Risk Factors for Hospital Death in Patients With Acute Aortic Dissection

High Serum VE-Cadherin and Vinculin Concentrations Are Markers of the Disruption of Vascular Integrity during Type B Acute Aortic Dissection

BACKGROUND

In the present study, we measured the serum vascular endothelial cadherin (VEC) and vinculin (Vcn) concentrations in patients with type B acute aortic dissection (TBAD) to evaluate their diagnostic value for this condition.

METHODS

A total of 100 patients with TBAD and 90 matched controls were included in the study. The serum concentrations of VEC and Vcn were measured using enzyme-linked immunosorbent assays.

RESULTS

The serum VEC and Vcn concentrations were significantly higher in participants with TBAD than in healthy controls. Compared with patients with acute myocardial infarction (AMI), the serum concentrations of VEC and Vcn in patients with TBAD were higher, and the Vcn showed significant difference, with statistical significance. Receiver operating characteristic analysis generated areas under the curves for VEC and Vcn that were diagnostic for TBAD (0.599 and 0.655, respectively). The optimal cut-off values were 3.975 ng/μL and 128.1 pg/mL, the sensitivities were 43.0% and 35.0%, and the specificities were 73.3% and 90.0%, respectively. In addition, the use of a combination of serum VEC and Vcn increased the AUC to 0.661, with a sensitivity of 33.0% and a specificity of 93.33%. A high serum Vcn concentration was associated with a higher risk of visceral malperfusion in participants with TBAD (odds ratio (OR) = 1.007, 95% confidence interval [CI]: 1.001-1.013, p = 0.014). In participants with refractory pain, the adjusted OR for the serum VEC concentration increased to 1.172 (95% CI: 1.010-1.361; p = 0.036), compared with participants without refractory pain.

CONCLUSION

This study is the first to show the diagnostic value of serum VEC and Vcn for AAD and their relationships with the clinical characteristics of patients with TBAD. Thus, VEC and Vcn are potential serum markers of TBAD.

Hybrid Technologies for Reconstruction of Proximal Aortic Dissection

The aim of the study is to evaluate the efficacy of various types of hybrid technology in compare to the classical repair of the aortic arch of type I aortic dissection treatment in the in-hospital period.

Materials and Methods

A retrospective observational study has been conducted, the results of surgical treatment of 213 patients with DeBakey type I aortic dissection operated on within the period from 2001 to 2017 were compared. Patients were divided into three groups: in group 1, patients undergone a hemiarch type of aortic repair or the total arch replacement (n=121); in group 2, a hemiarch aortic reconstruction and implantation of bare metal stent was performed (n=55); in group 3, a frozen elephant trunk technique was used (n=37). Taking into consideration the retrospective character of the investigation and nonequivalence of the groups by separate characteristics, they were equalized to improve the reliability of the results using the PSM (propensity score matching) pseudorandomization method. As a result, three groups of comparison were formed which were equalized by the PSM method and called PSM 1, 2, and 3. The mortality and complication rate in the in-hospital period, as well as the frequency of false lumen thrombosis development depending on the treatment method, have been analyzed.

Results

The mortality rate in the PSM 1 group was 15 patients: group 1 (standard technique) - 10 patients (9%), group 2 (uncoated stents) - 5 patients (11%). A significant difference was found in the number of major bleedings (group 1 - 8%, group 2 - 21%, p=0.031) and cases of bowel ischemia (group 1 - 1%, group 2 - 9%, p=0.028). Complete false lumen thrombosis of the thoracic aorta was observed significantly more often in group 1 than in group 2 (22% vs 5%, p=0.015).In the examined group PSM 2, hospital mortality rate was 4 patients: group 1 - 3 patients (12%), group 3 - 1 patient (3%). No differences between the groups were found in the number of complications. In group 3, complete false lumen thrombosis of the thoracic aorta was observed in 59% of cases, whereas in group 1 it was found only in 4% of patients (p<0.001).In comparison group PSM 3, the mortality was 8 patients: group 2 - 5 patients (11%), group 3 - 3 patients (9%). The number of neurological complications differed significantly: in group 2 - 27%, in group 3 - 6% (p=0.019). Besides, 3% of cases of complete false lumen thrombosis were found in group 2, while there appeared 55% (p<0.001) of such patients in group 3.

Conclusion

The comparative analysis showed that the use of bare metal stents and hybrid prostheses demonstrated a comparable low level of in-hospital mortality compared to the standard surgical technique of aortic arch reconstruction. At the same time, the use of the bare metal stents is associated with a higher rate of perioperative complications (bleeding, postoperative bowel ischemia, neurological complications) compared to the standard treatment and repair of the aortic dissection using hybrid prostheses. Complete thrombosis of the false lumen occurred significantly less commonly in case of using bare metal stents than with standard treatment and hybrid prostheses.

Validation of the German Registry for Acute Aortic Dissection Type A Score in predicting 30-day mortality after type A aortic dissection surgery

OBJECTIVES

No reliable scores are available to predict mortality following surgery for type A acute aortic dissection (TAAAD). Recently, the German Registry of Acute Aortic Dissection Type A (GERAADA) score has been developed. We aim to compare how the GERAADA score performs in predicting operative mortality for TAAAD to the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II.

METHODS

We calculated the GERAADA score and EuroSCORE II in patients who underwent TAAAD repair at the Bristol Heart Institute. As there are no precise criteria to calculate the GERAADA score, we used 2 methods: a Clinical-GERAADA score, which evaluated malperfusion with clinical and radiological evidence, and a Radiological-GERAADA score, where malperfusion was assessed by computed tomography scan alone.

RESULTS

207 consecutive patients had surgery for TAAAD, and the observed 30-day mortality was 15%. The Clinical-GERAADA score showed the strongest discriminative power with an area under the curve (AUC) of 0.80 [95% confidence interval (CI) 0.71-0.89], while the Radiological-GERAADA score had an AUC of 0.77 (95% CI 0.67-0.87). EuroSCORE II showed acceptable discriminative power with an AUC of 0.77 (95% CI 0.67-0.87).

CONCLUSIONS

Clinical GERAADA score performed better than the other scores and it is specific and easy to use in the context of a TAAAD. Further validation of the new criteria for malperfusion is needed.

Risk factors for in-hospital death in 2,179 patients with acute aortic dissection

Background

This study aims to investigate the risk factors for in-hospital death in patients with acute aortic dissection (AAD) and to provide a straightforward prediction model to assist clinicians in determining the outcome of AAD patients.

Methods

Retrospective analysis was carried out on 2,179 patients admitted for AAD from March 5, 1999 to April 20, 2018 in Wuhan Union Hospital, China. The risk factors were investigated with univariate and multivariable logistic regression analysis.

Results

The patients were divided into two groups: Group A, 953patients (43.7%) with type A AAD; Group B, 1,226 patients (56.3%) with type B AAD. The overall in-hospital mortality rate was 20.3% (194/953) and 4% (50/1,226) in Group A and B respectively. The multivariable analysis included the variables that were statistically significant predictors of in-hospital death (P < 0.05). In Group A, hypotension (OR = 2.01, P = 0.001) and liver dysfunction (OR = 12.95, P < 0.001) were independent risk factors. Tachycardia (OR = 6.08, P < 0.001) and liver dysfunction (OR = 6.36, P < 0.05) were independent risk factors for Group B mortality. The risk factors of Group A were assigned a score equal to their coefficients, and the score of -0.5 was the best point of the risk prediction model. Based on this analysis, we derived a predictive model to help clinicians determine the prognosis of type A AAD patients.

Conclusions

This study investigate the independent factors associated with in-hospital death in patients with type A or B aortic dissection, respectively. In addition, we develop the prediction of the prognosis for type A patients and assist clinicians in choosing treatment strategies.

Prediction of preoperative in-hospital mortality rate in patients with acute aortic dissection by machine learning: a two-centre, retrospective cohort study

OBJECTIVES

To conduct a comprehensive analysis of demographic information, medical history, and blood pressure (BP) and heart rate (HR) variability during hospitalisation so as to establish a predictive model for preoperative in-hospital mortality of patients with acute aortic dissection (AD) by using machine learning techniques.

DESIGN

Retrospective cohort study.

SETTING

Data were collected from the electronic records and the databases of Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and the First Affiliated Hospital of Anhui Medical University between 2004 and 2018.

PARTICIPANTS

380 inpatients diagnosed with acute AD were included in the study.

PRIMARY OUTCOME

Preoperative in-hospital mortality rate.

RESULTS

A total of 55 patients (14.47%) died in the hospital before surgery. The results of the areas under the receiver operating characteristic curves, decision curve analysis and calibration curves indicated that the eXtreme Gradient Boosting (XGBoost) model had the highest accuracy and robustness. According to the SHapley Additive exPlanations analysis of the XGBoost model, Stanford type A, maximum aortic diameter >5.5 cm, high variability in HR, high variability in diastolic BP and involvement of the aortic arch had the greatest impact on the occurrence of in-hospital deaths before surgery. Moreover, the predictive model can accurately predict the preoperative in-hospital mortality rate at the individual level.

CONCLUSION

In the current study, we successfully constructed machine learning models to predict the preoperative in-hospital mortality of patients with acute AD, which can help identify high-risk patients and optimise the clinical decision-making. Further applications in clinical practice require the validation of these models using a large-sample, prospective database.

TRIAL REGISTRATION NUMBER

ChiCTR1900025818.

Treatment and referral experiences of patients with type A aortic dissection and their families: a qualitative study

OBJECTIVES

This study aimed to analyse the experiences and feelings of patients with type A aortic dissection (TAAD) and their families during the medical treatment and referral process, investigate the entire process's needs and problems and provide evidence for improving the aortic dissection treatment system.

DESIGN

A qualitative descriptive design using a phenomenological study. Face-to-face semistructured interviews were conducted. Thematic analysis was used to analyse the interview data, which was transcribed verbatim.

SETTING

Department of Cardiovascular Surgery of Shanxi Bethune Hospital in China.

PARTICIPANTS

Fifteen family groups, consisting of patients with TAAD who underwent surgical treatment and their families, were selected.

RESULTS

Three primary themes were discussed and developed. Theme 1: the experiences of medical treatment and referral (confusion at the onset; complex inner feelings and emotional expressions of the medical treatment and referral; preoperative inner conflict); theme 2: problems with the TAAD medical treatment system (the quality of diagnosis and medical treatment needs to be improved; deficiency of medical system policies and procedures); and theme 3: real demands (demands for TAAD-related knowledge and access to the disease; economic-related demands).

CONCLUSION

Patients with TAAD and their families encounter complex inner experiences, multiple requirements and numerous challenges during the medical treatment and referral process. It is advised that the treatment and referral system of TAAD in China needs to be improved. Future research and clinical practice should standardise diagnosis and treatment training, establish a fast channel for TAAD to prioritise treatment, popularise aortic dissection-related knowledge and improve the funding system.

Admission D-dimer to lymphocyte counts ratio as a novel biomarker for predicting the in-hospital mortality in patients with acute aortic dissection

BACKGROUND

Inflammatory factors are well-established indicators for vascular disease, but the D-dimer to lymphocyte count ratio (DLR) is not measured in routine clinical care. Screening of DLR in individuals may identify individuals at in-hopital mortality of acute aortic dissection (AD).

METHODS

A retrospective analysis of clinical data from 2013 to 2020 was conducted to identify which factors were related to in-hospital mortality risk of AD. Baseline clinical features, cardiovascular risk factors, and laboratory parameters were obtained from the hospital database. The end point was in-hospital mortality. Forward conditional logistic regression was performed to identify independent risk factors for AA in-hospital death. The cutoff value of the DLR should be ideally calculated by receiver operating characteristic (ROC) analysis.

RESULTS

The in-hospital mortality rate was 15% (48 of 320 patients). Patients with in-hospital mortality had a higher admission mean DLR level than the alive group (1740 vs. 1010, P < .05). The cutoff point of DLR was 907. The in-hospital mortality rate in the high-level DLR group was significantly higher than that in the low-level DLR group (P < .05). Univariate analysis showed that 8 of 38 factors were associated with in-hospital mortality (P < .05), including admission WBC, neutrophils, lymphocytes, neutrophils/lymphocytes (NLR), prothrombin time (PT), heart rate (HR), D-dimer, and DLR. In multivariate analysis, DLR (odds ratio [OR] 2.127, 95% CI 1.034-4.373, P = 0.040), HR (odds ratio [OR] 1.016, 95% CI 1.002-1.030, P = 0.029) and PT (odds ratio [OR] 1.231, 95% CI 1.018-1.189, P = 0.032) were determined to be independent predictors of in-hospital mortality (P < .05).

CONCLUSION

Compared with the common clinical parameters PT and HR, serum DLR level on admission is an uncommon but independent parameter that can be used to assess in-hospital mortality in patients with acute AD.

Evaluation of descriptive performances of platelet indices, neutrophil/lymphocyte ratio, and platelet/lymphocyte ratio in aortic dissections

OBJECTIVE

Mechanical damage resulting from aortic dissection creates a thrombus in the false lumen, in which platelets are involved. Platelet index is useful for the function and activation of platelets. The aim of this study was to show the clinical relevance of the platelet index of aortic dissection.

METHODS

A total of 88 patients diagnosed with aortic dissection were included in this retrospective study. Demographic data and hemogram and biochemistry results of the patients were determined. Patients were divided into two groups: deceased and surviving patients. The data obtained were compared with 30-day mortality. The primary outcome was the relationship of platelet index with mortality.

RESULTS

A total of 88 patients, 22 of whom were female (25.0%), diagnosed with aortic dissection, were included in the study. It was determined that 27 (30.7%) of the patients were mortal. The mean age of the entire patient group was 58±13 years. According to the DeBakey classification of aortic dissection of the patients, the percentages of the 1-2-3 type were determined as 61.4, 8.0, and 30.7%, respectively. Platelet index was not found to be directly related to mortality. Increase in age, decrease in bicarbonate value, and presence of diabetes mellitus were associated with mortality.

CONCLUSION

Although there were no significant changes in platelet index in aortic dissection, neutrophil/lymphocyte ratio and platelet/lymphocyte ratio were found to be high in line with the literature. In particular, the presence of advanced age diabetes mellitus and decrease in bicarbonate are associated with mortality.

Outpatient management of patients after surgical operations for acute aortic dissection of type A

Acute aortic dissection of type A is still one of the most difficult diseases faced by doctors of all specialties. The current review is based on an analysis of current literature data and clinical guidelines. It covers various aspects of outpatient patient management and focuses on conservative therapy. The lack of an adequate diagnostic algorithm often leads to complications and, ultimately, death. The dynamic nature of the disease, the variability of clinical manifestations and the course of the pathological process require special attention. Both short-term and long-term survival of the patient depends on careful observation. Postoperative management of patients with acute aortic dissection of type A is entirely entrusted to the outpatient unit, which, due to the absence of the main aspects of the strategy in modern clinical recommendations, is not always prepared for the curation of this complex cohort of patients. The lack of experience in managing this pathology by outpatient hospital doctors causes significant difficulties in interpreting instrumental diagnostic methods, which leads to further erroneous tactics with the development of long-term complications. Due to the lack of a unified scheme of drug therapy, the question of prescribing drugs in these patients, who often receive a fairly large range of medications for concomitant pathology, remains open. These factors contribute to polyprogmasia or vice versa – insufficient volume of drug therapy, which further leads to the progression of the disease. As a result of insufficient emphasis on the basics of outpatient management of this cohort of patients, a whole complex of problems arises, leading to unsatisfactory treatment results and increased healthcare costs for their subsequent solution. The purpose of the review is to highlight the main problems of this issue from the point of view of evidence-based medicine.

Early dynamic behavior of lactate in predicting continuous renal replacement therapy after surgery for acute type A aortic dissection

Background

It has been well known that hyperlactatemia is an independent risk factor for postoperative mortality in patients who received acute type A aortic dissection (ATAAD) surgery. Some patients may require the assistance of continuous renal replacement therapy (CRRT) for acute postoperative renal deficiency and often associate with increased mortality rate. This study aimed to examine the association between the early dynamic change of lactate levels and postoperative CRRT in ATAAD patients who received surgical repairment.

Methods

This retrospective study included 503 patients who received ATAAD surgeries. Serum lactate levels were measured before operation and at 0, 1, 3, 6, 12, 24 h post intensive care unit (ICU) admission. We examined the association between dynamic changes of lactate and CRRT.

Results

Among all patients, 19.9% (100 patients) required CRRT. Our data showed that the lactate levels were higher in the CRRT group at all timepoints compared to the non-CRRT group. In a multivariate model, lactate levels at 12 h post ICU admission [odds ratio (OR), 1.362; p = 0.007] was identified as an independent predictor for requiring CRRT. Unsurprisingly, 30-day mortality in the CRRT group (41%) was 8.2 times higher than in the non-CRRT group (5%). To better understand the associations between CRRT and lactate levels, patients in the CRRT group were further stratified into the non-survivor group (n = 41) and survivor group (n = 59) based on the 30-day mortality. Elevated lactate levels measured upon ICU admission (OR, 1.284; p = 0.001) and decreased 24 h lactate clearance (OR, 0.237; p = 0.039) were independent risk factors for 30-day mortality in patients who received CRRT. The area under the curve to predict requirement for CRRT at 6 and 12 h post CICU admission were 0.714 and 0.722, respectively, corresponding to lactate cut-off levels of 4.15 and 2.45 mmol/L.

Conclusion

The CRRT is commonly required in patients who received ATAAD surgery and often associated with worse mortality. Early dynamic changes of lactate levels can be used to predict the requirement of postoperative CRRT.

Early Prediction Model of Acute Aortic Syndrome Mortality in Emergency Departments

Purpose

Acute aortic syndrome is a constellation of life-threatening medical conditions for which rapid assessment and targeted intervention are important for the prognosis of patients who are at high risk of in-hospital death. The current study aims to develop and externally validate an early prediction mortality model that can be used to identify high-risk patients with acute aortic syndrome in the emergency department.

Patients and Methods

This retrospective multi-center observational study enrolled 1088 patients with acute aortic syndrome admitted to the emergency departments of two hospitals in China between January 2017 and March 2021 for model development. A total of 210 patients with acute aortic syndrome admitted to the emergency departments of Peking University Third Hospital between January 2007 and December 2021 was enrolled for model validation. Demographics and clinical factors were collected at the time of emergency department admission. The predictive variables were determined by referring to the results of previous studies and the baseline analysis of this study. The study’s endpoint was in-hospital death. To assess internal validity, we used a fivefold cross-validation method. Model performance was validated internally and externally by evaluating model discrimination using the area under the receiver-operating characteristic curve (AUC). A nomogram was developed based on the binary regression results.

Results

In the development cohort, 1088 patients with acute aortic syndromes were included, and 88 (8.1%) patients died during hospitalization. In the validation cohort, 210 patients were included, and 20 (9.5%) patients died during hospitalization. The final model included the following variables: digestive system symptoms (OR=2.25; P=0.024), any pulse deficit (OR=7.78; P<0.001), creatinine (µmol/L)(OR=1.00; P=0.018), lesion extension to iliac vessels (OR=4.49; P<0.001), pericardial effusion (OR=2.67; P=0.008), and Stanford type A (OR=10.46; P<0.001). The model’s AUC was 0.838 (95% CI 0.784–0.892) in the development cohort and 0.821 (95% CI 0.750–0.891) in the validation cohort, and the Hosmer–Lemeshow test showed p=0.597. The fivefold cross-validation demonstrated a mean accuracy of 0.94, a mean precision of 0.67, and a mean recall of 0.13.

Conclusion

This risk prediction tool uses simple variables to provide robust prediction of the risk of in-hospital death from acute aortic syndrome and validated well in an independent cohort. The tool can help emergency clinicians quickly identify high-risk acute aortic syndrome patients, although further studies are needed for verifying the prospective data and the results of our study.

Predictive value of heart rate in patients with acute type A aortic dissection: a retrospective cohort study

OBJECTIVE

Heart rate (HR) is a risk factor of mortality in many cardiovascular diseases but no clinical studies have focused on the association between HR and prognosis in patients with acute type A aortic dissection (ATAAD). This study aimed to evaluate the association between HR and long-term mortality and establish the criteria of HR in patients with ATAAD who underwent total aortic arch replacement combined with the frozen elephant trunk (TAR+FET).

DESIGN, SETTING AND PARTICIPANTS

Retrospective cohort study that studied all consecutive patients with ATAAD who underwent TAR+FET in the Fuwai Hospital between 2009 and 2015.

MAIN OUTCOMES AND MEASURES

30-day postoperative, and estimated long-term mortality.

RESULTS

Overall, 707 patients with ATAAD who underwent TAR+FET were followed up for a median duration of 29 months (range, 5-77 months). In multivariate logistic analysis, HR (p<0.001), age (p<0.001), renal insufficiency (p=0.033), ejection fraction (p=0.005), cardiopulmonary bypass time (p<0.001) and intraoperative blood loss (p=0.002) were significantly associated with 30-day postoperative and estimated long-term mortalities. A hinge point with a sharp increase in estimated long-term mortality was identified at 80 beats/min (bpm), and compared with HR ≤80 bpm, HR >80 bpm was associated with an almost threefold higher long-term mortality. HRs ≤60, 60-70, 70-80, 80-90, 90-100, 100-110 and >110 bpm were associated with 3.9%, 4.0%, 3.8%, 7.2%, 9.5%, 10.1% and 14.4% yearly risks of death, respectively.

CONCLUSIONS

HR is a powerful predictor of long-term mortality in patients with ATAAD undergoing TAR+FET. HR >80 bpm is independently associated with elevated long-term mortality for patients with ATAAD.

Prognostic factors and prediction models for acute aortic dissection: a systematic review

OBJECTIVE

Our study aimed to systematically review the methodological characteristics of studies that identified prognostic factors or developed or validated models for predicting mortalities among patients with acute aortic dissection (AAD), which would inform future work.

DESIGN/SETTING

A methodological review of published studies.

METHODS

We searched PubMed and EMBASE from inception to June 2020 for studies about prognostic factors or prediction models on mortality among patients with AAD. Two reviewers independently collected the information about methodological characteristics. We also documented the information about the performance of the prognostic factors or prediction models.

RESULTS

Thirty-two studies were included, of which 18 evaluated the performance of prognostic factors, and 14 developed or validated prediction models. Of the 32 studies, 23 (72%) were single-centre studies, 22 (69%) used data from electronic medical records, 19 (59%) chose retrospective cohort study design, 26 (81%) did not report missing predictor data and 5 (16%) that reported missing predictor data used complete-case analysis. Among the 14 prediction model studies, only 3 (21%) had the event per variable over 20, and only 5 (36%) reported both discrimination and calibration statistics. Among model development studies, 3 (27%) did not report statistical methods, 3 (27%) exclusively used statistical significance threshold for selecting predictors and 7 (64%) did not report the methods for handling continuous predictors. Most prediction models were considered at high risk of bias. The performance of prognostic factors showed varying discrimination (AUC 0.58 to 0.95), and the performance of prediction models also varied substantially (AUC 0.49 to 0.91). Only six studies reported calibration statistic.

CONCLUSIONS

The methods used for prognostic studies on mortality among patients with AAD-including prediction models or prognostic factor studies-were suboptimal, and the model performance highly varied. Substantial efforts are warranted to improve the use of the methods in this population.

Protective effect of dexmedetomidine on perioperative myocardial injury in patients with Stanford type-A aortic dissection

OBJECTIVE

To investigate the protective effect and mechanism of dexmedetomidine (Dex) on perioperative myocardial injury in patients with Stanford type-A aortic dissection (AD).

METHODS

Eighty-six patients with Stanford type-A AD were randomly divided into Dex and control groups, with 43 cases in each group. During the surgery, the control group received the routine anesthesia, and the Dex group received Dex treatment based on routine anesthesia. The heart rate (HR) and mean arterial pressure (MAP) were recorded before Dex loading (t0), 10 min after Dex loading (t1), at the skin incision (t2), sternum sawing (t3), before cardiopulmonary bypass (t4), at the extubation (t5), and at end of surgery (t6). The blood indexes were determined before anesthesia induction (T0) and postoperatively after 12h (T1), 24h (T2), 48h (T3), and 72h (T4).

RESULTS

At t2 and t3, the HR and MAP in the Dex group were lower than in the control group (P < 0.05). Compared with the control group, in the Dex group at T1, T2, and T3, the serum creatine kinase-MB, cardiac troponin-I, C-reactive protein, and tumor necrosis factor-α levels were decreased, and the interleukin-10 level, the serum total superoxide dismutase, and total anti-oxidant capability increased, while the myeloperoxidase and malondialdehyde levels decreased (all P < 0.05).

CONCLUSIONS

Dex treatment may alleviate perioperative myocardial injury in patients with Stanford type-A AD by resisting inflammatory response and oxidative stress.

Perioperative risk factors predict one-year mortality in patients with acute type-A aortic dissection

Objective

The goal of this study was to analyze perioperative risk factors to predict one- year mortality after operation for acute type A aortic dissection (AAD).

Methods

A total of 121 consecutive patients undergoing Stanford type A AAD surgery in Beijing Anzhen Hospital were enrolled. Preoperative clinical and laboratory data from patients were collected.

Results

Multivariable Cox regression analysis showed that significant factors associated with increased one-year mortality were elder age (year) (hazard ratio (HR) 1.0985; 95% confidence interval (CI) 1.0334–1.1677), intraoperative blood transfusion ≥2000 mL (HR 8.8081; 95% CI 2.3319–33.2709), a higher level of serum creatinine (μmol/L) at postoperative one day (HR 1.0122; 95% CI 1.0035–1.0190) and oxygenation index (OI) < 200 (mmHg) at the end of surgery (HR 5.7575; 95% CI 1.1695–28.3458).

Conclusion

In this study, perioperative risk factors to predict one-year prognosis are age, intraoperative blood transfusion ≥2000 mL, postoperative OI < 200 mmHg and level of postoperative serum creatinine. The results aid in the comprehension of surgical outcomes and assist in the optimization of treatment strategies for those with perioperative risk factors to decrease one-year mortality.

Predicting in-hospital death in patients with type B acute aortic dissection

The outcome of patients with acute type B aortic dissection (BAAD) is largely dictated by whether or not the case is "complicated." The purpose of this study was to investigate the risk factors leading to in-hospital death among patients with BAAD and then to develop a predictive model to estimate individual risk of in-hospital death.A total of 188 patients with BAAD were enrolled. Risk factors for in-hospital death were investigated with univariate and multivariable logistic regression analysis. Significant risk factors were used to develop a predictive model.The in-hospital mortality rate was 9% (17 of 188 patients). Univariate analysis revealed 7 risk factors to be statistically significant predictors of in-hospital death (P < .1). In multivariable analysis, the following variables at admission were independently associated with increased in-hospital mortality: hypotension (odds ratio [OR], 4.85; 95% confidence interval [CI], 1.12-18.90; P = .04), ischemic complications (OR, 8.24; 95% CI, 1.25-33.85; P < .001), renal dysfunction (OR, 12.32; 95% CI, 10.63-76.66; P < .001), and neutrophil percentage ≥80% (OR, 5.76; 95% CI, 2.58-12.56; P = .03). Based on these multivariable results, a reliable and simple prediction model was developed, a total score of 4 offered the best point value.Independent risk factors associated with in-hospital death can be predicted in BAAD patients. The prediction model could be used to identify the prognosis for BAAD patients and assist physicians in their choice of management.

Left Ventricular Systolic Dysfunction in Patients With Type-A Aortic Dissection Is Associated With 30-Day Mortality

OBJECTIVE

The aim of this study was to analyze preoperative and postoperative echocardiographic parameters in patients with type-A acute aortic dissection (ATAAD) and to analyze whether impaired preoperative left ventricular function was associated with short- and long-term survival. To enable multivariable analysis, established risk factors of ATAAD were analyzed as well.

DESIGN

Retrospective single-center study.

SETTING

The German Heart Center Berlin.

PARTICIPANTS

The retrospective data of 512 patients with ATAAD who were treated between 2006 and 2014 were analyzed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Preoperative versus postoperative left ventricular ejection fraction (LVEF), right ventricular ejection fraction, left ventricular end-diastolic diameter, and right ventricular end-diastolic diameter were not significantly different, and the mean values were within the reference ranges. Because of the surgical intervention, incidences and severities of aortic regurgitation and pericardial effusion decreased. In multivariable logistic analysis, the authors identified age (odds ratio [OR] 1.04, p < 0.001), preoperative LVEF ≤35% (OR 2.20, p = 0.003), any ischemia (Penn non-Aa) (OR 2.15, p < 0.001), and longer cardiopulmonary bypass time (OR 1.04, p < 0.001) as independent predictors of 30-day mortality. Cardiopulmonary resuscitation, tamponade, or shock, and pre-existing cardiac disease, were not predictors of death.

CONCLUSION

After surgery, aortic insufficiency and pericardial effusion decreased, whereas cardiac functional parameters did not change. Severe LV dysfunction was identified as a new independent predictor of 30-day mortality.

The Relationship Between Renal Artery Involvement in Stanford B-Type Aortic Dissection and the Short-Term Prognosis: A Single-Centre Retrospective Cohort Study

BACKGROUND

Renal artery involvement has not received sufficient attention despite the fact that aortic computed tomography angiography (CTA) examinations of Stanford B-type aortic dissection patients usually show renal artery involvement [3]. To study the influence of renal artery involvement on aortic dissection, we performed a retrospective study on acute Stanford B-type aortic dissection patients with or without renal artery involvement to investigate its effect on the prognosis of aortic dissection.

METHODS

A total of 221 patients with acute Stanford-B type aortic dissection between January 2012 and January 2014 were enrolled. The patients were divided into a renal artery involvement group and a non-renal artery involvement group based on aortic computed tomography angiography (CTA) results. The clinical data of the two groups were compared. Univariate analyses and multiple logistic regression analyses were performed to determine risk factors related to in-hospital mortality. The effect of renal artery involvement on the prognosis of Stanford B-type aortic dissection patients was analysed.

RESULTS

Among the 221 patients with acute Stanford type-B aortic dissection, 100 patients (45.2%) exhibited renal artery involvement. The percentage of patients with a past history of hypertension in the renal artery involvement group was significantly higher than that in the non-renal artery involvement group (84.0% vs. 74.8%, p=0.025). The estimated glomerular filtration rate (eGFR), creatinine level, and urea nitrogen level at admission were not significantly different between the renal artery involvement group and the non-renal artery involvement group. The in-hospital mortality rate in the renal artery involvement group was higher than that in the non-renal artery involvement group; the difference in the percentage of in-hospital mortality between these two groups was statistically significant (12.0% vs. 4.1%, p<0.05). The results of multiple logistic regression analysis showed that renal artery involvement was a risk factor for in-hospital mortality in acute Stanford B-type aortic dissection patients (odds ratio (OR)=3.536 (1.127∼11.095)). In the renal artery involvement group, the in-hospital mortality rate in the conservative treatment group was significantly higher than that in the interventional treatment group (30.8% vs. 5.4%, p=0.001).

CONCLUSIONS

Although renal artery involvement was not associated with short-term renal function damage, it was a risk factor for in-hospital mortality after acute Stanford B-type aortic dissection.

Incidence and risk factors of recurrent pain in acute aortic dissection and in-hospital mortality

BACKGROUND

We investigated the prevalence of recurrent pain and its relationship with in-hospital mortality in acute aortic dissection (AAD).

PATIENTS AND METHODS

Between 2011 and 2016, 234 AAD patients were selected. Recurrent pain was defined as a mean of VAS > 3, within 48 hours following hospital admission or before emergency operation. Patients with and without recurrent pain were divided into group I and group II, respectively into type A AAD and type B AAD patients. Our primary outcome was in-hospital mortality.

RESULTS

The incidence of recurrent pain was 24.4 % in AAD patients. Incidence of recurrent pain was higher in type A AAD patients than type B AAD patients (48.9 vs. 9.6 %). Overall in-hospital mortality was 25.6 %. Type A AAD had a higher in-hospital mortality than type B AAD patients (47.7 vs. 12.3 %). Group I had significantly higher in-hospital mortality than group II (type A: 79.1 vs. 17.8 %; type B: 57.1 vs. 7.6 %, all P < 0.001), as was the case with medical managed patients (type A: 72.1 vs. 13.3 %; type B: 35.7 vs. 2.3 %, all P < 0.001). Logistic regression analysis showed that use of one drug alone and waist pain were predictive factors for recurrent pain in type A AAD and type A AAD patients, respectively (OR 3.686, 95 % CI: 1.103~12.316, P = 0.034 and OR 14.010, 95 % CI: 2.481~79.103, P = 0.003). Recurrent pains were the risk factors (type A: OR 11.096, 95 % CI: 3.057~40.280, P < 0.001; type B: OR 14.412, 95 % CI: 3.662~56.723, P < 0.001), while invasive interventions were protective (type A: OR 0.133, 95 % CI: 0.035~0.507, P < 0.001; type B: OR 0.334, 95 % CI: 0.120~0.929, P = 0.036) for in-hospital mortality in AAD patients.

CONCLUSIONS

Approximately one-fourth of AAD patients presented with recurrent pains, which might increase in-hospital mortality. Thus, interventional strategies at early stages are important.

Association of Plasma Pentraxin-3 Levels on Admission with In-hospital Mortality in Patients with Acute Type A Aortic Dissection

BACKGROUND

Acute aortic dissection is a life-threatening cardiovascular emergency. Pentraxin-3 (PTX3) is proposed as a prognostic marker and found to be related to worse clinical outcomes in various cardiovascular diseases. This study sought to investigate the association of circulating PTX3 levels with in-hospital mortality in patients with acute Type A aortic dissection (TAAD).

METHODS

A total of 98 patients with TAAD between January 2012 and December 2015 were enrolled in this study. Plasma concentrations of PTX3 were measured upon admission using a high-sensitivity enzyme-linked immunosorbent assay system. Patients were divided into two groups as patients died during hospitalization (Group 1) and those who survived (Group 2). The clinical, laboratory variables, and imaging findings were analyzed between the two groups, and predictors for in-hospital mortality were evaluated using multivariate analysis.

RESULTS

During the hospital stay, 32 (33%) patients died and 66 (67%) survived. The patients who died during hospitalization had significantly higher PTX3 levels on admission compared to those who survived. Pearson's correlation analysis demonstrated that PTX3 correlated positively with high-sensitivity C-reactive protein (hsCRP), maximum white blood cell count, and aortic diameter. Multivariate logistic regression analysis demonstrated that PTX3 levels, coronary involvement, cardiac tamponade, and a conservative treatment strategy are significant independent predictors of in-hospital mortality in patients with TAAD. The receiver operating characteristic curve analysis further illustrated that PTX3 levels on admission were strong predictors of mortality with an area under the curve of 0.89. A PTX3 level ≥5.46 ng/ml showed a sensitivity of 88% and a specificity of 79%, and an hsCRP concentration ≥9.5 mg/L had a sensitivity of 80% and a specificity of 69% for predicting in-hospital mortality.

CONCLUSION

High PTX3 levels on admission are independently associated with the in-hospital mortality in patients with TAAD.

Preoperative evaluation value of aortic arch lesions by multidetector computed tomography angiography in type A aortic dissection

The purpose of this study was to preoperatively evaluate the value of aortic arch lesions by multidetector computed tomography (MDCT) angiography in type A aortic dissection (AD).From January 2013 to December 2015, we enrolled 42 patients with type A AD who underwent MDCT angiography in our hospital. The institutional database of patients was retrospectively reviewed to identify MDCT angiography examinations for type A AD. Surgical corrections were conducted in all patients to confirm diagnostic accuracy.In this study, the diagnostic accuracy of MDCT angiography was 100% in all 42 patients. The intimal tear site locations that were identified in patients included the ascending aorta (n = 25), aortic arch (n = 12), and all other sites (n = 5). Compared with the control group, there were significant differences in the aortic arch anatomy among the cases. Regarding the distance between the left common carotid and left subclavian arteries, compared with the control group, most cases with type A AD had a significant variation.MDCT angiography plays an important role in detecting aortic arch lesions of type A AD, especially in determining the location of the intimal entry site and change of branch blood vessels. Surgeons can formulate an appropriate operating plan, according to the preoperative MDCT diagnosis information.

Hyperlactemia Predicts Surgical Mortality in Patients Presenting With Acute Stanford Type-A Aortic Dissection

OBJECTIVE

Inspired by the limited facility of the Penn classification, the authors aimed to determine a rapid and optimal preoperative assessment tool to predict surgical mortality after acute Stanford type-A aortic dissection (AAAD) repair.

DESIGN

Patients who underwent an attempted surgical repair of AAAD were determined using a de-identified single institution database. The charts of 144 patients were reviewed retrospectively for preoperative demographics and surrogates for disease severity and malperfusion. Bivariate analysis was used to determine significant (p≤0.05) predictors of in-hospital and 1-year mortality, the primary endpoints. Receiver operating characteristic curve generation was used to define optimal cut-off values for continuous predictors.

SETTING

Single center, level 1 trauma, university teaching hospital.

PARTICIPANTS

The study included 144 cardiac surgical patients with acute type-A aortic dissection presenting for surgical correction.

INTERVENTIONS

Surgical repair of aortic dissection with preoperative laboratory samples drawn before patient transfer to the operating room or immediately after arterial catheter placement intraoperatively.

MEASUREMENTS AND MAIN RESULTS

The study cohort comprised 144 patients. In-hospital mortality was 9%, and the 1-year mortality rate was 17%. Variables that demonstrated a correlation with in-hospital mortality included an elevated serum lactic acid level (odds ratio [OR] 1.5 [1.3-1.9], p<0.001), a depressed ejection fraction (OR 0.91 [0.86-0.96], p = .001), effusion (OR 4.8 [1.02-22.5], p = 0.04), neurologic change (OR 5.3 [1.6-17.4], p = 0.006), severe aortic regurgitation (OR 8.2 [2.0-33.9], p = 0.006), and cardiopulmonary resuscitation (OR 6.8 [1.7-26.9], p = 0.01). Only an increased serum lactic acid level demonstrated a trend with 1-year mortality using univariate Cox regression (hazard ratio 1.1 [1.0-1.1], p = 0.006). Receiver operating characteristic analysis revealed optimal cut-off lactic acid levels of 6.0 mmol/L and 6.9 mmol/L for in-hospital and 1-year mortality, respectively.

CONCLUSION

Lactic acidosis, ostensibly as a surrogate for systemic malperfusion, represents a novel, accurate, and easily obtainable preoperative predictor of short-term mortality after attempted AAAD repair. These data may improve identification of patients who would not benefit from surgery.

Novel Technique Using Polyester Fabric and Fibrin Sealant Patch for Acute Aortic Dissection

We describe a simple and effective technique for acute aortic dissection using a combination of polyester fabric and a fibrin sealant patch (FSP) to achieve effective reinforcement and haemostasis of the aortic stump. Firstly, the 0.61mm thick knitted polyester fabric sheet was cut to half of the size of the FSP. Next, fibrin glue was sprayed onto the collagen layer of the FSP. Subsequently, a fabric sheet was placed upon it, and the FSP was put together with the irrigated collagen layer, and then completely dried to bind the patch. As a result, the dry fibrinogen/thrombin layers, as an adhesive surface, faced outward. This patch was trimmed to a 10-15-mm-wide strip. The composite patch was inserted into the false lumen. The stump was gently pressed to fix the aortic intima and adventitia. There are several advantages: the combined patch can be prepared during systemic cooling, and therefore can minimise the circulatory arrest time; secondly, the false lumen is not directly exposed to fibrin glue and so the risk of embolism is extremely low; thirdly, the expected haemostatic effect is greater as FSP lines the exterior of the intima, achieving haemostasis for suture holes.