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Flower L, Arrowsmith JE, Bewley J, Cook S, Cooper G, Flower J, Greco R, Sadeque S, Madhivathanan PR. Management of acute aortic dissection in critical care. J Intensive Care Soc 2023; 24:409-418. [PMID: 37841293 PMCID: PMC10572474 DOI: 10.1177/17511437231162219] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Aortic dissections are associated with significant mortality and morbidity, with rapid treatment paramount. They are caused by a tear in the intimal lining of the aorta that extends into the media of the wall. Blood flow through this tear leads to the formation of a false passage bordered by the inner and outer layers of the media. Their diagnosis is challenging, with most deaths caused by aortic dissection diagnosed at post-mortem. Aortic dissections are classified by location and chronicity, with management strategies depending on the nature of the dissection. The Stanford method splits aortic dissections into type A and B, with type A dissections involving the ascending aorta. De Bakey classifies dissections into I, II or III depending on their origin and involvement and degree of extension. The key to diagnosis is early suspicion, appropriate imaging and rapid initiation of treatment. Treatment focuses on initial resuscitation, transfer (if possible and required) to a suitable specialist centre, strict blood pressure and heart rate control and potentially surgical intervention depending on the type and complexity of the dissection. Effective post-operative care is extremely important, with awareness of potential post-operative complications and a multi-disciplinary rehabilitation approach required. In this review article we will discuss the aetiology and classifications of aortic dissection, their diagnosis and treatment principles relevant to critical care. Critical care clinicians play a key part in all these steps, from diagnosis through to post-operative care, and thus a thorough understanding is vital.
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Affiliation(s)
- Luke Flower
- Central London School of Anaesthesia, London, UK
- William Harvey Research Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Joseph E Arrowsmith
- Department of Anaesthesia, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
- Association for Cardiothoracic Anaesthesia and Critical Care, UK
| | - Jeremy Bewley
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Samantha Cook
- The Royal Wolverhampton NHS Trust, Wolverhampton, UK
| | - Graham Cooper
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Jake Flower
- Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Renata Greco
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Syed Sadeque
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Pradeep R Madhivathanan
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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Nappi F, Petiot S, Salsano A, Avtaar Singh SS, Berger J, Kostantinou M, Bonnet S, Gambardella I, Biancari F, Almazil A, Santini F, Chaara R, Fiore A. Sex-Based Difference in Aortic Dissection Outcomes: A Multicenter Study. J Cardiovasc Dev Dis 2023; 10:jcdd10040147. [PMID: 37103025 PMCID: PMC10143202 DOI: 10.3390/jcdd10040147] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Background: Type A Acute Aortic Dissection (TAAAD) repair is a surgical emergency associated with high morbidity and mortality. Registry data have noted several sex-specific differences in presentation with TAAAD which may account for the differences in men and women undergoing surgery for this condition. Methods: A retrospective review of data from three departments of cardiac surgery (Centre Cardiologique du Nord, Henri-Mondor University Hospital, San Martino University Hospital, Genoa) between January 2005 and 31 December 2021 was conducted. Confounders were adjusted using doubly robust regression models, a combination of regression models with inverse probability treatment weighting by propensity score. Results: 633 patients were included in the study, of which 192 (30.3%) were women. Women were significantly older with reduced haemoglobin levels and pre-operative estimated glomerular filtration rate compared to men. Male patients were more likely to undergo aortic root replacement and partial or total arch repair. Operative mortality (OR 0.745, 95% CI: 0.491–1.130) and early postoperative neurological complication results were comparable between the groups. The adjusted survival curves using IPTW by propensity score confirmed the absence of a significant impact of gender on long-term survival (HR 0.883, 95% CI 0.561–1.198). In a subgroup analysis of women, preoperative levels of arterial lactate (OR 1.468, 95% CI: 1.133–1.901) and mesenteric ischemia after surgery (OR 32.742, 95% CI: 3.361–319.017) were significantly associated with increased operative mortality. Conclusions: The advancing age of female patients alongside raised preoperative level of arterial lactate may account for the increasing preponderance among surgeons to perform more conservative surgery compared to their younger male counterparts although postoperative survival was similar between the groups.
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Furukawa H. Current Clinical Implications of Frailty and Sarcopenia in Vascular Surgery: A Comprehensive Review of the Literature and Consideration of Perioperative Management. Ann Vasc Dis 2022; 15:165-174. [PMID: 36310738 PMCID: PMC9558142 DOI: 10.3400/avd.ra.22-00035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/15/2022] [Indexed: 11/27/2022] Open
Abstract
Frailty is a well-known geriatric syndrome of impaired physiological reserve and increased vulnerability to stressors. Sarcopenia is also used as a parameter of physical impairment characterized by muscle weakness. As population aging has become more prominent in recent years, both modalities are now regarded as clinically important prognostic tools defined by multidimensional factors that may affect clinical outcomes in various clinical settings. A preoperative surgical risk analysis is mandatory to predict clinical and surgical outcomes in all surgical practices, particularly in high-risk surgical patients. In vascular surgical settings, frailty and sarcopenia have been accepted as useful prognostic tools to evaluate patient characteristics before surgery, as these may predict perioperative clinical and surgical outcomes. Although minimally invasive surgical approaches, such as endovascular therapy, and hybrid approaches have been universally developed, achieving good vascular surgical outcomes for high-risk cohorts remains to be challenge due to the increasing prevalence of elderly patients and multiple preoperative co-morbidities in addition to frailty and sarcopenia. Therefore, to further improve clinical and surgical outcomes, these preoperative geriatric prognostic factors will be of great importance and interest in vascular surgical settings for both physicians and surgeons.
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Affiliation(s)
- Hiroshi Furukawa
- Department of Cardiovascular Surgery, Tokyo Women’s Medical University Adachi Medical Center
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Girdauskas E, Neumann N, Petersen J, Sequeira-Gross T, Naito S, von Stumm M, von Kodolitsch Y, Reichenspurner H, Zeller T. Expression Patterns of Circulating MicroRNAs in the Risk Stratification of Bicuspid Aortopathy. J Clin Med 2020; 9:jcm9010276. [PMID: 31963884 PMCID: PMC7020030 DOI: 10.3390/jcm9010276] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 12/27/2019] [Accepted: 01/14/2020] [Indexed: 11/16/2022] Open
Abstract
Objective: Aortic size-based criteria are of limited value in the prediction of aortic events, while most aortic events occur in patients with proximal aortic diameters < 50 mm. Serological biomarkers and especially circulating microRNAs (miRNAs) have been proposed as an elegant tool to improve risk stratification in patients with different aortopathies. Therefore, we aimed to evaluate the levels of circulating miRNAs in a surgical cohort of patients presenting with bicuspid aortic valve disease and distinct valvulo-aortic phenotypes. Methods: We prospectively examined a consecutive cohort of 145 patients referred for aortic valve surgery: (1) Sixty three patients (mean age 47 ± 11 years, 92% male) with bicuspid aortic valve regurgitation and root dilatation (BAV-AR), (2) thirty two patients (mean age 59 ± 11 years, 73% male) with bicuspid aortic valve stenosis (BAV-AS), and (3) fifty patients (mean age 56 ± 14 years, 55% male) with tricuspid aortic valve stenosis and normal aortic root diameters (TAV-AS) who underwent aortic valve+/-proximal aortic surgery at a single institution. MicroRNAs analysis included 11 miRNAs, all published previously in association with aortopathies. Endpoints of our study were (1) correlation between circulating miRNAs and aortic diameter and (2) comparison of circulating miRNAs in distinct valvulo-aortic phenotypes. Results: We found a significant inverse linear correlation between circulating miRNAs levels and proximal aortic diameter in the whole study cohort. The strongest correlation was found for miR-17 (r = −0.42, p < 0.001), miR-20a (r = −0.37, p < 0.001), and miR-106a (r = −0.32, p < 0.001). All miRNAs were significantly downregulated in BAV vs. TAV with normal aortic root dimensions Conclusions: Our data demonstrate a significant inverse correlation between circulating miRNAs levels and the maximal aortic diameter in BAV aortopathy. When comparing miRNAs expression patterns in BAV vs. TAV patients with normal aortic root dimensions, BAV patients showed significant downregulation of analyzed miRNAs as compared to their TAV counterparts. Further multicenter studies in larger cohorts are needed to further validate these results.
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Affiliation(s)
- Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
- German Center of Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, 20246 Hamburg, Germany; (Y.v.K.); (T.Z.)
- Correspondence: ; Tel.: +40-7410-57853; Fax: +40-7410-54931
| | - Niklas Neumann
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
| | - Johannes Petersen
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
- German Center of Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, 20246 Hamburg, Germany; (Y.v.K.); (T.Z.)
| | - Tatiana Sequeira-Gross
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
| | - Shiho Naito
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
| | - Maria von Stumm
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
| | - Yskert von Kodolitsch
- German Center of Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, 20246 Hamburg, Germany; (Y.v.K.); (T.Z.)
- Department of Cardiology, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany; (N.N.); (J.P.); (T.S.-G.); (S.N.); (M.v.S.); (H.R.)
- German Center of Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, 20246 Hamburg, Germany; (Y.v.K.); (T.Z.)
| | - Tanja Zeller
- German Center of Cardiovascular Research (DZHK), Partner site Hamburg/Lübeck/Kiel, 20246 Hamburg, Germany; (Y.v.K.); (T.Z.)
- Department of Cardiology, University Heart and Vascular Center Hamburg, 20246 Hamburg, Germany
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Nitta M, Tamakawa T, Kamimura N, Honda T, Endoh H. Aortoesophageal Fistula after Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injury. JOURNAL OF TRAUMA AND INJURY 2019. [DOI: 10.20408/jti.2019.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Masakazu Nitta
- Advanced Emergency and Critical Care Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Taro Tamakawa
- Advanced Emergency and Critical Care Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Natsuo Kamimura
- Advanced Emergency and Critical Care Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Tadayuki Honda
- Advanced Emergency and Critical Care Center, Niigata University Medical and Dental Hospital, Niigata, Japan
| | - Hiroshi Endoh
- Advanced Emergency and Critical Care Center, Niigata University Medical and Dental Hospital, Niigata, Japan
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