Malperfusion in Patients With Acute Type A Aortic Dissection: A Nationwide Analysis

BACKGROUND: This study describes in detail the clinical burden of malperfusion associated with acute type A aortic dissection (ATAAD) in a large, national cohort and the effect of treatment strategy on outcomes. METHODS: All patients undergoing repair of ATAAD between 2017 and 2020 in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database were studied. Malperfusion was defined using STS definitions on the basis of imaging or the surgeon's evaluation. Multivariable logistic regression was used to analyze the effect of patient and treatment factors on outcomes in patients with and without malperfusion. RESULTS: A total of 9958 patients undergoing ATAAD repair were studied. Preoperative malperfusion occurred in 27.7% (2748 of 9958) of cases and most often involved the extremity (14.9%; 1484 of 9958), renal (10.2%), or cerebral (9.8%) vascular beds. Operative mortality was much greater among patients with malperfusion (26.8% vs 13.6%; P < .001). After adjustment, coronary malperfusion was associated with the highest odds of mortality (odds ratio, 2.28; 95% CI, 1.85-2.81; P < .001) followed by mesenteric malperfusion (odds ratio, 1.82; 95% CI, 1.45-2.28; P < .001). Cerebral malperfusion was not independently associated with significantly increased odds of mortality (odds ratio, 1.14; 95% CI, 0.94-1.38; P = .18). Partial arch replacement (zone 1 or zone 2) compared with ascending aorta or hemiarch replacement only showed a similar rate of mortality in patients with malperfusion (24.8% vs 26.9%; P = .99) and without malperfusion (11.6% vs 13.6%; P = .54). CONCLUSIONS: Preoperative malperfusion in ATAAD was common and associated with significant operative mortality, which varied according to the malperfused region. Partial aortic arch replacement, compared with ascending aorta or hemiarch replacement alone, was not associated with increased mortality.