Preoperative shock determines outcome for acute type A aortic dissection.

ABSTRACT

BACKGROUND: Acute type A aortic dissection is a life-threatening catastrophe. Surgical results have not improved. METHODS: The charts of all 70 patients surgically treated for acute type A primary aortic dissection during the period of January 1988 through April 2001 were reviewed. RESULTS: Average age was 59 +/- 2 years. Comorbidities included hypertension (66%), coronary artery disease (17%), and Marfan's syndrome (11%). At presentation, 23% were in shock, 17% had neurologic dysfunction, and 36% had coronary ischemia. The aortic valve was preserved in 55. Distal aortic anastomosis was performed under aortic cross-clamp ("closed") in 32 and "open" under circulatory arrest in 38 patients. Operative mortality was 18.6% (13 of 70 patients). Patients in shock had an operative mortality of 50% compared with stable patients of 9% (p = 0.0002). Mortality was similar regardless of technique. Univariate analysis revealed preoperative shock (p = 0.0002), tamponade (p = 0.003), and neurologic deficit (p = 0.02) to be associated with mortality. Multivariate analysis revealed hemodynamic stability (odds ratio = 0.10, p = 0.04) and outside transfer (odds ratio = 0.12, p = 0.03) to be negative predictors of mortality. Of 57 survivors, follow-up was 93% complete for an average of 46 +/- 6 months. The overall late reoperation rate was 24.6% (14 of 57 patients) at 50.3 +/- 12.3 months. Twelve patients (21%) underwent future aortic aneurysmal repair. No difference in reoperation rate was seen comparing "closed" (26%) with "open" (18%; p = 0.46). Of 42 preserved native valves, only 3 (7.1%) needed future valve replacement. CONCLUSIONS: In our experience, operative mortality was determined by preoperative hemodynamic instability. Technique did not impact survival or late reoperation. Early diagnosis and repair is critical to improving survival.