Should we operate on patients with acute type A aortic dissection who present with cardiopulmonary resuscitation?

OBJECTIVES: Acute aortic dissection type A (AADA) is a life-threatening medical emergency. Emergent surgical repair is the gold standard but mortality remains high. Mortality is even higher in patients who arrive at the hospital in poor condition, especially after cardiopulmonary resuscitation (CPR). This study was designed to analyse the outcome of patients who underwent surgery for AADA and who require preoperative CPR. METHODS: Between 2000 and 2023, 810 patients underwent emergent surgery for AADA at our centre. Of these, 63 had preoperative CPR. We performed a retrospective analysis with follow-up. RESULTS: Mean age was 64 ± 13 years and 37 (59%) patients were male. Further, 50 (79%) patients had preoperative intubation, and 54 (86%) had pericardial effusion. Twenty-four (38%) patients had out-of-hospital CPR, 19 (30%) required CPR in hospital and 20 (32%) needed CPR in the operating room. Successful CPR with return of spontaneous circulation was achieved in 41 (65%) patients, and 22 (35%) underwent emergent surgery under ongoing CPR. The median time of CPR was 10 (interquartile range 12) min, and the median time from onset of symptoms to start of the operation was 5.5 (interquartile range 4.8) h. The majority of patients underwent ascending aortic replacement with hemiarch repair (n = 37, 59%). Further, 26 (41%) patients underwent full root replacement. Another 15 (24%) patients underwent total arch repair with or without (frozen) elephant trunk repair. Postoperative stroke was present in 8 (13%) patients. The 30-day mortality was 29 (46%). The 30-day mortality of patients with preoperative intubation was not significantly higher (n = 15/28, 54%, P = 0.446). The 1-, 5- and 10-year survival rates of the entire group were 42, 39 and 36%. CONCLUSIONS: Early mortality for patients undergoing surgery for AADA with preoperative CPR is extremely high (almost 50%). However, this means that also ∼50% of patients benefit from surgery despite poor preoperative prognosis. Patients with preoperative intubation after CPR and unknown neurological condition should also undergo surgery. Patients who survive the initial operation for AADA have acceptable long-term survival. Emergent surgery should be offered for all patients with AADA regardless of the preoperative condition, even after CPR.

Valve-sparing David I procedure in acute aortic type A dissection: a 20-year experience with more than 100 patients.

OBJECTIVES: The aortic valve-sparing David procedure has been applied to the elective treatment of patients with aortic aneurysms with excellent results. The use of this technique in patients with acute aortic dissection type A (AADA) is still a matter of debate. We present our long-term experience with 109 patients with AADA who had the valve-sparing David I procedure. METHODS: Between July 1993 and October 2015, 109 patients with AADA had the valve-sparing David I procedure at our centre. We conducted a retrospective review with follow-up. RESULTS: The mean age was 54 ± 12 years; 78 (72%) patients were men. Marfan syndrome was present in 6 (5%) patients and bicuspid aortic valve in 3 (3%). Only 4 (4%) patients received the isolated David procedure; 50 (46%) underwent additional proximal, 13 (12%) subtotal and 42 (39%) total aortic arch replacement. The in-hospital mortality rate was 11% ( n = 12). Intraoperative/discharge echocardiography showed aortic insufficiency ≤ I° in 93 of 97 patients (96%). Mean follow-up time was 8.3 ± 5.7 years. The survival rate after discharge at 1, 5 and 10 years was 94%, 90% and 78%, respectively. Thirteen percent ( n = 13) of patients underwent valve-related reoperation. Freedom from valve-related reoperation at 1, 5 and 10 years was 96%, 88% and 85%, respectively. Compared to patients who underwent the David I procedure for any reason other than AADA, there were no significant differences in long-term survival rates ( P = 0.29) and freedom from a valve-related reoperation ( P = 0.39). CONCLUSIONS: The valve-sparing David I procedure has acceptable long-term results even in emergent operations for AADA and is not inferior when performed in elective settings.

Complex aortic arch repair in a patient with Takayasu's disease presenting with acute aortic dissection type Stanford A and complete collateral perfusion of the brain.

We describe a rare case of a 46-year old woman suffering from Takayasu's disease. She had undergone aorto-biaxillary bypass and aorto-cerebral bypass surgery in 1985 for occlusive arterial disease and developed a large ascending pseudoaneurysm of the aorto-biaxillary bypass. The aorto-cerebral bypass and right axillary bypass were occluded. Native supra-aortic arteries were found to be proximally occluded and arterial blood supply to the brain was maintained by a dense arterial collateral network. The patient did not show neurological deficits and was able to work using both arms without restrictions. She refused early surgery but suffered from acute aortic dissection type Stanford A shortly after. Supracommissural ascending aortic and aortic arch repair under deep hypothermic circulatory arrest with no additional bypass to the head vessels was performed. This case demonstrates the significance of aortic complications in Takayasu's disease and the effectiveness of collateral brain perfusion in selected patients.