Proximal reoperations after repaired acute type A aortic dissection

Background. Concerned with the associated risks of proximal reoperation, some have proposed an aggressive approach of aortic root replacement during emergent repair of acute type A aortic dissection. Because few data exist regarding late reoperations, we report outcomes of proximal reoperation after repaired type A aortic dissection. Methods. Between January 1991 and March 2006, 63 patients underwent reoperation after previous repair for acute type A aortic dissection. Procedures performed at reoperation included ascending (94%, 59 of 63), total arch (62%, 39 of 63), elephant trunk (56%, 35 of 63), aortic valve replacement (38%, 24 of 63), aortic root (27%, 17 of 63), and coronary artery bypass graft (8%, 5 of 63). Preoperative, operative, and postoperative variables were analyzed retrospectively with regard to early and late mortality. Results. Thirty-day mortality was 11.1% (7 of 63). No strokes occurred. Incidence of renal failure, respiratory failure, and bleeding was 6% (4 of 63), 23% (15 of 63), and 6% (4 of 63), respectively. Mean time from initial repair to reoperation was 69 months (range, 1 to 258). Procedure performed (root versus ascending/esuspension) at initial repair did not affect the time to reoperation (p > 0.05). Median follow-up was 40 months; and 1-, 5-, and 10-year survival was 82%, 74%, and 62%, respectively. Multivariate predictors of late mortality were prior coronary artery bypass graft surgery (odds ratio = 6.5, p < 0.003), bypass time (odds ratio = 3.6, p < 0.02), and renal dysfunction (odds ratio = 3.7, p < 0.05). Conclusions. Proximal reoperations for repaired acute type A aortic dissection can be performed with acceptable early and late mortality. The concern for proximal reoperation should not dictate the initial procedure choice during acute type A aortic dissection. Continued clinical and radiographic surveillance of repaired type A aortic dissection is warranted.