Short- and Long-Term Outcome of Acute Type A Aortic Dissection after Previous Cardiac Surgery

Objectives: In acute type A aortic dissections (AAD), rapid surgical therapy is the gold standard to overcome shock and malperfusion. Especially in patients after previous cardiac surgery (PCS), surgical repair remains challenging. This study analyzes patients with AAD after PCS, analyzes risk factors for mortality, and evaluates short- and long-term outcome.

Methods: Patients were identified in our institutional database and analyzed retrospectively. Between January 2004 and December 2018, a total of 699 patients were operated for AAD. Of these, 33 patients (4.7%) had previous cardiac surgery 9.6 ± 6.8 years earlier. AAD patients with and without PCS were compared and risk factors analyzed.

Results: Mean age of PCS patients was higher (70 ± 14 vs. 64 ± 14, p = 0.009). DeBakey Type II was more frequently found in the PCS group (52 vs. 29%, p = 0.007). Less tamponade (3 vs. 19%, p = 0.023) and aortic valve insufficiency (48 vs. 76%, p = 0.001) were found in the PCS group. Clinical presentation according to the Penn classification was nevertheless similar (p = 0.39). In the PCS group, a higher incidence of CAD (55 vs. 16%, p = 0.001) and coronary malperfusion (24% vs 12% p = .03) resulted in more concomitant CABG procedures (30% vs 13%, p = .005). In hospital mortality was higher in the PCS group (27% vs 11%, p = .003). In hospital survivors showed no significant difference in long-term survival after ten years (64% vs 63%, p = .056).

Conclusion: Although AAD patients with PCS present less frequently with tamponade, their clinical status at the time of presentation is similarly impaired to those without PCS. Nevertheless, PCS patients suffer more frequently from cardiac malperfusion and have more preexisting cardiac conditions, resulting in more concomitant cardiac procedures. In-hospital mortality is significantly higher in PCS, but long-term survival is similar once discharged. Despite worse outcome, surgery remains the gold standard in those patients and should not be denied.