title: Acute type A aortic dissection: significance of multiorgan malperfusion.
abstract: OBJECTIVE
  Acute type A aortic dissection (AAAD) remains one of the most challenging diseases in cardiothoracic surgery, and despite numerous innovations, early mortality still remains high. The aim of this study was to review the Emilia-Romagna experience in the treatment of AAAD and to evaluate the effect of malperfusion on mortality and morbidity.
  
  
  METHODS
  We examined data of 502 patients between January 2000 and December 2008, from the Emilia-Romagna Regional Registry of AAAD. The mean age was 62.4 ± 13 years and 66.5% were male. At presentation, various types of malperfusion syndromes (cerebral, cardiac, ileo-femoral, renal, mesenteric and spinal cord) were present in 103 patients (20.5%; malperfusion [MPS] group). Three hundred ninety-nine patients (No-MPS group) did not have pre-operative malperfusion. Arterial access for cardiopulmonary bypass was usually via the femoral artery (81.9%), while the axillary artery was used only in 14.7%. The aortic repair was performed using the 'open technique' in 348 patients (69.3%) and with aortic cross-clamping without circulatory arrest in 154 patients (30.7%).
  
  
  RESULTS
  Overall in-hospital mortality was 20.9%: 43.7% in the MPS group vs 15% in the No-MPS group (P = 0.001). The operative technique and the cannulation site did not influence post-operative outcomes. Multivariate regression analysis identified mesenteric (odds ratio [OR] 9.5, confidence interval [CI] 2.4-37.4; P = 0.0012), cardiac malperfusion (OR 3.7, CI 1.7-8.0; P < 0.0001) and shock (OR 2.1, CI 1.2-3.5; P = 0.007) as significant risk factors for in-hospital mortality after surgery for type A dissection. Patients who presented single-organ malperfusion had a mortality rate of 34.7%, which increased to 61.9% and to 85.7% if two or more than two organ systems were involved, respectively.
  
  
  CONCLUSIONS
  The results of the surgical treatment of AAAD are acceptable and mainly influenced by patient's status at presentation. Malperfusion of more organ systems makes the prognosis unfavourable and immediate proximal aortic repair may be sub-optimal. In these situations, alternative management strategies should be considered.
authors.affiliation: Department of Cardiac Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy. dav.pacini@gmail.com
authors.forename: Davide
authors.initials: D
authors.lastname: Pacini
authors.forename: Alessandro
authors.initials: A
authors.lastname: Leone
authors.forename: Laura Maria Beatrice
authors.initials: LM
authors.lastname: Belotti
authors.forename: Daniela
authors.initials: D
authors.lastname: Fortuna
authors.forename: Davide
authors.initials: D
authors.lastname: Gabbieri
authors.forename: Claudio
authors.initials: C
authors.lastname: Zussa
authors.forename: Andrea
authors.initials: A
authors.lastname: Contini
authors.forename: Roberto
authors.initials: R
authors.lastname: Di Bartolomeo
mesh_terms: D000368:Aged; D000784:Aortic Dissection / Q000503:physiopathology* / Q000601:surgery; D001014:Aortic Aneurysm / Q000503:physiopathology* / Q000601:surgery; D006348:Cardiac Surgical Procedures; D016009:Chi-Square Distribution; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D012307:Risk Factors