Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations

• Published in: European journal of cardio-thoracic surgery Vol. 32; no. 2; pp. 255 - 262
• Main Authors: Geirsson, Arnar, Szeto, Wilson Y., Pochettino, Alberto, McGarvey, Michael L., Keane, Martin G., Woo, Y. Joseph, Augoustides, John G., Bavaria, Joseph E.
• Format: Journal Article
• Language: English
• Published: Amsterdam Elsevier Science B.V 01.08.2007; Elsevier Science
• Subjects: Acute Disease; Aneurysm, Dissecting - mortality; Aneurysm, Dissecting - surgery; Aortic Aneurysm - mortality; Aortic Aneurysm - surgery; Aortic dissection; Biological and medical sciences; Blood and lymphatic vessels; Blood Circulation - physiology; Cardiology. Vascular system; Cerebral complications; Cerebral Revascularization - methods; Coronary Circulation - physiology; Diseases of the aorta; Diseases of the peripheral vessels. Diseases of the vena cava. Miscellaneous; Female; Humans; Kaplan-Meier Estimate; Male; Malperfusion; Medical sciences; Motor Activity - physiology; Myocardial Revascularization - methods; Outcomes; Paraplegia - physiopathology; Postoperative Complications; Pulse; Renal Circulation - physiology; Risk Factors; Sensation - physiology; Splanchnic Circulation - physiology; Stroke - complications; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Syndrome; Treatment Outcome; Vascular Surgical Procedures - methods; Aortic dissection; Cerebral complications; Malperfusion; Outcomes; Corrective surgery; Prognosis; Acute; Cardiovascular disease; Syndrome; Encephalon; Arterial disease; Vascular disease; Dissecting aneurysm; Need; Treatment; Heart disease; Complication; Evolution; Repair; Aortic disease; Revascularization
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1016/j.ejcts.2007.04.012

Objective: The aim of this study was to assess the significance of malperfusion syndromes in patients with acute type A aortic dissection following a contemporary surgical management algorithm and the effects on morbidity, hospital mortality, and long-term survival. We believe that obliteration of the primary tear site with restoration of flow in the true aortic lumen results in decreased need for revascularization of malperfused organ systems. Methods: Our operative approach aims at replacing the entire ascending aorta, resuspension of the aortic valve with repair or replacement of the sinus segment, and routine open replacement of the arch under hypothermic circulatory arrest with retrograde cerebral perfusion with obliteration of false lumen at the distal arch/proximal descending thoracic aorta, thus reestablishing normal flow in the descending thoracic true lumen. From January 1993 to December 2004, 221 consecutive patients underwent repair of acute type A aortic dissection at our institution. Data were collected retrospectively and prospectively. Various types of malperfusion syndromes were present in 26.7% of patients. The organ systems with malperfusion were as follows: cardiac, 7.2%; cerebral, 7.2%; iliofemoral, 12.7%; renal, 4.1%; mesenteric, 1.4%; innominate, 5.4%; and spine, 2.2%. Results: Coronary malperfusion required coronary revascularization in 62.5% of cases. Distal revascularization was needed in 42.9% of patients with iliofemoral malperfusion. Patients with malperfusion were more likely to suffer perioperative myocardial infarction (p ≪ 0.001), postoperative coma (p = 0.012), delirium (p = 0.011), sepsis (p = 0.006), acute renal failure (p = 0.017), dialysis (p = 0.018), and acute limb ischemia (p ≪ 0.001). The in-hospital mortality was 30.5% in patients presenting with any malperfusion syndrome while only 6.2% in patients without malperfusion syndrome (p ≪ 0.001). Both cardiac (p = 0.020) and cerebral malperfusions (p ≪ 0.001) were risk factors for in-hospital mortality. The actuarial long-term survival in patients with malperfusion syndrome was estimated by Kaplan–Meier methods to be 67.8% ± 6.1% at 1 year, 54.0% ± 7.0% at 5 years, and 43.1% ± 8.0% at 10 years and for patient without malperfusion 82.7% ± 3.0% at 1 year, 66.3% ± 3.9% at 5 years, and 46.1% ± 6.7% at 10 years (log rank 2.55, p = 0.110). Cerebral malperfusion was a significant risk factor for decreased long-term survival (p = 0.0002). Conclusions: The occurrence of malperfusion in patients with acute type A dissection is associated with significant increased risk of in-hospital mortality and complications. Additional revascularization is generally needed in patients with coronary malperfusion and iliofemoral malperfusion. Patients presenting with cardiac and cerebral malperfusions have a high hospital mortality and preoperative cerebral malperfusion is associated with dismal long-term survival.