Thoracoscopic left atrial appendectomy and thoracic endovascular aortic repair (TEVAR) in a patient with cardiogenic stroke combined with acute aortic dissection

The simultaneous occurrence of cardiogenic stroke and acute aortic dissection is rare, and its treatment remains unclear. Although anticoagulation therapy is usually chosen for cardiogenic stroke due to atrial fibrillation, it is inappropriate for acute aortic dissection. Recently, thoracoscopic left atrial appendectomy (TLAA) has been suggested as an alternative for anticoagulation. We herein report a case of a 78-year-old man with combined cardiogenic stroke and acute aortic dissection in whom thoracic endovascular aortic repair (TEVAR) was performed after TLAA. Although anticoagulants were discontinued after TLAA, there was no recurrence of stroke, and he underwent TEVAR safely. This case indicates that TLAA followed by TEVAR is an ideal treatment for combined cardiogenic stroke and acute aortic dissection and also suggests a new indication of TLAA.

Acute ischemic stroke what is hidden behind?

Acute aortic dissection (AAD) is a rare and potentially fatal disease. The classic presentation is sudden and severe pain in the chest, back, or abdomen, described as tearing or ripping pain radiating to the interscapular region. Cerebral ischemic complications occur in 18-30% of aortic dissections and patients may present to the emergency department (ED) with isolated focal neurology and no chest pain. In AAD patients, presenting with stroke and subsequently thrombolized, a 71% mortality rate has been reported in patients receiving recombinant tissue plasminogen activator (r-TPA). We present a case of a 58-year-old male patient that presented to ED with sudden onset of headache and left-sided hemiparesis, computed tomography (CT) demonstrated an ischemic stroke of the right middle cerebral artery. When the question of whether to start r-TPA or mechanical thrombectomy was discussed, a cardiac point-of-care ultrasound was performed in ED and showed a type A aortic dissection; immediately a CT aortic angiogram was performed and confirmed the diagnosis. The patient was taken to theater and had a favorable outcome. <Learning objective: Acute aortic dissection (AAD) may present as acute ischemic stroke with no chest pain. In patients with acute ischemic stroke with an unclear etiology point-of-care ultrasound (POCUS), cardiac, and aortic ultrasound are important rapidly to diagnose AAD and avoid the deleterious effect of thrombolysis. This case supports the feasibility of emergency physicians performing POCUS assessments for AAD.>.

Consumption coagulopathy in acute aortic dissection: principles of management

Background

The effect of acute aortic dissection itself on coagulopathy or surgery-related coagulopathy has never been specifically studied. The aim of the present study was to perioperatively describe consumption coagulopathy in patients with acute aortic dissection.

Methods

Sixty-six patients with acute type A aortic dissection were enrolled in this study from January 2015 to September 2016. Thirty-six patients with thoracic aortic aneurysms were used as a control group during the same period. Consumption coagulopathy was evaluated using standard laboratory tests, enzyme-linked immunosorbent assay and thromboelastograghy at five perioperative time-points.

Results

A significant reduction in clotting factors and fibrinogen was observed at the onset of acute aortic dissection. Enzyme-linked immunosorbent assay and thromboelastograghy also revealed a persistent systemic activation of the coagulation system and the consumption of clotting factors. In contrast, although platelet counts were consistently low, we did not find that platelet function was more impaired in the acute aortic dissection group than the control group.

Conclusions

After surgery, clotting factors and fibrinogen were more impaired than platelet function. Thus, we proposed that hemostatic therapy should focus on the rapid and sufficient supplementation of clotting factors and fibrinogen to improve consumption coagulopathy in patients with acute aortic dissection.

Clinical characteristics of type A acute aortic dissection with CNS symptom

BACKGROUND AND PURPOSE

Accurate diagnosis of acute aortic dissection (AAD) is sometimes difficult because of accompanying central nervous system (CNS) symptoms. The purpose of this study was to investigate the clinical characteristics of Type A AAD (TAAAD) with CNS symptoms.

METHODS

We retrospectively reviewed the medical records of 8403 patients ambulanced to our emergency and critical care center between April 2009 and May 2014.

RESULTS

We identified 59 TAAAD patients for the analysis (mean age, 67.3±10.5years; 37 (62.0%) male). Eleven patients (18.6%) presented CNS symptoms at the onset of TAAAD, and these patients complained less frequently of typical chest and back pain than those without CNS symptoms (p<0.0001). Initial systolic and diastolic blood pressure were lower (p=0.003, and p=0.049, respectively) and involvement of the supra-aortic artery was more frequent in patients with CNS symptoms (p<0.0001).

CONCLUSION

Because CNS symptom can mask chest and back pain caused by TAAAD, physicians should always consider the possibility of TAAAD in patients with CNS symptoms in emergency medicine settings.

Rare spinal cord infarction in a patient with acute type B aortic dissection

A 69-year-old man was admitted to our hospital with acute epigastric discomfort and subsequent paraplegia. Computed tomography revealed acute type B aortic dissection with a thrombosed false lumen. Magnetic resonance imaging did not reveal spinal cord infarction. Paraplegia resolved completely within 1 h. However, on the following day, the patient developed motor impairment in the left leg, sensory disorder of the bilateral legs and urinary retention. The symptoms gradually improved with conservative medical therapy. Magnetic resonance imaging on hospitalization Day 20 revealed spinal cord infarction limited to the right posterior area at level T7/T8 and the conus medullaris. The patient was discharged 44 days after admission. The presented case is notable for its atypical presentation of spinal cord infarction resulting from acute aortic dissection. The aetiology of neurological symptoms, especially that of lower extremity monoplegia, remained undiagnosed.

Leaking abdominal aortic aneurysm mimicking ureteric colic: So rare but so real in Middle East

Aortic aneurysms are very rare in Middle East unlike Europe and America. Therefore, this pathology is very likely to be missed in acute presentation to the Emergency Medicine Department. We present a case of leaking abdominal aortic aneurysm mimicking right ureteric colic, which was missed in the initial assessment.

The effect of admission serum potassium levels on in-hospital and long-term mortality in type A acute aortic dissection

BACKGROUND

Mild fluctuations in serum potassium (K⁺) levels are related to the prognosis of cardiovascular disease. This study aimed to determine the effect of admission serum potassium levels on in-hospital and long-term mortality in patients with Stanford type A acute aortic dissection (AAD).

MATERIALS AND METHODS

A total of 588 consecutive patients with type A AAD were enrolled, and they were grouped according to admission serum potassium level: <3.5, 3.5 to <4.0, 4.0 to <4.5, 4.5 to <5.0, and ≥5.0mmol/L. Clinical outcomes were in-hospital death and long-term all-cause mortality.

RESULTS

The in-hospital and long-term all-cause mortality rates were 10.7% and 16.3%, respectively. A U-shaped relationship was observed between admission serum potassium levels and both in-hospital death and long-term mortality. Univariate Cox regression identified potassium levels outside the interval of <3.5 to 4.5mmol/L to be a risk factor for both in-hospital and long-term death. After adjusting for age, gender, surgery and other risk factors, potassium levels outside the interval of <3.5 to 4.5mmol/L still had a significant association with long-term death [hazard ratio (HR)=1.72, 95% confidence interval (95% CI): 1.07-2.74, P=0.024]. Surgical intervention was the main protective factor associated with both in-hospital (HR=0.01, 95% CI 0.01-0.06, P<0.001) and long-term survival (HR=0.06, 95% CI 0.03-0.12, P<0.001).

CONCLUSIONS

Among patients with Stanford type A AAD, admission serum potassium levels other than 3.5 to 4.5mmol/L might be associated with an increased risk of in-hospital death and long-term mortality.

Late Echocardiographic Study of Aortic Valve and Aortic Root after Surgery for Type A Acute Aortic Dissection

Objective:

In case of concomitant aortic regurgitation (AR) valve, sparing operation is considered the first choice in selected patients. The aim of this retrospective clinical and echocardiographic study was to evaluate the long-term survival results of conservative approach and the determinants of recurrent AR.

Methods:

From 2000 to 2011, fifty patients (median: 63 years and interquartile range: 53–72) underwent an aortic valve-sparing procedure for acute aortic dissection, and discharged alive. The long-term clinical and echocardiographic outcome was analyzed.

Results:

Late all-causes mortality was 18% (nine patients) at a median follow-up of 55.8 months. Ten patients (20%) underwent re-operations, five of them for aortic valve/root recurrent disease; freedom from proximal re-operation was 90%. Two-third of the patients had a preoperative AR grade <3; a non-negligible number of patients with acute significant AR (23% with grade ≥3) at the time of surgery underwent conservative aortic valve surgery. At a median echocardiographic follow-up of 50.5 months, we found no significant correlation between late recurrent AR and AR grade at the time of surgery and the aortic root diameter. Late recurrent AR grade was significantly higher in patients who underwent aortic commissures and cusps resuspension than those who underwent lone ascending aorta replacement (2.29 ± 1.05 vs. 1.58 ± 1.03, P = 0.028).

Conclusions:

Preoperative AR and late aortic root diameter were not the predictors of late AR. Late AR is higher in patients who underwent aortic commissures and cusps resuspension compared to the only replacement of the ascending aorta.

Early Coronary Thrombosis without ST-Segment Elevation Following Repair of Acute Aortic Dissection

Acute coronary thrombosis after emergent surgery for acute Type A aortic dissection is a rare event that can remain undiagnosed in absence of typical electrocardiogram readings. We report a case of left anterior descending artery thrombosis without ST-segment elevation three days after surgical repair, which was successfully treated with angioplasty and stenting.

Impact of admission serum total cholesterol level on in-hospital mortality in patients with acute aortic dissection

OBJECTIVE

To find out the association between serum total cholesterol (TC) on admission and in-hospital mortality in patients with acute aortic dissection (AAD).

METHODS

From January 2007 to January 2014, we enrolled 1492 consecutive AAD patients with serum TC measured immediately on admission. Baseline characteristics and in-hospital mortality were compared between the patients with serum TC above and below the median (4.00 mmol/L). Propensity score matching (PSM) was used to account for known confounders in the study. Cox proportional hazard model was performed to calculate the hazard ratio (HR) and 95% confidence interval (CI) for admission serum TC levels.

RESULTS

With the use of PSM, 521 matched pairs of patients with AAD were yielded in this analysis due to their similar propensity scores. Patients with admission serum TC < 4.00 mmol/L, as compared with those with admission serum TC ≥ 4.00 mmol/L, had higher in-hospital mortality (11.7% vs. 5.8%; HR, 2.06; 95% CI, 1.33-3.19, P = 0.001). Stratified analysis according to Stanford classification showed that the inverse association between admission serum TC and in-hospital mortality was observed in patients with Type-A AAD (24.0% vs. 11.3%; HR, 2.18; 95% CI, 1.33 - 3.57, P = 0.002) but not in those with Type-B AAD (3.8% vs. 2.2%; HR, 1.71; 95% CI, 0.67 - 4.34, P = 0.261).

CONCLUSIONS

Lower serum TC level on admission was strongly associated with higher in-hospital mortality in patients with Type-A AAD.

Current surgical results of acute type A aortic dissection in Japan

Current surgical results of acute type A aortic dissection in Japan are presented. According to the annual survey by the Japanese Association of Thoracic Surgery, 4,444 patients with acute type A aortic dissection underwent surgical procedures and the overall hospital mortality was 9.1% in 2013. The prevalence of aortic root replacement with a valve sparing technique, total arch replacement (TAR), and frozen stent graft are presented and strategies for thrombosed dissection or organ malperfusion syndrome secondary to acute aortic dissection are discussed.

Concurrence of Aneurysmal Subarachnoid Hemorrhage and Stanford Type A Acute Aortic Dissection

We report a rare case of concurrent aneurysmal subarachnoid hemorrhage (SAH) and acute aortic dissection (AAD). A 38-year-old man visited our hospital complaining of severe headache, and brain computed tomography (CT) revealed the presence of SAH. Thoracic to neck computed tomography angiography (CTA), performed in addition to brain CTA, suggested a tear in the aortic arch, and subsequent CT aortography established the diagnosis of Stanford type A AAD. The AAD in our patient, who reported no episodes of chest or back pain, was detected incidentally by thoracic to neck CTA. The imaging study has rarely been indicated for SAH except that it provides additional anatomical information in patients for whom extracranial-intracranial bypass surgery or endovascular treatment is considered. Nevertheless, our experience may highlight additional diagnostic value of thoracic to neck CTA in SAH patients.

Angiotensin II is related to the acute aortic dissection complicated with lung injury through mediating the release of MMP9 from macrophages

BACKGROUND

Acute aortic dissection (AAD) patients usually show concurrent lung injury mainly featured by hyoxemia. To date, no effective treatment method has been established for the AAD complicated with acute lung injury (ALI). Matrix metalloproteinases (MMPs), especially MMP2 and MMP9, have been considered to be closely related to the onset of aortic disease including AAD. To investigate the roles of MMP in the pathogenesis of AAD complicated with ALI, we determined the expression of MMP2 and MMP9 in serum and lung tissues of AAD patients. In addition, a new rat model of AAD complicated with ALI was established to investigate the pathogenesis of such complicated conditions.

METHODS AND RESULTS

Angiotensin II (Ang II) and MMP9 were up-regulated in the AAD complicated with ALI patients compared to those of the AAD without ALI patients, normal individuals and the patients with non-ruptured aneurysm. Besides, massive macrophages with MMP9 expression was noticed in the lung tissues in the AAD complicated with ALI patients. On this basis, AAD complicated with ALI rat model was established based on BAPN feeding and infusion of Ang II. Obvious lung injury was observed in the BAPN+Ang II group compared to that of the BAPN group, together with macrophage accumulation in lung tissues, as well as over-expression of MMP9 in lung tissues. After interference of MMP antagonist, a large number of macrophages were still accumulated in the lung tissues, but the lung injury was obviously attenuated. After the interference of AT1 receptor, the number of macrophages in the lung tissues was obviously decreased and the lung injury was obviously relieved.

CONCLUSIONS

Ang II is closely related to the lung injury at the early stage of AAD through mediating the release of MMP9 in the macrophages in the lung tissues.

High-sensitivity cardiac troponin T: A biomarker for the early risk stratification of type-A acute aortic dissection?

BACKGROUND

High-sensitivity cardiac troponin is the most specific and sensitive biomarker of myocardial injury. However, no study has investigated whether the early concentration of high-sensitivity cardiac troponin is increased or is of value in predicting short-term prognosis in patients with type-A acute aortic dissection (AAD) in the emergency department.

AIMS

To measure the high-sensitivity cardiac troponin T (hs-TnT) concentration in patients with type-A AAD upon hospital admission, and to assess its value in predicting short-term prognosis.

METHODS

We enrolled consecutive patients with type-A AAD. Blood samples were collected on admission; hs-TnT concentrations were measured on the Elecsys 2010 system. High-sensitivity C-reactive protein (hs-CRP), D-dimer and other biochemical indicators were measured. Patients were divided into two groups according to hs-TnT concentration on admission (< or ≥0.014ng/mL).

RESULTS

More than half (61.2%) of the 103 included patients had an hs-TnT concentration ≥0.014ng/mL. hs-TnT concentrations were significantly higher in those who died compared with survivors (0.292±0.516 vs. 0.069±0.154ng/mL; P=0.003). Multivariable Cox regression analysis suggested that hs-TnT is an independent factor for predicting in-hospital mortality risk (odds ratio: 2.202, 95% confidence interval: 1.111-4.367; P=0.024). Kaplan-Meier curves revealed a significant increase in hospital mortality in the hs-TnT(+) group compared with the hs-TnT(-) group (P=0.021). When hs-TnT was ≥0.042ng/mL, the sensitivity and specificity in predicting hospital short-term mortality were 70.8% and 76.4%, respectively.

CONCLUSIONS

Our study suggests that hs-TnT concentration could be used as an early biomarker for the risk stratification of patients with type-A AAD in the emergency department; the relationship between hs-TnT concentration and long-term prognosis needs further investigation.

Two-stage operation for Stanford type A acute aortic dissection originating from Kommerell's diverticulum

We report a rare case of Stanford type A acute aortic dissection involving an aberrant right subclavian artery and originating from Kommerell's diverticulum in a 52-year old man. Initially, as an emergency measure, total arch replacement and right axillary artery reconstruction were performed. However, due to the subsequent enlargement of the false lumen, thoracic endovascular aortic repair and right subclavian artery coiling were performed successfully 5 months after the first operation. Herein, we describe surgical management approaches for the treatment of a Stanford type A acute aortic dissection with aberrant right subclavian artery.

Differential expression of microRNAs in aortic tissue and plasma in patients with acute aortic dissection

Background

Biomarker-assisted diagnosis of acute aortic dissection (AAD) is important for diagnosis and treatment. However, identification of biomarkers for AAD in blood is a challenging task. The aim of this study is to search for new potentially microRNA (miRNAs) biomarkers in AAD.

Methods

The miRNAs expression profiles in ascending aortic tissue and plasma were examined by microarray analysis in two sets or groups. The tissue group was composed of four patients with AAD and four controls of healthy male organ donors. The plasma group included 20 patients with AAD and 20 controls without cardiovascular disease. Bioinformatics was used to analyze the potential targets of the differentially expressed miRNAs.

Results

Our study revealed that in AAD patients, the aortic tissue had 30 differentially expressed miRNAs with 13 up-regulated and 17 down-regulated, and plasma had 93 differentially expressed miRNAs, of which 33 were up-regulated and 60 were down-regulated. Four miRNAs were found to be up-regulated in both aortic tissue and plasma in AAD patients. The predicted miRNA targets indicated the four dysregulated miRNAs mainly targeted genes that were associated with cell-cell adhesion, extracellular matrix metabolism, cytoskeleton organization, inflammation, and multiple signaling pathways related to cellular cycles.

Conclusions

Four miRNAs, which are up-regulated both in aortic tissue and in plasma in AAD patients, have been identified in this study. These miRNAs might be potential diagnostic biomarkers for AAD. Larger sample investigations are needed for further verification.

Incidence and in-hospital mortality of acute aortic dissection in China: analysis of China Health Insurance Research (CHIRA) Data 2011

OBJECTIVE

Acute aortic dissection (AAD) is a catastrophic event with high early mortality rate, but to date, no data on the incidence of AAD in Mainland China is available. This study aimed to estimate the incidence of AAD in China and characterize the clinical profile, management and in-hospital outcomes of this vascular event.

METHODS

We used the China Health Insurance Research Data (the CHIRA Data) 2011 which comprises all inpatient hospital records (300,886) during the period of Jan. 1st 2011 to Dec. 31 2011 of 3,335,000 randomly sampled beneficiaries (1,718,500 men and 1,616,500 women) from 25 cities and counties in different economic-geographic regions of Mainland China. Patients with acute aortic dissection were identified according to International Classification of Disease 10(th) Revision (ICD-10) of I71.0. The estimated incidence of AAD was calculated using the equation: estimated incidence = 2.0 × (40% × hospital admission rate) + 60% × hospital admission rate.

RESULTS

The hospital admission rate was 2.0/100,000 (65/3,325,000, 95% CI: 1.2-2.8). The estimated annual incidence of AAD was 2.8/100,000 (95% CI: 1.9-3.6) and was higher in male than in female (3.7 vs. 1.5, P < 0.001). The mean age was 58.9 ± 13.4 years. During the mean hospital stay of 23 ± 6 days, the overall in-hospital mortality was 13.9% (9/65).

CONCLUSIONS

Our study showed relatively lower but not negligible incidence and in-hospital mortality of AAD in the mainland of China. The mean age of patients with AAD in Chinese was younger than that reported by researches from west countries, while the male to female incidence ratio is similar to those reported by other studies.

Relationship between acute kidney injury before thoracic endovascular aneurysm repair and in-hospital outcomes in patients with type B acute aortic dissection

Objective

Acute kidney injury (AKI) frequently occurs after catheter-based interventional procedures and increases mortality. However, the implications of AKI before thoracic endovascular aneurysm repair (TEVAR) of type B acute aortic dissection (AAD) remain unclear. This study evaluated the incidence, predictors, and in-hospital outcomes of AKI before TEVAR in patients with type B AAD.

Methods

Between 2009 and 2013, 76 patients were retrospectively evaluated who received TEVAR for type B AAD within 36 h from symptom onset. The patients were classified into no-AKI vs. AKI groups, and the severity of AKI was further staged according to kidney disease: improving global outcomes criteria before TEVAR.

Results

The incidence of preoperative AKI was 36.8%. In-hospital complications was significantly higher in patients with preoperative AKI compared with no-AKI (50.0% vs. 4.2%, respectively; P < 0.001), including acute renal failure (21.4% vs. 0, respectively; P < 0.001), and they increased with severity of AKI (P < 0.001). The maximum levels of body temperature and white blood cell count were significantly related to maximum serum creatinine level before TEVAR. Multivariate analysis showed that systolic blood pressure on admission (OR: 1.023; 95% CI: 1.003–1.044; P = 0.0238) and bilateral renal artery involvement (OR: 19.076; 95% CI: 1.914–190.164; P = 0.0120) were strong predictors of preoperative AKI.

Conclusions

Preoperative AKI frequently occurred in patients with type B AAD, and correlated with higher in-hospital complications and enhanced inflammatory reaction. Systolic blood pressure on admission and bilateral renal artery involvement were major risk factors for AKI before TEVAR.

Prognostic Implications of Acute Renal Failure after Surgery for Type A Acute Aortic Dissection

BACKGROUND

"Type A" acute aortic dissection (AAAD) is the most challenging among the emergency operations in cardiac surgery. The aim of this study was the evaluation of the role of acute renal failure (ARF) in postoperative survival of patients operated for AAAD.

METHODS

From February 2010 to April 2012, 37 consecutive patients were operated at our department for AAAD. We studied our population by subdividing the patients within groups according to the presence of ARF requiring continuous veno-venous hemofiltration (CVVH) and according to hypothermic circulatory arrest (HCA) times and degrees.

RESULTS

The overall 30-day mortality was 27% (50% group A with ARF, 13% group B no ARF). Acute renal failure requiring CVVH was 37.8%. Multivariate analysis revealed a significant association with 30-day mortality (odds ratio 6.6 and p = 0.020). Preoperative oliguria [urine output less than 30 ml/h (odds ratio 4.7 p = 0.039)], CPB greater than 180 minutes (odds ratio 6.5 p = 0.023) and postoperative bleeding requiring a surgical reopening (odds ratio 12.2 and p = 0.021) were the variables significantly associated with acute kidney injury.

CONCLUSIONS

The data obtained from our analysis bring out the high incidence of renal injuries after surgery for AAAD, and indicate a negative impact on renal injuries of a preoperative oliguria, longer Cardiopulmonary bypass (CBP)/HCA times, and postoperative bleeding requiring a surgical revision. Our data also suggest a better 30-day survival and better renal outcomes in case of shorter HCA and lesser degree of hypothermia. The option of lesser and shorter hypothermia may be very useful, especially for the elderly patients and octogenarians.

An extensive DeBakey type IIIb aortic dissection with massive right pleural effusion presenting as abdominal pain and acute anemia: particular case report

We describe the case of a 79-year-old male presented with sudden onset of abdominal pain and mild breathlessness, and complicated acute progressive anemia with haemoglobin which declined from 120 g/L to 70 g/L within five days. An urgent computed tomography angiography showed acute thoracic aortic dissection, DeBakey type IIIb, a dissecting aneurysm in the proximal descending thoracic aorta starting immediately after the origin of the left subclavian artery and extending distally below the renal arteries with evidence of rupture into the right pleural cavity for massive pleural effusion. Plasma D-dimer, brain natriuretic peptide and C reactive protein level were elevated. Our case showed that D-dimer can be used as a 'rule-out' test in patients with suspected aortic dissection. A raised BNP may exert a protective role through anti-inflammatory endothelial actions in the systemic circulation.

Italian multicentre study on type A acute aortic dissection: a 33-year follow-up†

OBJECTIVES

Despite substantial progress in surgical techniques and perioperative management, the treatment and long-term follow-up of type A acute aortic dissection (AAD) still remain a major challenge. The objective of this retrospective, multicentre study was to assess in a large series of patients the early and long-term results after surgery for type A AAD.

METHODS

We analysed the preoperative, intraoperative and postoperative conditions of 1.148 consecutive patients surgically treated in seven large referral centres from 1981 to 2013. We applied to each patient three different multi-parameter risk profiles (preadmission risk, admission risk and post-surgery risk) in order to compare risk factors and outcome. Long-term Kaplan-Meier survival was evaluated.

RESULTS

The median age was 64 years and the male population was predominant (66%). Identified diagnosis of collagen disease was present in 9%, and Marfan syndrome in 5%. Bicuspid aortic valve was present in 69 patients (6%). Previous cardiac surgery was identified in 10% of the patients. During surgery, the native aortic valve was preserved in 72% of the cases, including leaflet resuspension in 23% and David operation in 1.2%. Considering aortic valve replacement (AVR: 28%), bioprosthesis implantation was performed in 14.7% of the subjects. Neurological impairment at discharge was shown in 23% of the cases among which 21% of patients had new neurological impairment versus preoperative conditions. The overall 30-day mortality rate was 25.7%. All risk profiles remained independently associated with in-hospital mortality. During the available follow-up of hospital survivors (median: 70 months, interquartile range: 34-113, maximum: 396), cardiac-related death occurred in 7.9% of the subjects. The cumulative survival rate for cardiac death was 95.3% at 5 years, 92.8% at 10 years and 52.8% at 20 years. Severe aortic regurgitation (AR) (grade 3-4) at the time of surgery showed to be a significant risk factor for reintervention during the follow-up (P < 0.001). Among risk profiles, only the preadmission risk was independently associated with late mortality after multivariate analysis. Unexpectedly, there was no difference in freedom from cardiac death between patients with and without AVR.

CONCLUSIONS

Although surgery for type A has remained challenging over more than three decades, there is a positive trend in terms of hospital mortality and long-term follow-up. About 90% of patients were free from reoperation in the long term, although late AR remains a critical issue, suggesting that a thorough debate on surgical options, assessment and results of a conservative approach should be considered.