**2. Save the patient**

#### **2.1 Short-term mortality: statistics and causes**

Type A aortic dissection (TAAD) is a serious pathology with high short-term mortality rates. Indeed, series find a 50% mortality at 48 hours for nonoperated patients and an intrahospital mortality between 20 and 30% for operated patients [1].

This high mortality rate is due to the great number of serious complications associated to the TAAD. The main mortality cause in the TAAD is acute aortic rupture [1]. Concerning the cardiac complications, we observe an aortic regurgitation in 40–75% [4, 5], a cardiac tamponade in 20%, and a myocardial infarction in 10–15%. These complications lead to congestive heart failure in 10% of cases. The other complications are neurological such as spinal ischemia, stroke and coma, mesenteric ischemia, and renal failure.

The analysis of short-term mortality shows that the characteristics of the patient (age, history of aortic valve replacement) and the preoperative complications of the TAAD (migrating chest pain, preoperative limb ischemia, hypotension, shock, cardiac tamponade) have more impact on the early survival than the type of surgical management [2]. These results demonstrate that even with optimal medical and surgical management, TAAD will remain a serious pathology with high mortality rate. These short-term mortality risk factors distinguish the patients in two categories at the time of the surgery: stable patients and unstable patients. Patients are defined as unstable in case of cardiac tamponade, myocardial ischemia, congestive heart failure, shock, cerebrovascular accident, coma, mesenteric ischemia, and acute renal failure. The latter having short-term mortality rate twice as high as stable patients (31.4 versus 16.7%) [2]. This distinction is important for the choice of the surgical technique, which should depend in part upon the stability of the patient at the time of the surgery.

Management of patients with neurological complications at the onset of the dissection is still debated. To assess this issue, Tsukube presented the results of patients with coma on arrival [6]. They decided to operate immediately when coma was inferior to 5 hours. The surgical technique was a central repair performed under deep hypothermia with anterograde cerebral perfusion. For this group, intrahospital mortality was equal to 14%. Concerning the other patients, they were treated initially medically and in a second time surgically. Intrahospital mortality was equal to 67%. In terms of severity, the national institute of health stroke scale decreased significantly after the surgery in the immediate group. These results, confirmed by other series [7], show that coma, if managed immediately, should not be an operative contraindication.

Concerning the management of acute neurological deficit, Estrera showed that this complication, when managed surgically by central repair, was associated with an acceptable mortality rate (7 versus 100% of mortality for unoperated patients) [8].

Finally, surgery remains superior to optimal medical management even though the patient is unstable, in coma or over 80.

#### **2.2 Long-term mortality statistics and causes**

Even if the TAAD is an acute disease necessitating emergency treatment, this pathology presents an important long-term morbi-mortality. Thus, 10 years survival is between 50 and 70% [3, 9, 10], and 10 years re-operation rate is around 15% [11].

**91**

aortic valve is the key factor.

*Extensive Repair in Type A Aortic Dissection: To Save the Patient or to Ensure a Durable Repair?*

Several factors contribute to this excess morbi-mortality. In Tanaka's study [12], 243 patients were operated on for TAAD, and mortality causes at follow up were cancer, heart disease and acute aortic rupture for, respectively, 37, 23 and 13% of the cases. The reoperation rate for aortic aneurysm was 5.7%. These results are similar

Even if cancer and heart diseases cannot be decreased by the initial surgical strategy, death by acute aortic rupture and reoperation for aortic aneurysm could be prevented by the first surgery. Within this framework, the question is raised to treat not only the immediate complications of the aortic dissection but also to perform an optimal aortic repair in order to prevent long-term complications of

The main objective of the surgical treatment is to ensure the patient's survival. Thus, the replacement of the ascending aorta containing the primary tear and the re-establishment of the dominant flow through the true lumen prevent from acute

As seen before, the secondary objective of the surgical treatment is now to provide the best repair in order to prevent complications on the aortic valve and on the aorta. The challenge is to complete this preventing treatment without compromising the short-term survival. In this context, the European Society of Cardiology (ESC) provided recommendations upon the surgical treatment of

• Concerning the aortic root management, the discussion is to identify the

• As reported by the analysis of the International Registry of Acute Dissection (IRAD), aortic root replacement compared with conservative root management is not associated with increased inhospital mortality. Thus, the comparison based on 1995 patients found 18% of hospital mortality in root replacement group and 21.3% of hospital mortality in conservative root group (odds ratio [OR], 0.989; 95% CI, 0.710–1.379; *P* = 0.949 after covariate adjustment) [14]. Midterms observations at 3 years did not showed statistical difference between the two techniques concerning overall mortality (91.6 ± 1.3% survival for conservative root management, 92.5 ± 1.7% survival for aortic root replacement management, *P* = 0.623) and freedom from reintervention (99.3 ± 0.1% for conservative root group and 99.2 ± 0.1% for root replacement group *P* = 0.770). However, aortic root replacement must not be performed systematically. Thus, the latter is recommended for patients with sinuses of Valsalva involved by the dissection and for patients who need surgery on the aortic valve. An aortic root replacement is also recommended for patients with aneurysmal evolution risk factors such as Marfan's syndrome, increased

Several techniques are suitable for aortic root replacement. In this situation, the

patients who need an aortic root replacement and the patients who need a more

aortic rupture and mostly correct vascular complications [13].

**3.1 Proximal segment of the ascending aorta**

conservative aortic root treatment.

sinuses of Valsalva diameter, and young patients.

*DOI: http://dx.doi.org/10.5772/intechopen.89298*

to Kirsch's outcomes in his 2002 study [11].

the TAAD.

the TAAD.

**3. Ensure a durable repair**

*Extensive Repair in Type A Aortic Dissection: To Save the Patient or to Ensure a Durable Repair? DOI: http://dx.doi.org/10.5772/intechopen.89298*

Several factors contribute to this excess morbi-mortality. In Tanaka's study [12], 243 patients were operated on for TAAD, and mortality causes at follow up were cancer, heart disease and acute aortic rupture for, respectively, 37, 23 and 13% of the cases. The reoperation rate for aortic aneurysm was 5.7%. These results are similar to Kirsch's outcomes in his 2002 study [11].

Even if cancer and heart diseases cannot be decreased by the initial surgical strategy, death by acute aortic rupture and reoperation for aortic aneurysm could be prevented by the first surgery. Within this framework, the question is raised to treat not only the immediate complications of the aortic dissection but also to perform an optimal aortic repair in order to prevent long-term complications of the TAAD.
