PREDICTORS FOR IN HOSPITAL PREDICTORS FOR IN HOSPITAL MORTALITY IN PATIENTS WITH TYPE A MORTALITY IN PATIENTS WITH TYPE A

AORTIC DISSECTION FROM A TWO AORTIC DISSECTION FROM A TWO CENTRE EXPERIENCECENTRE EXPERIENCE

S Leontyev, J Légaré, MA Borger, K Buth, AK Funkat, J Gerhard, S Lehmann, J Seeburger, FW Mohr

Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany.

Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany.

Background

• Acute type A aortic dissection a cardiovascular emergency with a high potential for death.

worldwide prevalence 0.5 to 2.95 per 100,000 per year; the prevalence ranges from 0.2 to 0.8 per 100,000 per year in the U.S. - 2000 new cases per year (1).

Surgical mortality rates 9% to 36% (2,3)

• 3-year survival - 86% (4) and 5-year survival to 50-80%(3).

1Cohn et all 2007 2 Trimarchi et all 2005;

3 Thiappini et all 2005

4 Tsai et all 2006

Aim / Methods

Analysis of all patients (n=465)undergoing aortic surgery for acute Type A dissection in

Leipzig (Germany)(n=374) and Halifax (Canada) (n=91) over the same period between 1996

and 2010.

To evaluate predictors for in hospital mortality after surgical treatment in patients with type A

aortic dissection

 Totaln=465

Age (years) 61 13Female 36 %

NYHA III-IV 38% Coronary artery disease 20%

Diabetes 12 %Peripheral vascular disease 13 %

Marfan Syndrome 4 %

Demographics

  Total (n=465)

Critical preoperative state 31 %CPR 11 %

Preoperative intubation 19 %Preoperative inotropic support 19 %

Preoperative pericardial tamponade 38 %

Preoperative state

  Total (n=465)

Preoperative malperfision syndrome 35 %

Coronary malperfusion Coronary malperfusion 14 %Cerebral malperfusionCerebral malperfusion 10 %

Malperfusion of extremitiesMalperfusion of extremities 12 %Visceral malperfusionVisceral malperfusion 8 %

Preoperative malperfision

  Total (n=465)

Ascending aorta 94 %Aortic arch 87 %Descending aorta 59 % Abdominal aorta 48 %

Operative data

 Totaln=465

Cardio-pulmonary bypass [min] 202 ± 77

X-clamp time [min] 104 ± 52

Circulatory arrest 90%

Circulatory arrest time [min] 29 ± 20

Total(n = 465)

Modified Bental procedure 32 %32 %

Aortic valve sparing procedure (modified Yacoub or David) 23 %23 %

Isolated supracoronare aorta ascending replacement 25 %25 %

Partial or total aortic arch replacement 75 %75 %

Aortic arch replacement with elephant trunk 17%17%

Concomitant procedure - MV surgery or CABG 16%16%

Operation

Odds ratio CI p

critical preoperative critical preoperative statestate

3.13.1 1.7-5.61.7-5.6 <0.01<0.01

visceral malperfusionvisceral malperfusion 5.15.1 2.0-12.52.0-12.5 <0.01<0.01

malperfusion of malperfusion of extremitiesextremities

2.62.6 1.2-5.51.2-5.5 0.010.01

Multivariate analysis all patients( Preoperative risk factors)

Critical preoperative state - preoperative ventilation, inotropic support, cardiopulmonary resuscitation and unstable preoperative

status

Mortality

Total(n=465)

30 day mortality

23 %(n=107)

Mortality without critical preoperative

state and malperfusion syndrom (n=217)

10%(n=22)

Mortality

The reasons of death

• low cardiac output 50.5%• neurological complication 13.7%• multi-organ failure 7.5%• aortic rupture 5.3%• other 20%

107 patients died during first 30 days

Conclusion

•This represents one of the largest series of patients with Type A aortic dissection in which a risk model could be created

•The surgical treatment of patients with acute aortic Type A Dissection is associated with high operative mortality.

•We identified the following independent predictors of poor outcome:

•The critical preoperative state

•The presence of malperfusion