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Surgical treatment for acute aortic dissection with coronary malperfusion in Japan: Nationwide database analysis
Toshiki Fujiyoshi1, Hiraku Kumamaru2,3,4, Hitoshi Ogino1
1Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan.
Insights
Surgical outcomes for acute aortic dissection with coronary malperfusion remain poor, especially with left coronary malperfusion. Critical conditions like cardiac arrest increase mortality risk.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Vascular Surgery
Background:
- Acute aortic dissection (AAD) is a life-threatening condition.
- Coronary malperfusion (CM) in AAD significantly increases surgical risk.
- Limited data exists on AAD with CM surgical outcomes in Japan.
Purpose of the Study:
- To evaluate the surgical outcomes of AAD with CM in Japan.
- To identify risk factors associated with mortality in these patients.
Main Methods:
- Retrospective analysis of 188 patients with AAD and CM from the Japan Cardiovascular Surgery Database (2019-2021).
- Analysis of preoperative characteristics, interventions, and 30-day operative mortality.
- Stratification based on CM laterality (left vs. right) and Neri classification.
Main Results:
- The 30-day operative mortality rate for AAD with CM was 33.0%.
- Left CM (33.5%) had higher mortality (41.3%), particularly with advanced Neri classification (B/C).
- Right CM (56.4%) had lower mortality (25.0%), irrespective of Neri classification. Preoperative acute myocardial infarction, cardiopulmonary arrest, and mechanical circulatory support (MCS) were independent risk factors for mortality.
Conclusions:
- Surgical mortality for AAD with CM is high, especially for left CM and advanced Neri classifications.
- Patients requiring critical care interventions like MCS face significantly elevated mortality risks.
- Timely coronary reperfusion is crucial, though current interventions show similar mortality rates.
Objective:
To assess the surgical outcomes of acute aortic dissection (AAD) with coronary malperfusion (CM) in Japan through the Japan Cardiovascular Surgery Database.
Methods:
Between 2019 and 2021, 15,509 patients underwent surgical treatment for AAD. CM occurred in 304 (2.0%), of which 188 were analyzed.
Results:
The mean age of patients was 65 ± 11.8 years. Preoperative acute myocardial infarction, cardiopulmonary arrest, and mechanical circulatory support (MCS) were found in 49.5%, 16.5%, and 9.6%, respectively. The 30-day operative mortality rate was 33.0%. The left CM (33.5%) was associated with greater mortality rates (41.3%), particularly as Neri classification advanced to type B and type C. Conversely, right CM (56.4%) had a lower mortality rate (25.0%), regardless of Neri classification. Preoperative percutaneous coronary intervention was performed in 14.9% and concomitant coronary artery bypass grafting was performed in 57.4%. The 30-day operative mortality rate for coronary intervention showed no difference between percutaneous coronary intervention (41.7%) and coronary artery bypass grafting (38.0%), regardless of Neri classification. The median time from onset to coronary reperfusion was 361.5 minutes. Preoperative acute myocardial infarction, cardiopulmonary arrest, and the requirement for MCS as independent risk factors for 30-day operative mortality.
Conclusions:
The surgical mortality rate for AAD with CM remains high, particularly in cases with left CM, with this trend becoming more pronounced as the Neri's classification advanced to type B and type C. Patients in critical conditions, such as those requiring cardiopulmonary resuscitation or MCS, were at significantly greater risk of mortality.
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