Aortic Root Replacement in Type A Aortic Dissection Is Protective From Distal Reintervention
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0048
Submission Type:
Abstract Submission
Authors:
Adam Carroll (1), Michal Schafer (1), Robert King (1), Zihan Feng (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions:
(1) University of Colorado Anschutz, Denver, CO
Submitting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Co-Author(s):
Michal Schafer
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University of Colorado Anschutz
University of Colorado Anschutz
Robert King
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University of Colorado Anschutz
University of Colorado Anschutz
Zihan Feng
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University of Colorado Anschutz
University of Colorado Anschutz
*Muhammad Aftab
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University of Colorado Anschutz
University of Colorado Anschutz
*T. Brett Reece
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University of Colorado Anschutz
University of Colorado Anschutz
Presenting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Abstract:
Objective:
Acute Type A aortic dissections remain a devastating and life limiting pathology. Although modifications in surgical technique and perioperative care have significantly improved short-term morbidity and mortality, patients remain at high risk of long-term complications related to residual dissection, with up to 47% of patients requiring procedural re-intervention. Furthermore, there is significant variability in both index operative management and post-operative surveillance due to the heterogenous pathologic spectrum of disease. Management of the aortic root exemplifies this variability. Depending on patient and surgeon specific factors, preferences range from conservative preservation of the native root, to complete replacement of both the valve and aortic root (in addition to the myriad of options in between). Current literature suggests that both provide viable short-term outcomes, and further suggests that replacing a root decreases likelihood of future replacement. However, it is unknown if it provides any benefit in avoiding degeneration of distal pathology. Our goal was to evaluate freedom from all re-operation, including distal intervention, of patients who were treated for type A dissection based on index root treatment.
Methods: We performed a single center retrospective review of patients who presented with initial type A dissection without previous aortic pathology at our institution. Patient records were reviewed to determine freedom from re-operation, with re-operation defined as repeat aortic root, arch, or distal intervention, or if no re-operation occurred, furthest stable imaging from initial surgery. Aortic root replacement procedures included Davids, Bentalls, Biobentalls, and Freestyle grafts, while non-root replacement consisted of aortic valve resuspension. The freedom from re-operation analysis between the two groups was performed with Kaplan-Meier analysis with corresponding log-rank test and corresponding hazard ratios.
Results: 200 patients from 2009-2021 were included in our analysis, with median follow-up time of 390 days. Patients who underwent root replacement at the time of index surgery had higher freedom from re-operation with 2-year and 4-year freedom of 95% and 91% respectively, when compared to those who did not have root replacement (Plog-rank = 0.005, HR = 2.8 (95%CI: 1.2 – 6.3)) with 2- and 4-year freedom from re-operation of 71% and 60% respectively (Figure 1A). Considering re-operation requiring only arch-distal re-intervention as the clinical event, patients who underwent root replacement at the time of index surgery had higher freedom from re-operation with 2-year and 4-year freedom of 97% and 92% respectively, when compared to those who did not have root replacement (Plog-rank = 0.014, HR = 2.8 (95%Ci 1.3 – 5.6)) with 2- and 4-year freedom from re-operation of 77% and 67% respectively (Figure 1B).
Conclusion
Our findings suggest that aortic root replacement is protective from re-operation for arch and distal aortic pathology. This finding advocates for a more aggressive approach to the aortic root at initial intervention when possible. Further investigation is required to understand changes in pathology and physiologic alterations in flow that may contribute to this finding.
Acute Type A aortic dissections remain a devastating and life limiting pathology. Although modifications in surgical technique and perioperative care have significantly improved short-term morbidity and mortality, patients remain at high risk of long-term complications related to residual dissection, with up to 47% of patients requiring procedural re-intervention. Furthermore, there is significant variability in both index operative management and post-operative surveillance due to the heterogenous pathologic spectrum of disease. Management of the aortic root exemplifies this variability. Depending on patient and surgeon specific factors, preferences range from conservative preservation of the native root, to complete replacement of both the valve and aortic root (in addition to the myriad of options in between). Current literature suggests that both provide viable short-term outcomes, and further suggests that replacing a root decreases likelihood of future replacement. However, it is unknown if it provides any benefit in avoiding degeneration of distal pathology. Our goal was to evaluate freedom from all re-operation, including distal intervention, of patients who were treated for type A dissection based on index root treatment.
Methods: We performed a single center retrospective review of patients who presented with initial type A dissection without previous aortic pathology at our institution. Patient records were reviewed to determine freedom from re-operation, with re-operation defined as repeat aortic root, arch, or distal intervention, or if no re-operation occurred, furthest stable imaging from initial surgery. Aortic root replacement procedures included Davids, Bentalls, Biobentalls, and Freestyle grafts, while non-root replacement consisted of aortic valve resuspension. The freedom from re-operation analysis between the two groups was performed with Kaplan-Meier analysis with corresponding log-rank test and corresponding hazard ratios.
Results: 200 patients from 2009-2021 were included in our analysis, with median follow-up time of 390 days. Patients who underwent root replacement at the time of index surgery had higher freedom from re-operation with 2-year and 4-year freedom of 95% and 91% respectively, when compared to those who did not have root replacement (Plog-rank = 0.005, HR = 2.8 (95%CI: 1.2 – 6.3)) with 2- and 4-year freedom from re-operation of 71% and 60% respectively (Figure 1A). Considering re-operation requiring only arch-distal re-intervention as the clinical event, patients who underwent root replacement at the time of index surgery had higher freedom from re-operation with 2-year and 4-year freedom of 97% and 92% respectively, when compared to those who did not have root replacement (Plog-rank = 0.014, HR = 2.8 (95%Ci 1.3 – 5.6)) with 2- and 4-year freedom from re-operation of 77% and 67% respectively (Figure 1B).
Conclusion
Our findings suggest that aortic root replacement is protective from re-operation for arch and distal aortic pathology. This finding advocates for a more aggressive approach to the aortic root at initial intervention when possible. Further investigation is required to understand changes in pathology and physiologic alterations in flow that may contribute to this finding.
Aortic Symposium:
Aortic Root
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