Baseline risk factors of in-hospital mortality after surgery for acute type A aortic dissection: an ERTAAD study
Authors: Biancari Fausto , Demal Till , Nappi Francesco , Onorati Francesco , Francica Alessandra , Peterss Sven , Buech Joscha , Fiore Antonio , Folliguet Thierry , Perrotti Andrea , Hervé Amélie , Conradi Lenard , Rukosujew Andreas , Pinto Angel G. , Lega Javier Rodriguez , Pol Marek , Rocek Jan , Kacer Petr , Wisniewski Konrad , Mazzaro Enzo , Vendramin Igor , Piani Daniela , Ferrante Luisa , Rinaldi Mauro , Quintana Eduard , Pruna-Guillen Robert , Gerelli Sebastien , Di Perna Dario , Acharya Metesh , Mariscalco Giovanni , Field Mark , Kuduvalli Manoj , Pettinari Matteo , Rosato Stefano , D’Errigo Paola , Jormalainen Mikko , Mustonen Caius , Mäkikallio Timo , Dell’Aquila Angelo M. , Juvonen Tatu , Gatti Giuseppe 
Published: January 2024

Background

Surgery for type A aortic dissection (TAAD) is associated with high risk of mortality. Current risk scoring methods have a limited predictive accuracy.

Methods

Subjects were patients who underwent surgery for acute TAAD at 18 European centers of cardiac surgery from the European Registry of Type A Aortic Dissection (ERTAAD).

Results

Out of 3,902 patients included in the ERTAAD, 2,477 fulfilled the inclusion criteria. In the validation dataset (2,229 patients), the rate of in-hospital mortality was 18.4%. The rate of composite outcome (in-hospital death, stroke/global ischemia, dialysis, and/or acute heart failure) was 41.2%, and 10-year mortality rate was 47.0%. Logistic regression identified the following patient-related variables associated with an increased risk of in-hospital mortality [area under the curve (AUC), 0.755, 95% confidence interval (CI), 0.729–0.780; Brier score 0.128]: age; estimated glomerular filtration rate; arterial lactate; iatrogenic dissection; left ventricular ejection fraction ≤50%; invasive mechanical ventilation; cardiopulmonary resuscitation immediately before surgery; and cerebral, mesenteric, and peripheral malperfusion. The estimated risk score was associated with an increased risk of composite outcome (AUC, 0.689, 95% CI, 0.667–0.711) and of late mortality [hazard ratio (HR), 1.035, 95% CI, 1.031–1.038; Harrell's C 0.702; Somer's D 0.403]. In the validation dataset (248 patients), the in-hospital mortality rate was 16.1%, the composite outcome rate was 41.5%, and the 10-year mortality rate was 49.1%. The estimated risk score was predictive of in-hospital mortality (AUC, 0.703, 95% CI, 0.613–0.793; Brier score 0.121; slope 0.905) and of composite outcome (AUC, 0.682, 95% CI, 0.614–0.749). The estimated risk score was predictive of late mortality (HR, 1.035, 95% CI, 1.031–1.038; Harrell's C 0.702; Somer's D 0.403), also when hospital deaths were excluded from the analysis (HR, 1.024, 95% CI, 1.018–1.031; Harrell's C 0.630; Somer's D 0.261).

Conclusions

The present analysis identified several baseline clinical risk factors, along with preoperative estimated glomerular filtration rate and arterial lactate, which are predictive of in-hospital mortality and major postoperative adverse events after surgical repair of acute TAAD. These risk factors may be valuable components for risk adjustment in the evaluation of surgical and anesthesiological strategies aiming to improve the results of surgery for TAAD.

Clinical Trial Registration

https://clinicaltrials.gov, identifier NCT04831073.