OBJECTIVES: Several conditions associated with type A aortic dissection may require preoperative invasive mechanical ventilation (IMV). The current literature lacks data on this subset of patients' prevalence and postoperative outcomes. This study aims to investigate this unexplored issue in a multicenter European registry. METHODS: Data from 3735 patients included in the European Registry of Type A Aortic Dissection (ERTAAD) were the subject of this analysis. Bootstrapped Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression was performed for variable selection to identify key predictors of hospital death. In the second step, a multilevel multivariable logistic regression (MMLR) was carried out, given the clustered structure of the data. RESULTS: A total of 346 (9.3%) out of 3735 patients required preoperative IMV. Compared to the non-IMV patients, patients requiring IMV had a significantly higher rate of organ malperfusion (52% vs. 35%, p < 0.001) and a higher proportion of tears in the aortic root (p = 0.048). The in-hospital mortality rate among IMV patients was 38% vs. 15% in non-IMV patients (p < 0.001), without a difference in post-discharge survival (p = 0.84). At the MMLR, patients who required IMV had 135% higher odds of in-hospital death compared to the remaining patients. IMV yielded the second highest odds in the prediction model for in-hospital mortality (OR 2.13, CI 1.60 to 2.85, p < 0.001). Among IMV patients, the extension of surgery to the aortic arch was significantly associated with increased in-hospital mortality (p < 0.001, OR 2.98). In multivariable analysis, preoperative IMV was independently associated with increased odds of in-hospital mortality. CONCLUSIONS: The need for invasive mechanical ventilation before surgical repair for type A aortic dissection is not infrequent. In this subpopulation, the in-hospital mortality rate was twofold compared to patients who did not require IMV. The awareness of the preoperative risk profile and outcomes of this subset of patients should urge surgeons to tailor the surgical strategy more appropriately to improve the immediate postoperative results.

Cardiac Surgery Molinette Hospital University of Turin 10126 Turin Italy

Cardiothoracic Department University Hospital of Udine 33100 Udine Italy

Cardiovascular Surgery Department University Hospital Gregorio Marañón 28007 Madrid Spain

Department of Cardiac Surgery 3rd Faculty of Medicine Charles University and University Hospital Kralovske Vinohrady 10000 Prague Czech Republic

Department of Cardiac Surgery Centre Hospitalier Annecy Genevois 74370 Epagny Metz Tessy France

Department of Cardiac Surgery Cologne University Hospital 50937 Cologne Germany

Department of Cardiac Surgery Glenfield Hospital Leicester LE3 9QP UK

Department of Cardiac Surgery Hôpitaux Universitaires Henri Mondor Assistance Publique Hôpitaux de Paris 94000 Creteil France

Department of Cardiac Surgery LMU University Hospital Ludwig Maximilian University 81337 Munich Germany

Department of Cardiac Surgery University Hospital Halle 06120 Halle Germany

Department of Cardiac Surgery Ziekenhuis Oost Limburg 3600 Genk Belgium

Department of Cardiothoracic Surgery University Hospital Muenster 48149 Muenster Germany

Department of Cardiovascular Surgery Centro Cardioologico Monzino IRCCS 20138 Milan Italy

Department of Cardiovascular Surgery Hospital Clínic de Barcelona University of Barcelona 08036 Barcelona Spain

Department of Cardiovascular Surgery University Heart and Vascular Center Hamburg 20251 Hamburg Germany

Department of Medicine South Karelia Central Hospital University of Helsinki 53130 Lappeenranta Finland

Department of Thoracic and Cardiovascular Surgery University of Franche Comte 25030 Besancon France

Division of Cardiac Surgery Cardio thoracic and Vascular Department Azienda Sanitaria Universitaria Giuliano Isontina 34149 Trieste Italy

Division of Cardiac Surgery University of Verona Medical School 37129 Verona Italy

German Centre for Cardiovascular Research Partner Site Munich Heart Alliance 80802 Munich Germany

Heart and Lung Center Helsinki University Hospital University of Helsinki 00290 Helsinki Finland

Liverpool Centre for Cardiovascular Sciences Liverpool Heart and Chest Hospital Liverpool L14 3PE UK

National Center for Global Health Istituto Superiore di Sanitá 00161 Rome Italy

Research Unit of Surgery Anesthesia and Critical Care University of Oulu 90570 Oulu Finland

St Josef Hospital University Hospital of Ruhr University of Bochum 44791 Bochum Germany

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