Contemporary Medical Management of Acute Type A Aortic Dissection: Better Outcomes?
Rana-Armaghan Ahmad, Xiaoting Wu, *Karen Kim, *Shinichi Fukuhara, *Himanshu Patel, *George M. Deeb, Gorav Ailawadi, *Bo Yang
cardiac surgery , University of Michigan, Ann Arbor, Michigan, United States
Objective: To evaluate outcomes of medical management of acute type aortic dissection (ATAAD) in the contemporary era.
Methods: From 1996-2021, 920 ATAAD patients were admitted to our institution, including those treated with open aortic repair (surgical, n=797) or without (medical, n=123). The patients managed without open aortic repair were due to severe comorbidities, organ failure from malperfusion syndrome, and patients’ wishes. Data were obtained through a global EHR ICD-9/10 code and chart review, the STS warehouse, and the national death index.
Results: The medical group was older, had higher rates of various comorbidities, and a higher rate of malperfusion syndrome than the surgically managed cohort (all p<0.05). The combined in-hospital and 30-day mortality (since onset of aortic dissection) rate was higher for the medical group (70% vs. 7.9%, p<0.001). (Table 1) IMH (intramural hematoma) (vs. patent false lumen in the ascending aorta) was protective for in-hospital+30-day mortality in medical group (odds ratio=0.37, p=0.03).
In the medical group, the demographics and preexisting comorbidities were similar between first and second decade (1996-2010 vs. 2011-2021). However, patients in the 2011-2021 group had a lower combined in-hospital and 30-day mortality rate (58% vs. 84%, p=0.001) and death from aortic rupture (12% vs. 26%, p=0.04). (Table 2) Compared to patients with patent false lumen in the ascending aorta, patients with ascending IMH had more spinal malperfusion (16% vs. 4.1%, p=0.05), less lower extremity malperfusion (16% vs. 41%, p=0.02). The in-hospital+30-day mortality was lower in patients with IMH (52% vs. 75%, p=0.03). (Table 3) Compared to those with malperfusion syndrome, patients with no malperfusion syndrome were older (75 vs. 63, p<0.001) and less likely to be male (47% vs. 71%, p=0.01). The patients with no malperfusion syndrome had a higher rate of various preexisting comorbidities. The combined in-hospital and 30-day mortality rate was not different between the no malperfusion syndrome vs. malperfusion syndrome groups (64% vs. 72%, p=0.35), nor was death from aortic rupture (14% vs. 21%, p=0.38). (Table 4)
The 5-year survival was lower in the medical group compared to the surgical group (20% vs. 79%, p<0.001). (Figure 1) Within the medical group, patients treated in the first decade had a lower 3-year survival (14% vs. 22%, p=0.03), however, the 3-year survival rate in patients without malperfusion syndrome was similar to that in patients with malperfusion syndrome (29% vs. 16%, p=0.22).
Conclusions: The outcomes improved in last decade for ATAAD patients who were not surgical candidate, but it was still poor as patients frequently died from comorbidities and organ failure from malperfusion syndrome rather than aortic rupture. Surgery should be the treatment of choice for ATAAD patients if patients were candidate.
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