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J Thorac Cardiovasc Surg 2009;138:1349-1357
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Surgical management and long-term outcomes for acute ascending aortic dissection

^a Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
^b Division of Cardiology, Massachusetts General Hospital, Boston, Mass
^c Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada

Received for publication May 2, 2008; revisions received November 6, 2008; accepted for publication January 4, 2009.

^_* Address for reprints: Arvind K. Agnihotri, MD, Department of Cardiothoracic Surgery, Massachusetts General Hospital, 55 Fruit St, COX 630, Boston, MA 02114. (Email: aagnihotri{at}partners.org).

Objective: We sought to assess early and late survival and cardiovascular-specific mortality after surgical repair of acute ascending aortic dissection and the effect of differences in surgical technique, patient characteristics, and preoperative diagnostic testing.

Methods: Between 1979 and 2003, 195 consecutive patients underwent repair for acute ascending aortic dissection within 2 weeks of the onset of symptoms. Mean follow-up was 7.0 ± 5.9 years (range, 0–26 years) and was 100% complete.

Results: Patients were aged 62 ± 15 years on average and were mostly male (66%) and hypertensive (69%). Risk of death early and late after the operation decreased over the study period, with hospital mortality decreasing from 21% to 4% when comparing the first and most recent quartiles (P = .007, ² test for trend). At 1, 5, 10, and 20 years postoperatively, survival was 84%, 69%, 55%, and 30%, respectively, and freedom from cardiovascular death was 86%, 80%, 71%, and 51%, respectively. Additional independent risk factors for death were older age (P < .001), renal dysfunction (P < .003), syncope (P = .007), and peripheral vascular disease (P = .006). During the study period, echocardiographic and computed tomographic diagnostic imaging replaced routine aortic angiographic analysis, and operative techniques involved more frequent use of open distal anastomoses, retrograde cerebral perfusion, earlier restoration of antegrade perfusion, and a conservative approach to aortic arch repair. Freedom from reoperation on the aorta or aortic valve was 93% and 84% at 5 and 10 years, respectively.

Conclusions: Early and late survival after repair of acute ascending aortic dissection has improved progressively over 25 years in association with noticeable changes in preoperative and intraoperative management. Aortic reoperations were infrequent during follow-up.

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