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Ann Thorac Surg 2002;73:707-713
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Acute type A dissection: conservative methods provide consistently low mortality

^a Oxford Heart Centre, John Radcliffe Hospital, Oxford, England, UK

Accepted for publication October 24, 2001.

* Address reprint requests to Dr Westaby, Oxford Heart Centre, John Radcliffe Hospital, Headley Way, Headington, Oxford, England OX3 9DU, UK
e-mail: swestaby{at}ahf.org.uk

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. A wide spectrum of operative techniques are applied in acute type A dissection. Most convey hospital mortality between 10% and 20%. In this high-risk setting, we believe that a conservative approach to the aortic root and the complete resection of the primary tear are important. We reviewed the results of this policy from our aortic surgery database.

Methods. Between 1988 and December 2000, 95 acute type A dissection patients were operated on by one surgeon. They included 70 men and 25 women aged 37 to 81 years (mean 65 years). Six had Marfan syndrome. Aortic root restoration or replacement was performed during cooling, open arch repair during circulatory arrest, and hemostasis while rewarming. Eighty-seven patients had ascending aortic replacement with glue resuspension of the valve. Two others had had aortic valve replacement previously. Aortic root and partial arch replacement was performed in 6 Marfan patients. Eighteen patients had hemiarch replacement, and 6 had total arch replacement to excise the tear.

Results. Five patients died in hospital (5.3% 30-day mortality) and another after early readmission for mediastinal infection (6.3% total mortality). There were no deaths from bleeding. Two patients required aortic valve replacement for aortic regurgitation 2.5 and 3.0 years postoperatively. Two others required total arch replacement and thromboexclusion procedures, respectively.

Conclusions. Our policy of primary tear excision and preservation of the native aortic valve has resulted in low overall mortality. We still prefer to replace the aortic root in dissected Marfan patients. In this high-risk condition, hospital survival is of paramount importance. A conservative "pathology-oriented" approach helps to achieve this aim.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Acute type A dissection is the most lethal and taxing of cardiovascular emergencies. The literature suggests that even surgeons with an interest in aortic surgery will treat fewer than 10 cases per year [1–3]. Survival of the acute event is clearly of paramount importance. Recovery depends on early recognition and surgical repair using specialized operative techniques [3–5]. Prolonged operation can increase mortality through coagulopathy, cerebral ischemia, infection, or multiorgan failure. Our hypothesis was that a simple, easily reproducible and expeditious operation is likely to produce an intact patient. Accordingly, we followed three basic premises: first, the native aortic valve can be preserved by glue repair in virtually all patients without a genetic disorder. Second, the Marfan patient is best managed by aortic root replacement unless the surgeon has experience with root repair techniques. Third, routine open arch repair using hypothermic circulatory arrest provides the best opportunity to obliterate the false lumen and promote event-free survival.

For the past 12 years (the tissue glue era) we have undertaken aortic root restoration during cooling, arch repair during circulatory arrest, and hemostasis while rewarming. Here we have reviewed the results of this strategy in a consecutive series of 95 patients.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Patient population
For this series we defined acute type A dissection by presentation within 72 hours of the onset of symptoms. Subacute and chronic cases were not included. Between 1988 and December 2000, 95 patients with an acute type A dissection were operated on by one of us (S.W.). During this time, only 3 patients were declined operation: 2 on the grounds of extensive gut infarction and 1 for irreversible severe neurologic injury. Mesenteric infarction was diagnosed in dissection patients who were referred with generalized abdominal tenderness, dilated gut on ultrasound, and white blood cell counts more than 20,000/mL. Two patients resuscitated by emergency pericardiocentesis and 2 others presenting with stroke proceeded to operation.

The patients included 70 men and 25 women with ages ranging from 37 to 81 years (mean 64 ± 9 years). Six patients had Marfan syndrome. Two had a bicuspid aortic valve without flow restriction. Two had calcific aortic stenosis with a bicuspid valve. Five patients were operated on within 12 hours of thrombolysis. Three patients had undergone previous cardiac operation at least 2 years before acute dissection. Two had coronary bypass and one had stentless aortic valve replacement. A history of hypertension was the most common preoperative finding and 72% of patients were smokers. One patient had previously undergone thoracoplasty for tuberculosis.

Diagnosis was established by computerized tomography, transthoracic or transesophageal echocardiography, or both. Coronary angiography was undertaken early in the series only in 9 stable patients with a past history of angina. When the history, plain chest roentgenogram, and physical signs were strongly suggestive of type A dissection (in those presenting at our own center), patients were taken directly to the operating room and underwent transesophageal echocardiography under sedation before induction of anesthesia. Careful afterload control was instigated to attenuate major swings in blood pressure. Fifty-eight patients (61%) reached the operating room within 24 hours of dissection. The remainder (predominantly those presenting in other hospitals with delayed specialist opinion) underwent operation within 72 hours of presentation. Seventy-nine patients (83%) had aortic regurgitation on echocardiography. Although detection of valve incompetence supported the diagnosis of type A dissection, cardiac tamponade or cardiogenic shock often precluded an accurate estimate of the degree of aortic regurgitation. Those without significant aortic regurgitation had primary tears in the arch or distal ascending aorta though the dissection always reached the sinotubular junction. We did not attempt to image reentry tears in the thoracoabdominal aorta. Sixty-two patients (65%) had hemopericardium and 39 (41%) had cardiogenic shock from cardiac tamponade.

Surgical methods
Our operative strategy for acute type A dissection patients is summarized in Table 1. All patients underwent emergency operation on confirmation of the diagnosis. Each received a cerebral protective cocktail of phenobarbitone (6 mg/kg), the calcium-channel blocker nimodipine (6 mg/kg loading dose, then 6 mg · kg^-1 · h^-1), and mannitol (500 mg/kg). Femoral cannulation was obtained before the pericardium was opened. Venous drainage was established with a two-stage cannula inserted through the right atrial appendage. Cooling to 18°C was started immediately.

View larger version (29K): [in this window] [in a new window]   Fig 1. Schematic diagram showing the extent of aortic replacement in the 95 patients. (a) Transection of the aorta just above the sinotubular junction and proximal to the innominate artery. (b) Ascending aortic replacement with open distal anastomosis, the standard operation for a tear restricted in the ascending aorta. (c) Ascending aortic and hemiarch replacement for a tear extending into aortic arch. (d) Ascending aortic and total arch replacement for primary arch tear. (e) Aortic root replacement extending the resection to the proximal arch for patients with Marfan syndrome. (Numerals = number of patients.)

The valve annulus size was then determined to help select the ascending aortic graft. Valve competence depends on the integrity of the remodeled sinotubular junction, thus graft size should not exceed annulus diameter (irrespective of the size of the dissected ST junction). Because the sinotubular junction diameter increases with age, we do not believe that this must be revised down to 10% to 15% less than the annulus size in the dissected aorta. Both patients with aortic stenosis underwent valve replacement with the Freestyle stentless xenograft (Medtronic, Minneapolis, MN). The modified subcoronary technique excluded the dissected native sinuses and provided a secure anastomosis for the ascending aortic graft [6].

The impervious collagen impregnated Hemashield (Meadox, Oakland, NJ) graft was used routinely to replace the ascending aorta. The proximal graft anastomosis was performed with continuous 3-0 Prolene (Ethicon, Somerville, NJ) without Teflon (DuPont, Parkersburg, WV) buttress. Glue reinforced tissues provided a secure repair. The morphology and competence of the resuspended native valve were then checked before performing the distal anastomosis. Both well functioning bicuspid valves were preserved. In the 6 Marfan patients, aortic root replacement was performed electively using a Carboseal (CarboMedics, Austin, TX) valved conduit (Fig 1e). The coronary buttons were excised from the native aorta and reconstituted with glue before reimplantation into the graft. In the patient with a previous stentless valve replacement, the prosthesis was intact and well preserved.

The patient was then tipped head down and the circulation arrested. We did not use retrograde cerebral perfusion even when total arch replacement was performed. The cross-clamp was removed and the aorta completely transected just proximal to the innominate artery thereby excising the clamped vessel wall. The anatomy of the aortic arch was inspected in detail and extensions of the primary tear into the arch were excised. Seven patients with a complex arch tear were treated by complete aortic arch replacement using a separate graft (Fig 1d). Eighteen patients had hemiarch replacement after an oblique resection was made on the underside of the arch to remove the tear. In this case the ascending aortic graft was cut obliquely to replace the underside of the arch (Fig 1c). In the remaining 64 patients, in whom the tear was restricted to the ascending aorta, straightforward open distal anastomosis was performed (Fig 1b). The layers of the dissected arch were reconstituted with glue. Where there was substantial dilation of the false lumen an external circumferential Teflon buttress was used.

In 2 patients the proximal ends of previous aortocoronary vein grafts were reimplanted into the Dacron (C.R. Bard, Haverhill, PA) graft on a composite button. For new coronary bypass grafts in 9 patients, the proximal anastomoses were performed to the vascular graft before recommencing cardiopulmonary bypass. Before closing the suture line on the anterior aspect, the descending aorta was filled with blood and atheromatous debris removed from the lumen. We then switched the arterial cannula from the femoral artery to the vascular graft to recommence antegrade systemic perfusion with rewarming. We used a Dacron graft with a side branch for this purpose, but now we are beginning to use the subclavian artery for perfusion.

During reperfusion and rewarming the repair was carefully inspected for bleeding. The competence of native aortic valve was confirmed by low apical vent flow and failure of the left ventricle to distend. With the onset of cardiac ejection, air was removed from the graft and at full rewarming cardiopulmonary bypass was discontinued. Heparin was reversed by protamine and we routinely administered fresh frozen plasma and platelets.

Follow-up and investigations
Arterial blood pressure was controlled and life long ß-blockade implemented or continued. Transthoracic echocardiography was performed before hospital discharge to assess aortic valve function. In 24 patients, nuclear magnetic resonance imaging was performed at intervals of between 6 weeks and 2 years after the operation to determine the status of the aortic root and distal false lumen. For logistic reasons and cost, magnetic resonance imaging was not performed in all patients. Hospital and follow-up data were obtained independent of the operating surgeon. Hospital survivors were contacted by telephone to supplement information from the case notes.

	Results

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Intraoperative events
Reactive hypertension caused aortic rupture in 2 patients as cardiac tamponade was relieved. Bleeding was controlled by pressure until an aortic cross-clamp could be applied.

One patient had a critical intraoperative cerebral malperfusion. This complication was detected only 15 minutes after beginning cardiopulmonary bypass when the aortic root repair was already underway (Fig 2). The femoral arterial cannula was switched to the true lumen of the aortic arch, after which cerebral cooling proceeded as planned.

View larger version (143K): [in this window] [in a new window]   Fig 2. Arterial pressure trace and nasopharyngeal temperature monitoring in the cerebral malperfusion case. Each large square is 5 minutes. The systemic pressure was measured by arterial line in the right radial artery. The arterial pressure increased from 70 to 90 mm Hg when cardiac tamponade was relieved. At the onset of cardiopulmonary bypass the perfusion pressure fell to 10 mm Hg or less and the nasopharyngeal temperature did not fall significantly. The cerebral malperfusion was not recognized immediately. When the failure of the head to cool was recognized, the arterial perfusion cannula was switched to the aortic arch (15 minutes later). The perfusion pressure then increased and nasopharyngeal temperature fell as expected.

Two patients with coagulopathy had the mediastinum packed with gauze soaked in aprotinin and were managed without sternal closure for 24 to 36 hours. The packs were then removed and delayed primary sternal closure performed.

Morbidity and mortality
Five of the 95 patients died in hospital during same admission (5.3%, 30-day mortality). No deaths occurred from bleeding or technical complications related to the surgical repair. One patient with severe diffuse coronary artery disease and a second with a detached right coronary artery and preoperative myocardial infarction died from left ventricular failure in the operating room. A third patient had ventricular fibrillation in the intensive care unit and died of diffuse cerebral injury with intact hemodynamics on day 20. Two patients had prolonged preoperative cardiogenic shock and died of multiorgan failure on postoperative day 4 and day 25, respectively. Two of these deaths occurred in reoperation patients.

In addition, 1 patient with Marfan syndrome recovered initially and was discharged from hospital after aortic root replacement. He was readmitted 6 days later with mediastinitis. He subsequently died from the consequences of graft infection and multiorgan failure on day 48. The overall mortality was 6.3%. There were no hospital deaths from bleeding or distal aortic rupture, but 1 patient died suddenly at home 4 months after the operation. No autopsy was obtained.

Of 2 patients who presented with stroke, left hemiparesis persisted in 1, but resolved completely in the second. There were six new permanent neurologic events. Four patients had hemiparesis and 2 had monoplegia. Six patients required temporary hemodialysis for renal failure; all six patients recovered.

The patient with prolonged cerebral malperfusion recovered completely and returned to work as an accountant. He presented to us again several years later with an extensive aortic arch aneurysm perhaps because of pressurization of the false lumen, which caused the cerebral malperfusion.

Late results
Two patients required reoperation on the aortic root. The first case, a 46-year-old man, had a 3.5-cm aortic root at the time of dissection, but a competent valve after the repair. Follow-up echocardiography showed progressive dilation of the aortic sinuses to 6 cm, and the development of aortic regurgitation (Fig 3). Aortic root replacement was performed uneventfully with a valved conduit 2.5 years after the initial event. The second patient had persistent aortic regurgitation after the repair, which worsened progressively over 3 years. The aortic sinuses were found to be normal at reoperation. The attenuated valve cusps were excised and the valve replaced, leaving the aortic sinuses and coronary ostia in situ. This patient subsequently developed a mediastinal false aneurysm between the graft and native aortic sinuses. He was found to have cystic medial necrosis.

View larger version (164K): [in this window] [in a new window]   Fig 3. Aortogram showing the dilatation of the aortic sinuses and aortic regurgitation which required reoperation 1 year after glue repair.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Many factors contribute to hospital mortality in acute type A dissection. Some relate to the clinical condition at presentation [5, 7, 8], which may be complicated by myocardial infarction, stroke, mesenteric ischemia, or established renal failure. Early thrombolysis for acute chest pain may contribute to coagulopathy, but does not preclude early repair [9]. In this series, 39% of patients presented to the surgical center more than 24 hours after dissection. The delay was predominantly through initial misdiagnosis or the wait for review by a senior clinician to sanction interhospital transfer. Many of our patients traveled long distances by helicopter after diagnosis of dissection by computed tomography scan at their local hospital. We routinely ask the referring hospital to provide blood pressure control and rule out cardiac tamponade before transfer. Delayed presentation may result in natural patient selection (survival of the fittest) or operation in an advanced state of deterioration because of prolonged visceral malperfusion (Fig 4). These contrasting factors may balance outcome probabilities.

View larger version (117K): [in this window] [in a new window]   Fig 4. Contrast computerized tomography showing malperfusion of the left kidney in a patient who presented late (more than 24 hours later) with raised creatinine concentrations.

Attention to detail during preoperative and postoperative care is as important as the operation itself. Usually the diagnosis can be made on the history, physical signs, plain chest roentgenogram, and echocardiography [10]. Time need not be wasted on further investigations, and cardiac catheterization is contraindicated in the acute phase [11]. We only performed coronary angiography in 9 stable patients with previous treatment for angina whom we suspected might benefit from coronary bypass. Stroke is not a contraindication to early operation, but it is important to exclude extensive mesenteric ischemia, particularly in patients presenting more than 24 hours after the acute event with oliguria, abdominal distension, and a raised white cell blood count.

The primary objectives of operation are to restore competence to the aortic valve and to excise the tear, thereby reducing the risk of aortic rupture and decompressing the false lumen. We consider that this goal cannot be achieved without detailed inspection of the entire ascending aorta and arch under conditions of hypothermic circulatory arrest. Perhaps because of this policy we have no perioperative mortality from uncontrollable hemorrhage.

Although full-root replacement and the David procedure can be performed with low mortality by experienced aortic surgeons, most type A dissection patients are treated under emergency conditions by on-call personnel. With patients in such a high-risk condition, hospital survival is the first priority. Our hospital mortality has been consistently low and reflects the conservative tear-oriented approach.

Glue repair is simple, fast, and easily reproducible [2, 12]. We electively changed from GRF glue to Cryolife glue after GRF glue was implicated in so-called glue necrosis [13]. Our approach has been to perform aortic root repair with glue during the cooling period with an aortic cross-clamp in place. Because of the low mortality and morbidity, we have not changed this practice but concur with David, who prefers not to cross-clamp the aorta at all [4]. This practice avoids pressuring the false lumen through a distal intimal aortic tear during the cooling period, which may cause fatal brachiocephalic occlusion. We experienced critical cerebral malperfusion in 1 patient, which was recognized late. Cerebral blood flow was compromised for 15 minutes before antegrade perfusion was achieved. Recovery under these circumstances provided anecdotal support for the pharmacologic cerebral protection cocktail, which includes a neurone-specific calcium-channel blocker, a free radical scavenger, and a barbiturate. Whether pressurization of the false lumen contributed to late arch aneurysm formation in this patient remains speculative. An aortic cross-clamp will inevitably cause further damage to the dissected aortic wall. Consequently the cross-clamp site must be excised and the ascending aorta excluded by the repair.

Despite an interest in aortic root repair for other conditions we still prefer to replace the dissected root in patients with Marfan syndrome. In contrast, we acknowledge that others have similar success with the valve-sparing Yacoub and David techniques whereby the dissected aortic sinuses are removed [14, 15]. We perform complete arch replacement only for complex primary arch tears or in the presence of an extensive hematoma around the arch. However, we routinely perform an oblique anastomosis between the ascending aortic graft and the underside of the arch to completely excise an ascending aortic tear that extends into the arch (Fig 1). We then decompress the distal false lumen by antegrade perfusion of the true lumen through the graft during rewarming.

Despite the use of open-ended repair, our nuclear magnetic resonance studies have demonstrated that it is extremely difficult to promote thrombosis of the false lumen. This is probably because of secondary tears in the descending thoracic or abdominal aorta. However, persistence of flow in the false lumen is not necessarily associated with aneurysmal dilation. The same nuclear magnetic resonance studies and other investigators have confirmed durability of glue repair in the aortic root [16]. Only 1 of our patients had progressive dilation of the aortic sinuses; in retrospect, he had cystic medial necrosis and should have undergone aortic root replacement at the time of primary repair. Excessive use of the polymerizing agent of GRF has been suggested to cause tissue necrosis [17, 18]. We have only anecdotal evidence of this complication from secondary referrals with false aneurysm formation after type A dissection repair [13]. In some of these patients, the repaired aorta simply disintegrated during reoperation and necessitated radical re-replacement of the involved segments. This complication has not been reported with Cryolife tissue glue.

Bleeding has not been a problem with glue repair, which greatly improves the suture-holding capacity of dissected tissue. Early in our experience with aprotinin, we documented excessive blood loss in direct paradox to its hemostatic role [18]. This finding may have resulted from inadequate heparinization due to the combined effects of aprotinin and hypothermia on the activated clotting time [19]. An activated clotting time of longer than 1,000 seconds is now recommended when aprotinin is used during deep hypothermia, but to-date no prospective study has demonstrated a blood transfusion-sparing effect for aprotinin in hypothermic cases. We currently use aprotinin during rewarming after dissection repair unless the patient has been subject to defibrination by thrombolysis. Although dissection repair should not be delayed in thrombolysis patients, correction of fibrinolysis using fresh frozen plasma, cryoprecipitate, and platelets is advisable before chest closure. We have also used topical aprotinin on gauze packs to control diffuse abnormal bleeding [20].

In this series there were insufficient hospital deaths or late morbid events to perform risk factor analysis. Others have correlated longer cardiopulmonary bypass and circulatory arrest times with the risk of neurologic injury and death [1, 7]. Consistent with this is the greater surgical mortality in experienced centers where routine aortic root or arch replacement is advocated. Ehrlich and colleagues [1] recently reported the risk factors for hospital death to be advanced age, preoperative hemodynamic instability, and more extensive surgical resection, thereby suggesting that radical procedures are associated with higher mortality. This is also our impression from the literature.

Though seldom reported in risk factor analysis, the experience of the operating surgeon may be considered to be of primary importance. In an analysis of patient outcomes from our center (unpublished), the operating surgeon was the most important risk factor for morbid events. For this reason, specific referral practices should be considered.

In conclusion, recovery after acute type A dissection requires attention to detail from presentation to the time of hospital discharge. For non-Marfan patients aortic root repair with tissue glue, together with complete resection of the primary tear, can provide low hospital mortality. Even severe aortic regurgitation due to valve prolapse can be repaired. More extensive procedures should be tailored to specific needs. Valve-sparing operations in Marfan patients can be undertaken by experienced surgeons, and aortic root replacement provides excellent long-term results.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Ehrlich M.P., Ergin M.A., MuCullough J.N., et al. Results of immediate surgical treatment of all acute type A dissection. Circulation 2000;102(Suppl 3):III248-III252.[Abstract/Free Full Text]
2. Westaby S., Katsumata T., Freitas E. Aortic valve conservation in acute type A dissection. Ann Thorac Surg 1997;64:1108-1112.[Abstract/Free Full Text]
3. Bachet J., Goudot B., Dreyfus G.D., et al. Surgery for acute type A aortic dissection: the hospital foc experience (1977–1998). Ann Thorac Surg 1999;67:2006-2009.[Abstract/Free Full Text]
4. David T.E., Armstrong S., Ivanov J., Barnard S. Surgery for acute type A aortic dissection. Ann Thorac Surg 1999;67:1999-2001.[Abstract/Free Full Text]
5. Ehlrich M., Fang W.C., Grabenwoger M., Cartes-Zumelzu F., Wolner E., Havel M. Perioperative risk factors for mortality in patients with acute type A aortic dissection. Circulation 1998;98(Suppl):II294-II298.
6. Westaby S., Katsumata T., Houel R., Shinfeld A. Stentless xenograft repair of the dissected aortic root. Ann Thorac Surg 1998;65:1448-1450.[Abstract/Free Full Text]
7. Miller D.C., Mitchell R.S., Oyer P.E., et al. Independent determination of operative mortality for patients with aortic dissections. Circulation 1984;70(Suppl 1):153-164.[Free Full Text]
8. Passini S., Vincenzo P., Pompei E., et al. Early and late risk factors in surgical treatment of acute type A dissection. Ann Thorac Surg 1998;66:779-784.[Abstract/Free Full Text]
9. Westaby S., Parry A., Giannopoulos N. Streptokinase in acute type A dissection. Br Med J 1990;63:55-57.
10. Rizzo R.J., Aranki S.F., Aklog L., et al. Rapid noninvasive diagnosis and surgical repair of acute ascending aortic dissection; improved survival with less angiography. J Thorac Cardiovasc Surg 1994;108:567-575.[Abstract/Free Full Text]
11. Butler J., Ormerod O.J.M., Giannopoulous N., Pillai R., Westaby S. Diagnostic delay and outcome in surgery for type A aortic dissection. QJ Med 1991;89:391-396.
12. von Seggesser L.K., Lorenzetti E., Lachat M., et al. Aortic valve preservation in acute type A dissection: is it sound?. J Thorac Cardiovasc Surg 1996;111:381-391.[Abstract/Free Full Text]
13. Katsumata K., Moorjani N., Vaccari G., Westaby S. Mediastinal false aneurysm after thoracic surgery. Ann Thorac Surg 2000;70:547-552.[Abstract/Free Full Text]
14. Yacoub M.H., Gehle P., Chandrasekaran V., et al. Late results of a valve preserving operation in patients with aneurysm of the ascending aorta and root. J Thorac Cardiovasc Surg 1998;115:1080-1090.[Abstract/Free Full Text]
15. David TE, Armstrong S, Ivanov J, Feidel CM, Omran A, Webb G. Results of aortic valve-sparing operations. J Thorac Cardiovasc Surg 122;1:39–46.
16. Moore N., Parry A., Ormerod O., Westaby S. Fate at the native aorta after repair of acute type A dissection: a magnetic resonance imaging study. Heart 1996;75:62-66.[Abstract/Free Full Text]
17. Bachet J., Goudot B., Teodori G., et al. Surgery of type A acute aortic dissection with gelatine-resorcine-formol biological glue. A twelve year experience. J Cardiovasc Surg 1990;31:263-273.[Medline]
18. Weinschelbaum E.E., Schaumun C., Caramutti V., et al. Surgical treatment of acute type A dissecting aneurysm with preservation of the native aortic valve and use of biologic glue; follow-up to 6 years. J Thorac Cardiovasc Surg 1992;103:369-374.[Abstract]
19. Westaby S., Forni A., Dunning J., et al. Aprotinin and bleeding in profoundly hypothermic perfusion. Eur J Cardiothorac Surg 1994;8:82-86.[Abstract]
20. O’Regan D.J., Giannopoulos N., Mediratta N., et al. Topical aprotinin in cardiac operations. Ann Thorac Surg 1994;58:778-781.[Abstract]

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				L. N. Girardi, K. H. Krieger, L. Y. Lee, C. A. Mack, A. J. Tortolani, and O. W. Isom Management strategies for type A dissection complicated by peripheral vascular malperfusion Ann. Thorac. Surg., April 1, 2004; 77(4): 1309 - 1314. [Abstract] [Full Text] [PDF]

				K. Kawahito, H. Adachi, S.-i. Murata, A. Yamaguchi, and T. Ino Coronary malperfusion due to type a aortic dissection: mechanism and surgical management Ann. Thorac. Surg., November 1, 2003; 76(5): 1471 - 1476. [Abstract] [Full Text] [PDF]

				T. M. Fleck, H. Tschernich, M. Grabenwoger, D. Hutschala, H. Koinig, E. Wolner, and W. Mohl A double patch sandwich technique for surgical repair of acute aortic dissection type A Ann. Thorac. Surg., August 1, 2003; 76(2): 499 - 502. [Abstract] [Full Text] [PDF]

				K.-H. Park, K. Sung, K. Kim, T.-G. Jun, Y. T. Lee, and P. W. Park Ascending aorta replacement and local repair of tear site in type a aortic dissection with arch tear Ann. Thorac. Surg., June 1, 2003; 75(6): 1785 - 1790. [Abstract] [Full Text] [PDF]

				A. D. Milano, S. Pratali, G. Mecozzi, P. Boraschi, G. Braccini, E. Magagnini, and U. Bortolotti Fate of coronary ostial anastomoses after the modified Bentall procedure Ann. Thorac. Surg., June 1, 2003; 75(6): 1797 - 1801. [Abstract] [Full Text] [PDF]

				M. Pokela, J. Heikkinen, F. Biancari, E. Ronka, T. Kaakinen, V. Vainionpaa, K. T. Kiviluoma, P. Romsi, E. Leo, J. Hirvonen, et al. Topical head cooling during rewarming after experimental hypothermic circulatory arrest Ann. Thorac. Surg., June 1, 2003; 75(6): 1899 - 1910. [Abstract] [Full Text] [PDF]

				M. Massetti, E. Neri, G. Babatasi, O. Le Page, R. Sabatier, D. Buklas, G. Grollier, and A. Khayat Flap suffocation: An uncommon mechanism of coronary malperfusion in acute type A dissection J. Thorac. Cardiovasc. Surg., June 1, 2003; 125(6): 1548 - 1550. [Full Text] [PDF]

				D. Spielvogel, M. N. Mathur, and R. B. Griepp Aneurysms of the Aortic Arch Card. Surg. Adult, January 1, 2003; 2(2003): 1149 - 1168. [Full Text]

				S. Ohtsubo, T. Itoh, K. Takarabe, K. Rikitake, K. Furukawa, H. Suda, and Y. Okazaki Surgical results of hemiarch replacement for acute type A dissection Ann. Thorac. Surg., November 1, 2002; 74(5): S1853 - 1856. [Abstract] [Full Text] [PDF]

				J. Bachet Acute type A aortic dissection: can we dramatically reduce the surgical mortality? Ann. Thorac. Surg., March 1, 2002; 73(3): 701 - 703. [Full Text] [PDF]

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