Early and Late Surgical Outcomes of Acute Type A Aortic Dissection in Octogenarians

Morphological characteristics and outcomes of aortic repair of acute type A aortic dissection occurring in patients with aortic arch branching variants

PURPOSE

To investigate the morphological characteristics and operative outcomes of acute type A aortic dissection (ATAAD) in patients with aortic arch variants.

METHODS

Of 616 patients with ATAAD, 97 (15.7%) had aortic arch variants, including bovine aortic arch (BAA, n = 66), isolated left vertebral artery (ILVA, n = 25), and aberrant subclavian artery (ASA, n = 6). The characteristics and outcomes were compared between the normal branching group (control, n = 519) and the total/individual arch variant groups.

RESULTS

Compared to the control group, arch entry was more prevalent in the BAA (18.5% vs. 31.8%) and ILVA groups (44%) (both, P < 0.05), and right common carotid arterial occlusion was less common in the arch variant group (6.7% vs. 0%, P = 0.017). The in-hospital mortality (9.2% vs. 9.3%), new-onset stroke (7.3% vs. 7.2%), and 5-year survival (81.7% vs. 78.8%) did not differ markedly between the control and arch variant groups. Arch repair was performed in 28.9% (28/97) of the arch variant group using 3-4 vessel antegrade cerebral perfusion, with 3.8% in-hospital mortality and a 15.4% stroke rate, which were comparable to those of the control group.

CONCLUSIONS

Aortic arch variants may influence tear location and involvement of the supra-arch vessels but may not affect postoperative outcomes.

Perioperative and Long-Term Outcomes of Acute Stanford Type A Aortic Dissection Repair in Octogenarians

BACKGROUND

The aims of this study were to assess the perioperative morbidity, mortality and long-term survival of octogenarians undergoing acute type A aortic dissection repair (ATAAD), and to compare open and closed distal anastomosis techniques.

METHODS

This was a single-centre retrospective study (2007-2021). Open versus closed distal anastomosis were compared. Uni- and multivariable logistic regression analyses were performed to identify independent predictors of in-hospital mortality. Kaplan-Meier and Cox proportional hazards methods were used to compare long-term survival.

RESULTS

Fifty octogenarian patients were included (median age-82 years; closed distal-22; open distal-28). Median cardiopulmonary bypass time was 187 min (open distal vs. closed distal group; 219 min vs. 115.5 min, p < 0.01, respectively). Median cross-clamp time was 93 min (IQR; 76-130 min). Median circulatory arrest time was 26 min (IQR; 20-39 min) in the open-distal group. In-hospital mortality was 18% (open distal; 14.2% vs. closed distal; 22.7%, p = 0.44). Stroke was 26% (open distal; 28.6% vs. closed distal; 22.7%, p = 0.64). Median survival was 7.2 years (IQR; 4.5-11.6 years). Survival was comparable between open and closed distal groups (median 10.6 vs. 7.2 years, p = 0.35, respectively). Critical preoperative status (HR; 3.2, p = 0.03) and composite endpoint (renal replacement therapy, new neurological event, length of stay > 30 days or return to theatre; HR; 4.1, p = 0.02) predicted adverse survival. Open distal anastomosis did no impact survival.

CONCLUSIONS

ATAAD repair in selected octogenarians has acceptable short- and long-term survival. There is no significant difference between open versus closed distal anastomosis strategies.

Predictors of In-Hospital Mortality in Type A Acute Aortic Syndrome: Data From the RENADA-RO Registry

BACKGROUND

This study aimed to analyse the baseline characteristics of patients admitted with acute type A aortic syndrome (ATAAS) and to identify the potential predictors of in-hospital mortality in surgically managed patients.

METHODS

Data regarding demographics, clinical presentation, laboratory work-up, and management of 501 patients with ATAAS enrolled in the National Registry of Aortic Dissections-Romania registry from January 2011 to December 2022 were evaluated. The primary endpoint was in-hospital all-cause mortality. Multivariate logistic regression was conducted to identify independent predictors of mortality in patients with acute Type A aortic dissection (ATAAD) who underwent surgery.

RESULTS

The mean age was 60±11 years and 65% were male. Computed tomography was the first-line diagnostic tool (79%), followed by transoesophageal echocardiography (21%). Cardiac surgery was performed in 88% of the patients. The overall mortality in the entire cohort was 37.9%, while surgically managed ATAAD patients had an in-hospital mortality rate of 29%. In multivariate logistic regression, creatinine value (OR 6.76), ST depression on ECG (OR 6.3), preoperative malperfusion (OR 5.77), cardiogenic shock (OR 5.77), abdominal pain (OR 4.27), age ≥70 years (OR 3.76), and syncope (OR 3.43) were independently associated with in-hospital mortality in surgically managed ATAAD patients.

CONCLUSIONS

Risk stratification based on the variables collected at admission may help to identify ATAAS patients with high risk of death following cardiac surgery.

The Effect of Obesity on Short- and Long-Term Outcome after Surgical Treatment for Acute Type A Aortic Dissection

BACKGROUND

A paradox of lower morbidity and mortality in overweight or obese patients undergoing cardiac surgery has been described; however, knowledge about the influence of obesity in patients with acute Type A aortic dissection (AAD) is limited. This study aimed to evaluate the effect of obesity on short- and long-term outcomes after surgical treatment for AAD.

METHODS

Between 01/2004 and 12/2022, 912 patients with a BMI of 18.5 or greater were operated on for AAD. Patients were grouped according to their BMI (normal weight: BMI 18.5-24.9, n = 332; overweight: BMI 25-29.9, n = 367; obesity class I: BMI 30-34.9, n = 133; obesity class II+: BMI ≥ 35, n = 67), and the obtained clinical and surgical data were compared.

RESULTS

Obese patients were younger at the time of AAD (p = 0.001) and demonstrated higher rates of typical cardiovascular comorbidities (arterial hypertension, p = 0.005; diabetes mellitus, p < 0.001). The most important preoperative parameters, as well as the surgical approach, were similar between all four groups. The occurrence of renal failure requiring dialysis was higher in patients with BMI ≥ 35 (p = 0.010), but the in-hospital (p = 0.461) and long-term survival (p = 0.894) showed no significant differences.

CONCLUSIONS

There are no indications that the obesity paradox is applicable in the setting of AAD. Since obese patients are affected by AAD at a younger age, obesity might constitute a risk factor for AAD. However, obesity does not influence short- or long-term survival. Regardless of body weight, immediate surgical therapy remains the treatment of choice for AAD.

Comparison between Zone 2 and Zone 3 distal anastomoses for aortic arch replacement in terms of invasiveness

OBJECTIVES

Zone 2 anastomosis with total cervical branch reconstruction for acute type A aortic dissection and aortic arch aneurysms became possible after stent-graft introduction. This may be an easier procedure and reduce the risk of recurrent laryngeal nerve palsy. Therefore, this study aimed to compare the outcomes between Zone 2 and Zone 3 distal anastomoses.

METHODS

After evaluating the patient data in our institute between April 2016 and April 2022, the patients in whom distal anastomosis was performed at Zone 2 with a stent-graft were defined as the Zone 2 group (n = 70). The patients in whom distal anastomosis was performed at Zone 3 were defined as the Zone 3 group (n = 24).

RESULTS

The incidence of new-onset recurrent nerve palsy was one patient (1.4%) in the Zone 2 group and six patients (25.0%) in the Zone 3 group (p < 0.001). The lower body perfusion arrest time was 44.3 ± 9.1 min in the Zone 2 group and 52.9 ± 12.8 min in the Zone 3 group (p = 0.005). There were no significant differences in in-hospital mortality and morbidities. Multivariable analysis showed that only age was an independent predictor of overall mortality.

CONCLUSIONS

Performing distal anastomosis at Zone 2 with a frozen elephant trunk or stent-graft reduced the lower body perfusion arrest time and possibly prevented recurrent nerve palsy.

Sex-Related Differences Between Patients Undergoing Surgery for Acute Type A Aortic Dissection

Introduction This study aimed to evaluate the sex-specific characteristics and surgical outcomes in patients with acute type A aortic dissection (ATAAD). Materials and methods We reviewed the surgical records of patients who underwent ATAAD repair at our institution between 2004 and 2020 (n=213). Results Of the 213 patients, 100 (46.9%) were male, and 113 (53.1%) were female. Males were younger than females (62.5 vs. 72.9 years, p<0.0001). Females had more nonspecific symptoms (p=0.04), more frequently developed ATAAD before noon (45.0% vs. 53.1%, p=0.01), and had a significantly longer time from onset to surgery (425.1 vs. 595.8 min, p=0.03). The ascending aorta was replaced more frequently in females than in males (54.5% vs. 72.8%, p<0.01). No significant difference was observed in the in-hospital mortality rate between males and females (9.0% vs. 10.6%, p=0.69). The multivariable logistic analysis demonstrated that being male was not an independent predictor of operative mortality (OR, 0.96; 95% CI, 0.18-5.21; p=0.96). At 10 years, males had significantly better long-term survival rates in the unadjusted cohort than females (79.4% vs. 55.9%, p=0.02). Conclusions Male sex was not an independent predictor of early death in patients with ATAAD after surgery, although significant differences were noted in terms of age, onset time, chief complaint, imaging findings, and surgical procedures. A sex-based management strategy involving specific differences should be considered to improve outcomes.

Acute type A aortic dissection features and outcomes in octogenarians: a propensity score analysis

OBJECTIVES

The clinical characteristics and early outcomes of surgical repair in octogenarians with acute type A aortic dissection were compared with those in nonoctogenarians.

METHODS

All patients who underwent emergency surgical repair for acute type A aortic dissection in our institution between 2003 and 2022 were included in this study. The patients were divided into an octogenarian group and a nonoctogenarian group. The patients in the 2 groups were propensity score matched at a ratio of 1:1. Before matching, the baseline characteristics were compared between 2 groups. The major complication and 30-day mortality rates were compared in the matched population.

RESULTS

A total of 495 patients were screened, and 471 were included in the analysis, with 48 in the octogenarian group and 423 in the nonoctogenarian group. Before matching, DeBakey type II dissection was significantly more prevalent in the octogenarians (42% vs 14% in the octogenarians and nonoctogenarians, respectively, P < 0.001). Additionally, intramural haematomas (39.6% vs 14.4%, P < 0.001) were more prevalent in the octogenarians. However, severe aortic regurgitation (4.2% vs 15.4%, P = 0.046) and root enlargement (0% vs 13.7%, P = 0.009) were less prevalent in the octogenarians. After matching (36 pairs), the incidence of postoperative delirium was higher in the octogenarians (56% vs 25%, P = 0.027). However, there were no significant differences in 30-day and in-hospital mortality rates, intensive care unit stay or major complications, including stroke, paraplegia, respiratory complications, mediastinitis and haemodialysis.

CONCLUSIONS

The octogenarians with acute type A aortic dissection had higher incidences of DeBakey type II dissection and intramural haematomas and lower incidences of severe aortic regurgitation and aortic root enlargement than the nonoctogenarians. Being an octogenarian was not associated with an increased risk of early major complications or mortality after surgery for acute type A aortic dissection.

Current status of surgical treatment for acute aortic dissection in Japan: Nationwide database analysis

OBJECTIVE

To clarify the current status of surgical treatment of acute aortic dissection (AAD) in Japan through the Japan Cardiovascular Database analysis.

METHODS

In total, 7194 patients who underwent surgical treatment for AAD in 2021, including type A (TAAAD) (n = 6416) and type B (TBAAD) (n = 778), were investigated.

RESULTS

The median age was 70 years, with patients older than age 80 years constituting 21.7% and 23.4% of TAAAD and TBAAD cases. Emergency admission was 88.5% and 78.5%. Shock was found in 11.8% and 6.0%. Rupture/impending rupture occurred in 10.7%/6.0% and 24.0%/11.1%, respectively. Branch malperfusion was complicated in 10.4% and 25.2%. Open repairs were performed in 97.7% and 20.3%, whereas endovascular repairs were performed in 2.3% and 79.7%, respectively. In the increased prevalence of endografting procedures, neurological complications and renal failure occurred frequently after open repair with frozen elephant trunk for 29.9% and 50.3%. The operative mortality rate was 9.8% and 11.5% for open repair and 8.1% and 10.0% for endovascular repair. In patients with TAAAD, age older than 80 years, preoperative critical comorbidities, classical dissection, and coexisting chronic vital organ diseases were independent risk factors for mortality. In frozen elephant trunk procedures, neurologic complications and renal failure were frequent. The operative mortality was higher during the superacute phase within 1 or 2 hours from onset to arrival and between arrival and surgery.

CONCLUSIONS

The current status of surgical treatments for AAD including the increased prevalence of endografting of thoracic endovascular aortic repair and frozen elephant trunk were demonstrated with favorable outcomes in the Japan Cardiovascular Database analyses.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Impact of body mass index on perioperative mortality of acute stanford type A aortic dissection: a systematic review and meta-analysis

BACKGROUND

Obesity may increase perioperative mortality of acute Stanford type A aortic dissection (ATAAD). However, the available evidence was limited. This study aimed to systematically review published literatures about body mass index (BMI) and perioperative mortality of ATAAD.

METHODS

Electronic literature search was conducted in PubMed, Medline, Embase and Cochrane Library databases. All observational studies that investigated BMI and perioperative mortality of ATAAD were included. Pooled odds ratio (OR) and 95% confidence interval (CI) were calculated using a random-effects model. Meta-regression analysis was performed to assess the effects of different clinical variables on BMI and perioperative mortality of ATAAD. Sensitivity analysis was performed to determine the sources of heterogeneity. Egger's linear regression method and funnel plot were used to determine the publication bias.

RESULTS

A total of 12 studies with 5,522 patients were eligible and included in this meta-analysis. Pooled analysis showed that perioperative mortality of ATAAD increased by 22% for each 1 kg/m2 increase in BMI (OR = 1.22, 95% CI: 1.10-1.35). Univariable meta-regression analysis indicated that age and female gender significantly modified the association between BMI and perioperative mortality of ATAAD in a positive manner (meta-regression on age: coefficient = 0.04, P = 0.04; meta-regression on female gender: coefficient = 0.02, P = 0.03). Neither significant heterogeneity nor publication bias were found among included studies.

CONCLUSIONS

BMI is closely associated with perioperative mortality of ATAAD. Optimal perioperative management needs to be further explored and individualized for obese patient with ATAAD, especially in elderly and female populations.

TRIAL REGISTRATION

PROSPERO (CRD42022358619). BMI and perioperative mortality of ATAAD.

Hotspots and development frontiers of postoperative complications of AD: Bibliometric analysis - a review

The research on the postoperative complications of aortic dissection (AD) has received great attention from scholars all over the world, and the number of research articles in this field has consistently increased year after year. However, no bibliometric reports have been published yet to analyze the scientific output and the current situation in this field. The Bibliometrix R-package, VOSviewer, and CiteSpace software were used to conduct a bibliometric analysis of the hotspots and development frontiers of AD. A total of 1242 articles were retrieved. The USA, China, and Japan had the highest number of publications. The five keywords with the highest frequency were "analysis," "incidence," "acute type," "graft," and "risk factor." The results also indicated that the research in related fields had shifted from surgical treatment and utilizing experience to the evidence-based exploration of risk factors and the construction of prediction models to help better manage postoperative complications of AD. This is the first bibliometric analysis of global publications on the postoperative complications of AD. The current research hotspots focus on three areas: common postoperative complications of AD, exploration of the related risk factors, and management of complications. Future research could focus on identifying risk factors through meta-analysis and using a multicenter database for AD as well as building relevant models to predict the development of complications to better facilitate the clinical management of AD patients.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Outcomes of surgery for acute type A dissection in octogenarians versus non-octogenarians: a systematic review and meta analysis

INTRODUCTION

Acute Type A Aortic Dissection (ATAAD) is a cardiothoracic emergency that requires urgent intervention. Elderly status, particularly age over 80, is an independent risk factor for mortality and morbidity. The mid-term outcomes of this age group are also unknown. This systematic review and meta-analysis of observational studies was therefore performed to analyse short- and mid-term mortality and morbidity in octogenarians following surgery for ATAAD.

METHODS

A systematic review was conducted for studies published since January 2000. The primary endpoint was short-term mortality, either reported as 30-day mortality or in-hospital mortality and medium-term (five year) survival. Secondary endpoints were rates of postoperative complications, namely stroke, acute renal failure (ARF), re-exploration and intensive care unit (ICU) length of stay (LOS).

RESULTS

A total of 16 retrospective studies, with a total of 16, 641 patients were included in the systematic review and meta-analysis. Pooled analysis demonstrated that octogenarian cohorts are at significantly higher risk of short-term mortality than non-octogenarians (OR 1.93; 95% CI 1.33-2.81; P < 0.001). Actuarial survival was significantly lower in the octogenarian cohort, with a five-year survival in the octogenarian cohort of 54% compared to 76% in the non-octogenarian cohort (P < 0.001). There were no significant differences between the cohorts in terms of secondary outcomes: stroke, ARF, re-exploration or ICU LOS.

CONCLUSION

Octogenarians are twice as likely to die in the short-term following surgery for ATAAD and demonstrate a significantly lower five-year actuarial survival. Patients and family members should be well informed of the risks of surgery and suitable octogenarians selected for surgery.

Age, sex, and contemporary outcomes in surgical repair of type A aortic dissection: Insights from the National Inpatient Sample

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.

Early outcomes of Sun's procedure in elderly patients with acute aortic dissection: a single-center retrospective study

OBJECTIVE

The effect of patient age on the outcome of Sun's procedure for acute type A aortic dissection (ATAAD) remains controversial. We retrospectively investigated the early outcomes of Sun's procedure in elderly patients with ATAAD in our single center.

METHODS

This study involved 106 patients who underwent Sun's procedure. The patients were divided into the elderly group (≥70 years, n = 17) and younger group (<70 years). Baseline, intraoperative, and postoperative data were compared between the groups.

RESULTS

The mean age in the elderly and younger groups was 75.7 and 50.7 years, respectively. The type of aortic root operations were not significantly different between the groups. Concomitant surgeries were more frequently performed in the elderly group, but without statistical significance. All intraoperative cardiopulmonary bypass variables as well as the in-hospital and 30-day mortality rates were similar between the groups. The incidences of most postoperative complications were also similar except for a higher incidence of sepsis in the elderly group.

CONCLUSIONS

Emergency performance of Sun's procedure for patients with ATAAD characterized by dissection and/or entry tear in the aortic arch should not be denied on the basis of advanced age alone. Comparable early in-hospital outcomes can be achieved in elderly patients.

Surgical outcomes of acute type A aortic dissection in septuagenarians and octogenarians

BACKGROUND

We studied surgical outcomes of acute type A aortic dissection and compared early and late outcomes between septuagenarians and octogenarians.

METHODS

From 2010 to 2019, we evaluated 254 consecutive patients with acute type A aortic dissection. We performed emergent operations within 48 h of symptom onset for 188 patients, including 59 septuagenarians and 32 octogenarians.

RESULTS

The overall 30-day mortality rate was 8.5% in septuagenarians and 9.4% in octogenarians (p = 1.0). The hospital mortality rate was 10.2% in septuagenarians and 12.5% in octogenarians (p = 0.74). Multivariate analysis identified prolonged ventilation (≥ 72 h) as a significant risk factor for hospital mortality. Being an octogenarian was not significantly associated with hospital mortality. The actuarial survival rate at 5 years was 80.1% in septuagenarians and 58.5% in octogenarians (log-rank p = 0.09). The freedom from aortic event rate at 5 years was 91.0% in septuagenarians and 100% in octogenarians (log-rank p = 0.23).

CONCLUSION

The two groups showed no significant differences in hospital mortality or morbidity. Our tear-oriented strategies might be appropriate for both septuagenarians and octogenarians. Prolonged ventilation (≥ 72 h) was a significant risk predictor for hospital mortality.

Outcome of emergency surgery for acute type A aortic dissection in octogenarians

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.

Management of acute type A aortic dissection in the elderly: an analysis from IRAD

OBJECTIVES

We sought to examine management and outcomes of (Stanford) type A aortic dissection (TAAAD) in patients aged >70 years.

METHODS

All patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection database (1996-2018) were studied (n = 5553). Patients were stratified by age and therapeutic strategy. Outcomes for octogenarians were compared with those for septuagenarians. Variables associated with in-hospital mortality were identified by multivariable logistic regression.

RESULTS

In-hospital mortality for all patients (all ages) was 19.7% (1167 deaths), 16.1% after surgical intervention vs 52.1% for medical management (P < 0.001). Of the study population, 1281 patients (21.6%) were aged 71-80 years and 475 (8.0%) were >80 years. Fewer octogenarians underwent surgery versus septuagenarians (68.1% vs 85.9%, P < 0.001). Overall mortality was higher for octogenarians versus septuagenarians (32.0% vs 25.6%, P = 0.008); however, surgical mortality was similar (25.1% vs 21.7%, P = 0.205). Postoperative complications were comparable between surgically managed cohorts, although reoperation for bleeding was more common in septuagenarians (8.1% vs 3.2%, P = 0.033). Kaplan-Meier 5-year survival was significantly superior after surgical repair in all age groups, including septuagenarians (57.0% vs 13.7%, P < 0.001) and octogenarians (35.5% vs 22.6%, P < 0.001).

CONCLUSIONS

When compared with septuagenarians, a smaller percentage of octogenarians undergo surgical repair for TAAAD, even though postoperative outcomes are similar. Age alone should not preclude consideration for surgery in appropriately selected patients with TAAAD.

An increased prothrombin time-international normalized ratio in patients with acute type A aortic dissection: contributing factors and their influence on outcomes

PURPOSE

We investigated factors contributing to coagulopathy in patients with acute type A aortic dissection (ATAAD) and coagulopathy's influence on patient outcomes.

METHODS

We grouped 420 patients who underwent ATAAD repair-none under anticoagulation therapy or with liver disease-by the prothrombin time-international normalized ratio (PT-INR) at admission:  <  1.2 (no coagulopathy, n  =  371), 1.2-1.49 (mild coagulopathy, n  =  33), or  ≥  1.5 (severe coagulopathy, n  =  16). We then compared the clinical presentation, dissection morphology, and outcomes among the groups. We assessed the PT-INR in relation to the preoperative hemodynamics and searched for factors predictive of a PT-INR  ≥  1.2.

RESULTS

The transfusion volume and operation time were increased among patients with coagulopathy (P  <  0.05). The in-hospital mortality (15.2-37.5% vs. 5.1%, P  < 0.001) and 5-year survival (61.1-74.4% vs. 87.6%) were relatively poor for these patients. The median PT-INR was 1.03 (0.97-1.1) for patients with stable hemodynamics (n  =  318), 1.11 (1.02-1.21) for those in shock (blood pressure  <  80 mmHg) not given cardiopulmonary resuscitation (CPR) (n  =  81), and 1.1 (1.0-1.54) for those in shock given CPR (n  =  21) (P  < 0.001). A multivariable analysis identified shock (P  <  0.001), a partially thrombosed false lumen (P  =  0.006), and mesenteric malperfusion (P  =  0.016) as predictive variables.

CONCLUSIONS

Shock, a partially thrombosed false lumen, and mesenteric malperfusion appear to be predictive of dissection-related coagulopathy, which influences outcomes negatively.

Physical activities and surgical outcomes in elderly patients with acute type A aortic dissection

OBJECTIVE

Although elderly patients undergoing surgery for acute type A aortic dissection (ATAAD) is increasing, their physical activities are not fully understood. We report the physical activities and surgical outcomes in elderly patients who underwent ATAAD.

METHODS

From 2009 to 2019, 103 consecutive patients underwent surgery for ATAAD at our institution. Surgical outcomes along with pre- and postoperative physical activities in 52 elderly patients (≥70 years old) were compared with those in 51 younger patients (<70 years old). Postoperative walking difficulty was defined as taking ≥30 days to regain the ability to walk 200 m postoperatively or as the inability to walk at discharge.

RESULTS

It took longer for elderly patients to regain the ability to walk 100 or 200 m postoperatively. ROC analysis revealed the AUC of the duration for walking 200 m postoperatively as a prognostic indicator for late deaths was 0.878, with the highest accuracy at 30 days (sensitivity = 83.3%, specificity = 91.8%). Hospital mortality within 30 days was 3.8%, and 1-, 3-, and 5-years survival rates were 92%, 84.7%, 84.7%, respectively, for elderly patients, with no significant differences between groups. Cox proportional hazard analysis showed postoperative walking difficulty was an independent risk factor for late mortality in all cohorts (p = .017).

CONCLUSIONS

Elderly patients undergoing surgical ATAAD repair showed acceptable surgical outcomes. However, they were more likely to decrease their physical activities postoperatively. Postoperative difficulty in walking was an independent risk factor for the late mortality in patients with ATAAD.

Effects of Obesity on Outcomes of Acute Type A Aortic Dissection Repair in Japan

Background: The prevalence of obesity among Japanese acute type A aortic dissection (ATAAD) patients and its effect on repair outcomes remain to be elucidated.

Methods and Results: The prevalence of obesity (body mass index [BMI] ≥30.0 kg/m²) among 1,059 patients (mean [±SD] age 64.3±12.7 years) who underwent ATAAD repair between 1990 and 2018 was compared with that among the general Japanese population (National Health and Nutrition Survey data). The prevalence of obesity among male patients (17.1% [6/35], 20.0% [18/90], and 14.4% [20/139] for those aged 20–39, 40–49, and 50–59 years, respectively) was significantly higher than that among the age- and sex-matched general population. The 1,059 patients were divided into groups according to weight (normal [BMI <25.0 kg/m²; n=742], overweight [BMI 25.0–29.9 kg/m²; n=248], or obese [BMI ≥30.0 kg/m²; n=69]). Comparing the normal weight, overweight, and obese groups revealed significant differences among the 3 groups in median cardiopulmonary bypass time (143, 167, and 183 min, respectively), ventilation >48 h (44.5%, 60.1%, and 78.3%, respectively), and in-hospital mortality (7.0%, 7.3%, and 17.4%, respectively), but not in 30-day survival. Shock, visceral malperfusion, operation time >360 min, obesity, and coronary malperfusion were identified as predictors of in-hospital mortality.

Conclusions: The prevalence of obesity is increased among Japanese male patients with ATAAD aged ≤59 years. Obesity may increase these patients’ operative risk; overweight does not.

Outcomes of Acute Aortic Dissection Surgery in Octogenarians

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.

Clinical outcome of acute thoracic aortic syndrome in nonagenarians

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).

Early Mortality in Patients who Received Extensive Surgical Management for Acute Type A Aortic Dissection - Analysis of 452 Consecutive Cases from a Single-center Experience

Objective

To detect the potential risk factors associated with early mortality in patients who received extensive surgical management, in the form of total arch replacement plus frozen elephant trunk and arch debranching (hybrid repair technique), for acute type A aortic dissection.

Methods

The clinical and surgical data of 452 surgically treated patients with acute type A aortic dissection at our center, between March 2010 and December 2016, have been retrieved. Uni and multivariate logistic regression analyses were carried out to detect the effect of various preoperative demographics and different perioperative variables on early mortality.

Results

Overall 30-day mortality occurred in 70 out of 452 patients (15.4%). The principal causes of death were multiple organ failure (n=38), cardiac failure (n=18), and severe pulmonary infection (n=10). Risk factors for early mortality were identified with multivariate analysis. Preoperatively, overweight (P<0.025), alcohol drinking (P<0.002), coronary artery disease (P<0.014), hemodynamic shock (P<0.006), and elevated white blood cells count (P<0.002) were associated with higher mortality rate. Postoperatively, prolonged operation time (P<0.008), stroke (P<0.0001), and acute renal dysfunction (P<0.0001) were highly associated with death.

Conclusion

Considering the advantages of extensive surgical management for acute type A aortic dissection over the other less aggressive surgical approaches, it should be advised whenever indicated, provided that being carried out by experts in the field of adult aortic surgery in high-volume centers. The surgeon should be aware of the patient’s preoperative comorbidities and other risk factors for early mortality, in particular, prolonged operation time.

The results of an entry-oriented strategy for acute type A aortic dissection in octogenarians: an 18-year experience

OBJECTIVES

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 &lt;30 (P = 0.006), malperfusion (P = 0.001), rupture (P &lt; 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.

Midterm outcomes of emergency surgery for acute type A aortic dissection in octogenarians

OBJECTIVE

The incidence of elderly patients with acute type A aortic dissection is increasing. A recent analysis of the International Registry of Acute Aortic Dissection failed to show a mortality benefit with surgery compared with medical management in octogenarians. Therefore, we compared our institutional outcomes of emergency surgery for acute type A aortic dissection in octogenarians versus septuagenarians to understand the outcomes of surgical intervention in elderly patients.

METHODS

From 2002 to 2017, 70 octogenarians (aged ≥80 years) and 165 septuagenarians (70-79 years) underwent surgery for acute type A aortic dissection (N = 235, total). Quality of life was assessed by the RAND Short Form-36 quality of life survey. Midterm clinical and functional data were obtained retrospectively.

RESULTS

At baseline, septuagenarians had a higher prevalence of diabetes (20.6% vs 5.7%, P = .01). The prevalence of cardiopulmonary resuscitation was 4.8% versus 10.0% (P = .24) in septuagenarians and octogenarians. The prevalence of cardiogenic shock was 18.2% versus 27.1% (P = .17). Thirty-day/in-hospital mortality was 21.2% versus 28.6% (P = .29). Multivariable logistic regression identified cardiogenic shock as an independent risk factor for in-hospital mortality (odds ratio, 10.07; 95% confidence interval, 2.30-44.03) in octogenarians. Survival at 5 years was 49.7% (42.1%-58.6%) versus 34.2% (23.9%-48.8%) in septuagenarians and octogenarians, respectively. Responses to the quality of life survey were no different between septuagenarians and octogenarians across all 8 quality of life categories.

CONCLUSIONS

Clinical outcomes after surgery for acute type A aortic dissection are similar in octogenarians and septuagenarians. For discharged survivors, quality of life remains favorable and does not differ between the 2 groups.

Outcomes of Early-Onset Acute Type A Aortic Dissection - Influence of Etiologic Factors

BACKGROUND

Outcomes of early-onset acute type A aortic dissection (ATAAD) associated with Marfan syndrome (MFS) are known, but not with other etiologies. Methods and Results: ATAAD patients from 2 centers (n=1,001) were divided into 2 groups: age ≤45 years (n=93) and age >45 years (n=908). Although in-hospital death and 10-year survival were similar (12% vs. 7% and 62.6% vs. 67.3%), the 10-year aortic event-free survival differed (50.0% vs. 80.2%; P<0.01). ATAAD patients from 3 centers (n=132), all aged ≤45 years, were divided into 5 groups: lone hypertension (HTN, n=71), MFS (n=23), non-syndromic familial thoracic aortic aneurysm and dissection (NS-FTAAD, n=16), bicuspid aortic valve (BAV, n=11), and no known etiologic factor (n=11). The incidence of severe aortic insufficiency varied between groups (HTN: 11%, MFS: 39%, NS-FTAAD: 38%, BAV: 55%, no known factor: 46%; P<0.01), whereas in-hospital death did not (14%, 22%, 0%, 0%, and 9%; P=0.061). The 10-year survival was 52.2%, 64.7%, 83.6%, 100%, and 90.9%, respectively, and 10-year aortic event-free survival was 55.6%, 36.3%, 77.5%, 90.0%, and 30.0%. Median descending aorta growth (mm/year) was 1.1 (0.1-3.4), 2.3 (0.3-5.3), 1.9 (1.3-2.7), 0.9 (-0.1-2.0), and 1.0 (-0.2-2.9) (P=0.15), respectively.

CONCLUSIONS

Late aortic events are common in young ATAAD patients. Known etiologic factors, though not BAV, negatively influence late outcomes in these patients.

Comparison of surgical and conservative treatment outcomes for type a aortic dissection in elderly patients

Background

In recent years, surgical outcomes have improved, and positive reports on surgery for type A aortic dissection (AAD) in the elderly are increasing. However, the difference between surgical and conservative treatments in the elderly remains unclear. Therefore, we conducted this study to determine whether surgery should be performed for Stanford (AAD) in elderly patients.

Methods

Data of patients aged 80 years or older who were hospitalized for AAD from April 2014 to March 2016 were extracted from the Japanese national inpatient database. Outcome measures were all-cause in-hospital death, stroke, acute kidney injury and tracheotomy, and composite adverse events (consisting of all-cause in-hospital death, stroke, acute kidney injury, and tracheotomy), and we compared them between surgical and conservative treatments using propensity score matching.

Results

The study cohort included 3258 patients, with 845 matched pairs (1690 patients) in the propensity score matching. All-cause in-hospital death was significantly lower in the surgical treatment group than in the conservative treatment group before and after matching (15.6% vs. 51.1%, p < 0.001; 16.7% vs. 31.6%, p < 0.001, respectively); however, there was no significant difference in composite adverse events after matching (36.0%, conservative vs. 37.2%, surgical; p = 0.65), and adjusted odds ratio was 1.06 and 95% confidence interval was 0.86–1.29 (p = 0.61) with reference to conservative treatment.

Conclusions

All-cause in-hospital death among elderly patients with AAD was significantly lower in patients treated surgically than in those undergoing conservative treatment. However, there was no significant difference between the two groups in the event-free survival, which is important for the elderly. These findings may be used in the consideration of treatment course for elderly patients with AAD.

Electronic supplementary material

The online version of this article (10.1186/s13019-018-0814-6) contains supplementary material, which is available to authorized users.

Initial clinical evaluation of preoperative frailty in surgical patients with Stanford type A acute aortic dissection

BACKGROUND

We retrospectively assessed the initial clinical role of preoperative frailty in surgical patients with Stanford type A acute aortic dissection (AAAD).

METHODS

One hundred and fourteen consecutive patients who underwent emergent or urgent surgical interventions for AAAD in our institute between April 2000 and March 2016 participated in this retrospective study. Patients with more than three of the following six modalities were defined as being frail: age older than 75 years, preoperative requirement of assistance in daily living, body mass index less than 18.5 kg/m², female, history of major stroke, and chronic kidney disease greater than class 3b. Twenty-three patients (20.2%) were diagnosed with frailty (group F), while 91 patients (79.8%) were not (group N). Early clinical outcomes, major postoperative complications, postoperative recovery of activity, and early or mid-term survival were evaluated.

RESULTS

Although early clinical outcomes and the prevalence of major postoperative complications were similar in both groups, postoperative activity of daily living (ADL), such as the rate of being ambulatory on discharge (p < 0.05) and home discharge (p < 0.01), was significantly lower in group F than in group N. A Kaplan-Meier analysis revealed that 1- and 5-year survival rates were similar in groups F (85.9 and 76.4%, respectively) and N (86.0 and 76.9%, respectively).

CONCLUSIONS

Preoperative frailty in AAAD surgical patients has potential as a prognostic factor that affects delays in ADL recovery, but does not influence the early or mid-term clinical outcomes of prompt surgical strategies for life rescue in AAAD patients with frailty.