title: Outcomes for acute type A aortic dissection: effects of previous cardiac surgery.
abstract: BACKGROUND
  The standard of performing emergent surgical repair for acute aortic dissection type A has been questioned in patients with previous cardiac surgery. The effects of previous cardiac surgery on the presentation and operative outcome of these patients is understudied.
  
  
  METHODS
  Between 1998 and 2010, 190 patients were operated on for acute type A aortic dissection; there were 159 first cardiac operations (FCO) and 31 redo operations (REDO). Stepwise logistic regression analysis identified independent predictors of hospital mortality. Propensity score-matching yielded 31 FCOs who matched the REDOs with respect to age, sex, hypertension history, chronic obstructive pulmonary disease, and renal failure. The presentation, operative outcome, and complications were compared between the two groups.
  
  
  RESULTS
  Hospital mortality rate was 16.8% (32 of 190). Regression analysis identified mental status change (odds ratio [OR] = 5.9), hypertension (OR = 4.6), concomitant coronary artery bypass grafting (OR = 3), reoperation (OR = 2.9), and age of 70 years or older (OR = 2.8) as predictors of hospital mortality. After matching there was no difference between REDO and FCO groups in the presenting symptoms, but REDOs had a higher incidence of aortic rupture (29% [9 of 31] versus 3.2% [1 of 31]; p = 0.012). Cardiac tamponade was present in 3.2% (1 of 31) of REDOs versus 16.1% of FCOs (5 of 31; p = 0.195). Patients in the REDO group required more intraoperative blood transfusion, and had longer cardiopulmonary bypass time. Major complications occurred similarly between the two groups, except REDOs had worse renal function and a higher rate of sudden cardiac arrest (14.3% [4 of 28] versus 0; p = 0.045).
  
  
  CONCLUSIONS
  Although hospital mortality is higher among REDOs, it is still lower than the reported mortality for medical management, and major complications occurred at a rate similar to that of FCOs; hence, emergent surgery remains the prudent treatment.
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Florida, USA. charles.klodell@surgery.ufl.edu
authors.forename: Charles T
authors.initials: CT
authors.lastname: Klodell
authors.forename: Ashkan
authors.initials: A
authors.lastname: Karimi
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Beaver
authors.forename: Philip J
authors.initials: PJ
authors.lastname: Hess
authors.forename: Tomas D
authors.initials: TD
authors.lastname: Martin
mesh_terms: D000208:Acute Disease; D000368:Aged; D000784:Aortic Dissection / Q000401:mortality / Q000601:surgery*; D001014:Aortic Aneurysm / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000401:mortality*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D012086:Reoperation; D016896:Treatment Outcome