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Surgery for Type A Aortic Dissection With Cerebral Malperfusion
Quick Takes
- In a cohort of 2,402 patients with type A aortic dissection who were managed surgically, 362 (15.1%) presented with neurologic deficits indicative of cerebral malperfusion.
- Patients with cerebral malperfusion were more likely to present with syncope or shock and less likely to present with chest or back pain.
- Although cerebral malperfusion was an independent risk factor for in-hospital and 1-year mortality, survival to hospital discharge was nearly 75% among patients with cerebral malperfusion.
Study Questions:
Among patients with type A aortic dissection (TAAD) who are managed surgically, what is the incidence and prognosis of cerebral malperfusion (CM)?
Methods:
Data were drawn from the interventional cohort of the International Registry of Acute Aortic Dissection (IRAD), founded in 2010 and involving 36 centers. CM at the time of TAAD diagnosis was defined based on neurologic deficits on preoperative physical examination. Patients with and without CM were compared with regard to clinical characteristics and outcomes.
Results:
The study population included 2,402 patients who underwent surgical repair of TAAD, of whom 362 (15.1%) had CM. Patients with CM did not differ from the non-CM group with respect to aortic dissection risk factors such as hypertension, bicuspid aortic valve, or current smoking. CM patients were more likely to present with syncope (48.4% vs. 10.1%, p < 0.001), pulse deficits (52.7% vs. 38.0%, p < 0.001), and shock (16.1% vs. 4.1%, p < 0.001) and less likely to present with chest pain (66.0% vs. 86.5%, p < 0.001) or back pain (35.9% vs. 44.4%, p = 0.008). DeBakey type I dissection, which involves the ascending aorta, arch, and descending aorta, was more common among CM patients (63.8% vs. 47.1%, p < 0.001), as were arch vessel involvement (63.8% vs. 47.1%, p < 0.001), periaortic hematoma (25.2% vs. 17.5%, p = 0.009), and pericardial effusion (53.8% vs. 40.6%, p < 0.001).
Although there was no difference in hemiarch, partial arch, or complete arch replacement between the CM and non-CM groups, CM patients were cooled to a lower mean temperature during circulatory arrest (20ºC vs. 23ºC, p < 0.001). In-hospital mortality was greater in CM patients (25.7% vs. 12.0%, p < 0.001). CM patients more frequently had postoperative complications including stroke (17.5 vs. 7.2%), coma (9.2% vs. 2.6%), and acute renal failure (28.3% vs. 18.1%, all p < 0.001). Based on Kaplan-Meier estimates, 1-year survival was lower in the CM group (62.6% vs. 81.3%, p < 0.001). In multivariable logistic regression analysis, predictors of mortality included cerebral malperfusion (odds ratio [OR], 2.6; 95% confidence interval, 1.2-5.6; p = 0.012), prior cardiac surgery (OR, 2.2), myocardial ischemia/infarction (OR, 3.3), tamponade on presentation (OR, 5.3), peripheral malperfusion (OR, 2.1), and extension of dissection into the aortic root (OR, 1.9).
Conclusions:
Survival to hospital discharge was nearly 75% in a selected group of patients with TAAD and CM who underwent surgical repair. CM is an independent predictor of mortality among patients with TAAD who are managed operatively.
Perspective:
The fact that more CM patients presented with syncope than chest or back pain is noteworthy, as delays in diagnosis and treatment can contribute to poor outcomes among aortic dissection patients. End-organ malperfusion is consistently associated with higher morbidity and mortality in aortic dissection. This cohort was drawn from tertiary centers and did not include TAAD patients who were managed nonoperatively, who presumably would have been more ill and experienced worse outcomes.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Invasive Cardiovascular Angiography and Intervention, Pericardial Disease, Vascular Medicine, Aortic Surgery, Interventions and Vascular Medicine
Keywords: Acute Kidney Injury, Aneurysm, Dissecting, Aorta, Thoracic, Cardiac Surgical Procedures, Chest Pain, Coma, Dissection, Hematoma, Myocardial Infarction, Myocardial Ischemia, Neurologic Manifestations, Pericardial Effusion, Postoperative Complications, Risk Factors, Shock, Stroke, Syncope, Cardiac Tamponade
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