Mehmet ÇAKICI, Bülent KAYA, Evren ÖZÇINAR, Ahmet Rüçhan AKAR, Çağdaş BARAN, Fatih GÜMÜŞER, Alper ÖZGÜR, Levent YAZICIOĞLU

Geçirilmiş kalp cerrahisi sonrası geç başlangıçlı tip A aort diseksiyonlarının sonuçları: Geçirilmiş koroner arter baypas greftleme sağkalımı etkiler mi?

Amaç: Bu çalışmada primer kalp cerrahisi sonrasında geç başlangıçlı tip A aort diseksiyonunun sonuçları değerlendirildi ve daha önce koroner arter baypas greftleme yapılan ve yapılmayan hastaların sonuçları karşılaştırıldı. Çalışma planı: Ocak 2005 - Aralık 2015 tarihleri arasında kliniğimizde akut tip A aort diseksiyonu tanısı konan ve tamiri yapılan, daha önce kalp cerrahisi öyküsü olan 32 hastanın (16 erkek, 16 kadın; ort. yaş 58.1±10.9 yıl; dağılım 45-73 yıl) verileri retrospektif olarak incelendi. Hastalar geçirilmiş koroner arter baypas greftleme öyküsü olanlar (n=16) ve geçirilmiş koroner arter baypas greftleme öyküsü olmaksızın daha önce kalp cerrahisi yapılan hastalar (n=16) olmak üzere ikiye ayrıldı. Bulgular: Daha önce kalp cerrahisi geçiren 32 hastada (hastaların 12’sinde aort kapak replasmanı, ikisinde mitral kapak replasmanı, ikisinde aort kapak replasmanı + koroner arter baypas greftleme, 10’unda koroner arter baypas greftleme, dördünde mitral kapak replasmanı + koroner arter baypas greftleme ve ikisinde dual kapak replasmanı) çıkan aortta diseksiyon gelişti (22’sinde geç akut ve 10’unda geç kronik). İlk ameliyat ile diseksiyon arasında geçen ortalama zaman 4.0±1.5 yıl idi. Diseksiyonlar Bentall işlemi (n=8), çıkan aort replasmanı (n=14), çıkan aort replasmanı + yarım ark replasmanı (n=4), çıkan aort + aort kapak replasmanı (n=4) ve Bentall + ark replasmanı (n=2) ile tedavi edildi. Hastane içi mortalite (30 günlük mortalite), beş hastada gözlendi ve bir yıllık mortalite oranı %21.85 (n=7) idi. Primer kalp cerrahisi + koroner arter baypas greftlemeye kıyasla primer kalp cerrahisi hastalarında sağkalım oranı sırasıyla birinci yılda %75’e kıyasla %81.25, üçüncü yılda %68.75’e kıyasla %75, beşinci yılda %56.25’e kıyasla %75, yedinci yılda %56.25’e kıyasla %68.75 ve 10. yılda %56.25’e kıyasla %68.75 idi (p=0.71, CI: %95). Sonuç: Tip A aort diseksiyonları, koroner arter baypas greftleme ile veya olmaksızın kalp cerrahisi sonrasında herhangi bir zamanda gelişebilir ve histolojik ilişkiden bağımsız olarak genel hastane mortalitesi yüksektir. Zamanında müdahale ile dikkatli bir planlama sayesinde, aort diseksiyonlarında koroner arter baypas greftleme ile veya olmaksızın yapılan yeniden sternotomi ameliyatlarının sonuçları, spontan aort diseksiyonlarının sonuçları ile paralellik gösterecektir.

Results of late-onset type A aortic dissection after previous cardiac surgery: Does prior coronary artery bypass grafting affect survival?

Background: This study aims to evaluate the results of late-onset type A aortic dissection following primary cardiac surgery and to compare the outcomes of patients with or without prior coronary artery bypass grafting. Methods: Between January 2005 and December 2015, data of 32 patients (16 males, 16 females; mean age 58.1±10.9 years; range, 45 to 73 years) who were diagnosed with acute type A aortic dissection and underwent repair with a history of previous cardiac surgery at our institution were retrospectively analyzed. The patients were divided into two groups as those with a history of prior coronary artery bypass grafting (n=16) and the patients with a previous cardiac surgery without prior coronary artery bypass grafting (n=16).Results: Dissection of the ascending aorta occurred in 32 patients (late acute in 22 and late chronic in 10) who underwent previous cardiac surgery (aortic valve replacement in 12, mitral valve replacement in two, aortic valve replacement + coronary artery bypass grafting in two, coronary artery bypass grafting in 10, mitral valve replacement + coronary artery bypass grafting in four, and dual valve replacement in two patients). The mean time between the first operation and dissection was 4.0±1.5 years. Dissections were treated with the Bentall procedures (n=8), ascending aorta replacement (n=14), ascending aorta replacement + hemiarch replacement (n=4), ascending aorta+aortic valve replacement (n=4) and Bentall + arch replacement (n=2). In-hospital mortality (30-day mortality) was seen in five patients, and one-year mortality rate was 21.85% (n=7). The survival rates of the all patients for primary cardiac surgery vs primary cardiac surgery + coronary artery bypass grafting were 81.25% vs 75% at one year, 75% vs 68.75% at three years,75% vs 56.25% at five years, 68.75% vs 56.25% at seven years, and 68.75% vs 56.25% at 10 years, respectively (p=0.71, CI: 95%).Conclusion: Type-A aortic dissections may develop after cardiac operations with or without coronary artery bypass grafting at any time, and irrespective of associated histologies, they may result in high overall in-hospital mortality. With careful planning by prompt intervention, the outcomes in redo sternotomy operations with or without coronary artery bypass grafting for aortic dissections would be consistent the results of spontaneous aortic dissections.

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