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The Journal of Thoracic and Cardiovascular Surgery, Vol 78, 365-382, Copyright © 1979 by The American Association for Thoracic Surgery and The Western Thoracic Surgical Association
DC Miller, EB Stinson, PE Oyer, SJ Rossiter, BA Reitz, RB Griepp and NE Shumway
An unselected, consecutive cohort of 125 patients underwent operative
repair of acute and chronic aortic dissections with tubular graft
interposition over a 16 year span. The absence of remote geographical
referral biases and the unselected nature of this series provided a patient
population that was representative of the disease process (as assessed
heretofore only from autopsy series). Furthermore, this enabled high-risk
subsets to be defined by retrospective analysis. Patients were classified
according to whether the ascending aorta was involved (type A with
involvement, type B without), irrespective of the site of intimal tear, and
according to age of the dissection: Fifty- three patients had acute type A
(Ac-A), 29 had chronic type A (Ch-A), 20 had acute type B (Ac-B), and 23
had chronic type B (Ch-B) dissections. Fourteen percent (17/125) of the
dissections had ruptured. Concomitant aortic valve replacement (AVR) was
performed in 11% (6/53) for Ac-A cases and 38% (11/29) of the Ch-A cases. A
total of 391 patient-years of follow-up was analyzed; follow-up averaged
4.5 years and extended to 13.7 years. Over-all operative mortality rate was
34% (18/53) for Ac-A, 14% (4/29) for Ch-A, 45% (9/20) for Ac-B, and 22%
(5/23) for Ch-B; during the most recent 5 year interval these figures were
lower: 27%, 8%, 20%, and 20%, respectively, N = 50. Multiple preoperative
variables were found to correlate significantly with both operative death
and long-term survival. Operative survivors generally experienced
satisfactory functional benefit. Late attrition averaged 8% per year; 61%
of all late deaths were related to cardiac or cerebral causes. Over-all
actuarial survival (+/- SEM) for the entire cohort was 54% +/- 5% at 5
years and 26% +/- 7% at 10 years; for the 89 patients surviving operation,
these figures were 76% +/- 5% and 37% +/- 10%, respectively. No significant
differences in long-term survival were evident between the different
subgroups. Whether the primary intimal tear had been resected or
concomitant AVR had been performed had no statistically significant bearing
on operative mortality, functional result, necessity for late reoperation,
or late attrition. The long- term "natural" history of surgically treated
patients with aortic dissections, as defined in this study, should
facilitate comparison with other treatment modalities. Results of the
present analysis support immediate operative intervention for patients with
Ac-A dissections and probably for those with Ac-B dissections.
Additionally, surgical treatment of patients with symptomatic or enlarging
Ch-A and Ch-B dissections provides satisfactory rehabilitation and
long-term survival. Finally, we re-emphasize our recommendation for
simplified classification of aortic dissections, based solely upon the
presence or absence of ascending aortic involvement. Pathophysiology and
expected biologic behavior pivot on this feature, and appropriate clinical
strategy can thereby be defined.
ARTICLES
Operative treatment of aortic dissections. Experience with 125 patients over a sixteen-year period
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