Neil Parikh1, Santi Trimarchi2, Thomas G Gleason3, Arnoud V Kamman4, Marco di Eusanio5, Truls Myrmel6, Amit Korach7, Hersh Maniar8, Takeyoshi Ota9, Ali Khoynezhad10, Daniel G Montgomery1, Nimesh D Desai11, Kim A Eagle12, Christoph A Nienaber13, Eric M Isselbacher14, Joseph Bavaria11, Thoralf M Sundt14, Himanshu J Patel15. 1. Michigan Cardiovascular Outcomes Research and Reporting Program, University of Michigan Health System, Ann Arbor, Mich. 2. Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy. 3. Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa. 4. Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy; Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich. 5. Cardiac Surgery Department, University Hospital S Orsola, Bologna, Italy. 6. Thoracic and Cardiovascular Surgery, Tromso University Hospital, Tromso, Norway. 7. Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel. 8. Cardiovascular Surgery, Washington University, St Louis, Mo. 9. Cardiac and Thoracic Surgery, University of Chicago Medical Center, Chicago, Ill. 10. Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif. 11. Cardiothoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa. 12. Michigan Cardiovascular Outcomes Research and Reporting Program, University of Michigan Health System, Ann Arbor, Mich; Department of Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich. 13. Cardiology and Aortic Centre, Royal Brompton Hospital, Royal Brompton & Harefield NHS Trust, Imperial College London, London, United Kingdom. 14. Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass. 15. Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich. Electronic address: hjpatel@med.umich.edu.
Abstract
OBJECTIVE: Advancements in cardiothoracic surgery prompted investigation into changes in operative management for acute type A aortic dissections over time. METHODS: One thousand seven hundred thirty-two patients undergoing surgery for type A aortic dissection were identified from the International Registry of Acute Aortic Dissection Interventional Cohort Database. Patients were divided into time tertiles (T) (T1: 1996-2003, T2: 2004-2010, and T3: 2011-2016). RESULTS: Frequency of valve sparing procures increased (T1: 3.9%, T2: 18.6%, and T3: 26.7%; trend P < .001). Biologic valves were increasingly utilized (T1: 35.6%, T2; 40.6%, and T3: 52.0%; trend P = .009), whereas mechanical valve use decreased (T1: 57.6%, T2: 58.0%, and T3: 45.4%; trend P = .027) for aortic valve replacement. Adjunctive cerebral perfusion use increased (T1: 67.1%, T2: 89.5%, and T3: 84.8%; trend P < .001), with increase in antegrade cerebral techniques (T1: 55.9%, T2: 58.8%, and T3: 66.1%; trend P = .005) and hypothermic circulatory arrest (T1: 80.1%, T2: 85.9%, and T3: 86.8%; trend P = .030). Arterial perfusion through axillary cannulation increased (T1: 18.0%, T2: 33.2%, and T3: 55.7%), whereas perfusion via a femoral approach diminished (T1: 76.0%, T2: 53.3%, and T3: 30.1%) (both P values < .001). Hemiarch replacement was utilized more frequently (T1: 27.0%, T2: 63.3%, and T3: 51.7%; trend P = .001) and partial arch was utilized less frequently (T1: 20.7%, T2: 12.0%, and T3: 8.4%; trend P < .001), whereas complete arch replacement was used similarly (P = .131). In-hospital mortality significantly decreased (T1: 17.5%, T2: 15.8%, and T3: 12.2%; trend P = .017). CONCLUSIONS: There have been significant changes in operative strategy over time in the management of type A aortic dissection, with more frequent use of valve-sparing procedures, bioprosthetic aortic valve substitutes, antegrade cerebral perfusion strategies, and hypothermic circulatory arrest. Most importantly, a significant decrease of in-hospital mortality was observed during the 20-year timespan.
OBJECTIVE: Advancements in cardiothoracic surgery prompted investigation into changes in operative management for acute type A aortic dissections over time. METHODS: One thousand seven hundred thirty-two patients undergoing surgery for type A aortic dissection were identified from the International Registry of Acute Aortic Dissection Interventional Cohort Database. Patients were divided into time tertiles (T) (T1: 1996-2003, T2: 2004-2010, and T3: 2011-2016). RESULTS: Frequency of valve sparing procures increased (T1: 3.9%, T2: 18.6%, and T3: 26.7%; trend P < .001). Biologic valves were increasingly utilized (T1: 35.6%, T2; 40.6%, and T3: 52.0%; trend P = .009), whereas mechanical valve use decreased (T1: 57.6%, T2: 58.0%, and T3: 45.4%; trend P = .027) for aortic valve replacement. Adjunctive cerebral perfusion use increased (T1: 67.1%, T2: 89.5%, and T3: 84.8%; trend P < .001), with increase in antegrade cerebral techniques (T1: 55.9%, T2: 58.8%, and T3: 66.1%; trend P = .005) and hypothermic circulatory arrest (T1: 80.1%, T2: 85.9%, and T3: 86.8%; trend P = .030). Arterial perfusion through axillary cannulation increased (T1: 18.0%, T2: 33.2%, and T3: 55.7%), whereas perfusion via a femoral approach diminished (T1: 76.0%, T2: 53.3%, and T3: 30.1%) (both P values < .001). Hemiarch replacement was utilized more frequently (T1: 27.0%, T2: 63.3%, and T3: 51.7%; trend P = .001) and partial arch was utilized less frequently (T1: 20.7%, T2: 12.0%, and T3: 8.4%; trend P < .001), whereas complete arch replacement was used similarly (P = .131). In-hospital mortality significantly decreased (T1: 17.5%, T2: 15.8%, and T3: 12.2%; trend P = .017). CONCLUSIONS: There have been significant changes in operative strategy over time in the management of type A aortic dissection, with more frequent use of valve-sparing procedures, bioprosthetic aortic valve substitutes, antegrade cerebral perfusion strategies, and hypothermic circulatory arrest. Most importantly, a significant decrease of in-hospital mortality was observed during the 20-year timespan.
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