Managing Malperfusion Syndrome in Acute Type A Aortic Dissection with Previous Cardiac Surgery

Abstract Background Patients with acute type A aortic dissection (ATAAD) with a previous cardiac surgery (PCS) and malperfusion syndrome (MPS) are extremely difficult to manage and have poor outcomes. Methods From 1996-2018, 668 patients underwent emergent open aortic repair or endovascular fenestration/stenting for MPS for an ATAAD, including those with PCS (PCS, n=64) and those without PCS (No-PCS, n=604). The groups were further divided into PCS+MPS, PCS+No-MPS, No-PCS+MPS, and No-PCS+No-MPS groups. Results Compared to the No-PCS group, the PCS group had significantly more coronary artery disease, acute renal failure, and mesenteric and renal MPS. Forty-two percent of patients with PCS underwent upfront endovascular fenestration/stenting for endovascular-amendable MPS. The in-hospital mortality was significantly higher in patients with PCS+MPS (40%) compared to PCS+No-MPS (5.9%), No-PCS+MPS (30%), and No-PCS+No-MPS (6.7%). Multivariable logistic regression showed cardiogenic shock (odds ratio(OR)=7.3) and MPS (OR=6.6) were risk factors for in-hospital mortality, p Conclusions Because of severe preoperative comorbidities and the complexity of open aortic repair, in ATAAD patients with PCS and MPS, endovascular fenestration and stenting first with delayed redo-sternotomy and central aortic repair was a valid approach.