Optimized strategy to improve the outcomes of acute type A aortic dissection with malperfusion syndrome

The mortality of acute type A aortic dissection (ATAAD) with malperfusion syndrome (MPS) is high. However, the management strategy remains controversial. We aimed to evaluate the strategy for MPS at our institution.Among 724 patients with ATAAD, 167 patients with MPS were treated with immediate central repair (1st stage) or an optimized strategy (2nd stage). In 2nd stage, the optimized strategy used was based on 6-hour threshold from symptom onset. For MPS with symptom onset within 6 hours, immediate central repair was performed followed by endovascular reperfusion if malperfusion persisted. With symptom onset beyond 6 hours, individualized delayed central repair was performed. We compared outcomes between the 1st and 2nd stage.The in-hospital mortality of ATAAD was significantly decreased when the optimized strategy was used (4.3% in 2nd stage vs. 12.5% in 1st stage, P<0.01). In 2nd stage, the in-hospital mortality for MPS was decreased (10.2% vs. 33.9%, P<0.01). Moreover, the in-hospital mortality for MPS with symptom onset within or beyond 6 hours decreased from 24% to 7.5% and from 41.2% to 11.8%, respectively. The operative mortality of MPS in 2nd stage was comparable with patients without MPS (4.0% vs. 2.4%, P>0.05).The optimized strategy significantly improved the outcomes of MPS. The 6-hour threshold from symptom onset could be very useful in determining the timing of central repair. For MPS with symptom onset within 6 hours, immediate central repair is reasonable. For those with symptom onset beyond 6 hours, individualized delayed central repair should be considered.