Changes in operative strategy for patients enrolled in the International Registry of Acute Aortic Dissection interventional cohort program.
Advancements in cardiothoracic surgery prompted investigation into changes in operative management for acute type A aortic dissections over time.



One thousand seven hundred thirty-two patients undergoing surgery for type A aortic dissection were identified from the International Registry of Acute Aortic Dissection Interventional Cohort Database. Patients were divided into time tertiles (T) (T1: 1996-2003, T2: 2004-2010, and T3: 2011-2016).



Frequency of valve sparing procures increased (T1: 3.9%, T2: 18.6%, and T3: 26.7%; trend P < .001). Biologic valves were increasingly utilized (T1: 35.6%, T2; 40.6%, and T3: 52.0%; trend P = .009), whereas mechanical valve use decreased (T1: 57.6%, T2: 58.0%, and T3: 45.4%; trend P = .027) for aortic valve replacement. Adjunctive cerebral perfusion use increased (T1: 67.1%, T2: 89.5%, and T3: 84.8%; trend P < .001), with increase in antegrade cerebral techniques (T1: 55.9%, T2: 58.8%, and T3: 66.1%; trend P = .005) and hypothermic circulatory arrest (T1: 80.1%, T2: 85.9%, and T3: 86.8%; trend P = .030). Arterial perfusion through axillary cannulation increased (T1: 18.0%, T2: 33.2%, and T3: 55.7%), whereas perfusion via a femoral approach diminished (T1: 76.0%, T2: 53.3%, and T3: 30.1%) (both P values < .001). Hemiarch replacement was utilized more frequently (T1: 27.0%, T2: 63.3%, and T3: 51.7%; trend P = .001) and partial arch was utilized less frequently (T1: 20.7%, T2: 12.0%, and T3: 8.4%; trend P < .001), whereas complete arch replacement was used similarly (P = .131). In-hospital mortality significantly decreased (T1: 17.5%, T2: 15.8%, and T3: 12.2%; trend P = .017).



There have been significant changes in operative strategy over time in the management of type A aortic dissection, with more frequent use of valve-sparing procedures, bioprosthetic aortic valve substitutes, antegrade cerebral perfusion strategies, and hypothermic circulatory arrest. Most importantly, a significant decrease of in-hospital mortality was observed during the 20-year timespan.
Michigan Cardiovascular Outcomes Research and Reporting Program, University of Michigan Health System, Ann Arbor, Mich.
Neil
N
Parikh
Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy.
Santi
S
Trimarchi
Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa.
Thomas G
TG
Gleason
Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, San Donato Milanese, Italy; Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich.
Arnoud V
AV
Kamman
Cardiac Surgery Department, University Hospital S Orsola, Bologna, Italy.
Marco
M
di Eusanio
Thoracic and Cardiovascular Surgery, Tromso University Hospital, Tromso, Norway.
Truls
T
Myrmel
Cardiothoracic Surgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.
Amit
A
Korach
Cardiovascular Surgery, Washington University, St Louis, Mo.
Hersh
H
Maniar
Cardiac and Thoracic Surgery, University of Chicago Medical Center, Chicago, Ill.
Takeyoshi
T
Ota
Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif.
Ali
A
Khoynezhad
Michigan Cardiovascular Outcomes Research and Reporting Program, University of Michigan Health System, Ann Arbor, Mich.
Daniel G
DG
Montgomery
Cardiothoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa.
Nimesh D
ND
Desai
Michigan Cardiovascular Outcomes Research and Reporting Program, University of Michigan Health System, Ann Arbor, Mich; Department of Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich.
Kim A
KA
Eagle
Cardiology and Aortic Centre, Royal Brompton Hospital, Royal Brompton & Harefield NHS Trust, Imperial College London, London, United Kingdom.
Christoph A
CA
Nienaber
Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass.
Eric M
EM
Isselbacher
Cardiothoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa.
Joseph
J
Bavaria
Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass.
Thoralf M
TM
Sundt
Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich. Electronic address: hjpatel@med.umich.edu.
Himanshu J
HJ
Patel
D000208:Acute Disease; D000368:Aged; D000784:Aortic Dissection / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001014:Aortic Aneurysm / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001705:Bioprosthesis / Q000639:trends; D001807:Blood Vessel Prosthesis / Q000639:trends; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality / Q000639:trends*; D005260:Female; D006350:Heart Valve Prosthesis / Q000639:trends; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000401:mortality / Q000639:trends*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality; D011474:Prosthesis Design; D020127:Recovery of Function; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States
aortic dissection; operative strategy; surgical management; survival; trends