Hybrid Repair Of Stanford Type A Aortic Dissection In High Risk Patients

Objective-Analyze the surgical treatment information and patients records of Stanford type A aortic dissection during the last decade, combining foreign relative studies, and try to access the factors related to hospital mortality and the characteristics of patients with type A dissection. Analyze the data of patients of type A dissection, who were in high risks and total arch involved, treated with one-stage hybrid repair and open total arch replacement, aiming to discuss the clinical availability of hybrid technique in type A dissection.Methods-Consecutive766patients from aortic center in Fuwai hospital through Jan.2001to Sep.2010were analyzed. The mean age was44.87±11.6yrs.(16-78yrs.),586for male and180for female. Patients were grouped by hospital death, and Logistic regression model was made followed univariate analysis to access the risk factors. There were439acute type A aortic dissection sufferers of the all patients. And for the acute data, same analysis was made for risk factors of hospital mortality, additionally, the hospital mortality rate was adjusted based on age distribution of patients in IRAD (International Registry of Acute Aortic Dissection). Then, comparison was made between our study and IRAD. Through Jan.2009to Sep.2011,31patients were treated by one-stage hybrid technique (hybrid group) for type A dissection, and250open total arch replacement (open group) were carried simultaneously. Comparison of clinical and follow up results were made between the two groups to discuss the clinical availability of hybrid technique.Results-A total of37(4.83%) of all the type A dissection patients died in hospital, of the death,27were acute patient (6.2%). On univariate analysis, for the all patients, significant risk factors for hospital mortality were male (P=0.035), acute status (P=0.048), renal dysfunction (P<0.001), cardiac dysfunction (P=0.045), CPB (Cardiopulmonary Bypass) time (P=0.010), duration of operation (P=0.005), volume of blood transfusion (P=0.002), re-operation for bleeding (P<0.001). On logistic regression model, independent risk factors were acute status (OR=2.784,95%CI=1.166-6.649, P=0.021), renal dysfunction (OR=6.285,95%CI=1.738-22.723, P=0.005), cardiac dysfunction (OR=3.052,95%CI=1.083-8.606, P=0.035), re-operation for bleeding (OR=3.690,95%CI=1.262-10.791, P=0.017), volume of blood transfusion (OR=1.033,95%CI=1.008-1.058, P=0.010). Additionally, male (OR=0.387<1,95%CI=0.177-0.848, P=0.018) was protective factor, and alternatively, female was indeed one of the independent risk factors for hospital mortality.For acute type A aortic dissection, independent risk factors for hospital mortality were age (OR=1.059, P=0.006), renal insufficiency preoperatively (OR=6.427, P=0.015), and cardiopulmonary bypass time (OR=1.008, P=0.013). Contrary to results of769acute type A dissection from IRAD, our adjusted morality rate was10.2%, significant higher than the non-adjusted rate (P=0.015), but still lower than IRAD (24.2%).Contrary to open total arch replacement under DHCA (Deep Hypothermic Circulatory Arrest), hybrid technique (under moderate hypothermic CPB) had lower hospital mortality rate, though not significantly (3.2%vs.8.4%, P=0.312). Of the open group, the CPB time, aorta clamp time and duration of operation were222.66±67.88min、107.29130.35min、7.59±1.92hours, separately, comparing to131.31±27.88min,50.93116.21min,6.73±1.36hours of hybrid group (P value were<0.001,<0.001,0.016), separately. Post-operative re-do for bleeding, CRRT (Continuous Renal Replacement Therapy), re-tracheal intubation, stroke, paralysis, paraplegia and psteofascial compartment syndrome were not different significantly between groups. Each group had one death during follow up, and survival rate did not differ significantly (P=0.217) Conclusions-Female, acute status, renal insufficiency, cardiac insufficiency, re-do for bleeding, volume of blood transfusion were independent risk factors for hospital mortality after operations for type A aortic dissection. Contrary to western countries, the age was younger and hospital mortality rate was relative lower in this study. And the demographic distribution of age may be one of the primary causes of lower hospital mortality rate. For type A aortic dissection with total arch involved, open total arch replacement and hybrid technique can both have acceptable early results. But concerning with those who have with high risks, such as advanced age, hybrid was an alternative treatment. Furthermore, hybrid technique has the advantages of blood protection and simplification of CPB, but more studies are needed for mid-and long-term results.