Limited versus extended repair for acute type A aortic dissection: long-term outcomes of the Beijing approach beyond 10 years.

BACKGROUND: Long-term data are scarce regarding the efficacy of extended repair for acute type A aortic dissection (ATAAD) using frozen elephant trunk and total arch replacement (FET + TAR) technique. We seek to evaluate our single-center experience with the FET + TAR technique in patients with ATAAD, focusing on early and long-term survival and reoperation. METHODS: The early and long-term outcomes of FET + TAR were analyzed for 518 patients with ATAAD operated on between April 2003 and December 2012. Mean age 46.2 +/- 10.5 years and 426 were male (82.2%). Malperfusion occurred in 66 (12.7%) and Marfan syndrome (MFS) in 51 (9.8%). Bentall procedure was performed in 153 (29.5%), aortic cusp resuspension in 82 (15.8%), root remodeling (uni- or bi-Yacoub) in 19 (3.7%), ascending aortic replacement in 22 (4.2%) and extra-anatomic bypass in 15 patients (2.9%). The times of cardiopulmonary bypass time (CPB), cross-clamp and selective antegrade cerebral perfusion were 201 +/- 50, 112 +/- 34, and 26 +/- 10 minutes, respectively. RESULTS: Operative mortality rate was 7.5% (39/518). Spinal cord injury occurred in 2.5% (13/518), stroke in 2.9% (15/518), reexploration for bleeding in 2.5% (13/518) and acute kidney injury in 4.6% (24/518). Early reintervention with thoracic endovascular aortic repair (TEVAR) was performed in 3 (0.6%). Follow-up was complete in 98.7% (473/479) at mean 9.0 +/- 4.8 years (range 0.2-16.2). Late death occurred in 74, distal dilation in 31 and distal new entry in 9 patients. Late reoperation was performed in 31 patients, including TEVAR in 12, thoracoabdominal aortic replacement in 9, abdominal aortic replacement in 2, anastomotic leak repair in 5. Survival and freedom from distal reoperation were 77.3% (95% confidence interval [CI] 72.9-81.1%) and 69.8% (95% CI 63.4-75.3%), and 92.9% (95% CI 89.9-95.0%) and 92.9% (95% CI 89.9-95.0%) at 10 and 15 years, respectively. Competing risks analysis showed that at 12 years, the incidence was 28.0% for death, 8.5% for distal reoperation, and 63.5% of patients were alive without reoperation. Multivariable analyses found that CPB time (in minutes) (odds ratio [OR], 1.011; 95% CI 1.006-1.017; P < 0.001) and malperfusion syndrome (binary) (OR 2.291; 95% CI 1.283-6.650; P = 0.011) were predictive of operative mortality, while multiple malperfusion predicted late death (hazard ratio, HR 6.815; 95% CI 2.447-18.984; P < 0.001). Risk factors for late death and distal reoperation included MFS (HR, 1.824; 95% CI 1.078-3.087; P = 0.025) and malperfusion (HR, 1.787; 95% CI 1.042-3.064; P = 0.035). CONCLUSIONS: In this large series of ATAAD, the FET + TAR technique has achieved satisfactory early and long-term survival and freedom from reoperation up to 15 years. Marfan syndrome and malperfusion syndrome were risk factors for early and late mortality and distal reoperation. This study adds long-term evidence supporting the use of the FET + TAR technique in patients with ATAAD involving the arch and descending aorta.