Type A Aortic Dissection After Previous Cardiac Surgery: Results of an Integrated Surgical Approach

Background. Stanford type A aortic dissection in patients with previous cardiac surgery (PCS) is a catastrophic disease. This investigation evaluates the results of a standardized integrated approach to type A dissection after PCS. Methods. Between 1993 and 2013, 629 patients with acute type A dissection (median age 61 [50 to 73] years, 64% males) underwent aortic repair utilizing a standardized integrated approach. Of these, 56 (9%) patients had PCS. Median follow-up was 4.1 (1.9 to 7.4) years (2,812 patient-years). Results. Patients with PCS were older (70 [60 to 75] vs 60 [50 to 72] years, p < 0.001), fivefold more likely to have coronary artery disease (p < 0.001), and threefold less likely to have cardiac tamponade (p < 0.001). They had higher in-hospital mortality rate (25% vs 12%, p = 0.011), similar postoperative stroke rate (4% vs 5%, p = 0.821), and lower survival (60% +/- 7%, 50% +/- 7%, 38% +/- 8% vs 84% +/- 2%, 69% +/- 2%, 50% +/- 3%) at 1, 5, and 10 years, respectively (log rank, p = 0.003). Among PCS patients, the lowest in-hospital mortality was in those without prior myocardial revascularization (11% vs 32%, p = 0.185). Coronary malperfusion (odds ratio, 9.47; p = 0.034) and cardiac tamponade (odds ratio, 5.01; p = 0.076) were independent in-hospital mortality risk factors in PCS patients. Conclusions. Standardized integrated approach to acute type A aortic dissection in PCS patients results in acceptable postoperative mortality. Previous cardiac surgery should not be a reason to deny surgical repair in patients with type A dissection. (C) 2014 by The Society of Thoracic Surgeons