Acute type A aortic dissection and the consequences of a patent false lumen

Abstract

Acute type A aortic dissection (ATAAD) is a lifethreatening condition associated with high mortality and morbidity. 1 Without immediate surgical repair, mortality rates approach 50% within the first 48 hours. [2][3][4][5] Despite improvements in surgical technique and critical care, the short-and long-term mortality and morbidity associated with ATAAD, particularly the DeBakey I subgroup, remains high. Although standard repair for ATAAD involves resection of the primary intimal tear in the proximal aorta, persistence of flow through a large distal tear or a new entry tear at the distal aortic anastomosis may lead to persistent false lumen (FL) perfusion with unfavorable downstream consequences. 6 This manuscript aims to discuss the following concepts: (1) aortic true lumen (TL) and FL behavior after repair of ATAAD; (2) the concept of distal anastomotic new entry tear (DANE) following standard hemiarch repair; (3) how this impacts short-and long-term outcome of patients; and (4) strategies to prevent DANE. Better understanding of these hemodynamic conditions may serve to improve surgical technique, guide the creation of novel devices toward new therapeutic targets, reduce surgical risk, and ultimately improve patient outcomes.

Cardiac Surgery 2021 Reviewed

“…The less aggressive partial arch replacement with shorter circulatory arrest times and periprocedural complications has just been associated with a higher rate of residual dissections and new entries at the distal anastomotic site in a meta-analysis. 69 Thus, a current expert consensus comes to the recommendation that arch replacement potentially including elephant trunks may be an option in experienced hands. [68][69][70][71] In the treatment of terminal heart failure, the continuing shortness of donor organs makes left ventricular assist device therapy more and more a long-term alternative to heart transplantation.…”

“…69 Thus, a current expert consensus comes to the recommendation that arch replacement potentially including elephant trunks may be an option in experienced hands. [68][69][70][71] In the treatment of terminal heart failure, the continuing shortness of donor organs makes left ventricular assist device therapy more and more a long-term alternative to heart transplantation. A meta-analysis demonstrated that left ventricular assist device therapy is able to provide similar 2-year survival compared with heart transplantation.…”

“…The less aggressive partial arch replacement with shorter circulatory arrest times and periprocedural complications has just been associated with a higher rate of residual dissections and new entries at the distal anastomotic site in a meta-analysis. 69 Thus, a current expert consensus comes to the recommendation that arch replacement potentially including elephant trunks may be an option in experienced hands. 68 69 70 71…”

“…69 Thus, a current expert consensus comes to the recommendation that arch replacement potentially including elephant trunks may be an option in experienced hands. 68 69 70 71…”

Aortic Arch registry of type A aortic dissection (AoArch) - rationale, design and definition criteria

“…Effectively closing off the false lumen (FL) flow can lead to improved late remodeling. (9,10) Adverse remodeling, which has been linked to a nearly 20% risk of increased mortality at five years, can be caused by distal new entry tears. (11)(12)(13) Performing extended arch repair (EAR) in TAAAD is increasingly popular due to their ability to promote late remodeling and reduce the risk of distal new entry tears.…”