Hypotensive Systolic Blood Pressure Predicts Severe Complications and In-Hospital Mortality in Acute Aortic Dissection

Postoperative stroke in acute type A aortic dissection: incidence, outcomes, and perioperative risk factors

BACKGROUND

Despite advances in surgical techniques, the incidence of stroke following acute type A aortic dissection (ATAAD) repair remains markedly high, with substantial immediate and long-term adverse outcomes such as elevated mortality, extended hospital stays, and persistent neurological impairments. The complexity of managing ATAAD extends beyond the operation itself, highlighting a crucial gap in research concerning modifiable preoperative patient conditions and perioperative anesthetic management strategies.

OBJECTIVES

This investigation aimed to elucidate the incidence, consequences, and perioperative determinants of stroke following surgical intervention for acute type A aortic dissection (ATAAD).

METHODS

In a multicenter retrospective analysis, 516 ATAAD surgery patients were evaluated. The data included demographic information, clinical profiles, surgical modalities, and outcomes. The primary endpoint was postoperative stroke incidence, with hospital mortality and other complications serving as secondary endpoints.

RESULTS

Postoperative stroke occurred in 13.6% of patients (70 out of 516) and was associated with significant extension of the ICU (median 10 vs. 5 days, P < 0.001) and hospital stay (median 18 vs. 12 days, P < 0.001). The following key independent stroke risk factors were identified: modified Frailty Index (mFI) ≥ 4 (odds ratio [OR]: 4.18, 95% confidence interval [CI]: 1.24-14.1, P = 0.021), common carotid artery malperfusion (OR: 3.76, 95% CI: 1.23-11.44, P = 0.02), pre-cardiopulmonary bypass (CPB) hypotension (mean arterial pressure ≤ 50 mmHg; OR: 2.17, 95% CI: 1.06-4.44, P = 0.035), ≥ 20% intraoperative decrease in cerebral regional oxygen saturation (rSO2) (OR: 1.93, 95% CI: 1.02-3.64, P = 0.042), and post-CPB vasoactive-inotropic score (VIS) ≥ 10 (OR: 2.24, 95% CI: 1.21-4.14, P = 0.01).

CONCLUSIONS

Postoperative stroke significantly increases ICU and hospital durations in ATAAD surgery patients. These findings highlight the critical need to identify and mitigate major risks, such as high mFI, common carotid artery malperfusion, pre-CPB hypotension, significant cerebral rSO2 reductions, and elevated post-CPB VIS, to improve outcomes and reduce stroke prevalence.

TRIAL REGISTRATION

Thai Clinical Trials Registry (TCTR20230615002). Date registered on June 15, 2023. Retrospectively registered.

Predictive value of admission CO2 combining power combined with serum sodium for the prognosis in acute Stanford type A aortic dissection patients

Acute Stanford type A aortic dissection (ATAAD) with sudden onset and high mortality requiries a standard Bentall operation and a accurate prognosis in common, together with alteration of CO₂ combining power (CO₂CP) and serum sodium rase concern, hence, we evaluated the prognostic value of CO₂CP combined with serum sodium in ATAAD patients. This retrospective study included 183 patients who underwent Bentall operation for ATAAD from 2015 to 2021 in the Fourth Hospital of Hebei Medical University, subsequently followed grouping by the levels of CO₂CP and serum sodium. The study endpoint was 30-day all-cause mortality, and the prognostic value of CO₂CP combined with serum sodium levels in ATAAD patients were evaluated with multivariate logistic regression method. The postoperative incidence of in-hospital death and adverse events in patients with ATAAD were 18% and 25.7%, respectively. Combination of CO₂CP and serum sodium for predicting ATAAD death and adverse events presented a higher predictive value than each single indicator with ROC curve analysis (the AUC of CO₂CP combined with serum sodium was 0.786, 95% CI 0.706-0.869, P < 0.001), along with CO₂CP < 22.5 mmol/L + serum sodium > 138.5 mmol/L group had the worst prognostic. Multivariate regression analyse showed that CO₂CP < 22.5 mmol/L combined with serum sodium > 138.5 mmol/L preferably predicted the prognosis of ATAAD (OR =6.073, 95% CI 2.557-14.425, P < 0.001). Consistently, the cumulative 30-day survival after surgery in ATAAD patients with the low CO₂CP and high serum sodium simultaneously was the worst (log-rank P < 0.05). The combination of CO₂CP and serum sodium increases the predictive value of prognosis, which is conducive to risk stratification of patients with ATAAD.

Association Between the Admission Serum Bicarbonate and Short-Term and Long-Term Mortality in Acute Aortic Dissection Patients Admitted to the Intensive Care Unit

Objective

Serum bicarbonate (HCO3^-) level is strongly related to multiple cardiovascular complications. Currently, there is no study evaluating the prognostic ability of serum HCO3^- level in intensive care unit (ICU) patients with acute aortic dissection (AAD). Hence, this study was to assess the relationship between admission serum HCO3^- level and clinical outcomes in patients with AAD.

Design Settings and Participants

Clinical data were extracted from the MIMIC-III database. Cox proportional hazards models and Kaplan-Meier (KM) survival curve were used to evaluate the association between serum HCO3^- levels and short- and long-term mortality in ICU patients with AAD. The subgroup analysis and the receiver operating characteristic (ROC) curve analysis and further KM survival curve based on best cut-off value were applied to assessment of the performance of HCO3^- in predicting the mortality in each period (30 days, 90 days, 1 year and 5 years).

Main Results

Firstly, 336 eligible patients were trisected to low-HCO3^- level group (<22 mmol/L), mid-HCO3^- level group (22-24 mmol/L) and high-HCO3^- level group (>24 mmol/L). Then, in multivariate analysis, the serum HCO3^- of low levels (<22 mmol/L) was a significant risk predictor of all-cause mortality in 30 days, 90 days, 1 year and 5 years. Subgroup analyses indicated that there is no interaction in most strata. Finally, areas under ROC curve ranged from 0.60 to 0.69.

Conclusion

The low HCO3^- serum level measured at ICU admission significantly predicts short-term and long-term mortality in AAD patients.

Check the diastolic blood pressure twice in aortic dissection as it is associated with prognosis

Objective

In this study we aimed to determine the prediction level of admission diastolic blood pressure (DBP) on the prognosis and mortality in aortic dissection patients over 65 years old and under 65 years old.

Methods

We included 72 patients in this retrospective study and study groups were divided into two groups according to 65 age. Demographic data, dissection type (Stanford A-B), DBP, systolic blood pressure (SBP), mean arteriel pressure (MAP), heart rate (/min) main complaints, preoperative length of stay, hospitalisation clinic (clinic/intensive care unit), length of hospitaliisation, complications during hospitalisation (renal failure etc..) and the outcome (death/dischargement) results were noted. Preoperative lenth of stay, hospitalisation length, outcome and complications were compared between groups according to SBP, DBP, MAP and heart rate.

Results

Mean blood pressure values of the Stanford type B patients over 65 years old were higher than the other group (p<0.05). Fifty percent of patients under 65 years old were discharged but this ratio was 26.9% in the elder group. DBP was positively correlated with preoperative length of stay and hospitalisation length and negatively correlated with mortality. DBP under 65 mmHg was significantly related with high mortality (p<0.05). When the age and presentation time heart rate is added to each other, the values over 142 were significantly related with high mortality (p<0.05).

Conclusions

The presentation time vital signs especially the DBP may be helpful for emergency clinicians to predict the prognosis and outcome in aortic dissection patients which has high mortality ratio in patients over 65 years of age.

Efficacy of "Pinggan Formula" in Controlling Acute Type B Aortic Dissection Perioperative Blood Pressure: A Randomized Controlled Clinical Trial

Objective

To explore a new treatment that can proceed from the whole, control blood pressure smoothly and coordinate the treatment of multiple factors causing blood pressure fluctuations.

Method

We conducted a single-center, double-blinded, and randomized controlled clinical trial. 48 patients with acute Type B aortic dissection were randomly assigned into two groups: the experimental group, who received pinggan formula treatment, and the control group, who received placebo treatment. The drug was taken orally after meals three times a day. Only when the patients' blood pressure fluctuated, conventional antihypertensive drugs were given to maintain the blood pressure within the target range and the dosage was recorded to convert the DDD value. Meanwhile, the international standardized score was used to evaluate the defecation, sleep, pain, anxiety, and depression of patients in the two groups during the hospitalization.

Result

Univariate analysis was conducted on variables that might affect the assessment results, and it was found that grouping factors had a significant impact on the outcome variables, that is, after the intervention, the mean value of DDDs used in the perioperative period in the control group was 2.19 (0.38, 4.00). (P=0.0219), defecation score (2.13 (1.59, 2.67); P < 0.0001), sleep score (0.95 (0.40, 1.50); P=0.0014), pain score (1.77 (0.61, 2.93); P=0.0045), depression score (4.04 (2.95, 5.12); and P < 0.0001) were significantly higher than that of the experimental group, and the difference was statistically significant.

Conclusion

Pinggan formula has a clear therapeutic regulation effect on the overall hemodynamics of acute Stanford type B aortic dissection during the perioperative period and can be recommended as an auxiliary drug for conventional antihypertensive drugs at the current stage.