Right versus left coronary artery involvement in patients with type A acute aortic dissection

Biomarkers for Risk Stratification in Patients With Type A Acute Aortic Dissection

Type A acute aortic dissection (AAD) is a fatal disease and thus, accurate and objective risk stratification is essential. In this study, we evaluated the prognostic value of readily available and assessable biomarkers in patients with type A AAD. This was a retrospective, multicenter, observational study. A total of 703 patients with type A AAD diagnosed using contrast-enhanced computed tomography were included. Therapeutic strategies were left to the physician's discretion in a real-world clinical setting. The prognostic value for in-hospital mortality was examined in 15 circulating biomarkers on admission, which are routinely available in clinical practice. Of the 703 patients, 126 (17.9%) died during the hospitalization. Of the 15 biomarkers, the multivariable analysis identified positive cardiac troponin, a low total bilirubin (T-Bil) level, and increased levels of brain natriuretic peptide (BNP) and lactate dehydrogenase (LDH) as significant predictors of in-hospital death. The receiver operating characteristics curve analysis showed that these 4 biomarkers had an independent additive prognostic value. With the cut-off values of T-Bil, BNP, and LDH, in combination with positive troponin, the increase in the number of positive biomarkers was progressively associated with higher in-hospital mortality from 1.3% to 9.8%, 20.5%, 36.4%, and 75.0% (p <0.001). In conclusion, in patients with type A AAD, positive cardiac troponin, a low T-Bil level, and increased levels of BNP and LDH on admission were related to higher in-hospital mortality, with an incremental prognostic value, suggesting that the readily available and assessable biomarkers can aid in decision-making in therapeutic strategies.

Preoperative management using Impella support for acute aortic dissection with left coronary malperfusion: a case report

BACKGROUND

Acute aortic dissection (AAD) with impaired perfusion of the left coronary artery has a poor prognosis, even after urgent radical aortic surgery, due to extensive myocardial damage. Although Impella, a microaxial-flow catheter pump, is useful in managing acute myocardial infarction, it is generally contraindicated in patients with AAD because it is an intra-aortic device and the aortic structure is compromised in these cases. Here, we introduce a novel intervention that allowed a planned aortic repair after managing circulation using Impella and venoarterial extracorporeal membrane oxygenation in a case of AAD with left main trunk malperfusion.

CASE PRESENTATION

A 40-year-old man presented with cardiogenic shock. Percutaneous coronary intervention was performed to address left main trunk obstruction using an intra-aortic balloon pump; however, circulatory instability persisted. The patient was transferred to our hospital after venoarterial extracorporeal membrane oxygenation. Impella CP™ was used to improve his circulatory status. However, a subsequent CT scan confirmed an AAD diagnosis. After 5 days of stable circulatory support, the patient underwent aortic root replacement and coronary artery bypass grafting.

CONCLUSIONS

In patients with AAD and coronary malperfusion, adjunctive circulatory management with Impella may be a valuable therapeutic option.

Clinical characteristics and outcomes in patients with acute type A aortic intramural hematoma

BACKGROUND

Although type A acute aortic dissection (AAD) including classic double-channel aorta and intramural hematoma (IMH) is a life-threatening condition, the prognostic impact and predictors of IMH remain to be established. The present study evaluated the prevalence, baseline characteristics, and outcomes of IMH as compared with classic non-thrombosed type A AAD.

METHODS

This multicenter registry in Japan retrospectively included 703 patients with type A AAD. IMH was defined as a crescentic or circular area along the ascending aortic wall without contrast enhancement on computed tomography (CT). Non-thrombosed type A AAD was defined as the classic double-channel ascending aorta on contrast-enhanced CT. The primary endpoint was in-hospital mortality.

RESULTS

Of the 703 patients with type A AAD, 312 (44.3%) had IMH. Older age was an only baseline patient factor significantly associated with the presence of IMH in the multivariable analysis. The longitudinal extent of dissection was greater in patients with classic non-thrombosed AAD than those with IMH, resulting in an increased risk of end-organ malperfusion in the classic AAD group. During the hospitalization, 41 (13.1%) and 85 (21.7%) patients with and without IMH died (p < 0.001). IMH was associated with lower in-hospital mortality in a multivariable model, irrespective of age and the implementation of surgery.

CONCLUSIONS

The present study showed that IMH on CT was frequent among patients with type A AAD. Although IMH was more likely to be present in the elderly, its effect on the better survival was independent of age and surgical treatment.

Case report: Surgery combined with extracorporeal membrane oxygenation for a patient with type A aortic dissection complicated with myocardial infarction after percutaneous coronary intervention

Background

Aortic dissection (AD) is a severe cardiovascular disease characterized by aortic rupture, aortic valve insufficiency, aortic branch lumen stenosis, and occlusion. Acute ST-segment elevation myocardial infarction may be the primary manifestation when aortic dissection affects the coronary artery, leading to delayed or missed diagnosis of aortic dissection, and preventing patients from receiving timely and comprehensive treatment. Simultaneous aortic repair and coronary artery bypass grafting surgery are controversial because of their high mortality rates. Personalized and optimal treatment plans for patients should be taken seriously based on their different conditions and treatment options.

Case presentation

A 42-year-old man who experienced 1 h of persistent precordialgia was admitted to a local second-level hospital for emergency treatment. Electrocardiogram (ECG) showed evidence of ST-segment elevation, and myocardial enzyme levels were CK-MB 18.35 ng/ml and troponin 0.42 ng/ml. The patient was treated for acute myocardial infarction (AMI) and urgently sent to the interventional catheter room. Coronary angiography showed stenosis of the starting part of the right coronary artery trunk. Thus, stent implantation was performed, and the stenosis section recovered patency; however, postoperative precordialgia was not alleviated. Computed tomography angiography (CTA) revealed a type A AD. The patient was immediately transferred to a higher-level hospital, underwent emergency surgery with cardiopulmonary bypass (CPB) ascending aorta replacement, SUN's procedure (total arch replacement and stented elephant trunk implantation), and simultaneous implantation of extracorporeal membrane oxygenation (ECMO), and regained consciousness within intensive care unit care. ECMO was discontinued when hemodynamics stabilized. The patient ultimately recovered well and was discharged.

Conclusion

This case demonstrated that precordialgia is not limited to myocardial infarction but may also be accompanied by aortic dissection. Percutaneous coronary intervention (PCI) can timely and effectively restore coronary artery perfusion, strive for the opportunity of aortic repair surgery, and can overcome pump failure caused by myocardial infarction, cardiopulmonary bypass, heart block time, and myocardial ischemia-reperfusion injury. Personalized treatment is crucial for patients with complex type A aortic dissection.