Recurrent aortic insufficiency after emergency surgery for acute type A aortic dissection with aortic root preservation

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 161; no. 6; pp. 1989 - 2000.e6
• Main Authors: Bojko, Markian M., Habertheuer, Andreas, Bavaria, Joseph E., Suhail, Maham, Hu, Robert W., Harmon, Joey, Desai, Nimesh D., Milewski, Rita K., Williams, Matthew L., Szeto, Wilson Y., Mossey, Jana, Vallabhajosyula, Prashanth
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01-06-2021
• Subjects: aortic dissection; aortic insufficiency; regurgitation; root repair; OR; TTE; CI; regurgitation; AI; ATAAD; HR; aortic insufficiency; IQR; SOV; root repair; aortic dissection
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2020.01.116

Patients with acute type A aortic dissection demonstrate a wide range of aortic insufficiency. Outcomes after valve resuspension and root repair are not well studied in the long term. We evaluated the long-term effects of preoperative aortic insufficiency in patients undergoing emergency root-preserving surgery for acute type A aortic dissection.
From 2002 to 2017, 558 of 776 patients with acute type A aortic dissection underwent native aortic valve resuspension and root reconstruction. Patients were stratified into 4 groups by preoperative aortic insufficiency grade (n = 539): aortic insufficiency less than 2+ (n = 348), aortic insufficiency = 2+ (n = 72), aortic insufficiency = 3+ (n = 49), and aortic insufficiency = 4+ (n = 70). Multivariable ordinal longitudinal mixed effects and multi-state transition models were used to assess risk factors for recurrent aortic insufficiency.
The prevalence of cardiogenic shock in patients presenting with preoperative aortic insufficiency less than 2+, 2+, 3+, and 4+ was 53 of 348 (15.2%), 12 of 72 (16.7%), 10 of 49 (20.4%), and 24 of 70 (34.3%), respectively (P = .002). Postoperatively, 94.0% of patients had aortic insufficiency 1+ or less at discharge. Operative mortality was 34 of 348 (9.8%), 10 of 72 (13.9%), 6 of 49 (12.2%), and 12 of 70 (17.1%) (P = .303). In an ordinal mixed effects model, preoperative aortic insufficiency was associated with more severe postoperative aortic insufficiency. The multi-state transition model demonstrated that severe aortic insufficiency was associated with progression from no to mild aortic insufficiency (hazard ratio, 2.14; 95% confidence interval, 1.35-3.38), and progression from mild to moderate aortic insufficiency (hazard ratio, 5.70; 95% confidence interval, 1.88-17.30).
Preoperative aortic insufficiency is an important predictor of recurrent aortic insufficiency in patients undergoing valve resuspension with root reconstruction for emergency acute type A aortic dissection repair. Increased echocardiographic surveillance for recurrent aortic insufficiency may be warranted in this cohort.