Treatment of Type A Acute Aortic Dissection in Saitama
In acute Type A dissection, the concomitant arch replacement is generally indicated for patients (pts.) with intimai tears in the aortic arch. On the other hand, simple replacement of the ascending aorta in acute Type A dissection may avoid the sudden death caused by cardiac tamponade with acceptable early results. So, the classical issue “Should the arch be included?” remains still controversial in the treatment of acute Type A dissection. From January 1998 to October 1999, 285 pts. with acute aortic dissection (Type A; 143 pts., Type B; 142 pts.) were treated at Saitama Heart Center, Saitama Medical School. In 122 of 143 Type A pts. (85%), emergent surgery was performed. Thirty-six pts. underwent concomitant partial or total aortic arch replacement. The strategy for the treatment of acute Type A dissection at Saitama is in principle the concomitant replacement of the arch in pts. with intimai tears in the arch. In the last 4 years, operative mortality was reduced from 25% to 15%. In order to improve the diagnostic capability, we have searched for tears in the aortic arch more extensively using intraoperative TEE under general anesthesia, resulting in a higher detection rate of intimai tears in the aortic arch. Accurate information using intraoperative TEE on the presence or absence of intimai tears in the aortic arch contributed significantly to the immediate decision of management of acute Type A dissection and to the selection of the method of cerebral protection or safe perfusion sites, etc. The main causes of operative death were cerebral complications, myocardial infarction, intestinal necrosis, and infection.