Resuscitation and 30-day postoperative mortality in acute type A aortic dissection: A cohort study

Background Acute type A aortic dissection (AAAD) complicated by cardiopulmonary arrest is characterized by high mortality rates, rendering the selection of surgical candidates a subject of intense debate. Despite the necessity for cardiopulmonary resuscitation (CPR) prior to the completion of a definitive intervention, the prognostic impact of CPR duration on postoperative survival and neurological outcomes remains insufficiently elucidated. This study sought to evaluate the association between pre- and intra-operative CPR duration and the incidence of early mortality and central nervous system (CNS) complications in patients undergoing emergent surgical repair for AAAD. Methods This retrospective, cohort study was conducted at two tertiary community hospitals in Japan. All the patients who underwent emergency surgery for AAAD between January 2014 and December 2024 were enrolled. A multilevel Cox proportional hazards model, with each patient as level 1 and institutions as level 2, was used to evaluate the association between pre-or intra-operative CPR events and early postoperative mortality and CNS complications. Results Of the 880 patients enrolled, 785 (89.2%), 13 (1.5%), and 82 (9.3%) were without CPR, with CPR <15 min, and with CPR ≥15 min, respectively. Among them, death within 30 days post-surgery occurred in 76/785 (9.7%), 3/13 (23.1%), and 47/82 (57.3%), respectively. CNS complications within 30 days post-surgery occurred in 141/785 (18.0%), 5/13 (38.5%), and 38/82 (46.3%) without CPR, CPR <15 min, and ≥15 min, respectively. In multivariable analysis, CPR lasting ≥15 min was associated with mortality within 30 days post-surgery (adjusted hazard ratio, 7.66; 95% confidence interval [CI], 3.56–16.5; P<0.001). Both CPR <15 min and ≥15 min were associated with an increase in the sub-hazard ratio of CNS complications within 30 days post-surgery (adjusted sub-hazard ratios, 4.49; 95% CI, 3.92–5.11; P<0.001, and 3.62; 95% CI, 2.73–4.81; P<0.001, respectively). Conclusion A preoperative CPR duration of ≥15 min prior to the initiation of cardiopulmonary bypass or extracorporeal membrane oxygenation was associated with a substantial escalation in 30-day mortality compared with patients without CPR. These findings suggest that CPR duration might serve as a pivotal prognostic indicator, necessitating careful consideration for surgical indication in patients with AAAD complicated by CPR. CLINICAL PERSPECTIVE What is new? Pre- or intra-operative cardiopulmonary resuscitation lasting ≥15 min in patients with acute type A dissection is associated with a nearly seven-fold increase in 30-day postoperative mortality. Both short (<15 min) and prolonged (≥15 min) cardiopulmonary resuscitation are associated with a higher risk of early postoperative complications in the central nervous system. What are the clinical implications? Patients with acute type A dissection who require pre- or intra-operative cardiopulmonary resuscitation ≥15 min should undergo careful multidisciplinary evaluation, as the risk of early mortality is substantially elevated. Even brief cardiopulmonary resuscitation is associated with increased neurological complications, highlighting the need for early neurological monitoring and supportive care postoperatively.