Transpericardial ultrasound-guided management of visceral malperfusion in acute type A aortic dissection

Objectives Visceral malperfusion remains a major determinant of early mortality in acute type A aortic dissection. Rapid identification and classification of malperfusion mechanisms are crucial to guide treatment decisions and improve outcomes. Methods We retrospectively analyzed 108 patients undergoing surgical repair for acute type A aortic dissection. Transpericardial ultrasound was performed intraoperatively in 75 patients at 1 or more timepoints (pre-, intra-, or postcardiopulmonary bypass). Visceral flow in the superior mesenteric artery and celiac trunk was graded semiquantitatively. Flow improvement after cardiopulmonary bypass was considered diagnostic of dynamic malperfusion. Postoperative outcomes and causes of death were analyzed in relation to perfusion trends. Results Visceral malperfusion was diagnosed in 26 patients (24.1%). Superior mesenteric artery flow normalized intraoperatively in 22 (84.6%), indicating dynamic obstruction. Patients with flow normalization had significantly lower mortality (9.1%) than those with persistent malperfusion (60%). Transpericardial ultrasound findings guided surgical decision making, supporting extended arch repair or endovascular adjuncts only when flow remained impaired. Thirty-day mortality was 22.2% overall, with multiorgan failure and ischemia accounting for most deaths in patients with malperfusion. Conclusions Transpericardial ultrasound is a valuable tool for intraoperative assessment of visceral perfusion. It enables real-time distinction between reversible and irreversible malperfusion, supports a perfusion-guided repair-first strategy, and may reduce unnecessary interventions while improving risk stratification and outcomes. © 2026 The Author(s).