SELİM AYDIN, Bahar TEMUR, Mutlu ŞENOCAK, İsmail Yücesin ARSLAN, Mehmet YILMAZ, Tamer KEHLİBAR, Mehmet Fikri YAPICI, Azmi ÖZLER

KUT TİP A AORT DİSEKSİYONLARINDA AORT KAPAĞA MÜDAHALE EDİLEN VE EDİLMEYEN HASTALARIN ERKEN DÖNEM SONUÇLARININ KARŞILAŞTIRILMASI

Giriş: Bu çalışmada akut tip A aort diseksiyonu nedeniyle, kapağa müdahale edilmeden sadece suprakoroner asendan aort replasmanı uygulanan hastalar ile kapağa müdahale edilen hastalar arasında erken dönem morbidite ve mortalite sonuçlarını karşılaştırdık. Gereç ve Yöntem: Hastanemizde Ocak 2003 ile Kasım 2011 tarihleri arasında akut tip A aort diseksiyonu nedeniyle opere edilen 147 hasta çalışmaya dahil edildi. Doksan üç hastaya kapak yetmezliğine müdahale edilmeden suprakoroner asendan aort ve hemiark replasmanı (Grup 1), 54 hastaya ek olarak aort kapak resüspansiyonu veya kapak replasmanı (Grup 2) uygulandı. Hastaların demografik ve preoperatif verileri, peroperatif ve ilk 30 gün morbidite ve mortalite oranları karşılaştırıldı. Bulgular: Hastaların yaşları grup 1’de 58,79 ± 11,59 yıl, grup 2’de 51,89 ± 13,30 yıl olarak saptandı (p=0.0005). Başvurudan operasyona kadar geçen süre grup 1’de istatistiksel anlamlı olarak daha yüksekti (p=0.001). Operasyon verileri olarak operasyon süresi grup 2’de (p=0.030), antegrad serebral perfüzyon kullanım oranı grup 1’de (p=0.034) istatistiksel anlamlı olarak daha yüksekti. Grup 1’de 23 hasta (%24,73), grup 2’de 22 hasta (%40,74) eksitus oldu. İlk 30 günlük mortalite oranı grup 1’de istatistiksel anlamlı olarak daha yüksekti (p=0,043). Grup 1’de postoperatif nörolojik defisit görülme oranı anlamlı olarak daha düşüktü (p=0,029). Diğer parametrelerde iki grup arasında istatistiksel anlamlı bir fark saptanmadı. Sonuç: Eğer nativ kapakta organik bir patoloji yoksa ve aortik root çok geniş değilse, diseksiyona bağlı gelişen kapak yetmezliği derecesi ne olursa olsun, kapağa müdahale edilmeden suprakoroner aort replasmanı düşük erken dönem morbidite ve mortalite ile uygulanabilir.

COMPARISON OF EARLY RESULTS OF PATIENTS WITH AND WITHOUT AORTIC VALVE INTERVENTION IN ACUTE TYPE A AORTIC DISSECTION

Introduction: In this study, we compared early morbidity and mortality of patients who underwent supracoronary ascending aortic replacement withand withoutaortic valve intervention in acute type A aortic dissection. Material and Method: A total of 147 patients who were operated due to acute type A aortic dissection at our hospital between January 2003 and November 2011 were included in this study. Ninety-three patients underwent supracoronary ascending aortic and hemiarch replacement without intervention to the aortic valve (group 1), and 54 patients with aortic valve resuspension or valve replacement (group 2). Patients’ demographic and preoperative datas, peroperative and thirty-day morbidity and mortality rates were compared. Results: The average age of the patients were 58,79 ± 11,59 years in group 1 and 51,89 ± 13,30 years in group 2 (p=0,0005). The time interval between hospital admission andthe operation was significantly higher in group 1 (p=0.001). The duration of operation was significantly higher in group 2 (p=0.030) and the use of antegrade cerebral perfusion was significantly higher in group 1 (p=0.034). The mortality rates were 24,73% (23/93) in group 1 and 40,74% (22/54) in group 2. The 30-day mortality rate was significantly higher in group 2 (p=0.043). The incidence of postoperative neurologic deficits was significantly lower in group 1 (p=0,029). There are no statistically significant differences between other parameters. Conclusion:If there is no organic pathology in the native valve and the aortic root is not very large, supracoronary aortic replacement can be performed with low early morbidity and mortality, without intervention to the valve regardless of the degree of valve insufficiency due to dissection.

PDF

___

LeMaire SA, Russell L. Epidemiology of thoracic aortic dissection. Nat Rev Cardiol 2011; 8(2): 103-13.
Büket S, Apaydın A, Hamulu A, Özbaran M, Aşkar F, Sakarya M, et al. Aort diseksiyonlarında cerrahi tedavi. Turk Gogus Kalp Dama 1995; 3(2): 147-52.
Tsai TT, Trimarchi S, Nienaber CA. Acute aortic dissection: perspectives from the International Registry of Acute Aortic Dissection (IRAD). Eur J Vasc Endovasc Surg 2009; 37(2): 149-59.
Wang H, Wagner M, Benrashid E, Keenan J, Wang A, Ranney D, et al. Outcomes of reoperation after acute type A aortic dissection: implications for index repair strategy. J Am Heart Assoc 2017; 6(10): e006376.
Rylski B, Suedkamp M, Beyersdorf F, Nitsch B, Hoffmann I, Blettner M, et al. Outcome after surgery for acute aortic dissection type A in patients over 70 years: data analysis from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac Surg 2011; 40(2): 435-40.
Montalvo J, Razzouk A, Wang N, Bansal R, Rasi A, Hasaniya N, et al. Aortic root surgery does not increase the operative risk of acute type A aortic dissection. Am Surg 2011; 77(1): 88-92.
Pape LA, Awais M, Woznicki EM, Suzuki T, Trimarchi S, Evangelista A, et al. Presentation, diagnosis and outcomes of acute aortic dissection: 17-year trends from the International Registry of Acute Aortic Dissection. J Am Coll Cardiol 2015; 66(4): 350-8.
Westaby S, Saito S, Katsumata T. Acute type A dissection: conservative methods provide consistently low mortality. Ann Thorac Surg 2002; 73(3): 707-13.
Ovalı C, Sevin MB. Akut aort diseksiyonu tanısı ile cerrahi tedavisi yapılan hastalara ait erken ve orta dönem sonuçları. KÜ Tıp Fak Derg 2015; 17(1): 8-16.
Czerny M, Schoenhoff F, Etz C, Englberger L, Khaladj N, Zierer A, et al. The impact of pre-operative malperfusion on outcome in acute type A aortic dissection: results from the GERAADA registry. J Am Coll Cardiol 2015; 65(24): 2628-35.
Halstead JC, Spielvogel D., Meier DM, Rinke S, Bodian C, Malekan R, et al. Composite aortic root replacement in acute type A dissection: time to rethink the indications? Eur J Cardiothorac Surg 2005; 27(4): 626-32.
Niederhauser U, Rüdiger H, Vogt P, Künzli A, Zünd G, Turina M. Composite graft replacement of the aortic root in aortic dissection. Eur J Cardiothorac Surg 1998; 13(2): 144-50.
David TE, Feindel CM. An aortic valve sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992; 103(4): 617–21.
Estrera AL, Miller CC, Villa MA, Lee TY, Meada R, Irani A, et al. Proximal re-operations after repaired acute type A aortic dissection. Ann Thorac Surg 2007; 83(5): 1603-8.
Rylski B, Beyersdorf F, Blanke P, Boos A, Hoffmann I, Dashkevich A, et al. Supracoronary ascending aortic replacement in patients with acute aortic dissection type A: what happens to the aortic root in the long run? J Thorac Cardiovasc Surg 2013; 146(2): 285-90.
Emrecan B, Yılık L, Özsöyler İ, Lafcı B, Kestelli M, Göktoğan T, et al. Stanford tip A aort diseksiyonlarında aksiller arter kanülasyonu. Turk Gogus Kalp Dama 2006; 14(1): 3-8.
David TE, Armstrong S, Ivanov J, Barnard S. Surgery for acute type A aortic dissection. Ann Thorac Surg 1999; 67(6): 1999-2001.
Bashir M, Harky A, Fok M, Shaw M, Hickey GL, Grant SW, et al. Acute type A aortic dissection in the United Kingdom: Surgeoon volume-outcome relation. J Thorac Cardiovasc Surg 2017; 154(2): 398-406.
Lenos A, Bougioukakis P, Irimie V, Zacher M, Diegeler A, Urbanski PP. Impact of surgical experience on outcome in surgery of acute type A aortic dissection. Eur J Cardiothorac Surg 2015; 48(3): 491-6.