Background: Immediate open repair of acute type A aortic dissection (ATAAD) is traditionally recommended to prevent death from aortic rupture. However, organ failure due to malperfusion syndrome (MPS) might be the most imminent life-threatening problem for a subset of patients. Methods: From 1996–2017, among 597 ATAAD patients, 135 patients with MPS were treated with upfront endovascular reperfusion (fenestration/stenting) followed by delayed open repair (OR). We compared outcomes between the first and second decade, as well as observed mortalities with those expected with an “upfront OR for every patient” approach, determined using prognostic models from the literature (Verona, Leipzig-Halifax, Stockholm, Penn, and GERAADA models). Results: Overall, in-hospital mortality improved between the two decades (21.0% vs. 10.7%, p<0.001). In the second decade, for MPS patients initially treated with fenestration/stenting, mortality from aortic rupture decreased from 16% to 4% (p=0.05), the risk of dying from organ failure was 6.6 times higher than dying from aortic rupture (hazard ratio = 6.63, 95%CI 1.5–29, p=0.01), and 30-day mortality after OR for MPS patients was 3.7%. Compared to the expected mortalities with the “upfront OR for every patient” models, our observed 30-day and in-hospital mortalities (9% and 11%, respectively) of all ATAAD patients were significantly lower (p≤0.03). Conclusions: Immediate open repair is the strategy to prevent death from aortic rupture for the majority of ATAAD patients. However, relatively stable (no rupture, no tamponade) patients with MPS benefit from a staged approach: upfront endovascular reperfusion followed by open aortic repair at resolution of organ failure. Related to an abstract (“Malperfusion Syndrome Management in Acute Type A Aortic Dissection: Two-Decade Experience”) presented at the AHA Scientific Sessions 2017 (Anaheim, CA, Nov 2017).

Objective: To assess outcomes of endovascular reperfusion followed by delayed open aortic repair for stable patients with acute type A aortic dissection and mesenteric malperfusion syndrome (mesMPS).Methods: Among 602 patients with acute type A aortic dissection who presented to our center from 1996 to 2017, all 82 (14%) with mesMPS underwent upfront endovascular fenestration/stenting. Primary outcomes were in-hospital mortality and long-term survival. Patients with acute type A aortic dissection with no malperfusion syndrome of any organ (n ¼ 419) served as controls.Results: In-hospital mortality of all comers with mesMPS was 39%. After endovascular fenestration/stenting, 20 mesMPS patients (24%) died from organ failure and 11 patients (13%) died from aortic rupture before open aortic repair, 47 patients (58%) underwent aortic repair, and 4 patients (5%) survived without open repair. No patients died from aortic rupture during the second decade (2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015)(2016)(2017). The significant risk factors for death from organ failure after endovascular reperfusion were acute stroke (odds ratio, 23; 95% confidence interval, 4-144; P ¼ .0008), gross bowel necrosis at laparotomy (odds ratio, 7; 95% confidence interval, 1.4-34; P ¼ .016), and serum lactate 6 mmol/L (odds ratio, 13.5; 95% confidence interval, 2-97; P ¼ .0097). There was no significant difference in operative mortality (2.1% vs 7.5%; P ¼ .50) or long-term survival between patients with mesMPS who underwent open aortic repair after recovering from mesMPS and patients with no malperfusion syndrome.

Objective: The study objective was to evaluate the perioperative and long-term outcomes of aortic root repair and aortic root replacement and provide evidence for root management in acute type A aortic dissection.Methods: From 1996 to 2017, 491 patients underwent aortic root repair (n ¼ 307) or aortic root replacement (n ¼ 184) (62% bioprosthesis) for acute type A aortic dissection. Indications for aortic root replacement were intimal tear at the aortic root, root measuring 4.5 cm or more, connective tissue disease, or unrepairable aortic valvulopathy. Primary outcomes were in-hospital mortality, long-term survival, and reoperation rate for root pathology.Results: Patients' median age was 61 years and 56 years in the aortic root repair group and aortic root replacement group, respectively. The aortic root replacement group had more renal failure requiring dialysis, previous cardiac intervention or surgery, heart failure, coronary malperfusion syndrome, acute myocardial infarction, and severe aortic insufficiency, as well as concomitant coronary artery bypass grafting, tricuspid valve repair, and longer cardiopulmonary bypass and aortic crossclamp times but similar arch procedures. Perioperative outcomes were similar in the aortic root repair and aortic root replacement groups, including in-hospital mortality (8.5% and 8.2%), new-onset renal failure requiring permanent dialysis, stroke, myocardial infarction, and sepsis. Kaplan-Meier 10-year survival was 62% and 65%, and the 15-year cumulative incidence of reoperation was 11% and 7% in the aortic root repair and aortic root replacement groups, respectively. The primary indication for root reoperation was aortic root aneurysm in the aortic root repair group and bioprosthetic valve deterioration in the aortic root replacement group.Conclusions: Aortic root repair and aortic root replacement are appropriate surgical options for acute type A aortic dissection repair with favorable short-and long-term outcomes. Aortic root replacement should be performed for patients with acute type A aortic dissection presenting with an intimal tear at the aortic root, root aneurysm 4.5 cm or greater, connective tissue disease, or unrepairable aortic valvulopathy.

Background Post-operative pneumonia is the most prevalent of all hospital-acquired infections following isolated coronary artery bypass grafting (CAB). Accurate prediction of a patient’s risk of this morbid complication is hindered by its low relative incidence. In an effort to support clinical decision-making and quality improvement, we developed a pre-operative prediction model for post-operative pneumonia following CAB. Methods We undertook an observational study of 16,084 patients undergoing CAB between Q3 2011 – Q2 2014 across 33 institutions participating in the Michigan Society of Thoracic and Cardiovascular Surgeons – Quality Collaborative. Variables related to patient demographics, medical history, admission status, comorbid disease, cardiac anatomy and the institution performing the procedure were investigated. Logistic regression via forwards stepwise selection (p < 0.05 threshold) was utilized to develop a risk prediction model for estimating the occurrence of pneumonia. Traditional methods were employed to assess the model’s performance. Results Post-operative pneumonia occurred in 3.30% of patients. Multivariable analysis identified 17 pre-operative factors, including: demographics, laboratory values, comorbid disease, pulmonary and cardiac function, and operative status. The final model significantly predicted the occurrence of pneumonia, and performed well (C-statistic: 0.74). These findings were confirmed via sensitivity analyses by center and clinically important sub-groups. Conclusions We identified 17 readily obtainable pre-operative variables associated with post-operative pneumonia. This model may be used to provide individualized risk estimation and to identify opportunities to reduce a patient’s pre-operative risk of pneumonia through pre-habilitation.

Direct aortic root and arch repair with approximation of the aortic wall without use of technical adjuncts is safe and effective for patients with ATAAD. If warranted, preservation of the native aortic valve should be considered for a potential survival benefit.