Marco Di Eusanio1, Santi Trimarchi2, Mark D Peterson3, Truls Myrmel4, G Chad Hughes5, Amit Korach6, Thoralf M Sundt7, Roberto Di Bartolomeo8, Kevin Greason9, Ali Khoynezhad10, Jehangir J Appoo11, Gianluca Folesani8, Carlo De Vincentiis2, Daniel G Montgomery12, Eric M Isselbacher7, Kim A Eagle12, Christoph A Nienaber13, Himanshu J Patel14. 1. Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy. Electronic address: marco.dieusanio2@unibo.it. 2. Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato, Italy. 3. Division of Cardiac Surgery, St. Michael's Hospital, Toronto, Ontario, Canada. 4. Department of Thoracic and Cardiovascular Surgery, Tromsø University Hospital, Tromsø, Norway. 5. Division of Thoracic and Cardiovascular Surgery, Duke University Medical Center, Durham, North Carolina. 6. Department of Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel. 7. Thoracic Aortic Center, Massachusetts General Hospital, Boston, Massachusetts. 8. Cardiac Surgery Department, University Hospital S. Orsola, Bologna, Italy. 9. Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota. 10. Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California. 11. Division of Cardiac Surgery, University of Calgary Medical Centre, Calgary, Alberta, Canada. 12. Cardiovascular Center, University of Michigan Health System, Ann Arbor, Michigan. 13. Department of Internal Medicine, University of Rostock, Rostock, Germany. 14. Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan.
Abstract
BACKGROUND: Aortic root management in type A acute aortic dissection is controversial. This study compared outcomes of root replacement (RR) interventions versus more conservative root (CR) management. METHODS:Of 1,995 typeA acute aortic dissection patients enrolled in the International Registry of Acute Aortic Dissection, 699 (35%) underwent RR interventions and 1,296 (65%) underwent CR management. Independent predictors of hospital and 3-year survival were identified using multivariable logistic and Cox regression models. RESULTS: Compared with CR patients, RR patients were younger (56.9 versus 62.3 years; p = 0.023) and more likely to present with larger root diameter (4.7 cm versus 4.0 cm; p < 0.001), Marfan syndrome (8.7% versus 2.5%; p < 0.001), aortic insufficiency (64.0% versus 50.3%; p < 0.001), and hypotension, shock, or tamponade (33.0% versus 26.5%; p = 0.003). Root replacement management did not increase hospital mortality (propensity score-adjusted odds ratio, 1.14; p = 0.674). On Kaplan-Meier analysis, 3-year survival (RR, 92.5% ± 1.7% versus CR, 91.6% ± 1.3%; log-rank p = 0.623) and freedom from aortic root reintervention (RR, 99.2% ± 0.1% versus CR, 99.3% ± 0.1%; log-rank p = 0.770) were similar. Only 2 patients (1 per group) underwent follow-up root reintervention. Propensity score-adjusted Cox regression excluded a relationship between root treatment and follow-up survival (hazard ratio, 1.5; 95% confidence interval, 0.502 to 5.010; p = 0.432). CONCLUSIONS: In type A acute aortic dissection patients more-extensive RR interventions are not associated with increased hospital mortality. This supports such an approach in young patients and patients with connective tissue diseases and bicuspid aortic valves. Excellent midterm survival and freedom from root reintervention in both groups suggest stable behavior of the nonreplaced aortic sinuses at 3 years. Thus, pending studies with longer follow-up, the use of aggressive RR techniques can be determined by patient-specific and dissection-related factors.
RCT Entities:
BACKGROUND: Aortic root management in type A acute aortic dissection is controversial. This study compared outcomes of root replacement (RR) interventions versus more conservative root (CR) management. METHODS: Of 1,995 type A acute aortic dissection patients enrolled in the International Registry of Acute Aortic Dissection, 699 (35%) underwent RR interventions and 1,296 (65%) underwent CR management. Independent predictors of hospital and 3-year survival were identified using multivariable logistic and Cox regression models. RESULTS: Compared with CRpatients, RR patients were younger (56.9 versus 62.3 years; p = 0.023) and more likely to present with larger root diameter (4.7 cm versus 4.0 cm; p < 0.001), Marfan syndrome (8.7% versus 2.5%; p < 0.001), aortic insufficiency (64.0% versus 50.3%; p < 0.001), and hypotension, shock, or tamponade (33.0% versus 26.5%; p = 0.003). Root replacement management did not increase hospital mortality (propensity score-adjusted odds ratio, 1.14; p = 0.674). On Kaplan-Meier analysis, 3-year survival (RR, 92.5% ± 1.7% versus CR, 91.6% ± 1.3%; log-rank p = 0.623) and freedom from aortic root reintervention (RR, 99.2% ± 0.1% versus CR, 99.3% ± 0.1%; log-rank p = 0.770) were similar. Only 2 patients (1 per group) underwent follow-up root reintervention. Propensity score-adjusted Cox regression excluded a relationship between root treatment and follow-up survival (hazard ratio, 1.5; 95% confidence interval, 0.502 to 5.010; p = 0.432). CONCLUSIONS: In type A acute aortic dissection patients more-extensive RR interventions are not associated with increased hospital mortality. This supports such an approach in young patients and patients with connective tissue diseases and bicuspid aortic valves. Excellent midterm survival and freedom from root reintervention in both groups suggest stable behavior of the nonreplaced aortic sinuses at 3 years. Thus, pending studies with longer follow-up, the use of aggressive RR techniques can be determined by patient-specific and dissection-related factors.
Authors: Bo Yang; Elizabeth L Norton; Reilly Hobbs; Linda Farhat; Xiaoting Wu; Whitney E Hornsby; Karen M Kim; Himanshu J Patel; G Michael Deeb Journal: J Thorac Cardiovasc Surg Date: 2018-12-21 Impact factor: 5.209
Authors: Peter Chiu; Jeffrey Trojan; Sarah Tsou; Andrew B Goldstone; Y Joseph Woo; Michael P Fischbein Journal: J Thorac Cardiovasc Surg Date: 2017-09-19 Impact factor: 5.209
Authors: Paolo Berretta; Himanshu J Patel; Thomas G Gleason; Thoralf M Sundt; Truls Myrmel; Nimesh Desai; Amit Korach; Antonello Panza; Joe Bavaria; Ali Khoynezhad; Elise Woznicki; Dan Montgomery; Eric M Isselbacher; Roberto Di Bartolomeo; Rossella Fattori; Christoph A Nienaber; Kim A Eagle; Santi Trimarchi; Marco Di Eusanio Journal: Ann Cardiothorac Surg Date: 2016-07