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Objectives: We analyzed patients with acute type A aortic dissection complicated by malperfusion syndrome to establish whether the timing of operative treatment and the location of malperfusion are factors in determining outcomes., Methods: A total of 331 patients with acute type A aortic dissection were treated surgically between August 2003 and May 2019. Eighty-four patients (25%) presented with preoperative malperfusion syndrome. Fifty-eight patients with malperfusion syndrome (69%) were transferred to the operating room within 5 hours of the onset of symptoms (immediate repair); 26 patients (31%) were transferred after 5 hours (later repair). We analyzed the effects of immediate aortic repair on surgical outcomes., Results: There was no significant difference in the early mortality rates between patients with immediate and later aortic repair, which were 20.0% (n = 11/58) and 26.9% (n = 7/19), respectively (P = .12). Preoperative coronary malperfusion was the only predictor of early mortality. The cumulative 5-year survivals of patients with malperfusion syndrome in the immediate and later repair groups were 76.7% and 45.4%, respectively. A significant difference was noted in the long-term outcomes between the 2 groups (P = .02). On multivariable Cox survival analysis, coronary malperfusion and shock on arrival were associated with increased long-term mortality (P < .01 and P = .04). Conducting surgery within 5 hours of the onset of symptoms was a significant predictor of favorable long-term outcome (P = .03)., Conclusions: Although preoperative coronary malperfusion and shock on arrival worsened the long-term outcomes in patients undergoing aortic repair for acute type A aortic dissection with preoperative malperfusion syndrome, conducting an operation within 5 hours of the onset of symptoms significantly improved their long-term outcomes., (Copyright © 2021 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: The management of acute type A aortic dissection complicated by coma remains controversial. We previously reported an excellent rate of recovery of consciousness provided aortic repair was performed within 5 hours of the onset of symptoms. This study evaluates the early and long-term outcomes using this approach., Methods: Between August 2003 and July 2013, of the 241 patients with acute type A aortic dissection brought to the Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, 30 (12.4%) presented with coma; Glasgow Coma Scale was less than 11 on arrival. Surgery was performed in 186 patients, including 27 (14.5%) who were comatose. Twenty-four comatose patients underwent successful aortic repair immediately (immediate group). Their mean age was 71.0 ± 11.1 years, Glasgow Coma Scale was 6.5 ± 2.4, and prevalence of carotid dissection was 79%. For brain protection, deep hypothermia with antegrade cerebral perfusion was used, and postoperative induced hypothermia was performed. Neurologic evaluations were performed using the Glasgow Coma Scale, National Institutes of Health Stroke Scale, and modified Rankin Scale., Results: In the immediate group, the time from the onset of symptoms to arrival in the operating theater was 222 ± 86 minutes. Hospital mortality was 12.5%. Full recovery of consciousness was achieved in 79% of patients in up to 30 days. Postoperative Glasgow Coma Scale and National Institutes of Health Stroke Scale improved significantly when compared with the preoperative score (P < .05), and postoperative activities of daily living independence (modified Rankin Scale <3) was achieved in 50% of patients. The mean follow-up period was 56.5 months, and the cumulative survival was 48.2% after 10 years. Cox proportional hazards regression analysis indicated that immediate repair (hazard ratio, 4.3; P = .007) was the only significant predictor of postoperative survival over a 5-year period., Conclusions: The early and long-term outcomes as a result of immediate aortic repair for acute type A aortic dissection complicated by coma were satisfactory., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

The usefulness of dynamic cardiomyoplasty has been demonstrated repeatedly, both experimentally and clinically. Although clinical applications of dynamic cardiomyoplasty to ischemic heart disease have been reported, its effect on the coronary blood flow has never been discussed. Therefore, we tested the hypothesis that dynamic cardiomyoplasty might adversely affect coronary arterial blood flow through compression of the coronary arteries during systolic skeletal muscular contraction and incomplete relaxation of the skeletal muscle flap during diastole. Dynamic cardiomyoplasty was performed in seven mongrel dogs with the use of a left latissimus dorsi-muscle flap, paced synchronously with the R wave of the electrocardiogram. A 3F Doppler catheter was placed in the left main trunk of the coronary artery to assess the instantaneous changes of coronary flow velocity by fast Fourier transformation analysis, We compared systolic and diastolic properties during assisted versus unassisted cardiac cycles by calculating the peak velocity and the time-velocity integral. During assisted cardiac cycles, a significant enhancement of coronary arterial blood flow velocity was demonstrated by significant increases in both systolic and diastolic peak velocity (26.9% +/- 6.5%, p < 0.005; 4.0% +/- 1.6%, p < 0.05, respectively) and time-velocity integral (20.9% +/- 4.8%, p < 0.05; 10.0% +/- 4.6%, p < 0.05, respectively). Enhancement of coronary arterial blood flow velocity was associated with an increase in mean aortic pressure (16.4% +/- 1.3%, p < 0.005) and descending aortic flow (67.5% +/- 5.3%, p < 0.005). Also, the improved systolic coronary arterial blood flow velocity was consistent with an increase in systolic aortic pressure (15.8% +/- 1.5%, p < 0.005), and enhancement of diastolic coronary arterial blood flow velocity was associated with an increase in diastolic aortic pressure (8.6% +/- 2.3%, p < 0.01). We concluded that coronary arterial blood flow velocity was increased by the enhancement of cardiac function as a result of dynamic cardiomyoplasty, leading to an increase of coronary perfusion pressure and cardiac output.