Surgery for acute type A aortic dissection: the Hopital Foch experience (1977-1998).

BACKGROUND

In 1977, we proposed the use of gelatin-resorcinol-formol (GRF) biological glue during surgery for acute type A aortic dissection.

METHODS

From January 1977 to March 1998, 204 patients (146 men and 58 women) aged from 15 to 79 years (mean 54 +/- 11) underwent emergency operation for type A aortic dissection in our institution. One hundred sixty-five patients (84%) were operated on within 48 h after the onset of symptoms. Twenty-eight patients (13.7%) had Marfan's syndrome. In 43 patients (23%), the aortic valve was replaced either independently (6, 3%) or by means of a composite graft (37, 18.1%). Because of the location of the intimal tear, aortic replacement included the transverse arch in 60 patients (29.4%).

RESULTS

Hospital mortality was 21% (39 patients): 25% in patients with arch replacement and 19.4% in patients without arch replacement (ns). One hundred sixty-one patients were discharged and followed from 2 months to 21 years postoperatively (mean 85 +/- 66 months). During this interval, 25 patients (15.5%) required reoperation for a total of 33 reoperations. Seven patients (28%) died at reoperation. Upon univariate analysis, presence of Marfan's syndrome (p < 0.05) and absence of arch replacement (p < 0.02) were risk factors for reoperation. Emergency operation (p < 0.01) and thoracoabdominal replacement (p < 0.04) were risk factors for death at reoperation. The actuarial freedom from reoperation (Kaplan-Meier, confidence interval 95%) is 96.1% (90.9%-98.2%) at 1 year, 87.6% (79.8%-92.7%) at 5 years, 80.9% (70.8%-88.1%) at 10 years, and 66.4% (51.1%-78.9%) at 15 years. A total of 39 patients (24.3%) died during follow-up. The presence of Marfan's syndrome (p < 0.01), reoperation (p < 0.02), stroke (p < 0.05), and cardiac failure (p < 0.05) were risk factors for late mortality. The actuarial late survival including hospital mortality is 71.5% (64.3%-77.8%) at 1 year, 66% (58.3%-73%) at 5 years, 56.4% (47.7%-64.7%) at 10 years, and 46.3% (36.4%-56.5%) at 15 years.

CONCLUSIONS

The GRF glue has proven extremely useful during emergency initial surgery for acute type A dissection, making the procedure much easier and safer. As a result of this operative improvement, the use of the GRF glue seems to have had a beneficial influence on late results, but these also depend upon the patient's basic condition.