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Objectives: Acute type A aortic dissection is a life-threatening disease associated with significant morbidity and mortality. Treatment is challenging and requires emergency surgery. This study presents for the first time the short- and long-term outcome of acute type A aortic dissection repairs in Iceland.

Materials and methods: A retrospective review of 45 patients (mean age 60.7 ± 13.9 years, 68.9% male) treated for type A aortic dissection at Landspitali University Hospital between 1992 and 2014. Data was gathered from medical records about known risk factors, presenting symptoms, type of procedure, complications and operative mortality.

Results: Out of 45 operations the majority (73.3%) was performed in the second half of the study period. Nearly all patients presented with chest pain and 46.7% were in shock on arrival. Malperfusion syndrome was apparent in 26.7% of cases. A variety of operative methods were used, including hypothermic circulatory arrest in 31.1% of the cases and one-third of patients needed aortic root replacement. Reoperation rate for postoperative bleeding was 29.3% and perioperative stroke occurred in 14.6% of patients. The 30-day mortality rate was 22.2% (10 patients) and 5- and 10-year survival was 71.4 ± 8.2% and 65.4 ± 9.4%, respectively.

Conclusions: The short-term outcomes of surgical repair for acute type A aortic dissection in Iceland is comparable to neighbouring countries, including 30-day mortality and long-term survival. Complications, however, are common, especially reoperations for bleeding.

Table I. Demographics on 45 patients undergoing operations for acute type A aortic dissection in Iceland 1992-2014. Number and % except otherwise stated.

	Number	%
Male	31	68,9
Age, mean (SD)	60,7	(13,9)
Hypertension (n=42)	23	54,8
Diabetes (n=43)	1	2,2
History of smoking (n=39)	22	56,4
Active smoking	11	28,2
Body mass index, mean (SD)	26,8	(5,1)
Chronic obstructive pulmonary disease	2	4,4
Peripheral vascular disease	2	4,4
Stroke	3	6,7
Coronary artery disease (n=44)	9	20,4
Family history of dissection	7	15,6
Bicuspid aortic valve	3	6,7
Marfans syndrome	2	4,4
History of ascending aortic aneurysm	7	15,5
Diameter of aorta (mm), mean (SD)	53,4	(10,8)
EuroSCORE II, mean (SD)	8,7	(10,3)

SD: standard deviation.

 

Table II. Symptoms and workup of 45 patients undergoing operations for acute type A aortic dissection in Iceland 1992-2014. Patients can have more than one symptom or imanging work-up. Number (%).

	Number	%
Chest pain	43	95,6
Heart failure	4	8,9
Syncope	13	28,9
Hypotension (SBP <90 mmHg)	21	46,6
Cardiac tamponade	14	31,1
Malperfusion syndrome	12	26,7
Cardiac	5	11,1
Cerebral	1	2,2
Extremities	5	11,1
Renal	1	2,2
Spinal	3	6,7
Mesenteric	2	4,4
Computerized Tomography	42	93,3
Magnetic Resonance Imaging	0	0
Transthoracal echocardiogram	28	62,2
Transesophageal echocardiogram	5	11,1
Aortogram	5	11,1
Coronary angiography	13	28,8

SBP: systolic blood pressure.

Table III. Operative variables of 45 patients that underwent operations for acute type A aortic dissection in Iceland 1992-2014. Number (%) excect otherwise stated.

	Number	%
Arterial Cannulation (initial)
Femoral	30	66,7
Axillary	9	20,0
Ascending aorta	2	4,4
Arcus aorta	4	8,9
Distal operation (anastomosis)
Ascending aorta	30	66,7
Hemiarcus	9	20,0
Total arcus	5	11,1
Other	1	2,2
Circulatory arrest	14	31,1
Length (min), mean (SD)	30	(18)
Proximal operation
Aortic valve resuspension	10	22,2
Aortic root replacement	10	22,2
Valve sparing root replacement	4	8,9
Length of operation (minutes), mean (SD)	394	(162)
Cardiopulmonary bypass (min), mean (SD)	214	(87)
Crossclamp time (min), mean (SD)	115	(58)

SD: standard deviation

Table IV. Use of blood components in 41 patients undergoing operations for acute type A aortic dissection in Iceland 1992-2014. Four patients that died intraoperatively are excluded. Means with standard deviation (range).

	Mean	SD	Range
Bleeding first 24 hours (mL)	1505	1649	(125-9715)
Packed red blood cells (Units)	16,4	15,0	(2-68)
Fresh frozen plasma (Units)	18,1	17,0	(2-74)
Pooled platelets (Units) (n=38)	5,2	3,4	(2-14)
Fibrinogen (g) (n=27)	4,8	3,1	(2-12)
Tranexamic acid (g) (n=29)	5,0	4,7	(1-17,3)
Activated factor VII (mg) (n=11)	8,9	7,2	(2,4-28,8)

SD: standard deviation

Tafla V. Postoperative complications of 41 patients that underwent operations for acute type A aortic dissection in Iceland 1992-2014. Each patient can have more than one complication. Four patients that died intraoperatively were excluded. Number of patients (%).

	Number	%
Major complication	25	60,1
Reoperation for bleeding	12	29,3
Postop myocardial infarction* (N=35)	7	20,0
Tracheostomy	4	9,8
Renal replacement therapy	4	9,8
Stroke	6	14,6
Mediastinitis	1	2,4
Minor complications	36	87,8
Artial fibrillation/flutter	26	63,4
Ventilator >48 hours	26	63,4
Transient ischemic attach	2	4,9
Pneumonia	13	31,7
Pleurocentesis	15	36,6
Urinary tract infection	3	7,3
Superficial wound infection	0	0,0
Intraoperative death (N=45)	4	8,9
Surgical mortality (<30 days) (N=45)	10	22,2

*CK-MB >70 µg/L

Figure 1. Yearly rates of operations for acute type A aortic dissection in Iceland between 1992 and 2014.