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Observational study of mortality risk stratification by ischemic presentation in patients with acute type A aortic dissection: the Penn classification

Nature Clinical Practice Cardiovascular Medicine volume 6, pages 140–146 (2009)Cite this article

Abstract

Background Acute type A aortic dissection is a surgical emergency, with an operative mortality as high as 25%. Ischemia is a known predictor of mortality. We tested the efficacy of a classification system—the Penn classification, which is based on ischemic pattern at clinical presentation—to stratify operative mortality risk and identify high-risk groups of patients for further intervention and study.

Methods In this prospective observational study, patients underwent a standard aortic dissection repair protocol at the University of Pennsylvania, Philadelphia, PA, from 1993 to 2004. Patients were classified as having no ischemia, branch vessel malperfusion with localized organ ischemia, generalized ischemia with circulatory collapse, with or without cardiac involvement, or a combination of localized and generalized ischemia.

Results The cohort comprised 221 patients. The mean age was 61.6 (± 14.8) years and 66.5% were male. At presentation 57.9% of patients had no ischemia, 17.6% had localized ischemia, 15.4% had generalized ischemia, and 9.0% had both localized and generalized ischemia. Overall, 28 (12.7%) patients died during the perioperative period. All-cause mortality differed significantly between groups (no ischemia 3.1%, localized ischemia 25.6%, generalized ischemia 17.6%, combined ischemia 40.0%), yielding an overall 8.3-fold difference for no compared with any ischemia (3.1% versus 25.8%, P = 0.0001). Ischemic presentations together accounted for 85.7% of all deaths.

Conclusion The Penn classification of acute type A aortic dissection enabled stratification of patients by operative mortality risk. The system requires further validation, but might facilitate new ways to analyze mortality data for this disorder.

Key Points

  • Acute type A aortic dissection is a life-threatening surgical emergency that, despite substantial advances in operative management, is associated with high mortality

  • The Penn classification system for acute type A aortic dissection enables categorization of patients based on the pattern of ischemia at presentation

  • Mortality is lowest among patients without ischemia, but rises significantly among those with branch vessel malperfusion and localized organ ischemia, generalized ischemia, and is highest among patients with combined localized and generalized ischemia

  • Although the Penn classification requires further prospective validation across multiple centers, it has already shown promise for stratification of operative risk

  • Future research in acute type A aortic dissection might be improved by the application of this classification to improve selection of participants

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Acknowledgements

This study was supported by the Department of Anesthesiology and Critical Care (Cardiothoracic and Vascular Section) and Department of Surgery (Cardiothoracic Division) at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA. We appreciate the database management conducted by Katherine Cornelius and the statistical analysis expertise provided by Dr E Andrew Ochroch.

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Authors and Affiliations

  1. Department of Anesthesiology and Critical Care, Cardiothoracic and Vascular Section, University of Pennsylvania, Philadelphia, PA, USA

    John GT Augoustides

  2. Department of Surgery, Cardiothoracic Division, Yale University, New Haven, CT, USA

    Arnar Geirsson

  3. Department of Surgery, Cardiothoracic Division, University of Pennsylvania, Philadelphia, PA, USA

    Wilson Y Szeto, Elizabeth K Walsh, Brittany Cornelius, Alberto Pochettino & Joseph E Bavaria

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  1. John GT Augoustides
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  2. Arnar Geirsson
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Correspondence to John GT Augoustides.

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JR Bavaria has received speakers bureau honoraria from Vascutek USA. The other authors declared no competing interests.

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Augoustides, J., Geirsson, A., Szeto, W. et al. Observational study of mortality risk stratification by ischemic presentation in patients with acute type A aortic dissection: the Penn classification. Nat Rev Cardiol 6, 140–146 (2009). https://doi.org/10.1038/ncpcardio1417

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