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Eur J Cardiothorac Surg 2007;31:36-41. doi:10.1016/j.ejcts.2006.09.018
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Should a reimplantation valve sparing procedure be done systematically in type A aortic dissection?

Fadi Farhata,*, Marion Duranda, Loïc Bousselb, Ingrid Sanchezc, Jacques Villarda, Olivier Jegadena

a Department of Cardiovascular Surgery, Université Claude Bernard, Inserm E0226, Louis Pradel Hospital, Bron, France
b Department of Interventional Radiology, CREATIS, CNRS UMR 551, INSERM U 630, Louis Pradel Hospital, Bron, France
c Department of Cardiology and Intensive Care, Louis Pradel Hospital, Bron, France

Received 30 August 2006; received in revised form 19 September 2006; accepted 19 September 2006.

* Corresponding author. Address: Department of Cardiovascular Surgery B (Pr Jegaden), Hôpital Cardiovasculaire et Pneumologique Louis Pradel, Université Claude Bernard, INSERM E0226, 28, avenue du doyen Lépine, 69677 Bron, Cedex, France. Tel.: +33 4 72 35 75 29; fax: +33 4 72 35 75 32. (Email: fadi.farhat{at}chu-lyon.fr).

Objective: To evaluate the risks and benefits of a systematic reimplantation valve sparing procedure in the surgical treatment of type A aortic dissection (TAAD). Patients and methods: From February December 2005, 15 consecutive patients (mean age 61 ± 12 years) who underwent surgery for TAAD were analyzed prospectively. Eleven had a preoperative CT-scan and all had an echography. Eight patients presented with a preoperative aortic insufficiency > 2/4 and seven had an ascending aortic aneurysm over 50 mm. In 11 cases, arterial cannulation was performed directly into the ascending aorta. Surgical technique included complete resection and replacement of the ascending aorta using a reimplantation valve sparing technique (David), associated in 12 patients with an arch replacement, under mild (29.7 ± 3.0 °C) hypothermia and cerebral selective antegrade perfusion. Results: Aortic clamping, cerebral perfusion and cardiopulmonary bypass (CPB) times were respectively 93 ± 29, 18 ± 9, and 131 ± 38 min. Mean bleeding at 24 h was 1165 ± 846 ml. Troponin I level at 24 h was 21 ± 30 µg/l. One patient had a right coronary artery bypass for a chronically occluded coronary. Another had a triple arterial revascularisation for pre-existing coronary dissection. One patient presented with a postoperative regressive right hemiparesia (normal CT-scan). Two patients underwent revision for bleeding (one was undergoing treatment by clopidogrel). One patient had at day 7 an implantation of a covered stentgraft on the descending aorta for a concomitant penetrating aortic ulcer. One patient died suddenly on POD 7 during a tracheal aspiration. Intubation and ICU times were respectively 9.5 ± 16.3 and 16.2 ± 20.9 days. Four patients with severe preoperative co morbidities had long intubations. Echographic and CT-scan control, done in postoperative and after a mean follow up of 11.0 ± 4.8 months, did not show any residual aortic insufficiency (actuarial survival rate at 2 years of 93.3%). Conclusion: A reimplantation valve sparing procedure in the TAAD seems to be reliable and should be proposed systematically without emphasizing perioperative morbidity.

Key Words: Aortic dissection • David • Reimplantation technique • Arch replacement • Direct aortic cannulation




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Copyright © 2007 European Association for Cardio-Thoracic Surgery. Published by Elsevier. All rights reserved.