title: Type A aortic dissection after previous cardiac surgery: results of an integrated surgical approach.
abstract: 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.
authors.affiliation: Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Heart Center University Freiburg, Freiburg, Germany. Electronic address: bartosz.rylski@universitaets-herzzentrum.de.
authors.forename: Bartosz
authors.initials: B
authors.lastname: Rylski
authors.affiliation: Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Nimesh D
authors.initials: ND
authors.lastname: Desai
authors.affiliation: Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Joseph E
authors.initials: JE
authors.lastname: Bavaria
authors.affiliation: Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: William
authors.initials: W
authors.lastname: Moser
authors.affiliation: Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Prashanth
authors.initials: P
authors.lastname: Vallabhajosyula
authors.affiliation: Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Alberto
authors.initials: A
authors.lastname: Pochettino
authors.affiliation: Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.affiliation: Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Rita K
authors.initials: RK
authors.lastname: Milewski
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods / Q000401:mortality*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000379:methods; D002423:Cause of Death; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D061214:Patient Safety; D011183:Postoperative Complications / Q000401:mortality / Q000503:physiopathology; D011859:Radiography; D012086:Reoperation / Q000379:methods / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D018709:Statistics, Nonparametric; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome