Preoperative shock determines outcome for acute type A aortic dissection

Acute type A aortic dissection is a life-threatening catastrophe. Surgical results have not improved.

The charts of all 70 patients surgically treated for acute type A primary aortic dissection during the period of January 1988 through April 2001 were reviewed.

Average age was 59 +/- 2 years. Comorbidities included hypertension (66%), coronary artery disease (17%), and Marfan's syndrome (11%). At presentation, 23% were in shock, 17% had neurologic dysfunction, and 36% had coronary ischemia. The aortic valve was preserved in 55. Distal aortic anastomosis was performed under aortic cross-clamp ("closed") in 32 and "open" under circulatory arrest in 38 patients. Operative mortality was 18.6% (13 of 70 patients). Patients in shock had an operative mortality of 50% compared with stable patients of 9% (p = 0.0002). Mortality was similar regardless of technique. Univariate analysis revealed preoperative shock (p = 0.0002), tamponade (p = 0.003), and neurologic deficit (p = 0.02) to be associated with mortality. Multivariate analysis revealed hemodynamic stability (odds ratio = 0.10, p = 0.04) and outside transfer (odds ratio = 0.12, p = 0.03) to be negative predictors of mortality. Of 57 survivors, follow-up was 93% complete for an average of 46 +/- 6 months. The overall late reoperation rate was 24.6% (14 of 57 patients) at 50.3 +/- 12.3 months. Twelve patients (21%) underwent future aortic aneurysmal repair. No difference in reoperation rate was seen comparing "closed" (26%) with "open" (18%; p = 0.46). Of 42 preserved native valves, only 3 (7.1%) needed future valve replacement.

In our experience, operative mortality was determined by preoperative hemodynamic instability. Technique did not impact survival or late reoperation. Early diagnosis and repair is critical to improving survival.