Rapid Response in Type A Aortic Dissection: Is There a Decisive Time Interval for Surgical Repair?

ABSTRACT

BACKGROUND AND AIM OF THE STUDY The objective was to evaluate whether there is a decisive time interval for patients to undergo surgery and to analyze if a rapid response in acute aortic dissection type A (AADA) affects patient selection. METHODS: In 283 patients undergoing surgery for AADA, median time from onset of initial symptoms to skin incision was 6.9 hours (interquartile range [IQR], 5.0-11.7 hours). Patients were divided into three groups according to median time point of surgery (median ± 3 hours, i.e., 4-10; < 4; and >10 hours). RESULTS: Almost 50% of patients presented in a critical preoperative state at hospital admission. Subanalysis identified patients being operated within 4 hours as an exclusive high-risk cohort (higher rates of preoperative neurologic dysfunction, tamponade, and cardiopulmonary resuscitation). Patients undergoing surgery between 4 and 10 hours showed a significantly better long-term survival (p = 0.021). Surgery within this time interval had a clear protective effect on 30-day mortality (odds ratio [OR] 0.448. 95% confidence interval [CI] 0.219-0.915). High age (OR 1.037; 95% CI 1.008-1.067), preoperative malperfusion syndrome (OR 2.802; 95% CI 1.351-5.811), and preoperative tamponade (OR 2.621; 95% CI 1.171-5.866) were factors predicting 30-day mortality. CONCLUSION: Rapid response in AADA interacts with the natural course of the disease resulting in an overrepresentation of critical patients. While the cohort below 4 hours represents the high-risk patients, time from symptom onset to initiation of surgery should not exceed 10 hours.