Malperfusion syndrome without organ failure is not a risk factor for surgical procedures for type A aortic dissection

Malperfusion syndrome caused by acute type A aortic dissection is associated with high mortality. However, the impact of subclinical malperfusion is not clear. We reviewed surgical outcomes in acute type A dissection for the presence of clinical and subclinical malperfusion.

From 1998 to 2012 at Samsung Medical Center, 268 consecutive patients had an emergency operation for acute type A dissection. We divided patients into three groups: clinical, subclinical, and no malperfusion. Clinical malperfusion was identified by signs or symptoms of organ dysfunction (n=36). Subclinical malperfusion was defined as laboratory evidence of organ hypoperfusion or imaging findings without signs or symptoms (n=40). Patients with no evidence of malperfusion were defined as having no malperfusion (n=192).

The mean patient age was 57.3±13.8 years, and 141 patients (53%) were women. Antegrade selective cerebral perfusion was used in 213 patients (79%). Total arch replacement was performed in 53 patients (20%). The average cardiopulmonary bypass time was 218.31±72.17 minutes. Early mortality was 8% in all patients, 5% in the no-malperfusion group, 8% in the subclinical malperfusion group, and 25% in the clinical malperfusion group. Overall survival in the clinical malperfusion group was worse than in the subclinical (p=0.026) and no-malperfusion (p<0.001) groups. Survival rates in the subclinical and no-malperfusion groups were not different (p=0.482). On multivariate Cox regression analysis, older age, longer cardiopulmonary bypass time, and clinical malperfusion syndrome were predictors of mortality.

Mortality was not increased in asymptomatic patients with malperfusion by laboratory or imaging findings. Immediate operation before progression of organ malperfusion is still a valid option for patients with acute type A dissection.