Determination of Cerebral Blood Flow Dynamics During Retrograde Cerebral Perfusion Using Transcranial Doppler

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Outcomes of Acute Type A Aortic Dissection After
Previous Cardiac Surgery
AL Estrera, MD, CC Miller III, PhD, TK Lee, MD,
T Kaneko, MD, JC Walkes, MD, H Safi, MD
Department of Cardiothoracic and Vascular
Surgery The University of Texas Medical School
at Houston Memorial Hermann Heart Vascular
Institute
Aortic Surgery Symposium 2010 New York,
NY April, 2010
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Purpose

• Since few data exist, we report outcomes of acute
  type A aortic dissection (ATAAD) after previous
  cardiac surgery (PCS).

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Methods
330 Acute Type A Aortic Dissection Jan. 1991
March 2009 Median age 62 (21-91) 69
31
281 Primary (85)
49 PCS (15)
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Preoperative Variables in Acute Type A Aortic
Dissection with/without PCS
Variable Previous Cardiac Surgery Group Number () n49 Primary Group Number () n49 P-Value
Age 6312.8 57.913.9 lt.02
Male Gender 40 (82) 187 (67) lt.04
Chest Pain 40 (82) 256 (91) .07
Back Pain 36 (73) 215 (77) .72
Leg Weakness 10 (20) 48 (17) .55
Stroke 1 (2) 29 (10) .07
Paraplegia 4 (8) 17 (6) .53
Hypotension 10 (20) 70 (25) .59
Tamponade 6 (all CABG) (12) 48 (17) .42
Myocardial Ischemia 5 (10) 25 (9) .79
Al (Mod Sev) 15 (30) 132 (47) lt.05
Time Interval (Admission-OR) Hours 46.463.3 37.173.1 .40
Aortic Size 5.71.4 5.00.8 .0001
PA Rupture/Fistula 2 (4) 0 (0) lt.03
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Interval

• Mean Interval 56 77 months
• Interval range 3d - 370 months

2 pts 2 previous sternotomies
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Previous Cardiac Surgery
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Procedures (Re-Op)
Total Arch 10 ET1 4
Prox Arch 94
Ascending 100
CABG 16
Aortic Root 8
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Results
Variable Previous Cardiac Surgery Number () n49 No Previous Cardiac Surgery Number () n281 P-Value
MI 4 (8) 15 (5) .50
CVA/Coma 5 (10) 7 (2.5) lt.03
TND 12 (24) 28 (10) lt.007
Bleed 2 (4) 24 (8.5) .39
Renal Failure (Dialysis) 6 (12) 28 (9.9) .55
Repiratory Failure (Vent gt3 days) 16 (33) 85 (30) .58
Hospital Death 15 (31) 39 (13.8) lt.007
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Causes of Early Death
Cause N () N15
Cardiac Preoperative tamponade (4) Right ventricular failure (1) AMI (occlude RCA SVG) (1) EF10 (1) 7 (47)
Multiorgan failure (Necrotic bowel, ARF, PA fistula, paraplegia) 7 (47)
Neurological (Preoperative coma) 1 (6)
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Location of Aortic Dissection Tear
Location N () n49 Note
De Novo 25 (51)
Aortic Cannulation Site 2 (4)
Aortotomy 6 (12) 40 (Valves)
Saphenous Vein Graft Site 16 (33) 46 (CABG)
12/15 (80) of previous valves had a Bicuspid
Aortic Valve
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Survival Kaplan-Meier
1-year 5 10 15
Primary 80 76 58 53
PCS 62 57 50 36
Plt0.03
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Conclusions

• Patients with ATAAD following PCS exhibited risks
  for malperfusion, hypotension, and cardiac
  tamponade that were similar to primary ATAAD
  cases.
• This suggests that adhesions formed after PCS do
  not eliminate the risk of cardiac tamponade from
  aortic rupture.
• Although results from surgical repair are
  acceptable, and thus justifying timely repair,
  mortality still remains higher than without a
  prior history of cardiac surgery.
• Patients need to be individualized.