vent >3 days) 16 (33) 85 (30) .58

Hospital Death 15 (31) 39 (13.8) <.007

Results

Cause N (%) N=15

CardiacPreoperative tamponade (4)Right ventricular failure (1)AMI (occlude RCA SVG) (1)EF=10% (1)

7 (47)

Multiorgan failure(Necrotic bowel, ARF, PA fistula, paraplegia)

7 (47)

Neurological (Preoperative coma)

1 (6)

Causes of Early Death

Location N (%) n=49 Note

De Novo 25 (51)

Aortic Cannulation Site 2 (4)

Aortotomy 6 (12) 40% (Valves*)

Saphenous Vein Graft Site 16 (33) 46% (CABG)

Location of Aortic Dissection Tear

* 12/15 (80%) of previous valves had a Bicuspid Aortic Valve

Survival: Kaplan-Meier

P<0.03

1-year 5 10 15

Primary

80% 76% 58% 53%

PCS 62% 57% 50% 36%

Patients with ATAAD following PCS exhibited risks for malperfusion, hypotension, and cardiac tamponade that were similar to primary ATAAD cases.

This suggests that adhesions formed after PCS do not eliminate the risk of cardiac tamponade from aortic rupture.

Although results from surgical repair are acceptable, and thus justifying timely repair, mortality still remains higher than without a prior history of cardiac surgery.

Patients need to be individualized.

Conclusions