Early Mortality in Patients who Received Extensive Surgical Management for Acute Type A Aortic Dissection - Analysis of 452 Consecutive Cases from a Single-center Experience

Abstract Objective: To detect the potential risk factors associated with early mortality in patients who received extensive surgical management, in the form of total arch replacement plus frozen elephant trunk and arch debranching (hybrid repair technique), for acute type A aortic dissection. Methods: The clinical and surgical data of 452 surgically treated patients with acute type A aortic dissection at our center, between March 2010 and December 2016, have been retrieved. Uni and multivariate logistic regression analyses were carried out to detect the effect of various preoperative demographics and different perioperative variables on early mortality. Results: Overall 30-day mortality occurred in 70 out of 452 patients (15.4%). The principal causes of death were multiple organ failure (n=38), cardiac failure (n=18), and severe pulmonary infection (n=10). Risk factors for early mortality were identified with multivariate analysis. Preoperatively, overweight (P<0.025), alcohol drinking (P<0.002), coronary artery disease (P<0.014), hemodynamic shock (P<0.006), and elevated white blood cells count (P<0.002) were associated with higher mortality rate. Postoperatively, prolonged operation time (P<0.008), stroke (P<0.0001), and acute renal dysfunction (P<0.0001) were highly associated with death. Conclusion: Considering the advantages of extensive surgical management for acute type A aortic dissection over the other less aggressive surgical approaches, it should be advised whenever indicated, provided that being carried out by experts in the field of adult aortic surgery in high-volume centers. The surgeon should be aware of the patient’s preoperative comorbidities and other risk factors for early mortality, in particular, prolonged operation time.

摘要：
研究目的：本研究旨在探究针对急性A型主动脉夹层（acute type A aortic dissection）采用全弓置换联合冷冻象鼻术及弓部分支术（杂交修复技术（hybrid repair technique））这一扩大化外科治疗方案时，与患者早期死亡相关的潜在危险因素。
研究方法：回顾性收集2010年3月至2016年12月期间，本中心收治的452例接受外科手术治疗的急性A型主动脉夹层患者的临床及手术资料。采用单因素及多因素logistic回归分析（logistic regression），探究各类术前人口学特征与围术期变量对患者早期死亡的影响。
研究结果：452例患者中共有70例发生术后30天死亡，总死亡率为15.4%。主要死亡原因依次为多器官功能衰竭（n=38）、心力衰竭（n=18）及重症肺部感染（n=10）。经多因素回归分析明确早期死亡危险因素：术前因素包括超重（P<0.025）、饮酒史（P<0.002）、冠状动脉疾病（P<0.014）、血流动力学休克（P<0.006）及白细胞计数升高（P<0.002）；术后因素包括手术时间延长（P<0.008）、脑卒中（P<0.0001）及急性肾功能不全（P<0.0001），上述因素均与死亡风险升高显著相关。
研究结论：相较于其他侵袭性更低的外科术式，针对急性A型主动脉夹层的扩大化外科治疗方案具备显著优势，因此在高手术量中心由成人主动脉外科领域专家实施手术时，只要符合手术指征即应推荐采用该方案。外科医师需充分关注患者术前合并症及其他早期死亡危险因素，尤其需重视手术时间延长这一因素。