Abstract
(1) Background: Malperfusion is a central limiting factor in the setting of acute Type A aortic dissections (AAAD). We sought to find preoperative metabolic acidosis thresholds that might influence decision-making in this setting. (2) Methods: We retrospectively reviewed consecutive patients operated on with AAAD between January 2002 and December 2017. We analyzed preoperative variables that might influence early and long-term outcomes, with particular emphasis on malperfusion markers. (3) Results: Our sample consisted of 153 patients, most of them male (69.2%), with a mean age of 55.89 ± 12.8 years. Malperfusion was present in 20.9% of cases: peripheric 25, renal 7, cerebral 4, and mesenteric 3. Cardiogenic shock was present in 18.9% of patients. Logistic regression revealed entry site (odds ratio (OR) = 2.83, p = 0.03), cardiogenic shock (OR = 3.30, p = 0.03), prebypass pH (OR = 0.93, p = 0.02) as independent risk factors for early death (<30 days). Receiver operating characteristic (ROC) analysis identified a prebypass pH of 7.25 as a cutpoint for an unfavourable early outcome. Patients whose prebypass pH was ≤7.25 had a 2.98 higher relative risk (65.7% vs. 22%, p < 0.001). Prebypass pH 7.25 (hazard ratio (HR) = 4.00, p < 0.01) and entry site (HR = 2.10, p = 0.04) were independent predictors of early phase survival (<30 days), while long-term survival (>30 days) was determined by age >65 years (HR = 3.12, p = 0.02). (4) Conclusions: Patients with a prebypass pH ≤ 7.25 have an unacceptably high early mortality after AAAD repair. Those patients might benefit from a two-stage approach.
Highlights
Despite contemporary advances in surgical technique and anesthetic management, mortality in acute Type A aortic dissection (AAAD) remains high, ranging from 15–30% [1,2,3], there has been a constant trend to improve results over the last 20 years [4,5].In the last decade, a focus on malperfusion has resulted in the establishment and subsequent validation of the Penn classification [6]
Univariate analysis performed on 26 preoperative variables found age> 65 years (p < 0.01), prebypass pH (p < 0.01), prebypass base deficit (p < 0.01), cardiogenic shock (p < 0.01), Penn non-Aa (p < 0.001), serum creatinine >1.7 mg/dL on arrival (p = 0.02), a pericardial effusion >10 mm (p < 0.01), ejection fraction (p = 0.03) and entry site outside the ascending aorta (p = 0.04) as significantly linked to early death (Table 1)
Logistic regression performed with early death as the dependent variable, found entry site outside the ascending aorta (odds ratio (OR) = 2.83, 95% Confidence Interval (CI) = 1.07–7.42, p = 0.03), cardiogenic shock (OR = 3.30, 95% confidence interval (CI) = 1.10–9.82, p = 0.03), prebypass pH (OR = 0.93, 95% CI = 0.87–0.98, p = 0.02) as independent predictors of early death (Table 2)
Summary
Despite contemporary advances in surgical technique and anesthetic management, mortality in acute Type A aortic dissection (AAAD) remains high, ranging from 15–30% [1,2,3], there has been a constant trend to improve results over the last 20 years [4,5].In the last decade, a focus on malperfusion has resulted in the establishment and subsequent validation of the Penn classification [6]. Some recent reports have argued for an “ischemia-first” approach, in which severe malperfusion is addressed prior to aortic repair [9,10,11,12]. The Stanford Group have recently published excellent results using the traditional “aorta-first” technique [13]. There are no studies determining the most sensitive marker for preoperative malperfusion. Lactic acid levels above 6 mmol/L [14], as well as base deficit greater than −10 mEq/L [15], have very recently been proposed as cutoff points for an unfavorable outcome, none of these markers have been analyzed in conjunction with one another, as well as with preoperative pH
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