Rapid Diagnosis and Treatment of Patients with Acute Type A Aortic Dissection and Malperfusion Syndrome May Normalize Survival to that of Patients with Uncomplicated Type A Aortic Dissection.

Basmah Safdar,Arnar Geirsson,Jiajun Luo,Andrew Ulrich,Syed Usman Bin Mahmood,John A Elefteriades,Yawei Zhang,Makoto Mori,Abeel A Mangi

doi:10.1055/s-0039-1691790

Abstract

Objectives Malperfusion syndrome in the setting of acute Type A dissection (ATAD) is typically associated with poor prognosis. We evaluated the contemporary outcomes of patients with ATAD presenting with and without malperfusion syndrome who underwent aortic surgery. Methods We performed a single-center, retrospective review of 103 consecutive patients that underwent surgery for ATAD. The cohort was dichotomized by patients with and without malperfusion syndromes. Multivariate and bivariate analyses were performed to evaluate association between the presence of malperfusion syndrome and operative outcomes. Results A total of 29 (28.1%) patients presented with malperfusion syndrome. The 30-day mortality for patients presenting with and without malperfusion was 13.7 and 9.4%, respectively ( p = 0.49). Patients with malperfusion syndrome had a shorter mean admission-to-incision interval of 4.3 ± 2.5 hours compared with 6.3 ± 4.6 hours for those without malperfusion ( p = 0.02). Difference in 30-day mortality for patients with and without malperfusion syndrome was found to be nonsignificant on multivariate regression analysis (odds ratio: 1.53; 95% confidence interval: 0.40–5.82, p = 0.49). Conclusions This series demonstrated that there was nonsignificant difference in early- or midterm outcomes for patients with and without malperfusion syndrome. Patients with malperfusion were taken to the operating room more rapidly than those without, which offers a potential explanation for the comparable outcome of the malperfusion cohort.

Highlights

Acute Type A aortic dissection (ATAD) is a cataclysmic event requiring emergent surgery
Mean systolic and diastolic blood pressures measured at initial presentation were 131.4 Æ 34.6 and 73.9 Æ 22.7 mm Hg, respectively; 40 patients were on chronic betablocker therapy or started on anti-impulse therapy at an outside facility
Abdominal malperfusion was noted as a clinical suspicion in patients with acute abdomen coupled with newonset diarrhea and abdominal pain

Summary

Introduction

Acute Type A aortic dissection (ATAD) is a cataclysmic event requiring emergent surgery. Perioperative mortality for ATAD is inversely proportional to institutional experience, ranging from 16.4 to 27.4%, and averaging around 21.6% in the U.S.1,2. Malperfusion syndrome significantly compromises the outcomes of ATAD patients and warrants expeditious diagnosis. Malperfusion usually results from extension of the dissection flap into the branch vessel, with static or dynamic narrowing or obstruction of the branch orifice by the flap.[3] The subtle nature of compromised end-organ perfusion and ensuing ischemia may result in diagnostic delays and can result in comparatively higher mortality rates than ATAD without malperfusion.[4] Cases involving renal or mesenteric ischemia are known to have higher (> 50%) postoperative mortality rates.[3,4,5] Surgical mortality for patients presenting with any visceral malperfusion has been recorded to be as high as 43% Æ 4%, nearly twice in comparison to the overall ATAD cohort (25% Æ 3%).[5]

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