Extensive research has recently been done on the association between shock and the risk of acute type A aortic dissection (ATAAD) [1]. It has been shown that the presence of preoperative shock increases mortality in ATAAD [2, 3]. Much has been documented about early, short-term, and perioperative mortality for ATAAD [4, 5, 6]. Previous studies reported that advanced age, preoperative shock, including cardiopulmonary arrest (CPA) were significant predictors for the early mortality [7, 8]. However, in short- and long-term outcomes, the effect of shock in the mid to long-term has been poorly documented particularly with follow-up past 5 years [9]. We sought to focus on early and mid-term outcomes in patients with ATAAD complicated by preoperative shock evaluating predictors for mid to long-term mortality.

From October 2013 to November 2024, 181 patients with ATAAD underwent emergent aortic repair at Albany Medical Center, including 44 (24.3%) with preoperative shock (Fig. 1). We analyzed postoperative outcomes in patients with ATAAD complicated by preoperative shock (shock group) compared to patients without shock (non-shock group). Shock was defined as systolic pressure less than 90 mmHg, including preoperative CPA. The primary endpoint was early mortality and the cumulative survival rate at 10 years between the shock group and the non-shock group. Early mortality was defined as death within 30 days of the initial aortic repair. Predictors for early and mid-to-long-term mortality were evaluated in patients with preoperative shock. In a sub-analysis, each component of preoperative shock including cardiac tamponade, aortic rupture, and coronary malperfusion was analyzed for early and mid-term mortality. A survivor was defined as a patient who survived for at least 30 days from the initial aortic repair for ATAAD, and the mid-term outcome was assessed. A secondary endpoint was the need for an aortic reintervention after the initial aortic repair. An aortic reintervention included thoracic endovascular aortic repair and open descending repair, and thoracoabdominal aortic repair. All patients were annually followed as outpatients at cardiothoracic surgery and cardiology offices.

Fig. 1.

181 patients with ATAAD underwent emergent aortic repair. Of 181 patients, 44 presented with preoperative shock. There was a significant difference in the early mortality and mid to long-term survival between the shock and non-shock groups (p 0.01). ATAAD, acute type A aortic dissection.

Patient characteristics are listed in Table 1, and intraoperative data in Table 2. The mean age of all subjects was 60.4 $\pm$ 14.0 years old. When compared with the non-shock group, the mean age was higher in the shock group (66.6 $\pm$ 13.0 years old vs 58.2 $\pm$ 14.0 years old, p 0.01). In 44 patients in the shock group, the prevalence of cardiac tamponade, CPA, aortic rupture, and coronary malperfusion was 90.9% (40/44), 13.6% (6/44), 6.8% (3/44), and 6.8% (3/44), respectively. The incidence of preoperative altered consciousness was significantly higher in the shock group (52.3% vs 12.5%, p 0.01). Transfer time from diagnosis to OR did not differ between the two groups. Intraoperative procedures, cardiopulmonary bypass time, aortic cross clamp time, and circulatory arrest time were similar between the two groups except for the rate of hemiarch replacement (Table 2). A hemiarch procedure was performed more frequently in the shock group (90.9% vs 77.4%, p = 0.04) (Table 2).

3.2 Mid to Long-Term Outcomes

The mean follow-up period was 34.0 $\pm$ 36.6 months and 21 patients were lost. During this period, 3 patients in the shock group died due to heart failure in 2 patients, and the cause was unknown in 1 patient. Among the non-shock group, 10 patients expired during the follow-up period. The cause of death included heart failure in 3 patients, sudden cardiac death in 1 patient, sepsis in 1 patient, endocarditis in 1 patient, intracranial hemorrhage in 2 patients, and unknown in 2 patients. The cumulative survival rate including early mortalities in 10 years in the shock and non-shock groups was 54.5% and 65.8%, respectively (Table 3). A significant difference was noted between the two groups (p 0.01) (Fig. 2). The Cox hazard proportional analysis demonstrated that only older age was associated with mid-term mortality (p 0.01) while preoperative shock and transfer time from diagnosis to OR were not predictors (Table 4). In the sub-analysis with each component of preoperative shock, older age and preoperative CPA were significant predictors for the mid-term outcome (p 0.01) (Table 5). During the follow-up period, 14 patients required thoracic endovascular aortic repair, 1 patient with aortic valve replacement, 1 patient with redo aortic root replacement, and 1 patient with open thoracoabdominal aortic repair. The rate of aortic reintervention at 5 years was 25.0% in the shock group and 10.7% in the non-shock group (Table 3). There was no significant difference in the requirement for aortic reintervention between the two groups (p = 0.85) (Fig. 3).

Fig. 2.

Cumulative survival rates of patients with preoperative shock and non-shock. The cumulative survival rate at 10 years in the shock and non-shock group was 54.5% and 65.8%. There was a significant difference in the mid to long-term survival between the two groups (p 0.01).

Fig. 3.

Requirement of aortic reintervention after initial aortic repair. The rate of aortic reintervention in 5 years was 25.0% in the shock group and 10.7% in the non-shock group. There was no significant difference in the requirement of aortic reintervention between the two groups (p = 0.85).

3.3 Survivors From Initial Aortic Repair for ATAAD

The survivor’s preoperative and postoperative data are summarized in Table 6. The cumulative survival rate in the shock group was 96.0% while that of the non-shock group was 79.8%. The cumulative survival rates were comparable between the two groups (p = 0.52) (Fig. 4). Older age and preoperative shock were not related to the mid-term outcome in the survivor group (Table 7).

Fig. 4.

Cumulative survival rates of patients who survived for 30 days from the initial aortic repair. The cumulative survival rate in 10 years in the shock and non-shock group was 96.0% and 79.8%. There was no significant difference in the mid to long-term survival between the two groups (p = 0.52).

Table 6. Survivor’s characteristics.

Characteristic	Shock n = 25	Non-shock n = 113	p
Age, y	63.3 $\pm$ 15.0	56.5 $\pm$ 13.6	0.03
Male, n (%)	19 (76.0)	83 (73.5)	0.79
Cardiac tamponade, n (%)	24 (96.0)	0 (0)	0.01
Cardiopulmonary arrest, n (%)	1 (4.0)	0 (0)	0.18
Aortic rupture, n (%)	2 (8.0)	1 (0.9)	0.08
Coronary malperfusion, n (%)	1 (4.0)	2 (1.8)	0.45
Postoperative stroke, n (%)	7 (28.0)	11 (9.7)	0.01
Postoperative new dialysis requirement, n (%)	4 (16.0)	9 (8.0)	0.25
Follow-up term, months	41.5 $\pm$ 38.2	43.8 $\pm$ 35.9	0.77
Cumulative survival in 10 years, %	96.0	79.8	0.52

Table 7. Multivariable analysis for mid-term mortality in survivors after the first aortic repair.

Risk factors	Adjusted hazard ratio	95% confidence interval	p
Age	1.01	0.96–1.06	0.63
Male	1.80	0.31–10.44	0.51
Preoperative shock	1.60	0.38–6.67	0.52
Time from diagnosis to OR	1.00	0.998–1.004	0.43

Our study evaluated postoperative outcomes in patients with ATAAD comparing shock with non-shock patients. The results demonstrated that there was a higher incidence of adverse postoperative events in patients complicated by preoperative shock for ATAAD versus patients without preoperative shock. The cumulative survival rate at 10 years was 54.5% in the shock and 65.8% in the non-shock group. The mid to long-term outcomes might be acceptable given the disease severity in patients with ATAAD. While many reports and registries documented the correlation between preoperative shock and mortality for ATAAD, some lack documented follow-up periods after discharge [10, 11], while others reported mortality only for inpatient hospital stays rather than recording mid-to-long-term mortality after discharge [12]. Long et al. [2] reported preoperative shock to be associated with operative mortality during hospitalization or within 30 days with follow-up for survivors averaging 46 months [5], but did not report data for long-term mortality or preoperative CPA. Our study provided a ten-year follow-up and examined preoperative CPA. Bossone et al. [3] reported on survivors with cardiogenic shock on admission with follow-up to 5 years and reported that patients discharged alive after shock had similar mortality rates as those without cardiogenic shock on admission [6], and did not report the incidence of CPA. Our study differs, however, from Bossone’s study in that our study followed up on patients for up to 10 years including preoperative CPA, as well as showing that cardiopulmonary arrest predicted mid-term outcomes.

Previous studies on aortic dissections, which followed outcomes out to 15 years, found unfavorable aortic dissection outcomes associated specifically with preoperative need for cardiopulmonary resuscitation and failed to find significance with cardiogenic shock [13]. To the best of our knowledge, limited data exist for mid to long-term outcomes for preoperative shock in ATAAD. In our study, preoperative shock was an independent risk factor for early mortality although it did not predict the mid-to-long-term mortality. In the sub-analysis, preoperative CPA was a significant predictor for both short and mid-to-long-term mortality. However, in our Cox hazard proportional analysis, the early mortality events with preoperative CPA were included. Only one patient with preoperative CPA could survive for the mid-to-long-term outcomes while most patients after emergent aortic repair died within the admission. The result was consistent with the previous report [14].

To improve outcomes in patients with preoperative shock, prompt transfer from onset to the OR and preoperative management for cardiac tamponade, and CPA would be critical factors in addition to intraprocedural management in the OR [14, 15]. Most patients in our study were transferred from outside hospitals after the diagnosis was confirmed. As a result, there was a lot of missing data regarding time from onset to diagnosis. We could evaluate only transfer time from diagnosis to OR, which was not a predictor for postoperative outcome. At some outside hospitals, computed tomography to confirm ATAAD was delayed due to the facility’s capacity or staff shortages which required transfer to another hospital to obtain computed tomography. If we could assess transfer time from onset to diagnosis, the results have had different outcomes. In addition to the prompt transfer to OR, there was a point the management of preoperative cardiac tamponade was also important [16]. Controlled pericardial drainage was one of the options for patients with ATAAD complicated by cardiac tamponade and the procedure could be performed safely to stabilize those patients [16]. Most shock patients (89%) who were discharged alive from the hospital could survive for 5 years and the cumulative survival rate was similar to that of patients without shock (82%) [3]. Some patients underwent pericardial drainage before they were transferred to the OR at our facility. Most drainage procedures were successful in stabilizing the patients with cardiac tamponade. However, the drainage procedure was an isolated pericardiocentesis and not controlled pericardial drainage as reported. These results favor controlled pericardial drainage for patients with cardiac tamponade preoperatively when necessary.

Our study is unique in that the mid-to-long-term outcomes among the survivors after the first aortic repair were evaluated comparing the shock to non-shock group and there were no preoperative predictors for the mid-to-long-term survival including preoperative shock (Tables 6,7). One of possible reasons was the incidence of aortic reintervention during the follow-up period. Table 3 shows that the incidence of aortic intervention at 5 years was similar between the two groups (25.0% vs 10.7%, p = 0.85). Given the high mortality in patients with ATAAD complicated by preoperative shock, further studies should be performed to elucidate the difference between the survivors and non-survivors.

There were several limitations in our study. First, it was a retrospective single-center study. A multicenter study is needed in the future since the surgical management might differ at each facility. Second, some patients died or were lost during the follow-up periods. As a result, the number of remaining patients decreased and the analyses at 10-year follow-up were underpowered. Third, the mean age in the shock group was significantly higher than that of the non-shock group. Fourth, there was missing data on time from onset to diagnosis. Time from onset to diagnosis might be a critical factor in patients with shock.

The mid-to-long-term survival rate of acute type A aortic dissection patients with preoperative shock was not inferior to that of patients without shock if they survived after the first aortic repair. Preoperative shock was a risk factor for early mortality. Older age and cardiopulmonary arrest were significant predictors for mid-to-long-term mortality. Preoperative shock was not related to aortic reintervention after the initial aortic repair.

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

CN and SS designed the study design. AK, YHW, JL, ST, and NA collected the data. CN and ED analyzed statistically. CN, ED and ST drafted the manuscript. All authors contributed to critical revision of the manuscript for important intellectual content. All authors read and approved the final manuscript. All authors have participated sufficiently in the work and agreed to be accountable for all aspects of the work.

The study was carried out in accordance with the Declaration of Helsinki and approved by Albany Medical Center Institutional Review Board (Protocol No. 7051, November 15, 2024). This study would not adversely affect the rights and welfare of subjects. The procedure for ATAAD was clinically indicated; therefore would be done regardless of the research. The informed consent was waived by Institutional Review Boards at Albany Medical Center.

This research received no external funding.

The authors declare no conflict of interest.