Coronary Malperfusion in Acute Type A Aortic Dissection: Myocardial Injury Pattern and Impact on Outcome

Background: Coronary malperfusion in type A aortic dissection (AAD) is associated with high perioperative mortality. Depending on the type of lesion surgical repair reaches a higher complexity level. Aim of this study was to analyze if there is a certain myocardial injury pattern according to Neri classification and to investigate the impact on myocardial recovery during mid-term survival.

Method: Clinical database revealed 446 patients deemed for surgical repair due to AAD from 2000 until 2022. Coronary malperfusion was present in 19.5% (n = 87). Neri classification was used for subgroup analysis in patients with coronary malperfusion due to AAD. Chi-square test as well as ANOVA was used to describe differences between the groups in addition to Kaplan–Meier survival analysis.

Results: Patients presenting with coronary malperfusion had higher rates of preoperative resuscitation (15.1 vs. 6.1% without coronary malperfusion, p = 0.006) and death (9.3 vs. 3.4% without coronary malperfusion, p = 0.017). There was a significant difference in myocardial injury pattern with highest rates of right coronary involvement in Neri C patients, resulting in higher rates of additional revascularization in this patient group.

	None	Neri A	Neri B	Neri C	p-Value
Right coronary involvement (%)	0	17.4	55.6	68.8	<0.001
Root replacement (%)	29.5	10.3	66.7	64.3	<0.001
Additional CABG	9.8	2.6	33.3	64.3	<0.001
X-clamp time (min)	133 ± 57	109 ± 34	166 ± 53	180 ± 84	<0.001

Need for postoperative ECMO was higher in patients with complex coronary involvement (Neri A 2.6% vs. Neri B 23.5% vs. Neri C 35.7%, p < 0.001), being associated with higher 30-day mortality (Neri A 17.4% vs. Neri B 33.3% vs. Neri C 37.5%, p = 0.044). Neri B and C has severe impact on short- and long-term survival (p = 0.024). In survivors with Neri C coronary disruption 33.3% had to undergo subsequent heart failure surgery during follow-up.

Conclusion: Coronary malperfusion Neri B and C is associated with dismal pre- and postoperative prognosis. The right coronary artery is more susceptible to severe injury in terms of coronary dissection (Neri B) or even disruption (Neri C). This might be attributed to its anatomically unprotected offspring on the anterior aortic wall.

Publikationsverlauf

Artikel online veröffentlicht:
28. Januar 2023