Malperfusion in type A aortic dissection: results of emergency central aortic repair.

Abstract

Although outcomes of acute type A aortic dissection (ATAAD) have improved, malperfusion remains associated with high morbidity and mortality rates, and its optimal therapeutic treatment is unknown. Emergency central repair has been performed as our first-line approach for malperfusion. Here, we analyzed outcomes of ATAAD with malperfusion and reassessed emergency central repair. In total, 1026 ATAAD patients underwent emergency surgery within 48h of symptom onset, of whom 318 (30.9%) patients complicated with any preoperative malperfusion were included. Pathophysiology of malperfusion and surgical outcomes were analyzed. The in-hospital mortality rate was 12.9% for patients with malperfusion and 4.8% for patients without malperfusion (p < 0.0001). Coronary malperfusion was complicated in 7.5% of patients (% dead per group, 19.5%), mesenteric malperfusion in 3.6% (24.3%), renal malperfusion in 8.8% (14.4%), lower leg malperfusion in 12.6% (13.7%), brain malperfusion in 9.7% (12.0%), and spinal malperfusion in 1.1% (18.2%). Mortality rates varied substantially according to the number of affected organ systems (none, 4.8%; one system, 10.4%; two systems, 14.5%; three systems, 30.0%, and four systems; 30.3%; p < 0.0001). In malperfused patients, logistic regression analysis revealed that obesity (body mass index > 30kg/m2), preoperative shock (systolic blood pressure < 80mmHg), and visceral ischemia were independent predictors for hospital death. Malperfusion of more organ systems and mesenteric malperfusion resulted in unfavorable prognosis, and effects of central repair were limited in such severe/complex malperfusion. To further improve outcomes of ATAAD with malperfusion, emergency reperfusion of affected organs followed by central repair might be considered.