• Ibrahim Sultan, Valentino Bianco, Himanshu J Patel, George J Arnaoutakis, Marco Di Eusanio, Edward P Chen, Bradley Leshnower, Thoralf M Sundt, Udo Sechtem, Daniel G Montgomery, Santi Trimarchi, Kim A Eagle, and Thomas G Gleason.
• Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address: sultani@upmc.edu.
• J. Thorac. Cardiovasc. Surg. 2021 May 1; 161 (5): 1713-1720.e1.

BackgroundThe strategy for intervention remains controversial for patients presenting with type A aortic dissection (TAAAD) and cerebral malperfusion with neurologic deficit.MethodsSurgically managed patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection were evaluated to determine the incidence and prognosis of patients with cerebral malperfusion.ResultsA total of 2402 patients underwent surgical repair of TAAAD. Of these, 362 (15.1%) presented with cerebral malperfusion (CM) and neurologic deficits, and 2040 (84.9%) patients had no neurologic deficits at presentation. Patients with CM were more less likely to present with chest pain (66% vs 86.5%; P < .001) and back pain (35.9% vs 44.4%; P = .008). Patients with CM were more likely to present with syncope (48.4% vs 10.1%; P < .001), peripheral malperfusion (52.7% vs 38.0%; P < .001), and shock (16.2% vs 4.1%; P < .001). There was no difference in the incidence of Marfan syndrome (2.8% vs 3.0%; P = .870) or history of known aortic aneurysm (11.7% vs 13.9%; P = .296). Patients with CM were more likely to have a DeBakey I (63.8% vs 47.1%; P < .001) and a pericardial effusion (53.8% vs 40.6; P < .001) on presentation. There was no difference in total arch replacement (21.3% for CM vs 19.5% for no CM; P = .473). Patients with CM had an increased incidence of postoperative cerebrovascular accident (17.5% vs 7.2%; P < .001) and acute kidney injury (28.3% vs 18.1%; P < .001). In-hospital mortality was greater in patients with CM (25.7% vs 12.0%; P < .001).ConclusionsFifteen percent of patients with TAAAD presented with CM and neurologic deficits. Despite the fact that this subset of the population was older and more likely to present with peripheral malperfusion, cardiac tamponade, and in shock, in-hospital survival was noted in nearly 75% of the patients. Surgeons may continue to offer lifesaving surgery for TAAAD to this critically ill cohort of patients with acceptable morbidity and mortality.Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

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