A visceral organ function-focused therapeutic strategy using a 6-hour time window for patients with acute type a aortic dissection complicated by mesenteric malperfusion.

BACKGROUND: Acute type A aortic dissection (ATAAD) complicated by mesenteric malperfusion is a critical and complicated condition. The optimal treatment strategy remains controversial, debate exists as to whether aortic dissection or mesenteric malperfusion should be addressed first, and the exact time window for mesenteric ischemia intervention is still unclear. To solve this problem, we developed a new concept based on the pathophysiological mechanism of mesenteric ischemia, using a 6-hour time window to divide newly admitted patients by the time from onset to admission, applying different treatment protocols to improve the clinical outcomes of patients with ATAAD complicated by mesenteric malperfusion. METHODS: This was a retrospective study that covered a five-year period. From July 2018 to December 2020(phase I), all patients underwent emergency open surgery. From January 2021 to June 2023(phase II), patients with an onset within 6 h all underwent open surgical repair, followed by immediately postoperative examination if the malperfusion is suspected, while the restoration of mesenteric perfusion and visceral organ function was performed first, followed by open repair, in patients with an onset beyond 6 h. RESULTS: There were no significant differences in baseline and surgical data. In phase I, eleven patients with mesenteric malperfusion underwent open surgery, while in phase II, our novel strategy was applied, with sixteen patients with an onset greater than 6 h and eleven patients with an onset less than 6 h. During the waiting period, none died of aortic rupture, but four patients died of organ failure, twelve patients had organ function improvement and underwent surgery successfully survived. The overall mortality rate decreased with the use of this novel strategy (54.55% vs. 18.52%, p = 0.047). Furthermore, the surgical mortality rate between the two periods showed even stronger statistical significance (54.55% vs. 4.35%, p = 0.022). Moreover, the proportions of patients with sepsis and multiorgan failure also showed differences. CONCLUSIONS: Our novel strategy for patients with ATAAD complicated by mesenteric malperfusion not only improves the surgical success rate but also reduces the overall mortality rate.

Reported outcomes after aortic valve resuspension for acute type A aortic dissection: a systematic review and meta-analysis.

In the majority of patients presenting with acute type A aortic dissection (AAD) complicated by aortic valve insufficiency, the aortic valve (AV) can be preserved by AV resuspension. A meta-analysis was performed to investigate the outcomes following AV resuspension for AAD. A systematic literature search for publications reporting outcomes after AV resuspension in AAD published between January 1998 and June 2018 was conducted. Early outcome events and linearized occurrence rates for late outcome events were derived. The retrieval process yielded 18 unique studies involving 3295 patients with a total of 17 532 patient-years (pt-yrs). Pooled early mortality was 15.5% [95% confidence interval (95% CI) 11.5-19.4%, I2 = 91.9%], and the linearized late mortality rate was 3.21%/pt-yrs (95% CI 2.49-3.77, I2 = 29%). The linearized occurrence rates for aortic root reintervention was 1.4%/pt-yrs (95% CI 0.88-1.79, I2 = 48%); for recurrent significant aortic valve insufficiency (>2+), it was 1.12%/pt-yrs (95% CI 0.79-1.45, I2 = 68%); and for endocarditis, it was 0.01%/pt-yrs (95% CI 0-0.04, I2 = 7%). The composite rate of thromboembolism and bleeding was 1.41%/pt-yrs (95% CI 0.18-2.63, I2 = 82%). A more recent surgical period was associated with a decreased hazard of reoperation on the aortic root (P < 0.001). Requirement of AV resuspension alone in AAD is a risk factor for mortality. The long-term durability of AV resuspension is excellent, with low rates of endocarditis and thromboembolism and bleeding. Root reoperation hazard has become acceptable in recent years. Preoperative aortic valve insufficiency grade exceeding 2+ is a predictor for root reoperation.