Preoperative Perfusion in Type A Aortic Dissection | Journal Scan

Study Questions:

How does preoperative organ malperfusion affect outcomes among patients presenting with type A acute aortic dissection?

Methods:

Data from 2,137 patients enrolled in the German Registry for Acute Aortic Dissection type A (GERAADA) and operated on between July 2006 and June 2010 were retrospectively analyzed. Of these, 717 patients (33.6%) had evidence of any kind of preoperative malperfusion. The number and pattern of organ systems with evidence of malperfusion were assessed as predictors of postoperative outcomes.

Results:

All-cause 30-day mortality was 16.9%, and varied dramatically depending on the number of organ systems affected by malperfusion (0 organ systems, 12.6%; 1 organ system, 21.3%; 2 organ systems 30.9%; 3 organ systems 43.4%; p < 0.001). Preoperative cerebral malperfusion, comatose state, peripheral malperfusion, visceral malperfusion, involvement of supra-aortic branches, coronary malperfusion, and renal malperfusion, all were independent predictors of developing any postoperative malperfusion syndrome. Age, peripheral malperfusion, involvement of supra-aortic branches, coronary malperfusion, spinal malperfusion, primary entry in the descending thoracic aorta, and preoperative comatose state all were significant predictors of survival.

Conclusions:

Among patients undergoing surgery for acute type A aortic dissection, malperfusion is a severe clinical condition with a strong potential for adverse outcomes. The GERAADA registry suggests that the number of organs involved and the type of malperfusion substantially affect outcomes. The authors concluded that the introduction of an appropriate classification, such as “complicated” or “uncomplicated” acute type A dissection might help to predict individual risk, as well as help in the selection of a surgical strategy that might quickly resolve malperfusion.

Perspective:

Data from this large registry of patients operated for acute type A aortic dissection reveal that postoperative outcomes were associated with the number and pattern of organ systems with preoperative malperfusion. Although this study did not report details as to how malperfusion was assessed, and the registry did not report the extent of malperfusion within an organ system, the data are sobering and important. The authors’ proposal to allow the location and extent of malperfusion syndromes to help guide therapy deserves prospective assessment.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Aortic Surgery, Interventions and Vascular Medicine

Keywords: Aneurysm, Dissecting, Aorta, Aortic Aneurysm, Thoracic, Aorta, Thoracic, Cardiac Surgical Procedures, Coma, Outcome Assessment (Health Care), Preoperative Period, Postoperative Period, Prospective Studies, Registries, Retrospective Studies, Syndrome


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