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Pitts L, Kofler M, Montagner M, Heck R, Kurz SD, Buz S, Falk V, Kempfert J. The impact of malperfusion patterns in elderly patients undergoing surgery for acute type A aortic dissection. Eur J Cardiothorac Surg 2023; 64:ezad288. [PMID: 37589652 DOI: 10.1093/ejcts/ezad288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/28/2023] [Accepted: 08/16/2023] [Indexed: 08/18/2023] Open
Abstract
OBJECTIVES The aim of this study is to investigate the outcome of elderly patients with surgically treated acute type A aortic dissection (ATAAD) complicated by malperfusion. METHODS Patients ≥70 years old who underwent surgical treatment for ATAAD between January 2000 and December 2020 were enrolled in this study and stratified by their specific Penn Classification into 4 different subgroups, where Penn Abc was defined as multilevel malperfusion. Short- and long-term outcomes were investigated. Multivariable binary logistic regression was performed to identify risk factors for 1-year mortality. RESULTS Four hundred elderly patients underwent surgical treatment for ATAAD. A total of 204 (51%) patients had no evidence of malperfusion (Penn Aa), 106 (26.5%) had localized organic malperfusion (Penn Ab), 44 (11%) patients had systemic malperfusion (Penn Ac) and 46 (11.5%) suffered from multilevel malperfusion (Penn Abc). For the latter, in-hospital mortality was 70% (P < 0.001). Age (P < 0.006) and multilevel malperfusion (P < 0.001) were independent risk factors for 1-year mortality. Patients with multilevel malperfusion showed the worst 1-year survival (P < 0.001). In the case of Penn Aa, in-hospital mortality was 13% (P < 0.001). CONCLUSIONS Surgery may lead to satisfactory results in the absence of malperfusion, even in octogenarians. Elderly patients with multilevel malperfusion show very poor surgical outcome. In these patients, the decision for surgery should be taken with caution. Operation, if performed, should be carried out by experienced teams only.
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Affiliation(s)
- Leonard Pitts
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
| | - Matteo Montagner
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Roland Heck
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Stephan D Kurz
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Semih Buz
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
- Department of Health Sciences and Technology, Translational Cardiovascular Technologies, Institute of Translational Medicine, Swiss Federal Institute of Technology (ETH), Zurich, Switzerland
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany
- Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
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Catalano MA, Mamdouhi T, Pupovac S, Kennedy KF, Brinster DR, Hartman A, Yu PJ. Age, sex, and contemporary outcomes in surgical repair of type A aortic dissection: Insights from the National Inpatient Sample. JTCVS OPEN 2022; 11:23-36. [PMID: 36172443 PMCID: PMC9510847 DOI: 10.1016/j.xjon.2022.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 05/29/2022] [Accepted: 06/16/2022] [Indexed: 11/10/2022]
Abstract
Objective Acute type A aortic dissection (ATAAD) is a surgical emergency with significant morbidity and mortality, as well as significant center-level variation in outcomes. Our study aims to leverage a nationally representative database to assess contemporary in-hospital outcomes in surgical repair of ATAAD, as well as the association of age and sex with outcomes. Methods The National Inpatient Sample was queried to identify hospital discharge records of patients aged ≥18 years who underwent urgent surgical repair of ATAAD between 2017 and 2018. Patients with a diagnosis of thoracic aortic dissection, who underwent surgical intervention of the ascending aorta, were identified. Patient demographics were assessed, and predictors of in-hospital mortality were identified. Results We identified 7805 weighted cases of surgically repaired ATAAD nationally, with an overall mortality of 15.3%. Mean age was 60.0 ± 13.6 years. There was a male predominance, although female subjects made up a larger proportion of older age groups—female subjects up 18.4% of patients younger than 40 years with ATAAD but 53.6% of patients older than 80 years. In multivariable analysis controlling for sex, race, comorbidities, and malperfusion, age was a significant predictor of mortality. Patients aged 71 to 80 years had a 5.3-fold increased risk of mortality compared with patients ≤40 years old (P < .001), and patients aged >80 years had a 6.8-fold increased risk of mortality (P < .001). Sex was not significantly associated with mortality. Conclusions Surgical repair of ATAAD continues to carry high risk of morbidity and mortality, with outcomes impacted significantly by patient age, regardless of patient comorbidity burden.
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Qiu Z, Xiao J, Wu Q, Chai T, Zhang L, Li Y, Chen L. Partial upper sternotomy for extensive arch repair in older acute type A aortic dissection patients. BMC Cardiovasc Disord 2022; 22:117. [PMID: 35313815 PMCID: PMC8939131 DOI: 10.1186/s12872-022-02511-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 02/14/2022] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES The partial upper sternotomy (PUS) approach is acceptable for aortic valve replacement, and even aortic root operation. However, the efficiency of PUS for extensive arch repair of acute type A aortic dissection (AAAD) in older adult patients has not been well investigated. METHODS Between January 2014 and December 2019, 222 older adult patients (≥ 65 years) diagnosed with AAAD went through extensive arch repair, among which 127 received PUS, and 95 underwent full sternotomy (FS). Logistic regression analysis was used to identify risk factors for early death, and negative binomial regression analysis was applied to explore risk factors related to post-operative ventilator-supporting time and intensive care unit stay time. RESULTS Total early mortality was 8.1% (18/222 patients). The PUS group had shorter Cardiopulmonary bypass time (133.0 vs.155.0 min, P < 0.001), cross-clamp time (44.0 vs. 61.0 min, P < 0.001) and shorter selective cerebral perfusion time (11.0 vs. 21.0 min, P < 0.001) than the FS group. Left ventricle ejection fraction < 50% (odds ratio [OR] 17.05; 95% confidence interval [CI] 1.87-155.63; P = 0.012) and malperfusion syndromes (OR 65.83; 95% CI 11.53-375.86; P < 0.001) were related to early death. In the multivariate model, the PUS approach contributed to shorter ventilator-supporting time (incidence rate ratio [IRR] 0.76; 95% CI 0.64-0.91; P = 0.003), when compared with the FS group. CONCLUSIONS The early results of emergency extensive arch repair of AAAD via PUS in older adult patients were satisfactory. However, the long-term results remain to be investigated.
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Affiliation(s)
- Zhihuang Qiu
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, Fujian, China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, 350001, Fujian, China
| | - Jun Xiao
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, Fujian, China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, 350001, Fujian, China
| | - Qingsong Wu
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, Fujian, China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, 350001, Fujian, China
| | - Tianci Chai
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China.,Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, Fujian, China.,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, 350001, Fujian, China
| | - Li Zhang
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Fujian Medical University, Fuzhou, China
| | - Yumei Li
- Department of Toxicology, Fujian Center for Evaluation of New Drug, Fujian Medical University, Fuzhou, China
| | - Liangwan Chen
- Department of Cardiac Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, Fujian, China. .,Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, Fujian, China. .,Fujian Provincial Special Reserve Talents Laboratory, Fuzhou, 350001, Fujian, China.
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Chen JW, Sainbayar N, Hsu RB. Outcome of emergency surgery for acute type A aortic dissection in octogenarians. J Card Surg 2022; 37:610-615. [PMID: 34996133 DOI: 10.1111/jocs.16219] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 11/27/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergency surgery for acute type A aortic dissection (AAAD) was usually avoided or denied in octogenarians because of high surgical mortality. Refined surgical techniques and improved postoperative care have led to an improved in-hospital outcome. However, a significant number of operative survivors suffered from postoperative complications and had compromised quality of life. We sought to assess the clinical outcome of emergency surgery using a standard conservative approach in octogenarians with AAAD. METHODS From 2004 to 2021, 123 patients underwent emergency surgery for AAAD by one surgeon using a standard conservative approach with right subclavian artery cannulation, no aortic cross-clamp, selective antegrade cerebral perfusion, moderate systemic hypothermia, reinforced sandwich technique, and a strategy of limited aortic resection. Hospital and late outcomes were assessed in patients with age >80 years. RESULTS Eighteen patients (15%) were octogenarians with seven males (39%) and median age of 82 years (range, 80-89). Hypertension was present in six patients (33%). None had diabetes mellitus, Marfan, or bicuspid aortic valve. Dissection was intramural hematoma in six (33%) and DeBakey type I in 15 patients (83%). Cardiac tamponade with shock was present in seven patients (39%). Ascending aortic grafting was performed in 17 patients, and additional hemiarch replacement in one patient. The hospital mortality rate was 17% (3/18). Fourteen patients (82%) were alive and well at discharge. CONCLUSIONS Emergency surgery for AAAD using a standard conservative approach showed an improved outcome in octogenarians. The majority of patients could return home with an acceptable living.
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Affiliation(s)
- Jeng-Wei Chen
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Nyamsuren Sainbayar
- Department of Cardiovascular Surgery, Third State Central Hospital, Ulan Bator, Mongolia
| | - Ron-Bin Hsu
- Department of Surgery, Division of Cardiovascular Surgery, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Hsu ME, Chou AH, Cheng YT, Lee HA, Liu KS, Chen DY, Wu VCC, Chu PH, Chen TH, Chen SW. Outcomes of Acute Aortic Dissection Surgery in Octogenarians. J Am Heart Assoc 2020; 9:e017147. [PMID: 32912018 PMCID: PMC7726989 DOI: 10.1161/jaha.120.017147] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background Octogenarians (≥80 years old) are high-risk patients for acute aortic dissection (AAD) surgery. However, no population-based study has investigated the late outcomes of AAD surgery in octogenarians. This study aimed to investigate the late outcomes of AAD surgery in octogenarians. Methods and Results A total of 3998 patients who received AAD surgery from 2005 to 2013 were identified from the Taiwan National Health Insurance Research Database. In-hospital complications and late outcomes including all-cause mortality, major adverse cardiac and cerebrovascular event, respiratory failure, and redo aortic surgery were evaluated. The risks of late outcomes between octogenarians and nonoctogenarians were compared using the multivariable Cox proportional hazard model or Fine and Gray competing model. The numbers of the octogenarians who underwent type A and B AAD surgeries were 206 (6%; 206/3423) and 79 (13.7%; 79/575), respectively. Compared with the nonoctogenarians, the type A octogenarians had higher risks of in-hospital mortality and several in-hospital complications, whereas the type B octogenarians did not. Furthermore, compared with the nonoctogenarians, the type A octogenarians had a higher risk of all-cause mortality (61.7% vs 32.5%; hazard ratio [HR], 2.35; 95% CI, 1.95-2.84) and a higher cumulative incidence of major adverse cardiac and cerebrovascular event and respiratory failure, and the type B octogenarians demonstrated a higher risk of all-cause mortality (44.3% vs 30.4%; HR, 1.74; 95% CI, 1.18-2.55). The octogenarians receiving AAD surgeries had higher mortality rates than the normal octogenarian population. Conclusions Octogenarians receiving AAD surgeries exhibit worse late outcomes than nonoctogenarian counterparts.
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Affiliation(s)
- Ming-En Hsu
- Department of Medicine Chang Gung University Taoyuan City Taiwan.,Division of Thoracic and Cardiovascular Surgery Department of Surgery Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan
| | - An-Hsun Chou
- Department of Anesthesiology Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan
| | - Yu-Ting Cheng
- Division of Thoracic and Cardiovascular Surgery Department of Surgery Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan
| | - Hsiu-An Lee
- Division of Thoracic and Cardiovascular Surgery Department of Surgery Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan
| | - Kuo-Sheng Liu
- Division of Thoracic and Cardiovascular Surgery Department of Surgery Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan
| | - Dong-Yi Chen
- Department of Cardiology Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan
| | - Victor Chien-Chia Wu
- Department of Cardiology Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan
| | - Pao-Hsien Chu
- Department of Cardiology Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan
| | - Tien-Hsing Chen
- Department of Cardiology Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan
| | - Shao-Wei Chen
- Division of Thoracic and Cardiovascular Surgery Department of Surgery Chang Gung Memorial Hospital Linkou Medical Center Chang Gung University Taoyuan City Taiwan.,Center for Big Data Analytics and Statistics Chang Gung Memorial Hospital Linkou Medical Center Taoyuan City Taiwan
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Arakawa M, Okamura H, Miyagawa A, Kitada Y, Adachi H. Clinical outcome of acute thoracic aortic syndrome in nonagenarians. Asian Cardiovasc Thorac Ann 2020; 28:577-582. [PMID: 32819152 DOI: 10.1177/0218492320952654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Decision-making regarding the operability of thoracic aortic disease in nonagenarian patients remains controversial because outcomes of open surgical repair of the thoracic aorta are unclear. We investigated the surgical and nonsurgical outcomes of acute thoracic aortic syndrome treatment in nonagenarians. METHODS After evaluating data in our institute from April 2016 to March 2020, we included 10 nonagenarians who needed surgical intervention on the thoracic aorta via a median sternotomy for acute thoracic aortic syndrome. The mean age of the cohort was 91.9 ± 2.1 years. Five patients underwent open surgical repair of the thoracic aorta (surgical group), and 5 refused surgery (nonsurgical group). All patients in the surgical group performed activities of daily living independently, with a mean clinical frailty scale of 3.2 ± 0.4. The surgical group included 4 patients with type A aortic dissection and one with a ruptured thoracic aortic aneurysm. Hemiarch replacement was performed in 3 patients and total arch replacement in 2. The mean follow-up period was 17.8 ± 5.1 months. RESULTS Hospital mortality rates were 0% in the surgical and 80% in the nonsurgical group. The mean length of hospitalization was 28.4 ± 6.7 days in the surgical group. The 1-year survival rates were 100% in the surgical group and 20% in the nonsurgical group. CONCLUSION Open surgical repair for acute thoracic aortic syndrome via median sternotomy is a reasonable treatment option even in nonagenarians. Involvement of family members is important for decision-making to devise the optimal treatment strategy (surgical vs. medical).
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Affiliation(s)
- Mamoru Arakawa
- Department of Cardiovascular Surgery, 83943Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Homare Okamura
- Department of Cardiovascular Surgery, 83943Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Atsushi Miyagawa
- Department of Cardiovascular Surgery, 83943Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Yuichiro Kitada
- Department of Cardiovascular Surgery, 83943Nerima Hikarigaoka Hospital, Tokyo, Japan
| | - Hideo Adachi
- Department of Cardiovascular Surgery, 83943Nerima Hikarigaoka Hospital, Tokyo, Japan
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Ikeno Y, Yokawa K, Yamanaka K, Inoue T, Tanaka H, Okada K, Okita Y. Total arch replacement in octogenarians and nonagenarians: A single-center 18-year experience. J Thorac Cardiovasc Surg 2020; 160:346-356.e1. [DOI: 10.1016/j.jtcvs.2019.07.092] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 06/18/2019] [Accepted: 07/12/2019] [Indexed: 12/19/2022]
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Igarashi T, Sato Y, Satokawa H, Takase S, Wakamatsu H, Seto Y, Iwai-Takano M, Fujimiya T, Shinjo H, Yokoyama H. The results of an entry-oriented strategy for acute type A aortic dissection in octogenarians: an 18-year experience. Eur J Cardiothorac Surg 2020; 58:949-956. [DOI: 10.1093/ejcts/ezaa195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/20/2020] [Accepted: 04/23/2020] [Indexed: 01/01/2023] Open
Abstract
Abstract
OBJECTIVES
The aim of this study was to evaluate the 18-year results of emergency operations for acute type A aortic dissection, especially in octogenarians.
METHODS
We reviewed 199 patients who underwent surgical aortic repair of an acute type A aortic dissection from January 2001 to December 2018. If the primary entry existed in the ascending aorta, we limited the extent of the replacement to within the ascending aorta. We analysed the early and late outcomes and identified the predictive factors for in-hospital death and difficulty of direct discharge to home.
RESULTS
The hospital mortality was 16%. The causes of death were postoperative bleeding (n = 8, 4%), intestinal ischaemia (n = 6, 3%), respiratory failure (n = 5, 3%), systemic inflammatory response syndrome (n = 4, 2%), low output syndrome (n = 3, 2%), sudden death (n = 3, 2%), myonephrotic metabolic syndrome (n = 2, 1%) and stroke (n = 1, 1%). Multivariable analysis revealed that an estimated glomerular filtration rate <30 (P = 0.006), malperfusion (P = 0.001), rupture (P < 0.001) and cross-clamping time (P = 0.003) were independent predictive factors of in-hospital death. Age was not a significant factor for predicting in-hospital death. Ascending aorta replacement (P = 0.013), advanced age (P = 0.002) and prolonged extracorporeal circulation time (P = 0.009) were independent predictive factors of difficulty in direct discharge to home. In the late follow-up period, the 5-year survival and aortic event-free rates were 62.2% and 88.9% in octogenarians, respectively.
CONCLUSIONS
From the perspective of saving lives, the results of emergency surgery for octogenarians were acceptable. Avoiding the postoperative decline in activities of daily living in octogenarians is a consideration going forward.
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Affiliation(s)
- Takashi Igarashi
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Yoichi Sato
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Hirono Satokawa
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Shinya Takase
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Hiroki Wakamatsu
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Yuki Seto
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Masumi Iwai-Takano
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Tsuyoshi Fujimiya
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Hiroharu Shinjo
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
| | - Hitoshi Yokoyama
- Department of Cardiovascular Surgery, Fukushima Medical University, Fukushima, Japan
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Giambuzzi I, Mastroiacovo G, Roberto M, Pirola S, Alamanni F, Cavallotti L, Bonalumi G. Preoperative neurological dysfunctions: what is their meaning in patients presenting with acute type A aortic dissection? Minerva Cardioangiol 2020; 68:511-517. [PMID: 32524808 DOI: 10.23736/s0026-4725.20.05230-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Type A aortic dissection (AAD) is a life-threatening disease with very high mortality. The gold standard treatment is surgical, as medical treatment has been proven to be ineffective. It is still unclear the role of preoperative neurological dysfunction in the prognosis of the patient. Therefore, the choice of performing surgery in patients with neurological symptoms is still left to the surgeon at the time of the diagnosis. The aim of this study is to make a narrative review of the current literature about the management of patients with neurological symptoms in AAD patients. EVIDENCE ACQUISITION A bibliographical research was performed on PubMed, looking for papers containing the words: "((preoperative neurological symptoms in type a aortic dissection) OR brain injury type A aortic dissection) AND ("2010"[Date - Publication]: "3000"[Date - Publication])". A total of 35 papers were found. EVIDENCE SYNTHESIS A total of 6 papers were chosen to be reviewed. All of them concluded that even patients with severe neurological symptoms (up to comatose state) had a good chance to recover neurological functions after surgery if treated in the first hours from the onset of symptoms. Interestingly, a hemorrhagic stroke was rarely found. CONCLUSIONS Preoperative neurological dysfunction have been long considered a contraindication to surgery. Nevertheless, several authors show neurological and survival good results in patients with preoperative neurological dysfunction. They also stress the importance of surgical timing finding in 5 to 10 hours the surgical time limit to improve neurological dysfunction. A preoperative neurological dysfunction could be considered a strong advice towards surgical intervention. It is time to change and consider prompt surgery not only for survival but also for cerebral protection.
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Affiliation(s)
- Ilaria Giambuzzi
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy -
| | | | - Maurizio Roberto
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Sergio Pirola
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | | | - Laura Cavallotti
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
| | - Giorgia Bonalumi
- Unit of Heart Surgery, IRCCS Centro Cardiologico Monzino, Milan, Italy
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Al-Adhami A, Harky A, Bashir M, Kolvekar S. Replacing the ascending aorta in the elderly: do or do not. Indian J Thorac Cardiovasc Surg 2019; 35:106-111. [PMID: 33061074 DOI: 10.1007/s12055-018-0734-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 08/15/2018] [Accepted: 08/17/2018] [Indexed: 01/16/2023] Open
Abstract
Advanced age is a proven independent factor for perioperative morbidity and mortality in all forms of aortic surgery and forms an important variable in most available risk scores. Improvements in selection and perioperative management of high-risk elderly cohorts have reduced the incidence of adverse outcomes. Concerns remain however in the surgical and anesthesiology community that exposing elderly frail patients to ascending aortic surgery is associated with significant risk. As with many clinical scenarios, individualization of care for each patient is of paramount importance. With advances in our understanding of perioperative and intraoperative care, age should no longer be considered in isolation as a contraindication to ascending aortic surgery.
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Affiliation(s)
- Ahmed Al-Adhami
- Department of Cardiothoracic Surgery, Golden Jubilee National Hospital, Glasgow, G81 4DY UK
| | - Amer Harky
- Department of Vascular Surgery, Countess of Chester, Chester, CH1 2UL UK
| | - Mohamad Bashir
- Department of Aortovascular Surgery, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL UK
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Suzuki T, Asai T, Kinoshita T. Emergency Surgery for Acute Type A Aortic Dissection in Octogenarians Without Patient Selection. Ann Thorac Surg 2019; 107:1146-1153. [DOI: 10.1016/j.athoracsur.2018.10.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 09/12/2018] [Accepted: 10/01/2018] [Indexed: 10/27/2022]
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Kawahito K, Kimura N, Yamaguchi A, Aizawa K, Misawa Y, Adachi H. Early and Late Surgical Outcomes of Acute Type A Aortic Dissection in Octogenarians. Ann Thorac Surg 2018; 105:137-143. [DOI: 10.1016/j.athoracsur.2017.06.057] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/11/2017] [Accepted: 06/21/2017] [Indexed: 11/17/2022]
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The Standardized Concept of Moderate-to-Mild (≥28°C) Systemic Hypothermia During Selective Antegrade Cerebral Perfusion for All-Comers in Aortic Arch Surgery: Single-Center Experience in 587 Consecutive Patients Over a 15-Year Period. Ann Thorac Surg 2017; 104:49-55. [DOI: 10.1016/j.athoracsur.2016.10.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Revised: 09/01/2016] [Accepted: 10/10/2016] [Indexed: 11/19/2022]
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14
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Castaño M, Gualis J, Martínez-Comendador JM, Martín E, Maiorano P, Castillo L. Emergent aortic surgery in octogenarians: is the advanced age a contraindication? J Thorac Dis 2017; 9:S498-S507. [PMID: 28616346 DOI: 10.21037/jtd.2017.04.51] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Surgery of both the ascending and descending aortic segments in the context of an acute aortic syndrome is one of the greatest challenges for the cardiac surgeon. In the case of surgery of the descending aorta, surgical risk increases due to the technical complexity, the required aggressive approach and because surgical indication is usually established as a result of complications and therefore involves, almost always, critically ill patients. The aging of the population is causing such surgery to be considered in an increasing number of octogenarians. The present review analyzes the available scientific evidence on the surgical indications and outcomes of these complex procedures in this population, particularly in the emergent scenario. Ascending and descending thoracic aortic diseases are reviewed separately, and the role of both the current risk scores and frailty assessments are comprehensively discussed.
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Affiliation(s)
- Mario Castaño
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | - Javier Gualis
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | | | - Elio Martín
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | - Pasquale Maiorano
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
| | - Laura Castillo
- Department of Cardiac Surgery, University Hospital of Leon, León, Spain
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15
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Omura A, Matsuda H, Minami H, Nakai H, Henmi S, Murakami H, Yoshida M, Mukohara N. Early and Late Outcomes of Operation for Acute Type A Aortic Dissection in Patients Aged 80 Years and Older. Ann Thorac Surg 2017; 103:131-138. [DOI: 10.1016/j.athoracsur.2016.05.046] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 05/06/2016] [Accepted: 05/11/2016] [Indexed: 11/24/2022]
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16
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Langer NB, Hamid NB, Nazif TM, Khalique OK, Vahl TP, White J, Terre J, Hastings R, Leung D, Hahn RT, Leon M, Kodali S, George I. Injuries to the Aorta, Aortic Annulus, and Left Ventricle During Transcatheter Aortic Valve Replacement. Circ Cardiovasc Interv 2017; 10:CIRCINTERVENTIONS.116.004735. [DOI: 10.1161/circinterventions.116.004735] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The experience with transcatheter aortic valve replacement is increasing worldwide; however, the incidence of potentially catastrophic cardiac or aortic complications has not decreased. In most cases, significant injuries to the aorta, aortic valve annulus, and left ventricle require open surgical repair. However, the transcatheter aortic valve replacement patient presents a unique challenge as many patients are at high or prohibitive surgical risk and, therefore, an open surgical procedure may not be feasible or appropriate. Consequently, prevention of these potentially catastrophic injuries is vital, and practitioners need to understand when open surgical repair is required and when alternative management strategies can be used. The goal of this article is to provide an overview of current management and prevention strategies for major complications involving the aorta, aortic valve annulus, and left ventricle.
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Affiliation(s)
- Nathaniel B. Langer
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Nadira B. Hamid
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Tamim M. Nazif
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Omar K. Khalique
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Torsten P. Vahl
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Jonathon White
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Juan Terre
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Ramin Hastings
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Diana Leung
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Rebecca T. Hahn
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Martin Leon
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Susheel Kodali
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
| | - Isaac George
- From the Division of Cardiothoracic Surgery (N.B.L., D.L., I.G.) and Division of Cardiology (N.B.H., T.M.N., O.K.K., T.P.V., J.W., J.T., R.H., R.T.H., M.L., S.K., I.G.), Columbia University College of Physicians and Surgeons, New York, NY
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17
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Ohnuma T, Shinjo D, Fushimi K. Hospital mortality of patients aged 80 and older after surgical repair for type A acute aortic dissection in Japan. Medicine (Baltimore) 2016; 95:e4408. [PMID: 27495057 PMCID: PMC4979811 DOI: 10.1097/md.0000000000004408] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
To evaluate whether patients aged 80 and older have higher risk of hospital mortality after repair of type A acute aortic dissection (TAAAD).Emergency surgery for TAAAD in patients aged 80 and older remains a controversial issue because of its high surgical risk.Data from patients who underwent surgical repair of TAAAD between April 2011 and March 2013 were retrospectively extracted from the Japanese Diagnosis Procedure Combination database. The effect of age on hospital mortality was evaluated using multivariate logistic regression analysis.A total of 5175 patients were enrolled. The mean age of patients was 67.1 ± 13.0 years, and the male:female ratio was 51:49. Patients aged 80 and older more frequently received tracheostomy than their younger counterparts (9.5% vs 5.4%, P <0.001). Intensive care unit and hospital stays were significantly longer in the elderly cohort versus the younger cohort (7.6 vs 6.7 days, P <0.001, and 42.2 vs 35.8 days, P <0.001, respectively). Logistic regression analysis showed that age ≥80 years was significantly associated with a higher risk of hospital mortality (adjusted odds ratio, 1.62; 95% confidence interval, 1.28-2.06; P <0.001). In linear regression analysis, age ≥80 years was also significantly associated with longer hospital stay (P = 0.007).In a large, nationwide, Japanese database, patients aged 80 and older were at increased risk of hospital mortality and length of hospital stay.
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Affiliation(s)
| | | | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Tokyo, Japan
- Correspondence: Kiyohide Fushimi, Department of Health Policy and Informatics Tokyo Medical and Dental University Graduate School, 1-5-45 Yushima, Bunkyo-ku, Tokyo 1138519, Japan (e-mail: )
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18
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Kondoh H, Satoh H, Daimon T, Tauchi Y, Yamamoto J, Abe K, Matsuda H. Outcomes of limited proximal aortic replacement for type A aortic dissection in octogenarians. J Thorac Cardiovasc Surg 2016; 152:439-46. [DOI: 10.1016/j.jtcvs.2016.03.093] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/23/2016] [Accepted: 03/12/2016] [Indexed: 01/16/2023]
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19
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Inoue Y, Minatoya K, Oda T, Itonaga T, Seike Y, Tanaka H, Sasaki H, Kobayashi J. Surgical outcomes for acute type A aortic dissection with aggressive primary entry resection. Eur J Cardiothorac Surg 2016; 50:567-73. [DOI: 10.1093/ejcts/ezw111] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 02/01/2016] [Indexed: 11/13/2022] Open
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20
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Afifi RO, Sandhu HK, Leake SS, Rice RD, Azizzadeh A, Charlton-Ouw KM, Nguyen TC, Miller CC, Estrera AL, Safi HJ. Determinants of Operative Mortality in Patients With Ruptured Acute Type A Aortic Dissection. Ann Thorac Surg 2016; 101:64-71. [DOI: 10.1016/j.athoracsur.2015.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/26/2015] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
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21
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Tochii M, Takami Y, Hattori K, Ishikawa H, Ishida M, Higuchi Y, Takagi Y. Early and Late Outcomes of Surgical Repair for Stanford A Acute Aortic Dissection in Octogenarians. Circ J 2016; 80:2468-2472. [DOI: 10.1253/circj.cj-16-0918] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Masato Tochii
- Department of Cardiovascular Surgery, Fujita Health University
| | | | - Koji Hattori
- Department of Cardiovascular Surgery, Fujita Health University
| | | | - Michiko Ishida
- Department of Cardiovascular Surgery, Fujita Health University
| | - Yoshiro Higuchi
- Department of Cardiovascular Surgery, Fujita Health University
| | - Yasushi Takagi
- Department of Cardiovascular Surgery, Fujita Health University
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22
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Ascending aortic replacement for acute type A aortic dissection in octogenarians. Gen Thorac Cardiovasc Surg 2015; 64:138-43. [DOI: 10.1007/s11748-015-0613-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 11/29/2015] [Indexed: 10/22/2022]
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23
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Zindovic I, Sjögren J, Bjursten H, Danielsson E, Ingemansson R, Nozohoor S. Impact of Hemodynamic Instability and Organ Malperfusion in Elderly Surgical Patients Treated for Acute Type A Aortic Dissection. J Card Surg 2015; 30:822-9. [DOI: 10.1111/jocs.12633] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Igor Zindovic
- Department of Cardiothoracic Surgery; Skane University Hospital; Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University; Lund Sweden
| | - Johan Sjögren
- Department of Cardiothoracic Surgery; Skane University Hospital; Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University; Lund Sweden
| | - Henrik Bjursten
- Department of Cardiothoracic Surgery; Skane University Hospital; Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University; Lund Sweden
| | - Eric Danielsson
- Department of Cardiothoracic Surgery; Skane University Hospital; Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University; Lund Sweden
| | - Richard Ingemansson
- Department of Cardiothoracic Surgery; Skane University Hospital; Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University; Lund Sweden
| | - Shahab Nozohoor
- Department of Cardiothoracic Surgery; Skane University Hospital; Lund University; Lund Sweden
- Department of Clinical Sciences Lund; Cardiothoracic Surgery; Lund University; Lund Sweden
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