Impact of Malperfusion Burden on Early Outcomes After Surgery for Type A Acute Aortic Dissection: A Retrospective, Single-Center Investigation

Objectives: Malperfusion is a major determinant of outcome in acute type A aortic dissection (ATAAD), yet its heterogeneous patterns and prognostic impact remain incompletely defined. We investigated the association between malperfusion burden, territory-specific involvement, and early outcomes after emergency ATAAD repair. Methods: We performed a retrospective single-center study including 483 consecutive patients undergoing emergency surgery for ATAAD (2010-2022). Malperfusion was classified by coronary, visceral, and peripheral territories and stratified as none, single-territory, or multidistrict (≥2 territories). The primary outcome was in-hospital mortality. Secondary outcomes included stroke, renal replacement therapy, peri-procedural myocardial infarction, major vascular events, and a composite endpoint of major adverse events (MAEs). Multivariable logistic regression identified independent predictors. Results: Overall, 68.5% of the population were male with a mean age of 65.4 ± 12.1 years. Malperfusion was present in 151 patients (31.3%), including 131 (27.1%) with single-territory and 20 (4.1%) with multidistrict involvement. In-hospital mortality increased stepwise with malperfusion burden (12.7%, 19.8%, and 50.0%; p < 0.001). MAEs occurred in 36.6% of patients, with a similar gradient (31.2%, 46.2%, and 65.0%, p < 0.001). In multivariable analysis, preoperative shock, neurological deficit, descending aortic involvement, and redo surgery were independent predictors of MAEs, whereas malperfusion burden showed an attenuated association after adjustment. Territory-specific analyses revealed strong associations between coronary malperfusion and peri-procedural myocardial infarction, visceral malperfusion and postoperative dialysis, and peripheral malperfusion and major vascular events. Conclusions: Malperfusion burden is associated with worse early outcomes after ATAAD repair but largely reflects underlying clinical severity. Distinct malperfusion territories confer specific postoperative risks, supporting a pattern-based approach to perioperative risk stratification.