How Much Malperfusion Is Too Much in Acute Type A Aortic Dissections?

Abstract

(1) Background: Malperfusion is a central limiting factor in the setting of acute Type A aortic dissections (AAAD). We sought to find preoperative metabolic acidosis thresholds that might influence decision-making in this setting. (2) Methods: We retrospectively reviewed consecutive patients operated on with AAAD between January 2002 and December 2017. We analyzed preoperative variables that might influence early and long-term outcomes, with particular emphasis on malperfusion markers. (3) Results: Our sample consisted of 153 patients, most of them male (69.2%), with a mean age of 55.89 ± 12.8 years. Malperfusion was present in 20.9% of cases: peripheric 25, renal 7, cerebral 4, and mesenteric 3. Cardiogenic shock was present in 18.9% of patients. Logistic regression revealed entry site (odds ratio (OR) = 2.83, p = 0.03), cardiogenic shock (OR = 3.30, p = 0.03), prebypass pH (OR = 0.93, p = 0.02) as independent risk factors for early death (<30 days). Receiver operating characteristic (ROC) analysis identified a prebypass pH of 7.25 as a cutpoint for an unfavourable early outcome. Patients whose prebypass pH was ≤7.25 had a 2.98 higher relative risk (65.7% vs. 22%, p < 0.001). Prebypass pH 7.25 (hazard ratio (HR) = 4.00, p < 0.01) and entry site (HR = 2.10, p = 0.04) were independent predictors of early phase survival (<30 days), while long-term survival (>30 days) was determined by age >65 years (HR = 3.12, p = 0.02). (4) Conclusions: Patients with a prebypass pH ≤ 7.25 have an unacceptably high early mortality after AAAD repair. Those patients might benefit from a two-stage approach.

Cardiopulmonary bypass time is an independent risk factor for acute kidney injury in emergent thoracic aortic surgery: a retrospective cohort study

“…The presence or absence of malperfusion was based on the Penn classification which was established and subsequent validated in the last decade [31]. Preoperative shock was defined as a systolic blood pressure < 90 mmHg [11]. Patients with ST elevation on a 12-lead electrocardiogram associated with wall hypokinesis at the corresponding region on echocardiography were considered to have AMI [33].…”

“…Patients with ST elevation on a 12-lead electrocardiogram associated with wall hypokinesis at the corresponding region on echocardiography were considered to have AMI [33]. Renal malperfusion was diagnosed as at least one renal artery dissection with creatinine rise above 50% of the normal upper limit [11].…”

The effects of DeBakey type acute aortic dissection and preoperative peripheral and cardiac malperfusion on the outcomes after surgical repair

“…Lawton et al [ 30 ], Narayan et al [ 31 ], Feier et al [ 32 ], and Yang et al [ 25 ], in AAD patient populations of 282, 205, 153, of 602 cases, underline that in patients with preoperative lactic acidosis and mesenteric ischaemia, surgical treatment can lead to unacceptable mortality, with a 10-fold rise in mortality-RR values. Therefore, the authors suggest the absolute necessity of a 2-stage treatment to restore in first-stage intestinal adequate perfusion and, subsequently, after improvement of the patient’s general condition, surgical repair of the dissected aorta.…”

Low preoperative serum fibrinogen level is associated with postoperative acute kidney injury in patients with in acute aortic dissection

“…ATAAD was diagnosed by enhanced computed tomography scan and aortic valve regurgitation was con rmed by echocardiography. Renal malperfusion was diagnosed as at least one renal artery dissection with creatinine rise above 50% of the normal upper limit [9]. The postoperative AKI was de ned based on the Kidney Disease Improving Global Outcomes (KDIGO) criteria [10,11].…”