Acute Type A Aortic Dissection Repair After Hours: Does It Influence Outcomes?

BACKGROUND

Time of day has been associated with adverse outcomes in certain surgical pathologies. Because acute type A aortic dissection typically mandates immediate repair, relatively little attention has been paid to the potential impact of the day-night timing of the operation itself. We sought to determine whether patients with acute dissection treated during typical working hours demonstrated a difference in outcomes compared with those who required surgery after hours.

METHODS

We undertook a comprehensive review of our prospectively collected database from July 2014 to October 2018. A total of 164 consecutive patients underwent primary repair of an acute type A dissection. Based on the procedure start time, patients were divided into 2 groups: working hours (7 am to 4 pm, Monday to Friday; n = 60), and after hours (all other times, including weekends and holidays; n = 104). We propensity-matched 58 pairs of patients and analyzed perioperative data and short-term clinical outcomes.

RESULTS

Thirty-day mortality for all 164 patients was 10.4% (17 deaths), which was not significantly different between the matched groups (working-hours: 8 deaths [13.8%] versus after hours: 4 deaths [6.9%]; P = .36). Perfusion, cross-clamp, and circulatory arrest times did not differ between groups, nor did the types of aortic repairs performed. Postoperative complications were also comparable, including stroke, reoperation for bleeding, and new-onset renal failure requiring dialysis.

CONCLUSIONS

Thirty-day mortality and major morbidity after acute type A dissection repair are independent of when the operation is performed. Expeditious surgical intervention is recommended for all primary acute type A dissection, irrespective of time of day.

The aortic root does not dilate over time after replacement of the aortic valve and ascending aorta in patients with bicuspid or tricuspid aortic valves

OBJECTIVE

Whether the aortopathy associated with bicuspid aortic valve (BAV) disease occurs secondary to genetic or hemodynamic factors remains controversial. In this article we describe the natural history of the aortic root in patients with bicuspid versus tricuspid aortic valves (TAVs) after replacement of the aortic valve and ascending aorta.

METHODS

From 1990 to 2010, 406 patients (269 BAV, 137 TAV) underwent aortic valve and ascending aorta replacement at a single institution. Patients with aortic dissection, endocarditis, previous aortic surgery, or Marfan syndrome were excluded. All available follow-up imaging was reviewed.

RESULTS

Mean imaging follow-up was 5.5 (±5.3) years. Of all patients, 66.5% had at least 1 aortic root measurement after the index operation. Baseline aortic diameter was comparable between groups. In patients with BAV, aortic root diameter increased at a clinically negligible rate over time (0.654 mm per year; 95% confidence interval, 0.291-1.016; P < .001), similar to patients with TAV (P = .92). Mean clinical follow-up was 8.1 (±5.4) years. During follow-up, 18 patients underwent reoperation, 89% for a degenerated bioprosthetic aortic valve. Only 1 patient underwent reoperation for a primary indication of aortic aneurysmal disease, 22 years after the index operation. There were no differences in cumulative incidence rates of aortic reoperation (P = .14) between patients with BAV and TAV.

CONCLUSIONS

Mid-term imaging after aortic valve and ascending aorta replacement indicates that if the aortic root is not dilated at the time of surgery, the risk of enlargement over time is minimal, negating the need for prophylactic root replacement in patients with BAV or TAV.