Risk analysis and improvement of strategies in patients who have acute type A aortic dissection with coronary artery dissection.

OBJECTIVES To identify the risk factors for mortality and establish improved treatment strategies in patients who have acute type A aortic dissection with coronary artery dissection. METHODS From January 1994 through December 2011, we performed surgery in 516 patients with acute type A aortic dissection. We studied 75 (15%) of these patients who had coronary artery dissection. Myocardial ischaemia was present in 48 (64%) of the 75 patients. The culprit coronary artery was the right coronary artery (RCA) in 26 patients, the left coronary artery (LCA) in 19 and the RCA + LCA in 3. For coronary artery reconstruction, preoperative coronary stent placement was done in 7 patients (RCA, 4 and LCA, 3), aortic root replacement in 14, coronary artery bypass grafting in 23 and biological glue application in 28. The relationships of preoperative risk factors and coronary artery reconstruction procedure with in-hospital death and postoperative low cardiac output syndrome (LOS) were analysed using Fisher's exact test. RESULTS Hospital death was 18/75 patients (24%), 16/48 (33%) among patients with ischaemia and 2/27 (7.4%) without ischaemia. The culprit lesion involved the RCA in 4/26 patients (15%), the LCA in 9/19 (47%) and the RCA + LCA in 3/3 (100%). Factors related to operative mortality were ischaemia (P = 0.019), LCA territory ischaemia (P = 0.003) and preoperative cardiopulmonary arrest (CPA) (P = 0.013). Postoperative LOS was less common in patients with coronary stent placement (P = 0.042). CONCLUSIONS In patients who undergo surgery for acute type A dissection with coronary artery dissection, preoperative CPA and myocardial ischaemia (particularly LCA territory ischaemia) negatively affect survival outcomes. Early revascularization by coronary stent placement is effective in preventing postoperative LOS.