The impact of emergency intubation on surgical outcomes in patients with acute aortic dissection AADA (DeBakey I). Is a prompt treatment justified?

introductionAn acute aortic dissection Stanford type A (AADA) is a life-threatening disease and one of the urgent emergencies in cardiovascular surgery. Furthermore, mortality increases when further risk factors like malperfusion, cardiac tamponade or preoperative cardiopulmonary resuscitation (CPR) occur. This study retrospectively evaluates the impact of emergency intubation, performed prior to hospital admission, on early and long-term surgical outcomes in patients with acute aortic dissection Stanford type A (AADA, DeBakey Type I).

methodsBetween January 2000 and January 2018, 430 patients received aortic surgery due to an acute aortic dissection type A (DeBakey Type I) at our tertiary referral hospital. These patients were included in this study. The primary objective was to compare 30-day mortality and long-term survival between intubated and non-intubated AADA patients, while also analyzing differences in preoperative risk factors and postoperative complications. A retrospective analysis with follow-up was conducted.

resultsA minority (n = 55; 12.79%) of the entire cohort (n = 430) presented themselves in an intubated status and were assigned to Group A, whereas 375 patients were not intubated prior to surgery (Group B). The median age of the entire cohort of 430 patients was 63.7 years and 67.2% patients were male. Group A had a significantly higher number of patients with pericardial tamponade (Group A 58.2%; Group B: 34.7%) and an increased demand for mechanical resuscitation due to pulseless electrical activity (Group A: 29.1%; Group B: 5.9%). Preoperative malperfusion (Group A: 43.6%; Group B: 29.6%; p: 0.036) occurred significantly more often in the intubated cohort. Furthermore, Group A showed a higher number of supra-aortic artery dissections as well as neurological symptoms. The extent of the surgical treatment was comparable for both intubated and non-intubated patients. A total of 38.2% of the intubated AADA patients did not survive the first 30 days after surgery (Group A: 38.2%; Group B: 19.5%; p: 0.002).

conclusionPrehospital intubated AADA patients present severe risk factors for early mortality, including pericardial tamponade, severe malperfusion and preoperative resuscitation. Despite the particularly early mortality rate of 40%, the majority of patients benefitted from prompt surgical treatment. Furthermore, the study presents an acceptable long-term outcome after surviving the initial first year after treatment. We therefore recommend that emergent aortic repair should be offered to intubated patients with AADA.