Thoracic Surgery Directors Association Award. What is the optimal management of late-presenting survivors of acute type A aortic dissection?

BACKGROUND

Although type A aortic dissections represent a surgical emergency, some patients present late after the onset of symptoms. Optimal management of this cohort has not been defined.

METHODS

Data on 195 patients with type A dissections followed up at a single institution between 1985 and 2005 were collected prospectively. Of these, 93 patients (47.2%) presented 48 hours or later after the initial onset of pain (group A), and the remaining 102 patients underwent immediate operative repair (group B). Median follow-up was 41.8 months (range, 0 to 386 months).

RESULTS

Patients in group A were older (68.8 versus 59.3 years, p = 0.0005) and had a higher incidence of coronary artery disease (42.5% versus 14.6%, p < 0.0001), pulmonary disease (26.6% versus 8.4%, p = 0.0023), and congestive heart failure (14.1% versus 1.0%, p = 0.0004). Long-term survival was similar, although group B showed a trend toward improved 30-day mortality (16.5% versus 8.7%, p = 0.1035). Of the 92 patients in group A, 53 (57.6%) eventually underwent operative repair a median of 8.2 days after symptom onset. There was a trend toward improved long-term survival among patients undergoing repair (p = 0.1031).

CONCLUSIONS

Initial medical management with interval operative repair of selected patients referred greater than 2 days following an acute type A dissection is a viable option. Delayed repair after optimization of the clinical condition and detailed evaluation of concomitant diseases results in excellent long-term results.