Extra-anatomic revascularization and a new cannulation strategy for preoperative cerebral malperfusion due to severe stenosis or occlusion of supra-aortic branch vessels in acute type A aortic dissection

Objectives

Acute type A aortic dissection (ATAAD) with severe stenosis or occlusion of the true lumen of aortic arch branch vessels often leads to an increased incidence of severe postsurgical neurological complications and mortality rate. In this study, we aimed to introduce our institutional extra-anatomic revascularization and cannulation strategy with improved postoperative outcomes for better management of patients with cerebral malperfusion in the setting of ATAAD.

Methods

Twenty-eight patients with ATAAD complicated by severe stenosis or occlusion of the aortic arch branch vessels, as noted on combined computed tomography angiography of the aorta and craniocervical artery, between January 2021 and June 2022 were included in this study. Basic patient characteristics, surgical procedures, hospitalization stays, and early follow-up results were analyzed.

Results

The median follow-up duration was 16.5 months (interquartile range: 11.5-20.5), with a 100% completion rate. The 30-day mortality rates was 7.1% (2/28 patients); two patients had multiple cerebral infarctions on preoperative computed tomography and persistent coma. Postoperative transient neurological dysfunction occurred in 10.7% (3/28) of the patients, and no new permanent neurological dysfunction occurred. Of all the patients, 3.6% (1/28) had novel acute renal failure. No other deaths, secondary surgeries, or serious complications occurred during the early follow-up period.

Conclusions

Use of extra-anatomic revascularization and a new cannulation strategy before cardiopulmonary bypass is safe and feasible and may reduce the high incidence of postoperative neurological complications in patients with ATAAD and cerebral malperfusion.

D-dimer measurement is useful irrespective of time from the onset of acute aortic syndrome symptoms

BACKGROUND

In acute aortic syndrome (AAS) screening, D-dimer is a well-established biomarker whose usefulness has been scarcely studied with respect to its measurement timing. We aimed to evaluate the effectiveness of D-dimer-based AAS screening focused on the time interval between AAS onset and D-dimer measurement.

METHODS

We retrospectively analyzed consecutive patients diagnosed with AAS who visited our hospital between 2011 and 2021. For the primary analysis, we divided patients according to the quartiles of the time interval between AAS symptom onset and D-dimer measurement. D-dimer level ≥ 0.5 μg/mL and age-adjusted D-dimer ≥ [age (years) × 0.01] μg/mL (minimum of 0.5 μg/mL) were defined as positive. The primary endpoint was the comparative ability of D-dimer to detect AAS within and between each time quartile. In an exploratory secondary analysis, we reported patient and AAS characteristics in the subgroup of patients who underwent repeat D-dimer measurement within 48 h of the first D-dimer measure.

RESULTS

The 273 AAS patients were divided into four groups based on quartiles of the time interval (Group 1, ≤1 h; Group 2, 1-2 h; Group 3, 2-5 h; and Group 4, >5 h). There were no significant differences in D-dimer levels or in the proportions with positive D-dimer (Group 1: 97%, Group 2: 96%, Group 3: 99%, Group 4: 99%; P = 0.76) or positive age-adjusted D-dimer (Group 1: 96%, Group 2: 90%, Group 3: 96%, Group 4: 97%; P = 0.32) between the groups. Of the 147 patients who had D-dimer re-measured, nine had negative D-dimer levels on either the primary or secondary measurement. Of these nine patients, eight had AAS with a thrombosed false lumen and one with a patent false lumen had a short length of dissection. In all nine patients, D-dimer levels remained low (maximum of 1.4 μg/mL).

CONCLUSION

D-dimer levels were elevated from the early stages of AAS. The clinical utility of D-dimer is not affected by the time interval from AAS onset to D-dimer measurement, but rather is influenced by AAS characteristics.

The modified frozen elephant trunk may outperform limited and extended-classic repair in acute type I dissection

OBJECTIVES

A better surgical approach for acute DeBakey type I dissection has been sought for decades. We compare operative trends, complications, reinterventions and survival after limited versus extended-classic versus modified frozen elephant trunk (mFET) repair for this condition.

METHODS

From 1 January 1978 to 1 January 2018, 879 patients underwent surgery for acute DeBakey type I dissection at Cleveland Clinic. Repairs were limited to the ascending aorta/hemiarch (701.79%) or extended through the arch [extended classic (88.10%) or mFET (90.10%)]. Weighted propensity score matched established comparable groups.

RESULTS

Among weighted propensity-matched patients, mFET repair had similar circulatory arrest times and postoperative complications to limited repair, except for postoperative renal failure, which was twice as high in the limited group [25% (n = 19) vs 12% (n = 9), P = 0.006]. Lower in-hospital mortality was observed following limited compared to extended-classic repair [9.1% (n = 7) vs 19% (n = 16), P = 0.03], but not after mFET repair [12% (n = 9) vs 9.5% (n = 8), P = 0.6]. Extended-classic repair had higher risk of early death than limited repair (P = 0.0005) with no difference between limited and mFET repair groups (P = 0.9); 7-year survival following mFET repair was 89% compared to 65% after limited repair. Most reinterventions following limited or extended-classic repair underwent open reintervention. All reinterventions following mFET repair were completed endovascularly.

CONCLUSIONS

Without increasing in-hospital mortality or complications, less renal failure and a trend towards improved intermediate survival, mFET may be superior to limited or extended-classic repair for acute DeBakey type I dissections. mFET repair facilitates endovascular reintervention, potentially reducing future invasive reoperations and warranting continued study.

An Uncommon Presentation of Acute Thoracic Aortic Dissection

We present a case of a 40-year-old Caucasian male with past medical history of polysubstance abuse (cocaine and methamphetamine), who presented to the emergency department (ED) complaining of intermittent cough with associated chest discomfort and shortness of breath for 2 weeks. Initial vital signs demonstrated borderline tachycardia (98 beats per minute), tachypnea (37 times per minutes), and hypoxia (oxygen saturation 89% on room air), and his physical exam was grossly unremarkable. A preliminary workup including a computed tomography angiography (CTA) revealed a type A aortic dissection with both thoracic and abdominal involvement for which the patient was admitted. This patient had resection of the ascending aorta with graft placement, cardiopulmonary bypass, aortic root replacement using composite prosthesis and left and right coronary reconstruction and reimplantation and survived a complicated hospital course. This case demonstrates the classic association known to exist between recreational drug use, specifically stimulants such as cocaine and amphetamines, and acute aortic dissection (AAD). However, such a presentation of borderline subacute, painless dissection in the setting of polysubstance use raises further questions, since uncommon AAD is typically found in higher-risk populations such as those with connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome, Loeys-Dietz syndrome), bicuspid aortic valve, chronic hypertension, or previous aortic pathology. We therefore suggest clinicians strongly consider uncommon AAD as part of their differential diagnosis in patients with known or highly suspected polysubstance abuse.

Relationship between intralobar pulmonary sequestration and type A aortic dissection: A case report

BACKGROUND

Pulmonary sequestrations often lead to serious complications such as infections, tuberculosis, fatal hemoptysis, cardiovascular problems, and even malignant degeneration, but it is rarely documented with medium and large vessel vasculitis, which is likely to result in acute aortic syndromes.

CASE SUMMARY

A 44-year-old man with a history of acute Stanford type A aortic dissection status post-reconstructive surgery five years ago. The contrast-enhanced computed tomography of the chest at that time had also revealed an intralobar pulmonary sequestration in the left lower lung region, and the angiography also presented perivascular changes with mild mural thickening and wall enhancement, which indicated mild vasculitis. The intralobar pulmonary sequestration in the left lower lung region was long-term unprocessed, which was probably associated with his intermittent chest tightness since no specific medical findings were detected but only positive sputum culture with mycobacterium avium-intracellular complex and Aspergillus. We performed uniportal video-assisted thoracoscopic surgery with wedge resection of the left lower lung. Hypervascularity over the parietal pleura, engorgement of the bronchus due to a moderate amount of mucus, and firm adhesion of the lesion to the thoracic aorta were histopathologically noticed.

CONCLUSION

We hypothesized that a long-term pulmonary sequestration-related bacterial or fungal infection can result in focal infectious aortitis gradually, which may threateningly aggravate the formation of aortic dissection.

Acute Lung Injury in aortic dissection : new insights in anesthetic management strategies

Acute aortic dissection (AAD) is a severe cardiovascular disease characterized by rapid progress and a high mortality rate. The incidence of acute aortic dissection is approximately 5 to 30 per 1 million people worldwide. In clinical practice, about 35% of AAD patients are complicated with acute lung injury (ALI). AAD complicated with ALI can seriously affect patients' prognosis and even increase mortality. However, the pathogenesis of AAD combined with ALI remains largely unknown. Given the public health burden of AAD combined with ALI, we reviewed the anesthetic management advances and highlighted potential areas for clinical practice.

Outcomes of type A acute aortic dissection with cardiopulmonary arrest: Tokyo Acute Aortic Super-network Registry

OBJECTIVES

Preventing loss of life in patients with type A acute aortic dissection (AAD) who present with cardiopulmonary arrest (CPA) can be extremely difficult. Thus, we investigated the early outcomes in these patients.

METHODS

Patients with type A AAD who were transported to hospitals belonging to the Tokyo Acute Aortic Super-network between January 2015 and December 2019 were considered for this study. We assessed the early mortality of these patients presenting with CPA and also investigated the differences in outcomes between patients with out-of-hospital and in-hospital CPA.

RESULTS

A total of 3307 patients with type A AAD were transported, 434 (13.1%) of whom presented with CPA. The overall mortality of patients presenting with CPA was 88.2% (383/434), of which 94.5% (240/254) experienced out-of-hospital CPA and 79.4% (143/180) experienced in-hospital CPA (P < 0.001). Multivariable analysis revealed that aortic surgery [odds ratio (OR), 0.022; 95% confidence interval (CI), 0.008-0.060; P < 0.001] and patient age over 80 years (OR, 2.946; 95% CI, 1.012-8.572; P = 0.047) were related with mortality in patients with type A AAD and CPA. Between in-hospital and out-of-hospital CPA, the proportions of DeBakey type 1 (OR, 2.32; 95% CI, 1.065-5.054; P = 0.034), cerebral malperfusion (OR, 0.188; 95% CI, 0.056-0.629; P = 0.007), aortic surgery (OR, 0.111; 95% CI, 0.045-0.271; P = 0.001), age (OR, 0.969; 95% CI, 0.940-0.998; P = 0.039) and the time from symptom onset to hospital admission (OR, 1.122; 95% CI, 1.025-1.228; P = 0.012) were significantly different.

CONCLUSIONS

Patients with type A AAD presenting with CPA exhibited extremely high rates of death. Patient outcomes following in-hospital CPA tended to be better than those following out-of-hospital CPA; however, this difference was not significantly different. To prevent deaths, aortic surgery, when possible, should be considered in patients with type A AAD who sustained CPA.

Late outcomes of the frozen elephant trunk technique for acute and chronic aortic dissection: the angle change of the FROZENIX by "spring-back" force

OBJECTIVES

To evaluate the outcomes of total arch replacement using the frozen elephant trunk technique with a FROZENIX^® J Graft for patients with either acute or chronic aortic dissection, and to evaluate the late-phase outcomes.

METHODS

Between January 2015 and December 2020, we used the frozen elephant trunk technique in 47 patients with acute aortic dissection and 12 patients with chronic aortic dissection. The primary endpoints were 30-day mortality, late aorta-related death and late aortic events. The secondary endpoints included early surgical complications and any aortic events (e.g. stent graft-induced new entry, frozen elephant trunk angle change).

RESULTS

In the acute group, there were no aorta-related deaths, although 13 patients (27.7%) experienced an aortic event; stent graft-induced new entry occurred in 6 patients (12.8%). In the chronic group, 1 patient (9.1%) experienced aorta-related death, and 9 (81.8%) experienced an aortic event; stent graft-induced new entry occurred in 4 patients (36.4%). During the late phase after surgery, there was a significant increase in the frozen elephant trunk angle in both groups. In the AAD group, both the FET angle and spring-back angle were significantly enlarged in the late phase. There were no significant differences between groups in the degree of angle change, the overall survival, or aortic event-free survival.

CONCLUSIONS

Total arch replacement using the frozen elephant trunk technique affords good early-stage results for both acute and chronic aortic dissection. During follow-up, careful monitoring for aortic events and appropriate therapeutic interventions are required. If surgeons are to use this device, they must have a thorough understanding of its spring back force and other features.

Admission D-dimer to lymphocyte counts ratio as a novel biomarker for predicting the in-hospital mortality in patients with acute aortic dissection

BACKGROUND

Inflammatory factors are well-established indicators for vascular disease, but the D-dimer to lymphocyte count ratio (DLR) is not measured in routine clinical care. Screening of DLR in individuals may identify individuals at in-hopital mortality of acute aortic dissection (AD).

METHODS

A retrospective analysis of clinical data from 2013 to 2020 was conducted to identify which factors were related to in-hospital mortality risk of AD. Baseline clinical features, cardiovascular risk factors, and laboratory parameters were obtained from the hospital database. The end point was in-hospital mortality. Forward conditional logistic regression was performed to identify independent risk factors for AA in-hospital death. The cutoff value of the DLR should be ideally calculated by receiver operating characteristic (ROC) analysis.

RESULTS

The in-hospital mortality rate was 15% (48 of 320 patients). Patients with in-hospital mortality had a higher admission mean DLR level than the alive group (1740 vs. 1010, P < .05). The cutoff point of DLR was 907. The in-hospital mortality rate in the high-level DLR group was significantly higher than that in the low-level DLR group (P < .05). Univariate analysis showed that 8 of 38 factors were associated with in-hospital mortality (P < .05), including admission WBC, neutrophils, lymphocytes, neutrophils/lymphocytes (NLR), prothrombin time (PT), heart rate (HR), D-dimer, and DLR. In multivariate analysis, DLR (odds ratio [OR] 2.127, 95% CI 1.034-4.373, P = 0.040), HR (odds ratio [OR] 1.016, 95% CI 1.002-1.030, P = 0.029) and PT (odds ratio [OR] 1.231, 95% CI 1.018-1.189, P = 0.032) were determined to be independent predictors of in-hospital mortality (P < .05).

CONCLUSION

Compared with the common clinical parameters PT and HR, serum DLR level on admission is an uncommon but independent parameter that can be used to assess in-hospital mortality in patients with acute AD.

Low preoperative serum fibrinogen level is associated with postoperative acute kidney injury in patients with in acute aortic dissection

OBJECTIVE

Acute kidney injury (AKI) after cardiac surgery is associated with serious complication and high risk of mortality. The relationship between hemostatic system and the prognosis of patients with acute type A aortic dissection (ATAAD) has not been evaluated. The purpose of this study was to investigate the association between preoperative serum fibrinogen level and risk of postoperative AKI in patients with ATAAD.

METHODS

A total of 172 consecutive patients undergoing urgent aortic arch surgery for ATAAD between April 2020 and December 2021 were identified from Beijing Anzhen Hospital aortic surgery database. The primary outcome was postoperative AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. The univariate and multivariate logistic regression analysis were done to assess the independent predictors of risk for postoperative AKI. Receiver operating characteristic (ROC) curve was generated to evaluate the predictive probabilities of risk factors for AKI.

RESULTS

In our study, 51.2% (88/172) patients developed postoperative AKI. Multivariate logistic regression analysis identified low preoperative serum fibrinogen level (OR, 1.492; 95% CI, 1.023 to 2.476; p = 0.021) and increased body mass index (BMI) (OR, 1.153; 95% CI, 1.003 to 1.327; p = 0.046) as independent predictors of postoperative AKI in patients with ATAAD. A mixed effect analysis of variance modeling revealed that obese patients with low preoperative serum fibrinogen level had higher incidence of postoperative AKI (p = 0.04). The ROC curve indicated that low preoperative serum fibrinogen level was a significant predictor of AKI [area under the curve (AUC), 0.771; p < 0.001].

CONCLUSIONS

Low preoperative serum fibrinogen level and obesity were associated with the risk of postoperative AKI in patients with ATAAD. These data suggested that low preoperative serum fibrinogen level was preferred marker for predicting the postoperative AKI, especially in obese patients with ATAAD.

Prevention and management of difficult hemostasis in acute type A aortic dissection repair

Postoperative bleeding after surgery for acute aortic dissection is one of the most common complications and has an important influence on mortality and morbidity. Therefore, various methods have been introduced to prevent or manage postoperative bleeding. In this article, we investigated the causes of bleeding after surgery for acute aortic dissection, and introduce appropriate transfusion or pharmacologic treatment, topical hemostatic agents, and local compressive maneuver to manage it.

Case Report: Effects of Sars-CoV-2 on Marfan syndrome with resulting acute aortic dissection

Marfan syndrome is one of the most common inherited connective tissue disorders that affects the heart, eyes, blood vessels, and bones. It occurs in approximately 1-2 per 10,000 individuals annually. Many patients with Marfan syndrome eventually develop aortic wall abnormalities, often resulting in aortic dilatation, which increases the risk of acute aortic dissection. Recent studies involving SARS-CoV-2 propose that individuals with connective tissue disorders such as Marfan syndrome can have additional associated conditions that could impose a higher risk for morbidity and mortality from SARS-CoV-2. The purpose of this article is to discuss the interrelationship between Marfan Syndrome, Acute Type A Aortic Dissection in a patient with Sars-CoV-2 infection. Pertinent review of these conditions, diagnostic findings, treatment, and the patient's clinical course will be discussed. There is minimal research focused on the connection between this novel virus, Marfan Syndrome, and compounding risk for aortic dissection.

Identification of FERMT1 and SGCD as key marker in acute aortic dissection from the perspective of predictive, preventive, and personalized medicine

Acute aortic dissection (AAD) is a severe aortic injury disease, which is often life-threatening at the onset. However, its early prevention remains a challenge. Therefore, in the context of predictive, preventive, and personalized medicine (PPPM), it is particularly important to identify novel and powerful biomarkers. This study aimed to identify the key markers that may contribute to the predictive early risk of AAD and analyze their role in immune infiltration. Three datasets, including a total of 23 AAD and 20 healthy control aortic samples, were retrieved from the Gene Expression Omnibus (GEO) database, and a total of 519 differentially expressed genes (DEGs) were screened in the training set. Using the least absolute shrinkage and selection operator (LASSO) regression model and the random forest (RF) algorithm, FERMT1 (AUC = 0.886) and SGCD (AUC = 0.876) were identified as key markers of AAD. A novel AAD risk prediction model was constructed using an artificial neural network (ANN), and in the validation set, the AUC = 0.920. Immune infiltration analysis indicated differential gene expression in regulatory T cells, monocytes, γδ T cells, quiescent NK cells, and mast cells in the patients with AAD and the healthy controls. Correlation and ssGSEA analysis showed that two key markers' expression in patients with AAD was correlated with many inflammatory mediators and pathways. In addition, the drug-gene interaction network identified motesanib and pyrazoloacridine as potential therapeutic agents for two key markers, which may provide personalized medical services for AAD patients. These findings highlight FERMT1 and SGCD as key biological targets for AAD and reveal the inflammation-related potential molecular mechanism of AAD, which is helpful for early risk prediction and targeted prevention of AAD. In conclusion, our study provides a new perspective for developing a PPPM method for managing AAD patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s13167-022-00302-4.

Postoperative results of the in situ fenestrated open stent technique for acute aortic dissection type A

OBJECTIVE

Total arch replacement is commonly used for acute aortic dissection type A at some facilities, especially since open stent grafting became commercially available in Japan. Left subclavian artery (LSCA) reconstruction involves deep view manipulation, is difficult to expose and anastomose, and involves the risk of complications and surrounding vascular injury.

METHODS

We evaluated 137 patients (mean age 73.8 ± 15.6 years) who underwent total arch replacement for acute aortic dissection type A, at our hospital between September 2014 and March 2022, and divided them into two groups: 70 patients for total arch replacement with fenestrated open stent technique (FeneOS), and 67 for conventional total arch replacement with the reconstruction of three-branch cerebral vessels. We performed FeneOS by deploying the graft from the entry of the left subclavian artery into the descending aorta and fenestrating the LSCA side of the stenting portion. The four-branched artificial vessel was then anastomosed between the left common carotid artery and LSCA.

RESULTS

The surgical results of FeneOS were satisfactory and enabled significant reductions in operative time, selective cerebral perfusion time, cardiopulmonary bypass time, and lower body circulatory arrest time. Long-term observation (mean follow-up = 5.5 years) showed no left recurrent laryngeal nerve palsy or postoperative problems with left subclavian artery blood flow.

CONCLUSIONS

FeneOS can minimize LSCA exposure because there is no need for LSCA reconstruction, reducing operation time and avoiding the risk of left recurrent laryngeal nerve injury and bleeding problems associated with LSCA exposure and anastomosis during left subclavian artery exposure.

Recent trends of open surgery for acute type A aortic dissection in Japan

OBJECTIVE

Reporting clinical outcomes of acute type A aortic dissection.

METHODS

Data derived from the survey of the Japanese Association for Thoracic Surgery, the Japan Cardiovascular Database, and the Japanese Registry of All Cardiac and Vascular Diseases were analyzed.

RESULTS

Between 2012 and 2015, the Japanese Registry of All Cardiac and Vascular Diseases study collected 13,131 patients and the hospital mortality was 24.3%. The surgical mortality was significantly lower than medical one (11.8% vs 49.7%; p < 0.001). The Japanese Association for Thoracic Surgery survey disclosed the number of surgeries has been increased to 6157 in 2018 and the hospital death has decreased to 10.5%. The Japan Cardiovascular Database, collected 29,486 patients from 2013 to 2018. Age at surgery was 59.8  ±  14.2 years and patients younger than 65 years in 61% and 21% were older than 75 years. Ninety-four percent had surgery within 24 h after diagnosis. Antegrade cerebral perfusion was used in 74% and deep hypothermic circulatory arrest with/without retrograde cerebral perfusion in 26%. Replacement of the ascending aorta was performed in 62% and total arch replacement in 28%. The aortic valve was replaced in 7.9% and repaired in 4.4%. The hospital mortality was 11%. New stroke occurred in 12%, hemodialysis in 7.3%, paraplegia in 3.9%, and prolonged ventilation in 15%.

CONCLUSION

The number of operations for type A aortic dissection has increased, and hospital mortality has improved. Although the early results after surgery for type A aortic dissection are acceptable, new strategies to improve early outcomes in patients with preoperative comorbidities are required.

Acute ischemic Stroke combined with Stanford type A aortic dissection: A case report and literature review

BACKGROUND

Acute aortic dissection (AAD) is a high mortality disease that can lead to acute ischemic strokes (AIS). Some of the patients with AAD combined with AIS initially present with neurological symptoms, which can easily lead to missed or delayed AAD diagnosis. This is attributed to the lack of physician awareness or the urgency of patient thrombolysis. Intravenous administration of thrombolytic therapy (IVT) for AAD is associated with poor prognostic outcomes. We report a patient with AIS combined with AAD who developed a massive cerebral infarction after receiving IVT for a missed AAD diagnosis.

CASE SUMMARY

A 49-year-old man was admitted to a local hospital with an acute onset of left-sided limb weakness accompanied by slurred speech. The patient had a history of hypertension that was not regularly treated with medication. Physical examination revealed incomplete mixed aphasia and left limb hemiparesis. Cranial computed tomography (CT) scan showed bilateral basal ganglia and lateral ventricular paraventricular infarct lesions. The patient was diagnosed with AIS and was administered with IVT. After IVT, patient’s muscle strength and consciousness deteriorated. From the local hospital, he was referred to our hospital for further treatment. Emergency head and neck CT angiography (CTA) scans were performed. Results showed multiple cerebral infarctions, and aortic dissection in the ascending aorta, innominate artery, as well as in the right common carotid artery. Then, the CTA of thoracoabdominal aorta was performed, which revealed a Stanford type A aortic dissection and aortic dissection extending from the aortic root to the left external iliac artery. Laceration was located in the lesser curvature of the aortic arch. AAD complicated with AIS was considered, and the patient was immediately subjected to cardiovascular surgery for treatment. The next day, the patient underwent aortic arch and ascending aortic replacement and aortic valvuloplasty.

CONCLUSION

Clinical manifestations for AAD combined with AIS are diverse. Some patients may not exhibit typical chest or back pains. Therefore, patients should be carefully evaluated to exclude AAD before administering IVT in order to avoid adverse consequences.

A threatening meteor for cardiac surgeons: anomalous Left Main Coronary Origin in Type-A Aortic Dissection

We present the case of a type A aortic dissection originating from the right coronary ostium and an intraoperative diagnosis of the entire coronary artery system originating from a single right-sided coronary ostium.

Elevated cardiac troponin I and short-term mortality in patients with acute type A aortic dissection

AIMS

To explore the association between elevated cardiac troponin I (cTnI) on 30-day mortality in patients with acute type A aortic dissection (ATAAD).

METHODS AND RESULTS

A total of 1321 consecutive patients who were admitted to the emergency department of Fuwai Hospital from January 2016 to December 2020 were enrolled. Patients had computed tomography-confirmed ATAAD and were measured serum cTnI on admission. Patients were divided into the troponin-positive (cTnI > 0.02 ng/mL) or the troponin-negative group (cTnI ≤ 0.02 ng/mL). Troponin was detected by PATHFAST instrument produced by Medins Co., Ltd., and the reference range of normal value is 0-0.02 ng/mL. A total of 522 out of 1321 patients (39.5%) in our study had elevated cTnI, who had higher 30-day mortality rate compared with the troponin-negative group (44.4% vs. 19.4% P < 0.0001). Multivariate logistic regression results showed that elevated cTnI was an independent risk indicator for 30-day mortality (odds ratio: 2.582; 95% confidence interval: 1.357-4.914; P = 0.0039). The addition of elevated cTnI level to a clinical-based risk prediction model resulted in significant incremental prognostic value (AUC difference: 0.0261).

CONCLUSION

Elevated cTnI is common in patients with ATAAD, and is associated with increased 30-day mortality risk.

The aortic root in acute Type A dissection: repair or replace?

BACKGROUND

The effect of an "aggressive" approach on the aortic root in acute type A aortic dissection (ATAAD) remains insufficiently explored.

METHODS

Retrospective analysis of a single-center, prospective cohort of consecutive patients diagnosed with ATAAD aged ≥ 18 years, between 1992 and 2020. Patients were divided into 2 groups: aortic root replacement (ARR; prosthetic or valve-sparing root replacement; N=141) and conservative root approach (CRA; root sparing of (partially) dissected root, N=90, and supracoronary ascending replacement (SCAR) in non-dissected root, N=68). Inverse probability weighting was used to compare patients with different pre-operative characteristics. Mean follow-up was 5.1 (0-21) in ARR and 7.1 (0-25) years in CRA.

RESULTS

The frequency of aortic root replacement increased over the years, with 19% and 78% of patients undergoing ARR in the earliest and most recent periods, respectively. Early mortality decreased over the years, despite more aggressive approach, and remained lower in ARR. CRA was associated with higher hazard of late mortality (HR 1.38, 95% CI 1.12 - 1.68; P = 0.001) and reintervention (HR 2.08, 95% CI 1.44 - 3.56; P = 0.001). Following CRA, new-onset aortic valve insufficiency was a common cause of reintervention.

CONCLUSIONS

Over the years, there was a gradual increase in root replacement approach in ATAAD. Root replacement was associated with better long-term survival and less reinterventions compared to the conservative approach, while the in-hospital mortality decreased during these years. Hence, "aggressive" root replacement is safe and could be applied in ATAAD with good long-term clinical results, without increased hospital mortality.

HCMV-miR-US33-5p promotes apoptosis of aortic vascular smooth muscle cells by targeting EPAS1/SLC3A2 pathway

Background

In patients with acute aortic dissection (AAD), increased vascular smooth muscle cell (VSMC) apoptosis has been found. Human cytomegalovirus (HCMV)-miR-US33-5p was significantly increased in the plasma of patients with AAD. However, the roles of miR-US33-5p in human aortic VSMC (HA-VSMC) apoptosis remain to be elucidated.

Methods

In the current study, cell apoptosis was analyzed by flow cytometry, cell proliferation by CCK-8 assay, and differentially expressed genes by RNA sequencing. Luciferase reporter assay was used for binding analysis between miR-US33-5p and endothelial PAS domain protein 1 (EPAS1), and EPAS1 and amino acid transporter heavy chain, member 2 (SLC3A2). The enrichment degree of SLC3A2 promoter DNA was analyzed by chromatin immunoprecipitation assay. Quantitative reverse-transcription polymerase chain reaction (qRT-PCR) and immunoblotting were performed for measuring messenger RNA (mRNA) and protein levels, respectively.

Results

It was found that HCMV infection inhibited proliferation but promoted HA-VSMC apoptosis by upregulating HCMV-miR-US33-5p. Transfection of HCMV-miR-US33-5p mimics the significant effect on several signaling pathways including integrin signaling as shown in the RNA sequencing data. Western blotting analysis confirmed that HCMV-miR-US33-5p mimics suppression of the activity of key factors of the integrin signal pathway including FAK, AKT, CAS, and Rac. Mechanistic study showed that HCMV-miR-US33-5p bound to the 3′-untranslated region of EPAS1 to suppress its expression, leading to suppression of SLC3A2 expression, which ultimately promoted cell apoptosis and inhibited cell proliferation. This was confirmed by the findings that silencing EPAS1 significantly reduced the SLC3A2 expression and inhibited proliferation and key factors of integrin signal pathway.

Conclusions

HCMV-miR-US33-5p suppressed proliferation, key factors of integrin signal pathway, and EPAS1/SLC3A2 expression, but promoted HA-VSMC apoptosis. These findings highlighted the importance of HCMV-miR-US33-5p/EPAS1/SCL3A2 signaling and may provide new insights into therapeutic strategies for AAD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s11658-022-00340-w.

Total arch replacement with both frozen elephant trunk and transthoracic aorto-axillary extra-anatomical bypass through partial sternotomy for acute aortic dissection in a tracheostomy patient

Median sternotomy near an existing tracheostoma risks deep sternal wound infection after cardiac surgery. We present herein a case of acute type A aortic dissection in a patient with a permanent tracheostoma after laryngectomy. Total arch replacement with both frozen elephant trunk and extra-anatomical bypass for supra-aortic trunks was performed through T-shaped partial sternotomy, resulting in recovery without deep sternal wound infection.

On-line risk prediction models for acute type A aortic dissection surgery: validation of the German Registry of Acute Aortic Dissection Type A score and the European System for Cardiac Operative Risk Evaluation II

OBJECTIVES

The German Registry of Acute Aortic Dissection Type A (GERAADA) on-line score calculator to predict 30-day mortality in patients undergoing surgery for acute type A aortic dissection (ATAAD) was recently launched. Using the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), it is also possible to predict operative mortality for the same type of surgery. The goal of our study was to validate the prediction accuracy of these 2 on-line risk prediction models.

METHODS

Prospectively collected data for EuroSCORE II risk factors as well as all data for GERAADA scoring were extracted from an institutional database for 147 patients who underwent surgery for ATAAD between April 2018 and April 2021. The discriminative power was assessed using area under the receiver operating characteristic curve. The calibration of the models was tested by the Hosmer-Lemeshow statistics and by using the observed-to-expected (O/E) mortality ratio with the 95% confidence interval.

RESULTS

The observed operative mortality was 14.3%. The mean predicted mortality rates for the GERAADA score and the EuroSCORE II were 15.6% and 10.6%, respectively. The EuroSCORE II discriminative power (area under the curve = 0.799) significantly outperformed the discriminatory power of the GERAADA score (area under the curve = 0.550). The Hosmer-Lemeshow statistics confirmed good calibration for both models (P-values of 0.49 and 0.29 for the GERAADA score and the EuroSCORE II, respectively). The O/E mortality ratio certified good calibration for both scores [GERAADA score (O/E ratio of 0.93, 95% confidence interval: 0.53-1.33); EuroSCORE II (O/E ratio of 1.35, 95% confidence interval: 0.77-1.93)].

CONCLUSIONS

The EuroSCORE II has better discriminative power for predicting operative mortality in ATAAD surgery than the GERAADA score. Both scores confirmed good calibration ability.