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Malperfusion in type A aortic dissection: results of emergency central aortic repair

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Abstract

Background

Although outcomes of acute type A aortic dissection (ATAAD) have improved, malperfusion remains associated with high morbidity and mortality rates, and its optimal therapeutic treatment is unknown. Emergency central repair has been performed as our first-line approach for malperfusion. Here, we analyzed outcomes of ATAAD with malperfusion and reassessed emergency central repair.

Methods

In total, 1026 ATAAD patients underwent emergency surgery within 48 h of symptom onset, of whom 318 (30.9%) patients complicated with any preoperative malperfusion were included. Pathophysiology of malperfusion and surgical outcomes were analyzed.

Results

The in-hospital mortality rate was 12.9% for patients with malperfusion and 4.8% for patients without malperfusion (p < 0.0001). Coronary malperfusion was complicated in 7.5% of patients (% dead per group, 19.5%), mesenteric malperfusion in 3.6% (24.3%), renal malperfusion in 8.8% (14.4%), lower leg malperfusion in 12.6% (13.7%), brain malperfusion in 9.7% (12.0%), and spinal malperfusion in 1.1% (18.2%). Mortality rates varied substantially according to the number of affected organ systems (none, 4.8%; one system, 10.4%; two systems, 14.5%; three systems, 30.0%, and four systems; 30.3%; p < 0.0001). In malperfused patients, logistic regression analysis revealed that obesity (body mass index > 30 kg/m2), preoperative shock (systolic blood pressure < 80 mmHg), and visceral ischemia were independent predictors for hospital death.

Conclusions

Malperfusion of more organ systems and mesenteric malperfusion resulted in unfavorable prognosis, and effects of central repair were limited in such severe/complex malperfusion. To further improve outcomes of ATAAD with malperfusion, emergency reperfusion of affected organs followed by central repair might be considered.

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References

  1. Masuda M, Okumura M, Doki Y, Endo S, Hirata Y, Kobayashi J, et al. Thoracic and cardiovascular surgery in Japan during 2014: annual report by The Japanese Association for Thoracic Surgery. Gen Thorac Cardiovasc Surg 2016;64:665–97.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Geirsson A, Szeto WY, Pochettino A, McGarvey ML, Keane MG, Woo YJ, et al. Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations. Eur J Cardiothorac Surg. 2007;32:255–62.

    Article  PubMed  Google Scholar 

  3. Girdauskas E, Kuntze T, Borger MA, Falk V, Mohr FW. Surgical risk of preoperative malperfusion in acute type A aortic dissection. J Thorac Cardiovasc Surg. 2009;138:1363–9.

    Article  PubMed  Google Scholar 

  4. Pacini D, Leone A, Belotti LM, Fortuna D, Gabbieri D, Zussa C, et al. Acute type A aortic dissection: significance of multiorgan malperfusion. Eur J Cardiothorac Surg. 2013;43:820–6.

    Article  PubMed  Google Scholar 

  5. Czerny M, Schoenhoff F, Etz C, Englberger L, Khaladj N, Zierer A, et al. The impact of pre-operative malperfusion on outcome in acute type A aortic dissection: results from the GERAADA registry. J Am Coll Cardiol. 2015;65:2628–35.

    Article  PubMed  Google Scholar 

  6. Berretta P, Trimarchi S, Patel HJ, Gleason TG, Eagle KA, Di Eusanio M. Malperfusion syndromes in type A aortic dissection: what we have learned from IRAD. J Vis Surg. 2018;4:65.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Goldberg JB, Lansman SL, Kai M, Tang GHL, Malekan R, Spielvogel D. Malperfusion in type A dissection: consider reperfusion first. Semin Thorac Cardiovasc Surg. 2017;29:181–5.

    Article  PubMed  Google Scholar 

  8. Uchida K, Karube N, Kasama K, Minami T, Yasuda S, Goda M, et al. Early reperfusion strategy improves the outcomes of surgery for type A acute aortic dissection with malperfusion. J Thorac Cardiovasc Surg. 2018;156:483–9.

    Article  PubMed  Google Scholar 

  9. Aizawa K, Kawahito K, Misawa Y. Long-term outcomes of tear-oriented ascending/hemiarch replacements for acute type A aortic dissection. Gen Thorac Cardiovasc Surg. 2016;64:403–8.

    Article  PubMed  Google Scholar 

  10. Grimm JC, Magruder JT, Crawford TC, Sciortino CM, Zehr KJ, Mandal K, et al. Differential outcomes of type A dissection with malperfusion according to affected organ system. Ann Cardiothorac Surg. 2016;5:202–8.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Yang B, Patel HJ, Williams DM, Dasika NL, Deeb GM. Management of type A dissection with malperfusion. Ann Cardiothorac Surg. 2016;5:265–74.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Perera NK, Galvin SD, Seevanayagam S, Matalanis G. Optimal management of acute type A aortic dissection with mesenteric malperfusion. Interact Cardiovasc Thorac Surg. 2014;19:290–4.

    Article  PubMed  Google Scholar 

  13. Yamashiro S, Arakaki R, Kise Y, Inafuku H, Kuniyoshi Y. Management of visceral malperfusion complicated with acute type A aortic dissection. Interact Cardiovasc Thorac Surg. 2015;21:346–51.

    Article  PubMed  Google Scholar 

  14. Tsagakis K, Konorza T, Dohle DS, Kottenberg E, Buck T, Thielmann M, et al. Hybrid operating room concept for combined diagnostics, intervention and surgery in acute type A dissection. Eur J Cardiothorac Surg. 2013;43:397–404.

    Article  PubMed  Google Scholar 

  15. Shimamoto T, Komiya T. Clinical dilemma in the surgical treatment of organ malperfusion caused by acute type A aortic dissection. Gen Thorac Cardiovasc Surg. 2014;62:398–406.

    Article  PubMed  Google Scholar 

  16. Howard TJ, Plaskon LA, Wiebke EA, Wilcox MG, Madura JA. Nonocclusive mesenteric ischemia remains a diagnostic dilemma. Am J Surg. 1996;171:405–8.

    Article  CAS  PubMed  Google Scholar 

  17. Lawton JS, Moon MR, Liu J, Koerner DJ, Kulshrestha K, Damiano RJ Jr, et al. The profound impact of combined severe acidosis and malperfusion on operative mortality in the surgical treatment of type A aortic dissection. J Thorac Cardiovasc Surg. 2018;155:897–904.

    Article  PubMed  Google Scholar 

  18. Zindovic I, Luts C, Bjursten H, Herou E, Larsson M, Sjögren J, et al. Perioperative hyperlactemia is a poor predictor of outcome in patients undergoing surgery for acute type-A aortic dissection. J Cardiothorac Vasc Anesth. 2018;32:2479–84.

    Article  PubMed  Google Scholar 

  19. Kawahito K, Adachi H, Murata S, Yamaguchi A, Ino T. Coronary malperfusion due to type A aortic dissection: mechanism and surgical management. Ann Thorac Surg. 2003;76:1471–6.

    Article  PubMed  Google Scholar 

  20. Chiu P, Tsou S, Goldstone AB, Louie M, Woo YJ, Fischbein MP. Immediate operation for acute type A aortic dissection complicated by visceral or peripheral malperfusion. J Thorac Cardiovasc Surg. 2018;156:18–24.

    Article  PubMed  Google Scholar 

  21. Kimura N, Tanaka M, Kawahito K, Yamaguchi A, Ino T, Adachi H. Influence of patent false lumen on long-term outcome after surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg. 2008;136:1160–6.

    Article  PubMed  Google Scholar 

  22. Kimura N, Itoh S, Yuri K, Adachi K, Matsumoto H, Yamaguchi A, et al. Reoperation for enlargement of the distal aorta after initial surgery for acute type A aortic dissection. J Thorac Cardiovasc Surg. 2015;149(2 Suppl):91–8.

    Article  Google Scholar 

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Correspondence to Koji Kawahito.

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Koji Kawahito and the other authors have no conflict of interest.

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Kawahito, K., Kimura, N., Yamaguchi, A. et al. Malperfusion in type A aortic dissection: results of emergency central aortic repair. Gen Thorac Cardiovasc Surg 67, 594–601 (2019). https://doi.org/10.1007/s11748-019-01072-z

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  • DOI: https://doi.org/10.1007/s11748-019-01072-z

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