Interval or permanent nonoperative management of acute type A aortic dissection

Hypothesis: Selected patients with acute type A (ascending) aortic dissecti on who are treated with delayed operation or nonoperative therapy may have better early and short-term outcomes than was previously expected. Design and Setting: Retrospective cohort at a university hospital. Subjects: Data on 75 patients with acute or chronic type A aortic dissectio n treated at one institution from January 1, 1985, to November 30, 1997, we re analyzed. Of these 75 patients, 34 (21 male and 13 female, with a mean a ge of 65.5 years) did not undergo initial operative treatment, and 15 (10 m ale and 5 female, with a mean age of 72.6 years) never underwent surgery. F or the 19 patients who underwent delayed surgery, the mean period between a ortic dissection and intervention was 11.4 +/- 4.83 days. The follow-up per iod ranged from 0.27 to 149 months, with a mean of 20.2 months. Main Outcome Measures: Vascular complications, hospital mortality, and earl y survival. Results: Reasons for interval delay in surgical treatment included initial misdiagnosis or delay in diagnosis (13 [68%] of 19), need to address signif icant comorbidity (4 [21%] of 19), and initial refusal of operative interve ntion (2 [11%] of 19). For the 15 patients treated entirely by medical ther apy, reasons for electing nonoperative management included extensive comorb idity (5 [33%] of 15), refusal of surgical intervention (6 [40%] of 15), an d misdiagnosis or long delay in diagnosis (4 [27%] of 15). Of the 34 patien ts, 15 (44%) presented with moderate or severe aortic insufficiency, 5 (14% ) had evidence of pericardial effusion, 6 (21%) had evidence of concomitant coronary ischemia on electrocardiogram, and 8 (24%) had extension of the d issection into the descending aorta. Four patients (11.8%) died while in th e hospital. Of the 34 patients, 30 (88%) who underwent either delayed or no surgery received aggressive medical treatment (beta-adrenergic blocking ag ents and afterload-reducing agents) and were discharged from the hospital. All patients who were operative candidates in the interval treatment group survived to reach definitive operation. There was no statistically signific ant difference in short-term survival between the group of patients undergo ing delayed surgery or medical treatment only and the group of 41 patients undergoing early operation (P = .42), Conclusions: Immediate surgical therapy is still recommended for acceptable operative candidates with acute type A aortic dissection who seek immediat e treatment. However, this study permits the following 2 conclusions: (1) p atients with type A aortic dissection who are referred or whose conditions are diagnosed several days after presentation have survived the early dange rous period and can safely undergo surgery semielectively (rather than emer gently); and (2) selected patients who are not considered operative candida tes and who survive the initial type A aortic dissection without complicati on may be treated with aggressive medical therapy and achieve acceptable ea rly and short-term outcomes, which is better than previously expected.