title: Italian multicentre study on type A acute aortic dissection: a 33-year follow-up†.
abstract: OBJECTIVE
  Despite substantial progress in surgical techniques and perioperative management, the treatment and long-term follow-up of type A acute aortic dissection (AAD) still remain a major challenge. The objective of this retrospective, multicentre study was to assess in a large series of patients the early and long-term results after surgery for type A AAD.
  
  
  METHODS
  We analysed the preoperative, intraoperative and postoperative conditions of 1.148 consecutive patients surgically treated in seven large referral centres from 1981 to 2013. We applied to each patient three different multi-parameter risk profiles (preadmission risk, admission risk and post-surgery risk) in order to compare risk factors and outcome. Long-term Kaplan-Meier survival was evaluated.
  
  
  RESULTS
  The median age was 64 years and the male population was predominant (66%). Identified diagnosis of collagen disease was present in 9%, and Marfan syndrome in 5%. Bicuspid aortic valve was present in 69 patients (6%). Previous cardiac surgery was identified in 10% of the patients. During surgery, the native aortic valve was preserved in 72% of the cases, including leaflet resuspension in 23% and David operation in 1.2%. Considering aortic valve replacement (AVR: 28%), bioprosthesis implantation was performed in 14.7% of the subjects. Neurological impairment at discharge was shown in 23% of the cases among which 21% of patients had new neurological impairment versus preoperative conditions. The overall 30-day mortality rate was 25.7%. All risk profiles remained independently associated with in-hospital mortality. During the available follow-up of hospital survivors (median: 70 months, interquartile range: 34-113, maximum: 396), cardiac-related death occurred in 7.9% of the subjects. The cumulative survival rate for cardiac death was 95.3% at 5 years, 92.8% at 10 years and 52.8% at 20 years. Severe aortic regurgitation (AR) (grade 3-4) at the time of surgery showed to be a significant risk factor for reintervention during the follow-up (P < 0.001). Among risk profiles, only the preadmission risk was independently associated with late mortality after multivariate analysis. Unexpectedly, there was no difference in freedom from cardiac death between patients with and without AVR.
  
  
  CONCLUSIONS
  Although surgery for type A has remained challenging over more than three decades, there is a positive trend in terms of hospital mortality and long-term follow-up. About 90% of patients were free from reoperation in the long term, although late AR remains a critical issue, suggesting that a thorough debate on surgical options, assessment and results of a conservative approach should be considered.
authors.affiliation: Cardio-Thoraco-Vascular Department, Niguarda Hospital, Milan, Italy claudio.russo@ospedaleniguarda.it claudiofrancesco.russo@fastwebnet.it.
authors.forename: Claudio F
authors.initials: CF
authors.lastname: Russo
authors.affiliation: Department of Heart and Vessels, Cardiac Surgery Unit-Ospedale di Circolo, Varese, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Mariscalco
authors.affiliation: Cardiac Surgery, Università of Padova Medical School, Padova, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Colli
authors.affiliation: II Università of Napoli Medical School, Ospedale Monaldi, Napoli, Italy.
authors.forename: Pasquale
authors.initials: P
authors.lastname: Santè
authors.affiliation: Cardiac Surgery, Università of Parma Medical School, Parma, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Nicolini
authors.affiliation: Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Miceli
authors.affiliation: Cardio-Thoraco-Vascular Department, Niguarda Hospital, Milan, Italy.
authors.forename: Benedetta
authors.initials: B
authors.lastname: De Chiara
authors.affiliation: Department of Heart and Vessels, Cardiac Surgery Unit-Ospedale di Circolo, Varese, Italy.
authors.forename: Cesare
authors.initials: C
authors.lastname: Beghi
authors.affiliation: Cardiac Surgery, Università of Padova Medical School, Padova, Italy.
authors.forename: Gino
authors.initials: G
authors.lastname: Gerosa
authors.affiliation: Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Mattia
authors.initials: M
authors.lastname: Glauber
authors.affiliation: Cardiac Surgery, Università of Parma Medical School, Parma, Italy.
authors.forename: Tiziano
authors.initials: T
authors.lastname: Gherli
authors.affiliation: II Università of Napoli Medical School, Ospedale Monaldi, Napoli, Italy.
authors.forename: Gianantonio
authors.initials: G
authors.lastname: Nappi
authors.affiliation: Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Michele
authors.initials: M
authors.lastname: Murzi
authors.affiliation: Cardiac Surgery, Università of Parma Medical School, Parma, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Molardi
authors.affiliation: Cardio-Thoraco-Vascular Department, Niguarda Hospital, Milan, Italy.
authors.forename: Bruno
authors.initials: B
authors.lastname: Merlanti
authors.affiliation: Cardiology Units, Spedali Civili, Brescia, Italy.
authors.forename: Enrico
authors.initials: E
authors.lastname: Vizzardi
authors.affiliation: Cardiology Units, Spedali Civili, Brescia, Italy.
authors.forename: Ivano
authors.initials: I
authors.lastname: Bonadei
authors.affiliation: Cardiac Surgery, Spedali Civili, Brescia, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Coletti
authors.affiliation: Cardiac Surgery, Università of Padova Medical School, Padova, Italy.
authors.forename: Massimiliano
authors.initials: M
authors.lastname: Carrozzini
authors.affiliation: Department Heart and Vessels, Careggi Hospital, Firenze, Italy.
authors.forename: Sandro
authors.initials: S
authors.lastname: Gelsomino
authors.affiliation: II Università of Napoli Medical School, Ospedale Monaldi, Napoli, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Caiazzo
authors.affiliation: Cardiac Surgery, Spedali Civili, Brescia, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Lorusso
mesh_terms: D000328:Adult; D000368:Aged; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery*; D001014:Aortic Aneurysm / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000401:mortality*; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality; D006801:Humans; D007558:Italy; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
keywords: Acute aortic dissection; Aortic prosthesis; Aortic surgery; Aortic valve; Prognosis