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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
Summary
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.
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