Trends and Risk Factors for Stroke and Mortality following Surgical Repair of acute Type A Aortic Dissection: A Single-Center Experience Over 15 Years

Objectives: Surgery for acute type A aortic dissection (AAAD) is a challenging operation associated with high mortality and morbidity. Nevertheless, only little evidences are disposable concerning risk factors for mortality and postoperative new onset of neurological deficits.

Methods: We retrospectively analyzed all patients operated between 2003 and March 2018 at our institution. Eighty-eight pre-, intra- and postoperative variables (including hemodynamic status, laboratory values, anatomical extension of disease assessed by computer tomography, clinical and echocardiographic data, as well as surgical times and strategy) were collected by screening medical records and analyzed through a multivariate binary logistic regression (LR). Only variables with univariate p-values < 0.1 were selected.

Results: A total of 311 patients were included in the study (mean age: 59 ± 13.1 years [range: 18–85]; 63% male). 91% underwent emergent surgery. The number of complex operations (valve replacement = 29%, valve-sparing root intervention = 11%, arch replacement = 29.6%, elephant trunk = 14%) increased over the time (2003–2007 = 24; 2008–2012 = 51; 2013–2017 = 118). Overall intraoperative and 30-day mortality were 4 and 22%, respectively. 30-day mortality for isolated aortic replacement was 21.17%, with a significant decrease over last 5-year period (2003–2007 = 22.2%; 2008–2012 = 25%; 2013–2017 = 11.1%). On LR performed on all study population, baseline cardiogenic shock (OR = 7.93; 95% CI: 1.08–57.87; p = 0.041), concomitant coronary artery bypass grafting (OR = 26.27; 95% CI: 1.18–581.68; p = 0.039), and postoperative troponin T peak value (OR: 1.82; 95% CI: 1.30–2.54; p < 0.0001) were significant risk factors for in-hospital mortality. Concerning 30-day mortality, connective tissue disease (OR = 1.003; 95% CI: 1–1.005; p = 0.018) and postoperative troponin T (OR = 1.6; 95% CI: 1.17–0.2; p = 0.004) were found as significant risk factors. Baseline neurological deficits were observed in 18% of patients, and postoperatively in 10%. On LR, no significant risk factor for stroke were identified.

Conclusion: Postoperative increase of troponin T is a significant risk factor for mortality after surgery for AAAD, suggesting a central role of perioperative (pre- or intraoperative) myocardial injury in determining the fatal outcome, thus demanding future improvements of the perioperative cardioprotection techniques. Our multimodality approach failed to identify risk factors for postoperative stroke, confirming the complex scenario of AAAD’s surgery.

No conflict of interest has been declared by the author(s).