Determinants of Operative Mortality in Patients With Ruptured Acute Type A Aortic Dissection

Abstract

Background: Acute type A aortic dissection (ATAAD) is a surgical emergency associated with high mortality and morbidity. We analyzed our 15-year experience in the management of ruptured ATAAD (rATAAD) and non-rATAAD to determine the predictors of early and late mortality.

Methods: We reviewed all cases with ATAAD between 1999 and 2014. Patients were grouped into rATAAD and non-rATAAD based on intraoperative confirmation. Clinical data on preoperative characteristics and in-hospital and long-term outcomes were analyzed to determine risk factors for early and long-term mortality. Survival was analyzed using Kaplan-Meier and log rank statistics.

Results: Of the 489 total ATAAD repairs, 75 patients (15.3%) had rATAAD. The rATAAD patients were older compared with non-rATAAD (64.4 ± 16.2 versus 57.3 ± 14.2 years, respectively; p = 0.0001) and commonly female (31 of 75 [41.3%] versus 107 of 414 [25.9%], respectively; p = 0.006). Early mortality was higher among rATAAD patients that among non-rATAAD patients (19 of 75 [25.3%] versus 48 of 414 [11.6%], respectively; p = 0.002); predictors included rupture, age, malperfusion syndrome, and coronary artery disease. Patients aged 70 years or more with malperfusion syndrome had a 7.7-fold risk of 24-hour mortality (p = 0.0003) that was augmented by rATAAD (p = 0.004). Long-term survival was lower among rATAAD than non-rATAAD (57.4% versus 78.2%, respectively, at 5 years; p < 0.0001); independent predictors included rupture (p = 0.01), low glomerular filtration rate (p = 0.001), and high-risk group (p = 0.004). These risk factors were used to construct a predictive model for estimating the probability of early mortality in ATAAD.

Conclusions: Rupture is associated with significantly higher mortality in ATAAD. This predictive model provides surgical risk assessment for early mortality after rATAAD. For acceptable surgical candidates, immediate aortic repair can provide favorable outcomes.