TITLE:
Surgery for Acute Stanford Type A Aortic Dissection in an Inner City Community Hospital: Single Surgeon’s Experience
AUTHORS:
Jonathan Nwiloh
KEYWORDS:
Acute Aortic Dissection, Surgical Outcome, Surgeon’s Experience, Community Hospitals
JOURNAL NAME:
World Journal of Cardiovascular Surgery,
Vol.6 No.2,
February
29,
2016
ABSTRACT: Objective: An inverse relationship between volume and mortality in some cardiothoracic surgical
procedures has been previously established, leading to suggestions that acute aortic dissection
should not be operated in community or low volume heart centers. We therefore reviewed our
experience to compare with published data. Methods: Retrospective review of 27 patients who
underwent proximal aortic surgery by a single surgeon at an inner city community hospital between
May 2004 and April 2015. 16 patients, mean age 51.7 ± 13.6 years old, 75.0% males underwent
emergency surgery for acute Stanford type A aortic dissection, while 9 with root or ascending
aortic aneurysm, mean age 50.3 ± 15.0 years old, 88.9% males had elective proximal aortic
surgery. 2 patients with arch aneurysm were excluded. Results: Four (25.0%) patients with acute
dissection were in Penn class A, 3 (18.7%) Penn B, 3 (18.7%) Penn C and 6 (37.5%) Penn B+C. 10
(62.5%) patients underwent emergency root replacement with 60.0% (6/10) mortality all related
to malperfusion including 2 patients with bloody stools, while 6 (37.5%) underwent supracoronary
graft replacement with 16.6% (1/6) mortality from cardiac tamponade. The 5-year survival
was 89.0%. In patients with aortic aneurysm, 8 (88.9%) underwent elective root replacement and
1 (11.1%) supracoronary graft replacement with zero mortality. Conclusion: Supracoronary graft
replacement is performed for the majority of uncomplicated acute type A dissections and can be
undertaken by the average general cardiac surgeon with acceptable results. Visceral malperfusion
especially when associated with bloody stools portends a poor prognosis, and aortic dissection
should be excluded in any Marfan patient presenting with acute abdomen. Delaying intervention
in attempting transfer to a tertiary hospital can potentially increase preoperative mortality,
known to rise with each passing hour from onset of acute dissection. Patients presenting therefore
to community hospitals should probably undergo surgery there to avoid complications associated
with delay.