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Kim H, Lee JH, Chung SR, Park PW, Park TK, Kang IS, Huh J, Kim DK, Cho YH, Sung K. Impact of early diagnosis on surgical outcomes in patients with Loeys-Dietz syndrome. Front Cardiovasc Med 2024; 11:1429222. [PMID: 39221421 PMCID: PMC11363540 DOI: 10.3389/fcvm.2024.1429222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 08/06/2024] [Indexed: 09/04/2024] Open
Abstract
Background This study aimed to investigate the influence of early diagnosis (ED) on surgical outcomes in patients definitively diagnosed with Loeys-Dietz syndrome (LDS). Methods A retrospective review was conducted on 38 patients with LDS who underwent aortic surgery at our institution between January 1995 and June 2022. The primary endpoint was freedom from aortic reoperation. Results Among the patients, the median age at the initial surgery was 33 (range: 39-44) years, and 23 (60.5%) patients were male. Twenty-one (55.3%; aortic dissection or rupture (n = 2) and aneurysm (n = 19)) patients were diagnosed with LDS before the initial surgery (ED group). Meanwhile, the remaining 17 (44.7%; aortic dissection or rupture (n = 13) and aneurysm (n = 4)) patients were after surgery [delayed diagnosis (DD) group]. The ED group had significantly lower rates of emergency surgery and concomitant arch procedure (P < .001, respectively) but a higher rate of valve-sparing root surgery (P = .018) compared to the DD group. No in-hospital mortality was observed in either group. Nevertheless, the ED group had a shorter postoperative hospital stay (median difference: 3 days, P = .032) and a lower rate of aortic reoperation (P = .013). Conclusion Early detection of LDS may help in preventing acute aortic syndrome, reducing the risk of aortic reoperation, and potentially shortening hospital stay. Careful medical management before surgery could contribute to better clinical outcomes and an improved quality of life for patients with LDS.
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Affiliation(s)
- Hongsun Kim
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
| | - Jun Ho Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Su Ryeun Chung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Pyo Won Park
- Department of Thoracic and Cardiovascular Surgery, Incheon Sejong Hospital, Incheon, Republic of Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - I-Seok Kang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - June Huh
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Duk-Kyung Kim
- Division of Cardiology, Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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Qin W, Wang J, Huang F, Chen X. Management for lower limb malperfusion in acute type a aortic dissection patients. Perfusion 2023; 38:1461-1467. [PMID: 35848456 DOI: 10.1177/02676591221116491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Acute type A aortic dissection (ATAAD) accompanied with lower limb malperfusion (LLM) is considered to be a catastrophic event, and remains a great challenge for cardiac surgeons. Here we introduce our experience in treating ATAAD patients accompanied with LLM. METHODS 61 patients diagnosed with ATAAD accompanied by LLM enrolled in this study. All patients received aortic repair (Total-arch replacement or Hemi-arch replacement) as soon as possible on admission. Patients who still suffered LLM were performed extra-anatomic bypass using artificial vessels. All the discharged patients underwent the standard follow-up protocol. RESULTS 38 patients (38/61, 62.3%) got satisfied reperfusion of the lower limbs after aortic repair while the others did not. Five patients had femorofemoral bypass, 16 received aortofemoral bypass, and two underwent aortofemoral bypass plus femorofemoral bypass. The ICU stay time was 5.4 ± 3.6 days. Fifty-five patients were discharged home successfully, while six patients died postoperatively with hospital mortality of 9.8%. Major postoperative complications included acute kidney injury requiring hemodialysis in seven patients, delayed wake-up (>3 days) in 5, prolonged ventilation (>4 days) in 8, and lower limb ischaemia in 1. Follow-up was successfully conducted in 50 patients with a mean follow-up time 4.9 ± 2.6 years. Five patients died during the follow-up. The estimated 5-year survival rate was 87.5 ± 6.1%. CTA images showed 100% patency of the extra-anatomic bypass. CONCLUSION Aortic repair plus concomitant extra-anatomic bypass grafting in one operative setting could be a simple, safe and effective treatment on ATAAD patients with LLM.
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Affiliation(s)
- Wei Qin
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital Nanjing Medical University, Nanjing, Jiangsu, P.R. China
| | - Jiankai Wang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital Nanjing Medical University, Nanjing, Jiangsu, P.R. China
| | - Fuhua Huang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital Nanjing Medical University, Nanjing, Jiangsu, P.R. China
| | - Xin Chen
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital Nanjing Medical University, Nanjing, Jiangsu, P.R. China
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Eranki A, Wilson-Smith AR, Williams ML, Gupta A, Flynn C, Iliopoulos J, Manganas C. The role of delayed aortic surgery in type A aortic dissection and mesenteric ischemia: a systematic review and meta-analysis. J Cardiothorac Surg 2023; 18:247. [PMID: 37596605 PMCID: PMC10439544 DOI: 10.1186/s13019-023-02341-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 07/21/2023] [Indexed: 08/20/2023] Open
Abstract
INTRODUCTION Approximately one third of patients with Acute Type A Aortic Dissection (ATAAD) present with pre-operative malperfusion syndromes (MPS). Of these, mesenteric malperfusion represents the greatest risk to patients with respect to increased short-term mortality. In select patients, it may be feasible to offer a staged approach by treating the mesenteric malperfusion first, optimizing the patient in the intensive care setting and then, following with a central aortic repair. The aim of this systematic review is to summarize cohort studies assessing the role of pre-operative interventions for mesenteric malperfusion. METHODS An electronic literature search of five databases was performed to identify all relevant studies providing studies examining short-term mortality on patients who underwent either endovascular or open revascularisation of mesenteric ischemia prior to central aortic repair. The primary outcome was all-cause, short-term mortality. Secondary outcomes were comparative mortality between a delayed repair vs. aortic repair first strategy, rates of postoperative laparotomy, bowel resection, and mortality following delayed aortic repair. RESULTS The search strategy identified 8 studies qualifying for inclusion, with a total of 180 patients who underwent delayed aortic surgery in the setting of mesenteric MPS. The weighted short-term mortality following a mesenteric revascularisation first, delayed aortic surgery strategy was 22.5%. This strategy was also associated with a significantly lower mortality than a central repair first strategy (OR 0.07, 95% CI 0.02-0.27), and a significantly lower rate of postoperative laparotomy/bowel resection (OR 0.05, 95% CI 0.02-0.14). If patients survive to receive central repair, the weighted short-term mortality postoperatively is low (2.1%). CONCLUSION A summary of this evidence reveals a lower short-term mortality in hemodynamically stable patients with mesenteric malperfusion, along with a reduction in postoperative laparotomy/bowel resections. Of those patients who survive to receive central repair, short-term mortality remains very low in the select group of hemodynamically stable patients. Further high-quality studies with randomized or propensity matched data are required to verify these results.
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Affiliation(s)
- Aditya Eranki
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.
- Department of Cardiothoracic Surgery, St George Hospital, Kograh, Sydney, 2217, Australia.
| | - Ashley R Wilson-Smith
- John Hunter Hospital, New Lambton Heights, Newcastle, Australia
- The Collaborative Research Group (CORE), Sydney, Australia
- The University of Sydney, Sydney, Australia
| | - Michael L Williams
- Department of Cardiothoracic Surgery, Gold Coast University Hospital, Gold Coast, Australia
| | - Aashray Gupta
- University of Adelaide, Adelaide, Australia
- Department of Cardiothoracic Surgery, St George Hospital, Kograh, Sydney, 2217, Australia
| | - Campbell Flynn
- Department of Cardiothoracic Surgery, St George Hospital, Kograh, Sydney, 2217, Australia
| | - Jim Iliopoulos
- Department of Vascular Surgery, St George Hospital, Kograh, Sydney, Australia
| | - Con Manganas
- Department of Cardiothoracic Surgery, St George Hospital, Kograh, Sydney, 2217, Australia
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Ma M, Cao H, Li K, Pan J, Zhou Q, Tang X, Qin X, Zhu F, Wang D. Evaluation of Two Online Risk Prediction Models for the Mortality Rate of Acute Type A Aortic Dissection Surgery: The German Registry of Acute Aortic Dissection Type A Score and the European System for Cardiac Operative Risk Evaluation II. J Clin Med 2023; 12:4728. [PMID: 37510842 PMCID: PMC10381328 DOI: 10.3390/jcm12144728] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/26/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
EuroSCORE II is one of the most widely utilized cardiovascular surgery risk scoring systems. Recently, a new online score calculator, namely the German Registry of Acute Aortic Dissection Type A (GERAADA), was launched to predict 30-day surgical mortality for acute type A aortic dissection (ATAAD) patients. The aim of this study is to evaluate the predictive performance of these two scores. We calculated the two scores for 1346 ATAAD patients from January 2012 to December 2021. The overall performance was evaluated using Brier scores and Hosmer-Lemeshow statistics. Receiver Operating Characteristic (ROC) curves were employed to assess diagnostic ability, and the standardized mortality ratio (SMR) was utilized to evaluate calibration. The GERAADA score and EuroSCORE II predicted 30-day mortality rates of 14.7% and 3.1%, respectively, while the observed rate was 12.5%. The predictive ability of EuroSCORE II (AUC 0.708, 95% CI: 0.664-0.792) was superior to that of the GERAADA score (0.648, 95% CI: 0.605-0.692). The GERAADA score had higher sensitivity but lower specificity than EuroSCORE II. And the GERAADA score may overestimate mortality (0.76, 95% CI: 0.65-0.89), while EuroSCORE II may underestimate the mortality rate (3.17, 95% CI: 2.92-3.44). The EuroSCORE II was superior in predicting surgical mortality among ATAAD patients. But the observed 30-day mortality rate certified a good calibration for the GERAADA score.
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Affiliation(s)
- Ming Ma
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Hailong Cao
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Kai Li
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Jun Pan
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Qing Zhou
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Xinlong Tang
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Xichun Qin
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Feng Zhu
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Dongjin Wang
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
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Gemelli M, Di Tommaso E, Natali R, Dixon LK, Mohamed Ahmed E, Rajakaruna C, Bruno VD. Validation of the German Registry for Acute Aortic Dissection Type A Score in predicting 30-day mortality after type A aortic dissection surgery. Eur J Cardiothorac Surg 2023; 63:ezad141. [PMID: 37027220 PMCID: PMC10824554 DOI: 10.1093/ejcts/ezad141] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 04/08/2023] Open
Abstract
OBJECTIVES No reliable scores are available to predict mortality following surgery for type A acute aortic dissection (TAAAD). Recently, the German Registry of Acute Aortic Dissection Type A (GERAADA) score has been developed. We aim to compare how the GERAADA score performs in predicting operative mortality for TAAAD to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II. METHODS We calculated the GERAADA score and EuroSCORE II in patients who underwent TAAAD repair at the Bristol Heart Institute. As there are no precise criteria to calculate the GERAADA score, we used 2 methods: a Clinical-GERAADA score, which evaluated malperfusion with clinical and radiological evidence, and a Radiological-GERAADA score, where malperfusion was assessed by computed tomography scan alone. RESULTS 207 consecutive patients had surgery for TAAAD, and the observed 30-day mortality was 15%. The Clinical-GERAADA score showed the strongest discriminative power with an area under the curve (AUC) of 0.80 [95% confidence interval (CI) 0.71-0.89], while the Radiological-GERAADA score had an AUC of 0.77 (95% CI 0.67-0.87). EuroSCORE II showed acceptable discriminative power with an AUC of 0.77 (95% CI 0.67-0.87). CONCLUSIONS Clinical GERAADA score performed better than the other scores and it is specific and easy to use in the context of a TAAAD. Further validation of the new criteria for malperfusion is needed.
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Affiliation(s)
- Marco Gemelli
- Cardiothoracic Surgery, Bristol Heart Institute, University Hospitals of Bristol and Weston NHS Foundation Trust, Bristol, UK
- Department of Cardiac, Thoracic, Vascular and Public Health Sciences, University of Padova, Padova, Italy
| | - Ettorino Di Tommaso
- Cardiothoracic Surgery, Bristol Heart Institute, University Hospitals of Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Roberto Natali
- Cardiothoracic Surgery, Bristol Heart Institute, University Hospitals of Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Lauren Kari Dixon
- Cardiothoracic Surgery, Bristol Heart Institute, University Hospitals of Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Eltayeb Mohamed Ahmed
- Cardiothoracic Surgery, Bristol Heart Institute, University Hospitals of Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Cha Rajakaruna
- Cardiothoracic Surgery, Bristol Heart Institute, University Hospitals of Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Vito D Bruno
- Cardiothoracic Surgery, Bristol Heart Institute, University Hospitals of Bristol and Weston NHS Foundation Trust, Bristol, UK
- Cardiovascular Translational Health Sciences, University of Bristol, Bristol, UK
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Treating lower extremity malperfusion syndrome in acute type A aortic dissection with endovascular revascularization followed by delayed aortic repair. JTCVS OPEN 2022; 10:101-110. [PMID: 36408122 PMCID: PMC9667713 DOI: 10.1016/j.xjon.2022.02.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 02/17/2022] [Indexed: 11/23/2022]
Abstract
Objective To assess the outcomes of emergency revascularization with endovascular fenestration/stenting followed by delayed open aortic repair in patients with acute type A aortic dissection with lower extremity (LE) malperfusion syndrome (MPS); that is, necrosis and dysfunction of the lower extremity. Methods From 1996 to 2019, among 760 consecutive acute type A aortic dissection patients 512 patients had no malperfusion syndrome (Non-MPS), whereas 26 patients had LE-MPS with/without renal MPS and underwent endovascular fenestration/stenting, open aortic repair, or both. Patients with coronary, cerebral, mesenteric, and celiac MPS, or managed with thoracic endovascular aortic repair, were excluded (n = 222). All patients with LE-MPS underwent upfront endovascular fenestration/stenting except 1 patient (with signs of rupture) who initially underwent emergency open aortic repair. Results Among the LE-MPS patients, 17 (65%) had LE pain, 15 (58%) had abnormal motor function with 8 (31%) having paralysis, 10 (38%) had LE pallor, 17 (65%) had LE paresthesia, and 20 (77%) had LE pulselessness. Of the 25 patients undergoing upfront endovascular fenestration/stenting, 16 went on to open aortic repair, 3 survived to discharge without aortic repair, and 6 died before aortic repair (3-aortic rupture and 3-organ failure). In-hospital mortality among all patients was significantly higher in the LE-MPS group (31% vs 6.3%; P = .0003). Among those undergoing open aortic repair, postoperative outcomes were similar between groups, including operative mortality (18% vs 6.5%; P = .10). LE-MPS was a significant risk factor for in-hospital mortality (odds ratio, 6.0 [1.9, 19]; P = .002). Conclusions In acute type A aortic dissection, LE-MPS was associated with high in-hospital mortality. Emergency revascularization with endovascular fenestration/stenting followed by delayed open aortic repair may be a reasonable approach.
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Inoue T, Omura A, Chomei S, Nakai H, Yamanaka K, Inoue T, Okada K. Early and late outcomes of type A acute aortic dissection with common carotid artery involvement. JTCVS OPEN 2022; 10:1-11. [PMID: 36004235 PMCID: PMC9390160 DOI: 10.1016/j.xjon.2022.01.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 01/12/2022] [Indexed: 11/23/2022]
Abstract
Objective The relationship between common carotid artery (CCA) involvement in acute type A aortic dissection (ATAAD) and postoperative outcomes remains unclear. We investigated outcomes and described our current advanced strategy. Methods Of 492 patients who underwent surgical repair for ATAAD between September 1999 and February 2021, CCA involvement was identified in 114. Eighty of these 114 patients (70.2%) were classified as having a thrombosed CCA and 34 (29.8%) were classified as nonthrombosed. To prevent postoperative cerebral malperfusion, we initiated a strategy of early reperfusion and direct reconstruction of dissected and thrombosed CCAs regardless of neurologic symptoms. Results Fifty-five patients (48.2%) showed preoperative neurologic symptoms. No significant differences between the thrombosed and nonthrombosed groups were seen in postoperative mortality (20.0% vs 11.8%; P = .421) or frequency of postoperative modified Rankin scale (mRS) score ≥5 (30.0% vs 17.6%; P = .245). The rate of postoperative neurologic deficit was significantly higher (48.8% vs 23.5%; P = .013) and long-term survival rate was significantly lower (5 years; 59.1 ± 6.3% vs 77.9 ± 7.4%; 10 years: 50.0 ± 7.9% vs 72.3 ± 8.7%; P = .041) in the thrombosed group. Risk factors for mRS ≥5 from multivariable analysis included occluded thrombosed CCA, preoperative coma, preoperative shock, and prolonged operation time. Fifteen patients were treated with the early reperfusion and direct reconstruction strategy; postoperative mortality 13.3% (2 patients). No patients showed cerebral reperfusion syndrome. Conclusions In patients with CCA involvement, a thrombosed false lumen, especially an occluded CCA, resulted in worse outcomes regardless of preoperative neurologic symptoms. Further study is needed to evaluate the efficacy of the current strategy.
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Shetty V, Shetty DP, Rao PV, Hosabettu PK, Subramanian S, Vikneswaran G, Narayan P. Determinant of outcome in late presenting type A aortic dissection. J Card Surg 2022; 37:1654-1660. [DOI: 10.1111/jocs.16401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Varun Shetty
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Devi Prasad Shetty
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Parachuri Venkat Rao
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Praveen Kumar Hosabettu
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Sendur Subramanian
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Gunaseelan Vikneswaran
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Pradeep Narayan
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
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Shetty V, Shales S, Narayan P. Lactate levels: A reliable tool to predict mortality in acute type A aortic dissections? J Card Surg 2022; 37:1212-1214. [PMID: 35172380 DOI: 10.1111/jocs.16322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 11/28/2022]
Abstract
Lactate levels are surrogate markers of malperfusion in patients presenting with type A aortic dissections. Lactate measurement is simple, easy to perform, universally available, and thus can be an important tool for predicting mortality. However, the discriminatory power varies between studies and no cut-off point has been defined that can determine outcomes in the most reliable fashion. The risk prediction based on lactate levels can be improved when combined with other clinical and laboratory prognostic factors. Further studies with a much larger sample size, need to be carried out using serial measurements at well-defined time points to try and identify a cut-off value. The addition of lactate values to existing risk prediction scores or developing a new score based on it should be the subject of future research.
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Affiliation(s)
- Varun Shetty
- Department of Cardiac Surgery, Narayana Institute of Cardiac Sciences, Narayana Health, Bengaluru, Karnataka, India
| | - Sufina Shales
- Department of Cardiac Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India
| | - Pradeep Narayan
- Department of Cardiac Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India
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Heo W, Lee GH, Kim TH, Lee Y, Huh H, Ha H, Song SW, Yoo KJ. Quantification of visceral perfusion and impact of femoral cannulation: in vitro model of aortic dissection. Eur J Cardiothorac Surg 2021; 62:6469048. [PMID: 34921317 DOI: 10.1093/ejcts/ezab508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/18/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We aimed to simulate blood flow at an aortic dissection in an in vitro vascular model and assess the impact of the cannulation method on visceral perfusion. METHODS An aortic-dissection model with an acrylic aortic wall and silicone intimal flap was developed to study visceral perfusion under various cannulation conditions. The primary tear was placed in the proximal descending aorta and the re-entry site in the left common iliac artery. A cardiovascular pump was used to reproduce a normal pulsatile aortic flow and a steady cannulation flow. Axillary and axillary plus femoral cannulation were compared at flow rates of 3-7 l/min. Haemodynamics were analysed by using four-dimensional flow magnetic resonance imaging. RESULTS Axillary cannulation (AC) was found to collapse the true lumen at the coeliac and superior mesentery arteries, while combined axillary and femoral cannulation did not change the size of the true lumen. Combined axillary and femoral cannulation resulted in a larger visceral flow than did AC alone. When axillary plus femoral cannulation was used, the visceral flow increased by 125% at 3 l/min, by 89% at 4 l/min, by 67% at 5 L/min, by 98% at 6 l/min and by 101% at 7 l/min, respectively, compared to those with the AC only. CONCLUSIONS Our model was useful to understanding the haemodynamics in aortic dissection. In this specific condition, we confirmed that the intimal flap motion can partially block blood flow to the coeliac and superior mesenteric arteries and that additional femoral cannulation can increase visceral perfusion.
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Affiliation(s)
- Woon Heo
- Department of Medicine, Yonsei University Graduate School, Seoul, Republic of Korea.,Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Gyu-Han Lee
- Department of Mechanical and Biomedical Engineering, Interdisciplinary Program in Biohealth-Machinery Convergence Engineering, Kangwon National University, Chuncheon, Republic of Korea
| | - Tae-Hoon Kim
- Department of Medicine, Yonsei University Graduate School, Seoul, Republic of Korea.,Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Youngjin Lee
- Department of Mechanical and Biomedical Engineering, Interdisciplinary Program in Biohealth-Machinery Convergence Engineering, Kangwon National University, Chuncheon, Republic of Korea
| | - Hyungkyu Huh
- Daegu-Gyeongbuk Medical Innovation Foundation, Medical Device development Center, Daegu, Republic of Korea
| | - Hojin Ha
- Department of Mechanical and Biomedical Engineering, Interdisciplinary Program in Biohealth-Machinery Convergence Engineering, Kangwon National University, Chuncheon, Republic of Korea
| | - Suk-Won Song
- Department of Medicine, Yonsei University Graduate School, Seoul, Republic of Korea.,Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Jong Yoo
- Department of Medicine, Yonsei University Graduate School, Seoul, Republic of Korea.,Department of Cardiovascular Surgery, Cardiovascular Hospital, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Nežić DG, Živković IS, Miličić MD, Milačić PA, Košević DN, Boričić MI, Krasić SD, Mićović SV. 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. Eur J Cardiothorac Surg 2021; 61:1068-1075. [PMID: 34915555 DOI: 10.1093/ejcts/ezab517] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/21/2021] [Accepted: 10/03/2021] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Duško G Nežić
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
| | - Igor S Živković
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
| | - Miroslav D Miličić
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
| | - Petar A Milačić
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
| | - Dragana N Košević
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
| | - Mladen I Boričić
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
| | - Staša D Krasić
- Department of Pediatric Cardiology, Mother and Child Health Care Institute of Serbia, Belgrade, Serbia
| | - Slobodan V Mićović
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
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Hirata K, Oda S, Suzuki R, Sugahara T. Long-term prognostic value of the combined assessment of clinical and computed tomography findings in type: An acute aortic dissection. Medicine (Baltimore) 2020; 99:e23008. [PMID: 33157946 PMCID: PMC7647554 DOI: 10.1097/md.0000000000023008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Type A acute aortic dissection (TAAAD) carries a high mortality rate in the absence of surgical treatment. This study sought to determine whether combining the assessment of clinical and computed tomography (CT) findings can be used to predict the long-term all-cause mortality rate of patients with TAAAD.Eighty-five consecutive patients with TAAAD who had undergone CT imaging and surgery were retrospectively reviewed. For the clinical and CT findings, univariate testing followed by multivariate logistic regression analysis was conducted to identify independent predictors of death. Then, the area under the receiver operating characteristic curve of the combined prediction model was calculated.The long-term mortality rate was 34.1% in our cohort (a median follow-up period of 60 months). Multivariate logistic regression analysis identified the following presenting variables as predictors of death: male sex (odds ratio [OR]: 6.67; 95% confidence interval [CI]: 1.67-25.0; P = .007), kidney malperfusion (OR: 2.18; 95% CI: 1.16-4.1; P = .02), and descending aorta size (OR: 1.12; 95% CI: 1.00-1.25; P = .05). Receiver operating characteristic curve analysis revealed an area under the receiver operating characteristic curve of 0.84 when using the combined model for prediction of long-term all-cause mortality (P ≤ .01).The combined assessment of clinical and CT findings can reasonably predict the long-term prognosis of TAAAD with surgery.
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Affiliation(s)
| | - Seitaro Oda
- Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University
| | - Ryusuke Suzuki
- Department of Cardiovascular Surgery, Kumamoto Red-Cross Hospital, Kumamoto, Japan
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13
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Norton EL, Khaja MS, Williams DM, Yang B. Type A aortic dissection complicated by malperfusion syndrome. Curr Opin Cardiol 2020; 34:610-615. [PMID: 31397690 DOI: 10.1097/hco.0000000000000667] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Malperfusion is present in up to 40% of acute type A aortic dissections (ATAADs) and results in increased morbidity and mortality. This review presents different management strategies in patients with ATAAD and malperfusion to improve outcomes. RECENT FINDINGS While the ideal management strategy of ATAAD complicated by malperfusion has yet to be determined, the literature provides evidence for additional techniques to be used in conjunction with central aortic repair to reduce mortality. SUMMARY Recent findings support a role for initial reperfusion and delayed central aortic repair, although optimal management strategy remains debated.
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Affiliation(s)
| | | | | | - Bo Yang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
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14
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Leone A, Beckmann E, Aandreas M, Di Marco L, Pantaleo A, Reggiani LB, Haverich A, Di Bartolomeo R, Pacini D, Sherestha M. Total aortic arch replacement with frozen elephant trunk technique: Results from two European institutes. J Thorac Cardiovasc Surg 2020; 159:1201-1211. [DOI: 10.1016/j.jtcvs.2019.03.121] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 11/17/2022]
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15
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Lee H, Cho YH, Sung K, Kim WS, Park KH, Jeong DS, Park PW, Lee YT. Clinical Outcomes of Root Reimplantation and Bentall Procedure: Propensity Score Matching Analysis. Ann Thorac Surg 2018; 106:539-547. [DOI: 10.1016/j.athoracsur.2018.02.057] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 01/29/2018] [Accepted: 02/20/2018] [Indexed: 11/28/2022]
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16
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Narayan P, Rogers CA, Benedetto U, Caputo M, Angelini GD, Bryan AJ. Malperfusion rather than merely timing of operative repair determines early and late outcome in type A aortic dissection. J Thorac Cardiovasc Surg 2017; 154:81-86. [PMID: 28420536 DOI: 10.1016/j.jtcvs.2017.03.041] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 02/23/2017] [Accepted: 03/08/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although generally better outcomes are reported in patients undergoing early repair of type A aortic dissection, patients who survive the first 48 hours self-select themselves toward better outcomes as well. Malperfusion is another important determinant of outcome in these patients. The aim of this study was to examine the hypothesis that malperfusion, not the timing of operation, is the dominant determinant of outcome in repair of type A aortic dissection. METHODS A total of 205 patients underwent operative repair of acute type A aortic dissection in our hospital over a 17-year period. The time from symptom onset to surgical repair was reliably established in 152 cases. Patients were grouped into those who had undergone surgery within 12 hours of symptom onset (early surgery group; n = 72 [47%]) and those who underwent surgery beyond 12 hours of symptom onset (late surgery group; n = 80 [53%]). RESULTS Thirty-day mortality was similar in the 2 groups (early surgery: 19.4% [95% confidence interval [CI] 12.0%-30.6%]; late surgery: 13.8% [95% CI, 7.9%-23.5%]; P = .08). The log-rank test for equality of survivor functions was 0.08. However, malperfusion with hemodynamic compromise was more common in the early surgery group (47% vs 31%; P = .029) and was identified as an independent predictor of long-term mortality (hazard ratio, 2.65; 95% CI, 1.21-5.79; P = .014). CONCLUSIONS Malperfusion at presentation rather than timing of intervention is the major risk factor of death both in the hospital and at long-term follow-up in patients undergoing surgery for type A aortic dissection.
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Affiliation(s)
- Pradeep Narayan
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Chris A Rogers
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Umberto Benedetto
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Gianni D Angelini
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Alan J Bryan
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom.
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Goldberg JB, Lansman SL, Kai M, Tang GH, Malekan R, Spielvogel D. Malperfusion in Type A Dissection: Consider Reperfusion First. Semin Thorac Cardiovasc Surg 2017; 29:181-185. [DOI: 10.1053/j.semtcvs.2016.10.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/26/2016] [Indexed: 11/11/2022]
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18
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Lee H, Cho YH, Sung K, Kim WS, Park KH, Park PW, Lee YT. Clinical outcomes of valve-sparing root replacement in acute type A aortic dissection. SCAND CARDIOVASC J 2015; 49:331-6. [DOI: 10.3109/14017431.2015.1072236] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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