Aortic Root Conservative Repair
in Acute Type A Aortic Dissection
Involving Aortic Root:
Fate of Aortic Root & Aortic Valve Function
Joon Bum Kim, Su Kyung Hwang, Sung Ho Jung,
Suk Jung Choo, Cheol Hyun Chung, Jae Won Lee
Department of Thoracic and Cardiovascular Surgery,
Asan Medical Center,
University of Ulsan, College of Medicine, Seoul, Korea
Background
• “Conservative versus more aggressive
approaches” in the surgical management of
aortic root in acute type A aortic dissection has
been debated
• Changes in aortic valve function and aortic root
geometry after conservative aortic root repair in
acute type A aortic dissection have been poorly
understood.
Study Aims
• To evaluate the aortic root geometry and aortic
valve function long after surgery for acute type A
aortic dissection involving the aortic root.
• And thereby…
To elucidate the best patient and patho-anatomic
substrate amenable to a conservative versus a
more aggressive approach to the aortic root and
thus refine our surgical decision-making process
Methods
• Between January 1999 and December 2010,
289 patients underwent aortic replacement for Acute
type A aortic dissection
• Aortic root involvement: n=214
• Exclusion:
- Prosthetic aortic valve in-situ (n=1)
- Concomitant root or aortic valve replacement (n=17)
• Final enrollment: n=196
Methods
• Conservative root surgery:
- Preservation of aortic sinus and valve
- Sinotubular / commissural resuspension
- Sinotubular junction reduction
• Total arch replacement: n=41 (20.9%)
Hemiarch replacement: n=155 (79.1%)
• Concomitant CABG in 13 (6.6%)
Baseline Characteristics
Total number of patients
Demographic & baseline risks
Age, year
Female gender, n (%)
Marfan or Loeys-Dietz syndrome, n (%)
Type of aortic dissection, n (%)
DeBakey type I
DeBakey type II
Debakey subtype III-D (retro-A)
Intramural hematoma, n (%)
Aortic regurgitation grade, n (%)
None
1+
2+
3+
4+
196
56.9 ± 11.4
100 (51.0)
6 (3.1)
152 (77.6)
17 (8.7)
27 (13.8)
9 (4.6)
71 (36.2)
62 (31.6)
25 (12.8)
19 (9.7)
19 (9.7)
Operative Results
• 30-day mortality: n=10 (5.1%)
• Late death: n=28 (14.4%)
Echocardiography & CT Follow-Up
• 6-month survival: n=177 (90.3%)
• Echo follow-up (n=115, 65.0%): 44.9 ± 32.7 months
• CT follow-up (n=138, 78.0%): 41.8 ± 31.3 months
Changes in AR grade
(P < 0.001)
Echocardiography & CT Follow-Up
• Root diameter at last follow-up: 38.9 ± 6.5mm
• Root diameter > 45mm: 9.7% (19/138)
Freedom from AR (2+) or root dilatation (>45mm)
Risk Factor Analysis
• Cox-regression analysis to determine the risk
factor for composite of AR (>2+) and the aortic
root dilatation (>45mm):
Maximal root diameter at initial preoperative
presentation was the only significant predictor
(Hazard ratio 1.10, 95% confidence interval
1.02-1.19, P = 0.014)
Initial Root Diameter & Freedom
from AR or Root Dilatation
Receiver operating curve method:
Greatest accuracy at 47.5mm
(75% sensitivity, 58.7% specificity)
Freedom from AR or root dilatation
according to the cut-off value of 47mm
Conclusions
• Conservative aortic root repair in acute type A
aortic dissection showed acceptable long-term
clinical outcomes.
• However, more aggressive approaches should
be considered in patients who have aortic root
dilatation (>47mm) because these patients have
a greater propensity to develop root aneurysm
late after surgery.