Area-level Socioeconomic Status, Preoperative Comorbidities, Mortality And Malperfusion In Acute Type A Aortic Dissection

Abstract

Despite advances in surgical and postoperative care, in-hospital mortality from Acute Type A Aortic Dissection (ATAAD) remains as high as 22%. If left untreated, the mortality rate is 1% per hour from the emergence of symptoms with 24% mortality within 24 hours. The risk of death is increased further in patients who develop end-organ malperfusion, particularly cerebral and mesenteric, with mesenteric malperfusion being the second most common cause of death after aortic rupture. End-organ malperfusion is an independent risk factor for early mortality that occurs in up to 34% of patients with ATAAD, with in-hospital mortality rates reaching 86% if more than two organ systems are involved. Despite the time-sensitive nature of ATAAD, interfacility transfer for stable patients to high-volume centers is a class IIa recommendation in major guidelines because of improved survival. Identifying the social determinants of health, particularly socioeconomic status (SES), and examining its relationship with interfacility transfer and access to care at high-volume centers may offer insights into the challenges faced by ATAAD patients from lower SES backgrounds – particularly in relation to timely transfers and its relationship to their short- and long-term outcomes. Furthermore, exploring whether the characteristics of patients with ATAAD and end-organ malperfusion differ from patients without end-organ malperfusion could offer valuable insights into the pathophysiology of the complication and its established impact on postoperative outcomes. To answer these questions, we studied the relationship between area-level SES and in-hospital mortality in patients with ATAAD, as well as the relationship between several demographic and preoperative conditions and the occurrence of end-organ malperfusion. We hypothesized that 1) patients with ATAAD from lower area-level socioeconomic background have worse short-term outcomes compared to patients from higher area-level socioeconomic backgrounds at high-volume centers, and 2) ATAAD patients with end-organ malperfusion differ in demographic and preoperative characteristics from patients without end-organ malperfusion.