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Malperfusion in Patients With Acute Type A Aortic Dissection: A Nationwide Analysis

Nicholas J Goel1, John J Kelly1, William L Patrick1

  • 1Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Philadelphia, Pennsylvania.

The Annals of Thoracic Surgery
|January 23, 2025
PubMed

Insights

Malperfusion in acute type A aortic dissection (ATAAD) is common and significantly increases operative mortality, with outcomes varying by affected region. Surgical strategies like partial arch replacement did not worsen mortality in these high-risk patients.

Area of Science:

  • Cardiovascular Surgery
  • Thoracic Surgery
  • Aortic Disease Research

Background:

  • Acute type A aortic dissection (ATAAD) presents a significant clinical challenge with high mortality.
  • Malperfusion, a complication of ATAAD, further exacerbates poor patient outcomes.
  • Understanding the scope and impact of malperfusion is crucial for optimizing ATAAD treatment.

Purpose of the Study:

  • To quantify the clinical burden of malperfusion in a large national cohort of ATAAD patients.
  • To evaluate the impact of different surgical treatment strategies on outcomes in ATAAD patients with and without malperfusion.
  • To identify specific vascular beds most affected by malperfusion and their association with mortality.

Main Methods:

  • Analysis of The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database from 2017-2020.
  • Inclusion of all patients undergoing repair for ATAAD.
  • Definition of malperfusion based on STS criteria; multivariable logistic regression for outcome analysis.

Main Results:

  • Preoperative malperfusion occurred in 27.7% of 9958 ATAAD repair patients, commonly affecting extremities, renal, and cerebral circulations.
  • Operative mortality was substantially higher in patients with malperfusion (26.8%) compared to those without (13.6%).
  • Coronary and mesenteric malperfusion were independently associated with increased mortality; cerebral malperfusion was not.

Conclusions:

  • Preoperative malperfusion is a frequent and serious complication of ATAAD, significantly increasing operative mortality.
  • The mortality risk associated with malperfusion varies depending on the specific vascular territory affected.
  • Partial aortic arch replacement demonstrated similar mortality rates to ascending aorta or hemiarch replacement in ATAAD patients, irrespective of malperfusion status.
Abstract

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