Changes in operative strategy for patients enrolled in the International Registry of Acute Aortic Dissection interventional cohort program.

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.