Acute Type A Aortic Dissection Repair: Short-term analysis of surgical outcomes.
Abdulrahman H. Hassab*, James Antonios, Prashanth Vallabhajosyula, Roland Assi
Surgery, Yale University, New Haven, CT
Objectives
We sought to investigate the short-term operative outcomes and the 12-month survival rates after surgery for acute type A aortic dissection on 80 consecutive patients with the identification of predictors for major adverse events and operative mortality.
Methods
This is a retrospective single-center study. Data from 80 consecutive patients who had surgery for acute type A aortic dissection between October 2019 and October 2022 at Yale New Haven Hospital were collected. All patients were operated on by aortic surgeons following the same operative techniques. Two separate analyses were performed to identify predictors associated with the development of major adverse events (n=29) and operative mortality (n=8). Major adverse events (MAEs) include operative mortality, postoperative permanent stroke, postoperative renal failure requiring permanent dialysis, postoperative cardiac arrest, reoperation, and prolonged ventilation necessitating tracheostomy. Operative mortality is defined as death, regardless of the cause occurring during the same hospitalization or within 30 days after surgery. Kaplan"“Meier analysis was used to identify the 3, 6, and 12-month probability of survival after hospital discharge for patients who developed MAEs (operative mortality excluded) and those who did not.
Results
The mean age for patients was 65.2 "± 13.7 years with males representing 65%. Hypertension was the most common risk factor detected. Cardiogenic shock, free rupture, and visceral malperfusion had a statistically significant association with both MAEs and operative mortality, while preoperative creatinine was only associated with MAEs. No operative differences were seen among those who developed MAEs or who expired. Of all patients who had postoperative ECMO, 100% developed major adverse events and 50% died. Peak postoperative creatinine level (P<0.001), pneumonia (P=0.002), and sepsis (P=0.02) were statistically associated with MAEs. Postoperative renal failure (P=0.05), and unplanned reoperation (P=0.007) demonstrated a statistically significant association with operative mortality. Multiple logistic regression analyses indicate that cardiogenic shock, visceral malperfusion, and preoperative creatinine levels are strong predictors for both MAEs and operative mortality. Survival analysis after hospital discharge at 3, 6, and 12 months show lower survival rates for those who developed postoperative MAEs.
Conclusions
Preoperative presentations and not patients "™demographics nor associated comorbidities were the strongest predictors for the development of postoperative major adverse events and operative mortality, particularly cardiogenic shock and visceral malperfusion. Minimizing inter-surgeon variability in the surgical treatment of ATAADs helped to limit the impact of the operative technique on postoperative outcomes. Even after discharge, patients who developed MAEs had lower survival rates than those who didn"™t.
Predictors for major adverse events identified by multivariable logistic regression analysis.
| Predictors | Odds Ratio (OR) | 95% confidence interval (CI) | P-value |
| CNS malperfusion | 1.38 | 0.405 - 4.67 | 0.60 |
| Cardiogenic shock | 4.99 | 1.56 - 17.6 | 0.009 |
| Preoperative creatinine level | 2.23 | 1.17 - 6.05 | 0.046 |
| Visceral malperfusion | 6.82 | 1.94 - 27.2 | 0.004 |
| Illiofemoral malperfusion | 0.755 | 0.176 - 3.02 | 0.70 |
Predictors for operative mortality identified by multivariable logistic regression analysis.
| Predictors | Odds Ratio (OR) | 95% confidence interval (CI) | P-value |
| CNS malperfusion | 1.08 | 0.139 - 8.38 | 0.94 |
| Cardiogenic shock | 15.9 | 1.91 - 439 | 0.031 |
| Preoperative creatinine level | 2.98 | 1.37 - 9.92 | 0.02 |
| Visceral malperfusion | 9.76 | 1.26 - 120 | 0.042 |
| Illiofemoral malperfusion | 0.253 | 0.0184 - 2.54 | 0.26 |
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