title: Outcomes of patients presenting with acute type A aortic dissection in the setting of prior cardiac surgery: an analysis from the International Registry of Acute Aortic Dissection.
abstract: BACKGROUND
  Prior cardiac surgery (PCS) can complicate the presentation and management of patients with type A acute aortic dissection (TAAAD). This report from the International Registry of Acute Aortic Dissection examines this hypothesis.
  
  
  RESULTS
  A total of 352 of 2196 patients with TAAAD (16%) enrolled in the International Registry of Acute Aortic Dissection had cardiac surgery before dissection, including coronary artery bypass grafting (34%), aortic or mitral valve surgery (36%), aortic surgery (42%), and other cardiac surgery (16%). Those with PCS were older, had a higher frequency of diabetes mellitus, hypertension, and atherosclerosis, and presented later from symptom onset to hospital presentation and diagnosis (all P<0.05). In-hospital mortality was significantly higher for PCS patients (34% versus 23%; P<0.001). Five-year mortality was independently predicted by PCS (hazard ratio [HR], 2.04; 95% confidence interval [CI], 1.05-3.95), age >70 years (HR, 2.65; 95% CI, 1.40-5.05), medical management (HR, 5.10; 95% CI, 2.43-10.71), distal communication (HR, 2.64; 95% CI, 1.35-5.14), and coma (HR, 9.50; 95% CI, 2.05-44.05). Among patients with PCS, in-hospital (43% medical versus 30% surgical; P=0.033) and intermediate-term mortality was higher in patients with medical versus surgical management. Propensity-matched analysis revealed significant increase in mortality with medical management, but not with PCS.
  
  
  CONCLUSIONS
  PCS delays presentation, diagnosis, and treatment of TAAAD and is an important adverse risk factor for early and intermediate-term mortality. This effect may be because of increased medical management in this patient population.
authors.affiliation: Department of Cardiac Surgery (N.R.T., G.M.D., H.J.P.), Department of Internal Medicine (K.A.E.), Michigan Cardiovascular Outcomes Research and Reporting Program (D.G.M.), University of Michigan Health System, Ann Arbor, MI; Department of Surgery, St. Michael's Hospital, Toronto, Ontario, Canada (M.D.P.); Department of Surgery, University of Chicago Medical Center, Chicago, IL (M.J.R.); Department of Cardiothoracic Surgery, University of Vienna, Vienna, Austria (M.P.E.); Department of Clinical Medicine, Tromso University Hospital, Tromsø, Norway (T.M.); Department of Surgery, University of Virginia Health System, Charlottesville, VA (G.R.U.); Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN (K.G.); Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH (M.F.); Department of Cardiac Surgery, Hospital Universitario "12 de Octubre," Madrid, Spain (A.F.); Massachusetts General Hospital, Boston, MA (E.M.I.); and Department of Cardiology, University Hospital Eppendorf-Rostock, Rostock, Germany (C.A.N.).
authors.forename: Nicholas R
authors.initials: NR
authors.lastname: Teman
authors.forename: Mark D
authors.initials: MD
authors.lastname: Peterson
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Russo
authors.forename: Marek P
authors.initials: MP
authors.lastname: Ehrlich
authors.forename: Truls
authors.initials: T
authors.lastname: Myrmel
authors.forename: Gilbert R
authors.initials: GR
authors.lastname: Upchurch
authors.forename: Kevin
authors.initials: K
authors.lastname: Greason
authors.forename: Mark
authors.initials: M
authors.lastname: Fillinger
authors.forename: Alberto
authors.initials: A
authors.lastname: Forteza
authors.forename: George Michael
authors.initials: GM
authors.lastname: Deeb
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Montgomery
authors.forename: Kim A
authors.initials: KA
authors.lastname: Eagle
authors.forename: Eric M
authors.initials: EM
authors.lastname: Isselbacher
authors.forename: Christoph A
authors.initials: CA
authors.lastname: Nienaber
authors.forename: Himanshu J
authors.initials: HJ
authors.lastname: Patel
mesh_terms: D000208:Acute Disease; D000368:Aged; D000784:Aortic Dissection / Q000175:diagnosis / Q000401:mortality*; D001014:Aortic Aneurysm / Q000175:diagnosis / Q000401:mortality*; D006348:Cardiac Surgical Procedures / Q000401:mortality* / Q000639:trends; D015331:Cohort Studies; D003937:Diagnosis, Differential; D005260:Female; D006801:Humans; D038622:Internationality; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000175:diagnosis / Q000401:mortality*; D011446:Prospective Studies; D012042:Registries; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome
keywords: aorta; aortic diseases; mortality; thoracic; thoracic surgery