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Operative Delay for Malperfusion Syndrome in Acute Type A Aortic Dissection: A Long Term Analysis
H. J. Patel, D. M. Williams, G. M. Deeb. University of Michigan Hospitals, Ann Arbor, MI,
BACKGROUND:
Successful recovery from operative repair of acute Type A dissection in the setting of malperfusion with end-organ dysfunction remains a considerable challenge. Based on previous work from our institution suggesting an improvement in early outcome, we have applied a consistent strategy over the last decade in treating patients admitted with acute Type A dissection with suspected malperfusion. This entails percutaneous intervention to restore end-organ perfusion, and delayed operative repair following resolution of the malperfusion syndrome. This study reports the long term results obtained with this strategy and contrasts these outcomes with those obtained in patients presenting with presumed uncomplicated dissection.
METHODS:
178 consecutive patients were admitted with acute Type A dissection from 1997-2006. 60 patients (33.7%) were suspected of having neurologic, visceral, renal and/or limb malperfusion with end-organ dysfunction (MP-AD). This group underwent immediate angiography with percutaneous fenestration and aortic and/or branch vessel stenting where appropriate. Operative therapy was planned following resolution of the malperfusion syndrome. An outcomes analysis on an intent to treat basis was performed, comparing patients presenting with uncomplicated (UC-AD, n=118) vs. suspected malperfusion (MP-AD, n=60) acute dissection. Followup was 100% complete at a mean of 43±38 months.
RESULTS:
The mean age of the cohort was 56.6 years (71.9% male) and was similar between groups (p=0.91). Univariate analysis revealed similar prevalences of comorbidities between groups. Operative therapy was undertaken in 157 patients (n=118, UC-AD and n=39, MP-AD). For the operated MP-AD subgroup, operative therapy was delayed by a median of 3 days from the time of initial presentation. The remaining 21 MP-AD patients expired prior to repair, secondary to complications of malperfusion (12) or aortic rupture (9), while awaiting resolution of the malperfusion syndrome. Extent of operation, including need for CABG (11), root replacement (64) and extended arch resection (58) was similar between groups. Seventeen patients (10.8%) had prior cardiac surgery. Mean perfusion, cross clamp and hypothermic circulatory arrest times were similar between groups. Operative mortality was seen in 9.6% of all patients (UC-AD 9.3% vs. operated MP-AD 10.3%, p=1.0). Major morbidity included need for dialysis in 10.8% (UC-AD 8.5% vs. operated MP-AD 17.9%, p=0.13) and postoperative stroke in 7.6% (UC-AD 8.5% vs. operated MP-AD 5.4%, p=0.7). When analyzing the entire cohort (n=178), long-term survival was higher for the uncomplicated group (Kaplan-Meier mean survival UC-AD 90.8 months vs. MP-AD 53.3 months, p<0.001). However, a subgroup analysis of only operated patients (n=157) revealed similar long-term survival between uncomplicated and operated MP-AD groups (Kaplan-Meier mean survival UC-AD 90.8 months vs. operated MP-AD 82 months, p=0.96).
CONCLUSIONS:
Presentation with acute Type A dissection, malperfusion and end-organ dysfunction is an important adverse factor for long term survival. A strategy of immediate reperfusion, stabilization and planned operative repair still carries a significant risk for early mortality. However, those patients who survive the initial malperfusion and undergo repair have a similar operative and late survival when compared to those patients presenting with uncomplicated dissection.
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