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Matei DC, Antohi EL, Radu RI, Ciobanu CG, Geavlete OD, Filipescu D, Bubenek Ș, Moldovan H, Iliescu VA, Chioncel OD. Predictors of In-Hospital Mortality in Type A Acute Aortic Syndrome: Data From the RENADA-RO Registry. Heart Lung Circ 2024:S1443-9506(24)00154-9. [PMID: 38955595 DOI: 10.1016/j.hlc.2024.02.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/07/2024] [Accepted: 02/21/2024] [Indexed: 07/04/2024]
Abstract
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.
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Affiliation(s)
- Diana-Cristina Matei
- Emergency Institute for Cardiovascular Diseases "Prof. Dr. C.C. Iliescu" Bucharest, Romania; University of Medicine and Pharmacy "Carol Davila" Bucharest, Romania.
| | - Elena-Laura Antohi
- Emergency Institute for Cardiovascular Diseases "Prof. Dr. C.C. Iliescu" Bucharest, Romania; University of Medicine and Pharmacy "Carol Davila" Bucharest, Romania
| | - Răzvan Ilie Radu
- Emergency Institute for Cardiovascular Diseases "Prof. Dr. C.C. Iliescu" Bucharest, Romania; University of Medicine and Pharmacy "Carol Davila" Bucharest, Romania
| | - Celia Georgiana Ciobanu
- Emergency Institute for Cardiovascular Diseases "Prof. Dr. C.C. Iliescu" Bucharest, Romania; University of Medicine and Pharmacy "Carol Davila" Bucharest, Romania
| | - Oliviana Dana Geavlete
- Emergency Institute for Cardiovascular Diseases "Prof. Dr. C.C. Iliescu" Bucharest, Romania; University of Medicine and Pharmacy "Carol Davila" Bucharest, Romania
| | - Daniela Filipescu
- Emergency Institute for Cardiovascular Diseases "Prof. Dr. C.C. Iliescu" Bucharest, Romania; University of Medicine and Pharmacy "Carol Davila" Bucharest, Romania
| | - Șerban Bubenek
- Emergency Institute for Cardiovascular Diseases "Prof. Dr. C.C. Iliescu" Bucharest, Romania; University of Medicine and Pharmacy "Carol Davila" Bucharest, Romania
| | - Horațiu Moldovan
- University of Medicine and Pharmacy "Carol Davila" Bucharest, Romania; Emergency Clinical Hospital, Bucharest, Romania; The Academy of Romanian Scientists (AOSR), Bucharest, Romania
| | - Vlad Anton Iliescu
- Emergency Institute for Cardiovascular Diseases "Prof. Dr. C.C. Iliescu" Bucharest, Romania; University of Medicine and Pharmacy "Carol Davila" Bucharest, Romania
| | - Ovidiu Dragomir Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof. Dr. C.C. Iliescu" Bucharest, Romania; University of Medicine and Pharmacy "Carol Davila" Bucharest, Romania
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Vendramin I, Lechiancole A, Piani D, Sponga S, Bressan M, Auci E, Isola M, De Martino M, Bortolotti U, Livi U. Influence of a regional network combined with a systematic multidisciplinary approach on the outcomes of patients with acute type A aortic dissection. Int J Cardiol 2023; 391:131278. [PMID: 37598911 DOI: 10.1016/j.ijcard.2023.131278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 08/01/2023] [Accepted: 08/17/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Whether in patients with acute type A aortic dissection reduction of intervals between onset of symptoms and diagnosis influences patient outcomes is still not completely defined. METHODS In 199 patients with acute type A aortic dissection, the efficacy of a systematic multidisciplinary approach and institution of a regional network were evaluated; 90 patients operated before 2016 (Group1) were compared with 109 repaired after 2016 (Group2) for early and late outcomes. RESULTS Mortality was reduced from 13% in Group1 to 4% in Group2 (p = 0.013). In Group2 a more patients (46%) had arch replacement compared to Group1 (29%)(p = 0.06). In Group2 axillary artery cannulation was almost routinely used (91% vs 67%, p < 0.001) with shorter circulatory arrest time (37 vs 44 min, p < 0.001). The interval from diagnosis to surgery dropped from 210 min in Group1 to 160 min in Group2 (p < 0.001); this reduction was evident both in patients admitted to the emergency department of a spoke and/or a hub center. Patients presenting with or developing shock were reduced from Group1 to Group2 and in particular those reaching the hub center from spoke centers. Survival at 1 and 5 years was 82 ± 4% and 70 ± 5% in Group1 vs 92 ± 3% and 87 ± 8% in Group2 (p = 0.007). CONCLUSIONS Outcomes of patients with acute type A aortic dissection improved using a systematic multidisciplinary approach while a network between spoke and hub centers reduced intervals between diagnosis, transportation to hub center and repair, limiting the incidence of tamponade and shock.
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Affiliation(s)
- Igor Vendramin
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy.
| | - Andrea Lechiancole
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Daniela Piani
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Sandro Sponga
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Marilyn Bressan
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Elisabetta Auci
- Department of Anesthesia, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Miriam Isola
- Department of Medical Area, University of Udine, Udine, Italy
| | | | - Uberto Bortolotti
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Ugolino Livi
- Cardiothoracic Department, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy; Department of Medical Area, University of Udine, Udine, Italy
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Zhu X, Wang J, Chong H, Jiang Y, Fan F, Pan J, Cao H, Xue Y, Wang D, Zhou Q. Analysis of risk factors for postoperative mortality in acute type A aortic dissection patients under different critical levels. Sci Rep 2023; 13:8107. [PMID: 37208480 DOI: 10.1038/s41598-023-35351-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 05/16/2023] [Indexed: 05/21/2023] Open
Abstract
We built up a risk stratification model to divide acute type A aortic dissection (aTAAD) patients into low- and high-risk groups, further, to evaluate the risk factors for postoperative mortality. A total of 1364 patients from 2010 to 2020 in our center were retrospectively analyzed. More than twenty clinical variables were related with postoperative mortality. The postoperative mortality of the high-risk patients was doubled than the low-risk ones (21.8% vs 10.1%). The increased operation time, combined coronary artery bypass graft, cerebral complications, re-intubation, continuous renal replacement therapy and surgical infection were risk factors of postoperative mortality in low-risk patients. In addition, postoperative lower limbs or visceral malperfusion were risk factors, axillary artery cannulation and moderate hypothermia were protective factors in high-risk patients. A scoring system for quick decision-making is needed to select appropriate surgical strategy in aTAAD patients. For low-risk patients, different surgical treatments can be performed with similar clinical prognosis. Limited arch treatment and appropriate cannulation approach are crucial in high-risk aTAAD patients.
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Affiliation(s)
- Xiyu Zhu
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Junxia Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Hoshun Chong
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Yi Jiang
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital Clinical College of Nanjing Medical University, Nanjing, China
| | - Fudong Fan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Jun Pan
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Hailong Cao
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Yunxing Xue
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Dongjin Wang
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Qing Zhou
- Department of Cardio-Thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, No. 321 Zhongshan Rd, Nanjing, 210008, Jiangsu, China.
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China.
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Kayali F, Jubouri M, Al-Tawil M, Tan SZCP, Williams IM, Mohammed I, Velayudhan B, Bashir M. Coronary artery involvement in type A aortic dissection: Fate of the coronaries. J Card Surg 2022; 37:5233-5242. [PMID: 36177668 DOI: 10.1111/jocs.16981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 09/10/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Type A aortic dissection (TAAD) involves a tear in the intimal layer of the thoracic aorta proximal to the left subclavian artery, and hence, carries a high risk of mortality and morbidity and requires urgent intervention. This dissection can extend into the main coronary arteries. Coronary artery involvement in TAAD can either be due to retrograde extension of the dissection flap into the coronaries or compression and/or blockage of these vessels by the dissection flap, possibly causing myocardial ischemia. Due to the emergent nature of TAAD, coronary involvement is often missed during diagnosis, thereby delaying the required intervention. AIMS The main scope of this review is to summarize the literature on the incidence, mechanism, diagnosis, and treatment of coronary artery involvement in TAAD. METHODS A comprehensive literature search was performed using multiple electronic databases, including PubMed, Ovid, Scopus and Embase, to identify and extract relevant studies. RESULTS Incidence of coronary artery involvement in TAAD was seldom reported in the literature, however, some studies have described patients diagnosed either preoperatively, intraoperatively following aortic clamping, or even during autopsy. Among the few studies that reported on this matter, the treatment choice for coronary involvement in TAAD was varied, with the majority revascularizing the coronary arteries using coronary artery bypass grafting or direct local repair of the vessels. It is well-established that coronary artery involvement in TAAD adds to the already high mortality and morbidity associated with this disease. Lastly, the right main coronary artery was often more implicated than the left. CONCLUSION This review reiterates the significance of an accurate diagnosis and timely and effective interventions to improve prognosis. Finally, further large cohort studies and longer trials are needed to reach a definitive consensus on the best approach for coronary involvement in TAAD.
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Affiliation(s)
- Fatima Kayali
- School of Medicine, University of Central Lancashire, Preston, UK
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | | | - Sven Z C P Tan
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ian M Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Idhrees Mohammed
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Bashi Velayudhan
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Mohamad Bashir
- Vascular and Endovascular Surgery, Velindre University NHS Trust, Health Education and Improvement Wales (HEIW), Cardiff, UK
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5
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Shmukler A, Alis J, Patel S, Latson L, Ko JP. Pitfalls and Pearls of Imaging Non-traumatic Thoracic Aortic Disease. Semin Ultrasound CT MR 2022; 43:204-220. [PMID: 35688532 DOI: 10.1053/j.sult.2022.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Imaging of the thoracic aorta is a common request in both the acute and outpatient settings, playing a crucial role in diagnosis and treatment planning of aortic disease. The findings of aortic pathology may be obvious or occult on imaging. Recognizing subtle changes is essential and may lead to early detection and prevention of serious morbidity and mortality. Knowledge of the anatomy and understanding the pathophysiology of aortic disease, as well as selecting the appropriate imaging modality and protocol will enable prompt diagnosis and early intervention of aortic pathology. Currently, computed tomography angiography and magnetic resonance angiography of the aorta are the most commonly used imaging modalities to evaluate the aorta. This review focuses on a spectrum of aortic pathology manifestations on computed tomography and magnetic resonance, including atherosclerosis and acute aortic syndromes, highlighting diagnostic challenges and approaches to aid in image interpretation.
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Affiliation(s)
- Anna Shmukler
- Department of Radiology, NYU Langone Health, New York, NY.
| | - Jonathan Alis
- Department of Radiology, Jacobi Medical Center, Bronx, NY
| | - Smita Patel
- Department of Radiology, University of Michigan Health System, Ann Arbor, MI
| | - Larry Latson
- Department of Radiology, NewYork-Presbyterian / Weill Cornell Medicine, New York, NY
| | - Jane P Ko
- Department of Radiology, NYU Langone Health, New York, NY
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6
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Xing L, Zhou Y, Han Y, Chen C, Dong Z, Zheng X, Chen D, Yu Y, Liao F, Guo S, Yao C, Tang M, Gu G. Simple Death Risk Models to Predict In-hospital Outcomes in Acute Aortic Dissection in Emergency Department. Front Med (Lausanne) 2022; 9:890567. [PMID: 35677829 PMCID: PMC9168913 DOI: 10.3389/fmed.2022.890567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 04/08/2022] [Indexed: 11/24/2022] Open
Abstract
Objective We sought to find a bedside prognosis prediction model based on clinical and image parameters to determine the in-hospital outcomes of acute aortic dissection (AAD) in the emergency department. Methods Patients who presented with AAD from January 2010 to December 2019 were retrospectively recruited in our derivation cohort. Then we prospectively collected patients with AAD from January 2020 to December 2021 as the validation cohort. We collected the demographics, medical history, treatment options, and in-hospital outcomes. All enrolled patients underwent computed tomography angiography. The image data were systematically reviewed for anatomic criteria in a retrospective fashion by three professional radiologists. A series of radiological parameters, including the extent of dissection, the site of the intimal tear, entry tear diameter, aortic diameter at each level, maximum false lumen diameter, and presence of pericardial effusion were collected. Results Of the 449 patients in the derivation cohort, 345 (76.8%) were male, the mean age was 61 years, and 298 (66.4%) had a history of hypertension. Surgical repair was performed in 327 (72.8%) cases in the derivation cohort, and the overall crude in-hospital mortality of AAD was 10.9%. Multivariate logistic regression analysis showed that predictors of in-hospital mortality in AAD included age, Marfan syndrome, type A aortic dissection, surgical repair, and maximum false lumen diameter. A final prognostic model incorporating these five predictors showed good calibration and discrimination in the derivation and validation cohorts. As for type A aortic dissection, 3-level type A aortic dissection clinical prognosis score (3ADPS) including 5 clinical and image variables scored from −2 to 5 was established: (1) moderate risk of death if 3ADPS is <0; (2) high risk of death if 3ADPS is 1–2; (3) very high risk of death if 3ADPS is more than 3. The area under the receiver operator characteristic curves in the validation cohorts was 0.833 (95% CI, 0.700–0.967). Conclusion Age, Marfan syndrome, type A aortic dissection, surgical repair, and maximum false lumen diameter can significantly affect the in-hospital outcomes of AAD. And 3ADPS contributes to the prediction of in-hospital prognosis of type A aortic dissection rapidly and effectively. As multivariable risk prediction tools, the risk models were readily available for emergency doctors to predict in-hospital mortality of patients with AAD in extreme clinical risk.
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Affiliation(s)
- Lingyu Xing
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yannan Zhou
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yi Han
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen Chen
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zegang Dong
- Suzhou Zhi Zhun Medical Technology Co., Ltd., Suzhou, China
| | - Xinde Zheng
- Department of Radiological Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dongxu Chen
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yao Yu
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Fengqing Liao
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shuai Guo
- CANON Medical Systems (China) Co., Ltd., Shanghai, China
| | - Chenling Yao
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Chenling Yao
| | - Min Tang
- Department of Radiological Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Min Tang
| | - Guorong Gu
- Department of Emergency Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- *Correspondence: Guorong Gu
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Idhrees M, Jubouri M, Bashir M, Velayudhan BV. Type A aortic dissection during in pregnancy: Confront without aversion or delay. J Card Surg 2022; 37:1712-1713. [PMID: 35333416 DOI: 10.1111/jocs.16446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 03/16/2022] [Indexed: 11/28/2022]
Abstract
Type A aortic dissection (TAAD) is a life-threatening clinical emergency requiring timely surgical intervention. Concomitant with pregnancy at any stage, it adds an additional level of complexity which mandates careful planning for the management strategy that will yield the optimal outcomes. It is life-threatening pathology to both the mother and fetus, with mortality rates of up to 30% and 50% reported, respectively. Safe imaging modalities that do not expose the fetus to radiation and contrast are recommended to reach an accurate diagnosis. In addition, meticulous multidisciplinary team planning is pivotal to ensure optimal outcomes are achieved through careful choice of surgical technique as well as strict control of medications. Although TAAD in pregnancy is associated with high mortality and morbidity to both the mother and her fetus, success in the treatment of this small subset of patients can certainly be achieved.
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Affiliation(s)
- Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Matti Jubouri
- Hull York Medical School, University of York, York, UK
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India.,Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales (HEIW), Cardiff, UK
| | - Bashi V Velayudhan
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
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Jubouri M, Tan SZCP, Bashir M. Monocyte to high‐density lipoprotein ratio as a predictive biomarker for in‐hospital mortality following surgery for type A aortic dissection: Reality or myth? J Card Surg 2022; 37:1203-1205. [DOI: 10.1111/jocs.16317] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 12/30/2022]
Affiliation(s)
| | - Sven Z. C. P. Tan
- Barts and The London School of Medicine and Dentistry Queen Mary University of London London UK
| | - Mohamad Bashir
- Vascular and Endovascular Surgery Velindre University NHS Trust, Health Education & Improvement Wales (HEIW) Cardiff UK
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9
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Chong JH, Zhang Y, Harky A, Field M. Management and Outcomes of Proximal Aortic Graft Infection: A Systematic Review. Heart Lung Circ 2021; 31:49-58. [PMID: 34602347 DOI: 10.1016/j.hlc.2021.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 07/25/2021] [Accepted: 07/30/2021] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Proximal aortic graft infection (PAGI) is a rare but often fatal postoperative complication. Its management often relied on surgical preferences and resource availability of each centre, until the recent unifying guidelines published by the European Society for Vascular Surgery (ESVS). This paper aimed to amalgamate the published experience in managing PAGI and their outcomes. METHODS PubMed, Scopus and Cochrane Library databases were searched systematically. All primary studies besides single-patient case reports were included. Data extracted included study and patient characteristics, type of index surgery, type of microorganisms involved, definitive treatment modality, and any outcome measures reported. RESULTS Of the 20 studies included, 157 of the 290 PAGI patients underwent complete graft explantation and replacement, 106 underwent graft-preservation interventions (debridement and/or irrigation), and 25 had antibiotics alone. Adjunctive interventions included graft coverage, vacuum-assisted closure, use of infection-resistant graft materials, and lifelong suppressive therapy. In-hospital mortality was 20.8% (n=60), with postoperative sepsis and multiorgan failure (n=24) being the most common cause. Recurrent infection occurred in 10 post-discharge patients. Post-discharge mortality rate was 11.4% (n=33), with cardiac complications and stroke being the most common cause in surgically-treated and medically-treated patients, respectively. CONCLUSIONS Given the risk of mortality, the management approach of PAGI highly depends on the fitness of the patient. We believe that early referral to specialised aortic centres is essential to plan for optimal management strategies and improve patient outcomes. Further studies are also required to parse out the most effective adjunctive interventions to maximise patient outcomes.
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Affiliation(s)
- Jun Heng Chong
- GKT School of Medical Education, King's College, London, UK
| | - Yi Zhang
- Barts and The London School of Medicine and Dentistry, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.
| | - Mark Field
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
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10
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Harky A, Mason S, Othman A, Shaw M, Nawaytou O, Harrington D, Kuduvalli M, Field M. Outcomes of acute type A aortic dissection repair: Daytime versus nighttime. JTCVS OPEN 2021; 7:12-20. [PMID: 36003743 PMCID: PMC9390141 DOI: 10.1016/j.xjon.2021.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 12/22/2022]
Abstract
Objective We sought to report our experience of repairing acute type A aortic dissection (ATAAD) over 21 years during in-hours versus out-of-hours before and after the establishment of specialized aortic service and rota. Methods A retrospective analysis of all patients who had ATAAD repair between November 1998 and December 2019 in our center. In-hours were defined as 08:00 to 19:59 hours and out of hours were defined as 20:00 to 07:59 hours. Results A total of 286 patients underwent repair of ATAAD. Eighty operations took place during the prerota period (43 operations in hours, 37 out of hours) and 206 operations during the specialized rota period (110 in hours, 96 out of hours). There was no difference in 30-day mortality between the in-hours and out-of-hours groups in either the prerota (23.3% vs 32.4%; P = .36) or specialized rota periods (11.6% vs 11.5%; P = .94). Mean number of cases per year increased by 83% between the prerota and specialized rota periods. Thirty-day mortality reduced in both the in-hours (23.3% vs 11.6%) and out-of-hours (32.4% vs 11.5%) groups since introduction of the specialized aortic rota. Conclusions Outcomes in repair of ATAAD during in-hours and out-of-hours periods are similar when operated on in a specialized unit with a dedicated aortic team. This emphasizes the current global trend of service centralization without particular attention to time of day to operate on such critical cohort patients.
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Affiliation(s)
- Amer Harky
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,School of Medicine, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Sabrina Mason
- School of Medicine, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Ahmed Othman
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Matthew Shaw
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Omar Nawaytou
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Deborah Harrington
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Manoj Kuduvalli
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Mark Field
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,School of Medicine, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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Toh S, Yew DCM, Choong JJ, Chong TL, Harky A. Acute type A aortic dissection in-hours versus out-of-hours: A systematic review and meta-analysis. J Card Surg 2020; 35:3432-3439. [PMID: 33001480 DOI: 10.1111/jocs.15070] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/27/2020] [Accepted: 09/05/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We sought to compare clinical outcomes in patients with acute type A aortic dissection that undergone surgical repair during in-hours (IH) versus out-of-hours (OOH). METHODS An electronic literature search was done till March 2020 to include studies with comparative cohorts of IH versus OOH. Primary outcomes were 30-day mortality, stroke, and reoperation for bleeding; secondary outcomes were acute kidney injury, total hospital stay, and intensive care unit stay. RESULTS Six articles with a total of 3744 patients met the inclusion criteria. Mean age was similar, 60 ± 12 versus 60 ± 13 in IH versus OOH (p = .25). Aortic root and total arch replacement were similar in both cohorts, 22% in IH versus 25% in OOH (risk ratio [RR], 1.10; 95% confidence interval [CI: 0.78, 1.55]; p = .58) and 29% in IH versus 32% in OOH (RR, 0.96; 95% CI [0.89, 1.04], p = .37) respectively. Reoperation for bleeding and stroke rate were similar, with 18% in IH versus 23% in OOH (RR, 0.89; 95% CI [0.73, 1.08]; p = .24), and 12% in IH versus 13% in OOH (RR, 0.83; 95% CI [0.66, 1.03]; p = .09) respectively. Thirty-day mortality was significantly lower in IH (RR, 0.81; 95% CI [0.72, 0.90]; p = .0001). CONCLUSION There was higher 30-day mortality rate during OOH surgery, yet this difference diminished following sensitivity analysis. There were no significant differences in major postoperative outcomes. Therefore, operating on such cases should be decided on clinical priority without delay.
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Affiliation(s)
- Steven Toh
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK
| | | | | | - Tze Lin Chong
- School of Medicine, Monash University, Sunway, Malaysia
| | - Amer Harky
- School of Medicine, Faculty of Life Science, University of Liverpool, Liverpool, UK.,Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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