Impact of Surgery Timing and Malperfusion on Acute Type A Aortic Dissection Outcomes

OBJECTIVE

 This study aimed to determine the impact of symptom-to-surgery time on mortality in acute type A aortic dissection (ATAAD) patients, with and without malperfusion.

METHODS

 A retrospective analysis of 288 ATAAD patients was conducted. Patients were separated into the early (≤10 h) and late (>10 h) groups by symptom-to-surgery time. Data on characteristics, surgery, and complications were compared, and multivariable logistic regression determined mortality risk factors.

RESULTS

 Mortality rates did not significantly differ between early and late groups. Age (odds ratio [OR] 1.09, 95% CI 1.05-1.13, p < 0.001), extracorporeal membrane oxygenation use (OR 10.73, 95% CI 2.51-45.87, p = 0.001), and malperfusion (OR 6.83, 95% CI 2.84-16.45, p < 0.001) predicted operative death. Subgroup analysis showed cerebral (OR 3.20, 95% CI 1.11-9.26, p = 0.031), cardiac (OR 5.89, 95% CI 1.32-26.31, p = 0.020), and limb (OR 6.20, 95% CI 1.75-22.05, p = 0.005) malperfusion as predictors of operative death. One (OR 6.30, 95% CI 2.39-16.61, p < 0.001), two (OR 12.79, 95% CI 2.74-59.81, p = 0.001), and three (OR 46.99, 95% CI 7.61-288.94, p < 0.001) organs malperfusion, together with Penn B (OR 7.96, 95% CI 3.04-20.81, p < 0.001) and Penn B-C (OR 12.50, 95% CI 2.65-58.87, p = 0.001) classifications predict operative mortality. Survival analysis revealed significant differences between malperfusion and no malperfusion (34% vs. 9%, p < 0.001) but not between late and early (14% vs. 21%, p = 0.132) groups. Malperfusion remained an essential predictor of operative (OR 7.06 95% CI 3.11-17.19, p < 0.001) and midterm mortality (OR 3.38 95% CI 1.97-5.77, p < 0.001) in subgroup analysis.

CONCLUSION

 Preoperative malperfusion status, rather than symptom-to-surgery time, significantly impacts both operative and midterm mortality in ATAAD patients.

Total aortic arch replacement in acute type A aortic dissection - a single institutional experience

Aim

Total arch replacement in the presence of acute aortic dissections is one of the most challenging areas of aortic surgery. Data on outcome in the Indian scenario is sparse. The aim of this study was to assess the outcome of arch replacements in a single tertiary care center.

Material and methods

In this single-center experience, 20 patients underwent total arch replacement between 2012 and 2022. Demographic, intraoperative, and postoperative data were abstracted from hospital records. Only patients with acute type A aortic dissection needing an arch repair were included. Patients with hemi-arch repairs, hybrid repairs, and those operated upon due to aneurysmal disease were excluded from the study. Comparison was made between survivors and non-survivors. Temporal trends for the procedure were assessed.

Results

The study included 20 patients who underwent total aortic arch replacement (TAR) during the study period (2012-2022). The mean age was 49.3 ± 12.5 years, and 15 (75%) of the patients were males. Seven (35%) patients were operated within 24 h of symptom onset. Permanent stroke was seen in 1 (5%) patient and temporary neurological dysfunction was observed in 1 (5%) patient. The re-exploration rate was 6 (30%) in the entire cohort and in-hospital mortality was 4 (20%). Follow-up was complete in 18 (90%) of the study population and 14 (87.5%) among survivors. There was one late death in our study which occurred after 46 months of the index operation. The overall mean survival was 76.1 months (95% CI: 49.86-102.43).

Conclusion

TAR can be performed both with acceptable mortality and morbidity in the presence of acute aortic dissections.

Onset of pain to surgery time in acute aortic dissections type A: a mandatory factor for evaluating surgical results?

Objective

An acute aortic dissection type A (AADA) is a rare but life-threatening event. The mortality rate ranges between 18% to 28% and mortality is often within the first 24 h and up to 1%-2% per hour. Although the onset of pain to surgery time has not been a relevant factor in terms of research in the field of AADA, we hypothesize that a patient's preoperative conditions depend on the length of this time.

Methods

Between January 2000 and January 2018, 430 patients received surgical treatment for acute aortic dissection DeBakey type I at our tertiary referral hospital. In 11 patients, the exact time point of initial onset of pain was retrospectively not detectable. Accordingly, a total of 419 patients were included in the study. The cohort was categorized into two groups: Group A with an onset of pain to surgery time < 6 h (n = 211) and Group B > 6 h (n = 208), respectively.

Results

Median age was 63.5 years (y) ((IQR: 53.3-71.4 y); (67.5% male)). Preoperative conditions differed significantly between the cohorts. Differences were detected in terms of malperfusion (A: 39.3%; B: 23.6%; P: 0.001), neurological symptoms (A: 24.2%; B: 15.4%; P: 0.024), and the dissection of supra-aortic arteries (A: 25.1%; B: 16.8%; P: 0.037). In particular, cerebral malperfusion (A 15.2%: B: 8.2%; P: 0.026) and limb malperfusion (A: 18%, B: 10.1%; P: 0.020) were significantly increased in Group A. Furthermore, Group A showed a decreased median survival time (A: 1,359.0 d; B: 2,247.5 d; P: 0.001), extended ventilation time (A: 53.0 h; B: 44.0 h; P: 0.249) and higher 30-day mortality rate (A: 25.1%; B: 17.3%; P: 0.051).

Conclusions

Patients with a short onset of pain to surgery time in cases of AADA present themselves not only with more severe preoperative symptoms but are also the more compromised cohort. Despite early presentation and emergency aortic repair, these patients show increased chances of early mortality. The "onset of pain to surgery time" should become a mandatory factor when making comparable surgical evaluations in the field of AADA.

"Time is aorta?": Timeliness of surgical repair in type A aortic dissection

Acute type A aortic dissection is a life‐threatening event that requires prompt management, a complex interaction among the timing of aortic surgical repair, presence or absence of organ malperfusion, and surgical outcomes exists. Whether resection of intimal entry tear should be deferred after reversal of malperfusion and end‐organ ischemia is a matter of controversy. In fact, the timing of aortic repair should be considered within the clinical presentation and baseline characteristics of each patient. Moreover, every effort should be made to minimize times between symptom onset, diagnosis, and surgery.