Importance of Blood Pressure Control After Repair of Acute Type A Aortic Dissection: 25-year Follow-up in 252 Patients
Spencer J Melby, MD*, Andreas Zierer, MD*, Michael K Pasque, MD*, Jennifer S Lawton, MD*, Hersh S Maniar, MD*, Nicholas T Kouchoukos, MD, Ralph J Damiano, Jr., MD, Marc R Moon, MD
Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, MO
Our aim was to evaluate factors which impacted outcome following repair of acute type A aortic dissection.
Over a 25-year period(1984-2009), 252 patients underwent repair of acute type A dissection by 26 surgeons. Mean late follow-up for reoperation or death was 6.9±5.9 years.
Operative mortality was 16%(41/252). Multivariate analysis identified one risk factor for operative death: branch-vessel malperfusion on presentation(p=0.003). For 211 operative survivors, 5, 10, and 20-year survival was 78%±3%, 59%±4%, and 24%±6%, respectively. Late death occurred earlier in patients with previous stroke(p=0.02) and chronic renal insufficiency(p=0.007) but was independent of operative approach(ascending versus hemiarch, cross-clamp versus circulatory arrest, AV repair versus replacement; p>0.20 for all). Risk factors for late reoperation included male gender(p=0.006), Marfan syndrome(p<0.001), elevated systolic blood pressure(SBP, p<0.001), and absence of beta-blocker therapy(p<0.001). Kaplan-Meier analysis demonstrated that at 10-year followup, patients who maintained SBP<120mmHg had improved freedom from reoperation(92%±5%) compared to those with 120-140mmHg(74%±7%) or SBP>140mmHg(49%±14%, p<0.001), and patients on beta-blocker therapy experienced 86%±5% freedom from reoperation compared to 57%±11% for those without beta-blockers(p<0.001).
Operative survival was decreased in the presence of preoperative malperfusion. Long-term survival was dependent on underlying comorbidities but not operative approach. Reoperation was markedly increased in patients not on beta-blocker therapy, and decreased with better control of SBP. Strict control of hypertension with beta-blocker therapy for life is warranted in these patients.
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