Malperfusion on Presentation Versus Complexity of Operation as Determinants of Early Mortality in Acute Type A Aortic Dissection

Abstract Degree of malperfusion on presentation is a known determinant of early mortality in acute Type A aortic dissection (TAAD). Its prediction of mortality when stratified by complexity of central repair has not been well-described. Over a 6-year period, 183 patients had a central repair for TAAD, 146 of whom had a spontaneous etiology and an acute presentation (≤14 days). Each patient was assigned a Penn Class based on ischemia (malperfusion): A-none, B-regional, or C-global. The index operation was identified as simple (ascending aorta and/or hemiarch replacement) or complex (concomitant root replacement, arch replacement, or coronary artery bypass grafting). Early mortality was defined as in-hospital or within 30 days of surgery, if discharged. The overall early mortality was 10.3% (15/146), and it was significantly different in each Penn Class: 1.5% (1/65) for A, 8.7% (4/46) for B, 22.8% (8/35) for C (p = 0.002). Six patients in Penn Class C had preincision cardiac arrest with cardiopulmonary resuscitation, three surviving. The early mortality differences, however, between the simple (8.3%) and complex (14.0%) operative groups overall and within each Penn Class were not significant. Of the six groups, the lowest mortality was evident in the 41 patients in Penn Class A who had a simple operation, whereas the highest was seen in the 13 Penn Class C patients who underwent a complex operation (0 vs. 23.1%, p = 0.001). In spontaneous acute TAAD, degree of malperfusion on presentation, rather than operative complexity, was the dominant factor in early mortality.