Impact of Aortic Root and Arch Management on Long-Term Postoperative Outcomes for Type A Aortic Dissection Open Access
Wang, Yanhua (Fall 2023)
Abstract
Objectives: Acute type A aortic dissection (ATAAD) is a life-threatening illness with fatal complications. It is considered a medical emergency that requires surgery. The reoperation rate and post-surgery mortality remain high. The purpose of this retrospective cohort study is to compare the long-term survival of patients who received different aortic operations at the root and arch.
Methods: Data were drawn from the medical records of patients with ATAAD from 2004 to 2019 at Emory University School of Medicine Department of Surgery. A total number of 529 ATAAD patients aged 20-86 who underwent root replacement, total arch replacement, hemiarch replacement, or valve resuspension were selected. Kaplan-Meier curves were plotted to describe graphically the survival experience of patients who underwent each surgical procedure. Univariable and multivariable Cox proportional hazards regression models were constructed to assess the statistical significance of the type of surgical procedure and also to identify the risk factors for long-term mortality. Multiple imputation was used to handle incomplete data, which were assumed to be missing at random.
Results: The mean age (± standard deviation) of patients was 55.4 ± 13.5 years, and the majority of patients were male (71.5%). The overall five-year and ten-year survival probabilities were 79.1% and 59.1%, respectively. Five-year and ten-year survival comparing root replacement versus valve resuspension were 77% vs 81%, and 60% vs 59%, respectively. Five-year and ten-year survival comparing total arch replacement versus hemiarch replacement were 70% vs 81%, and 59% vs 59%, respectively. In the univariable analysis, advanced age, large thoracic aortic maximum diameter, renal failure, aortic valve replacement, and respiratory failure were associated with an increased risk of death. In the multivariable analysis, advanced age, being female, large thoracic aortic maximum diameter, and a longer stay in hospitals were associated with a higher risk of death. Adjusting for age, thoracic aortic maximum diameter (42 mm), and length of stay in hospitals (9 days), the hazard ratio was not statistically significant: 1.03 (95% CI: 0.57-1.77) for root replacement vs valve resuspension, 1.50 (95% CI: 0.65-3.07) for total arch replacement vs hemiarch replacement.
Conclusion: When comparing root replacement to valve resuspension, and total arch replacement to hemiarch replacement, there was not a significant difference in long-term survival. When adjusting for age, thoracic aortic maximum diameter, and length of stay in hospitals, root replacement and total arch replacement were not significantly different in hazards when compared to valve resuspension and hemiarch replacement, respectively. In the multivariable analysis, advanced age, being female, larger thoracic aortic maximum diameter, and longer length of hospital stays significantly contributed to late mortality among ATAAD patients. In the univariable analysis, other predictors such as renal failure and aortic valve replacement were identified as additional risk factors.
Table of Contents
ABSTRACT.. i
ACKNOWLEDGMENTS. iv
LIST OF ABBREVIATIONS. vi
Chapter I: Introduction. 1
1.1 Problem Statement 1
1.2 Theoretical Framework. 3
1.3 Purpose Statement 3
1.4 Research Questions. 4
1.5 Significance. 4
Chapter II: Review of the Literature. 6
2.1 History. 6
2.2 Classifications. 6
2.3 Epidemiology and Risk Factors. 8
2.4 Diagnosis and Surgical Treatment 10
Chapter III: Methodology. 14
3.1 Data Sources. 14
3.2 Population and Sample. 14
3.3 Research Design. 14
3.4 Data Analysis. 15
Chapter IV: Results. 17
4.1 Preoperative, intraoperative and postoperative characteristics. 17
4.2 Long-Term Survival 22
4.2.1 Overall Survival of all patients. 22
4.2.2 Overall Survival of patients with root management 23
4.2.3 Overall Survival of patients with arch management 24
4.3 Hazard Ratios of Risk Factors for Long-Term Mortality. 26
Chapter V: Discussion and Conclusion. 28
Reference. 35
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