The Impact of Pre-Operative Malperfusion on Outcome in Acute Type A Aortic Dissection

Abstract

Malperfusion remains a severe clinical condition with strong potential for adverse outcomes in patients undergoing surgery for acute type A aortic dissection. The GERAADA registry suggests that the impact of the number of organs involved and the type of malperfusion on outcome differs substantially. Introducing an appropriate classification system, such as "complicated" and uncomplicated" acute type A aortic dissection, might help predict individual risk as well as select a surgical strategy that may quickly resolve malperfusion.

The effect of postoperative malperfusion after surgical treatment of type A acute aortic dissection on early and mid-term survival

“…A 12.6% early mortality rate was observed in the absence of malperfusion versus 43.4% mortality in patients with three organ systems affected by malperfusion. [13] Here, preoperative clinical symptoms and/or imaging evidence of malperfusion occurred in 119 patients. After surgery, 55 (25.7%) patients had malperfusion syndrome.…”

Management of type A dissection with malperfusion

“…Cumulative survival curves also showed no statistical significance (P=0.45), with uncomplicated patients having a median survival of 96 months versus 81 months for the malperfused patients who proceeded to surgery (Figure 14). A recent GERAADA analysis demonstrated that malperfusion is dependent on the number of affected systems (11). An analysis of our data was also undertaken to determine whether malperfusion of any particular vascular bed was an independent correlate of mortality and mesenteric malperfusion was a statistically significant independent predictor of mortality.…”

Aortic dissection: medical, interventional and surgical management

“…Operative mortality of acute type A AAD is approximately 20%, depending on the surgical technique and patient selection 24. For our own centre, 30-day mortality has been 16.0% between 2004 and 2015, with 7.1% mortality in the hands of an experienced surgeon using routine axillary cannulation and an open arch approach during replacement of the ascending aorta.…”

“…Although there are some factors predictive of negative outcome (pericardial effusion, cardiogenic shock, organ malperfusion and comatose state), all patients with type A AAD should undergo surgery because they are otherwise unlikely to survive 24. Even in patients aged >70 years, a large registry demonstrated superiority of surgery over medical treatment 25.…”

“…The aortic arch should be opened and inspected, which makes the anastomosis on the distal AA easily facilitated. Nevertheless, more than a replacement of the aortic hemi-arch is rarely needed, which can be performed safely, and carries a lower risk of aortic-related reintervention in the long term 24. In case of dissection of supra-aortic branches, end-to-end grafting may be needed.…”