1
|
Nappi F, Schoell T, Singh SSA, Salsano A, Abdou I, Gambardella I, Francesco Santini F, Fiore A, Garufi L, Demondion P, Leprince P, Nicolas Bonnet N, Spadaccio C. Aortic arch registry of type a aortic dissection (AoArch) - rationale, design and definition criteria. J Cardiothorac Surg 2024; 19:514. [PMID: 39238045 PMCID: PMC11375872 DOI: 10.1186/s13019-024-03002-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Accepted: 08/13/2024] [Indexed: 09/07/2024] Open
Abstract
BACKGROUND Type A acute aortic dissection (TAAAD) is a deadly condition that demands immediate surgery, because it involves a critically. The mortality and morbidity associated with it are significant, and it is vital that the patient's conditions and treatment strategies are fully understood to ensure the appropriate management of TAAAD. This study aims to ascertain whether hemiarch repair (HAR) versus extended arch repair (EAR) with or without descending aortic intervention results in better perioperative and late outcomes for patients with TAAAD. METHODS Four leading centers of cardiac surgery from two European countries have joined forces to create a groundbreaking multicenter observational registry (AoArch). This study was approved by the institutional review board (IRB 202201173). We conducted a retrospective review (NCT00591263) of our prospectively maintained database for patients who underwent operative repair of DeBakey type I or type II dissection from January 1, 2005 to March 2024 (NCT05927090). We will analyze how patient co-morbidities, referral conditions, and surgical strategies involving hemi-arch repair (HAR) and extended arch repair (EAR) impact early and late adverse events. We have developed a procedure urgency algorithm based on the severity of preoperative hemodynamic conditions and malperfusion due to TAAAD, and we will use it to assess the primary clinical outcomes: in-hospital mortality, late mortality, and reoperations on the aorta. We will define secondary outcomes as permanent neurologic deficit, the need for new dialysis, respiratory failure, a composite of major adverse events (myocardial infarction, cerebrovascular accidents, the need for dialysis, or the need for tracheostomy), and a composite of major adverse pulmonary events (intubation over 48 h, pneumonia, reintubation, tracheostomy), and reoperation due to bleeding. DISCUSSION This multicenter registry will definitively determine the prognostic significance of critical preoperative conditions and the efficacy of extended arch interventions and hemiarch repair in reducing the risk of early adverse events after surgery for TAAAD. This registry will provide insights into the long-term durability of different strategies of surgical repair for TAAAD.
Collapse
Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, 93200, France.
| | - Thibaut Schoell
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, 93200, France
| | | | - Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Genoa, Italy
- DISC Department, University of Genoa, Genoa, Italy
| | - Ibrahim Abdou
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, 93200, France
| | - Ivancarmine Gambardella
- Department of Cardiothoracic Surgery, Weill Cornell Medicine-New York. Presbyterian Medical Center, 505 E 70th St, New York, NY, USA
| | - F Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Genoa, Italy
- DISC Department, University of Genoa, Genoa, Italy
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, 94000, France
| | - Luigi Garufi
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47-83, Paris, 75013, France
| | - Pierre Demondion
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47-83, Paris, 75013, France
| | - Pascal Leprince
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47-83, Paris, 75013, France
| | - N Nicolas Bonnet
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint-Denis, 93200, France
| | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, 45267-0558, USA
- Department of Cardiothoracic Surgery, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
2
|
Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024:ehae179. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
|
3
|
Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K, Siepe M, Estrera AL, Bavaria JE, Pacini D, Okita Y, Evangelista A, Harrington KB, Kachroo P, Hughes GC. EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ. Ann Thorac Surg 2024; 118:5-115. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany.
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria; Medical Faculty, Sigmund Freud Private University, Vienna, Austria.
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France; EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy; Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, Texas
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany; The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, United Kingdom
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany; Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany; Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| | - Matthias Siepe
- EACTS Review Coordinator; Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Anthony L Estrera
- STS Review Coordinator; Department of Cardiothoracic and Vascular Surgery, McGovern Medical School at UTHealth Houston, Houston, Texas
| | - Joseph E Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Davide Pacini
- Division of Cardiac Surgery, S. Orsola University Hospital, IRCCS Bologna, Bologna, Italy
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Arturo Evangelista
- Department of Cardiology, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Vall d'Hebron Institut de Recerca, Barcelona, Spain; Biomedical Research Networking Center on Cardiovascular Diseases, Instituto de Salud Carlos III, Madrid, Spain; Departament of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Instituto del Corazón, Quirónsalud-Teknon, Barcelona, Spain
| | - Katherine B Harrington
- Department of Cardiothoracic Surgery, Baylor Scott and White The Heart Hospital, Plano, Texas
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Missouri
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Duke University, Durham, North Carolina
| |
Collapse
|
4
|
Ede J, Teurneau-Hermansson K, Ramgren B, Moseby-Knappe M, Åström DO, Larsson M, Sjögren J, Wierup P, Nozohoor S, Zindovic I. Retrograde cerebral perfusion reduces embolic and watershed lesions after acute type a aortic dissection repair with deep hypothermic circulatory arrest. J Cardiothorac Surg 2024; 19:302. [PMID: 38811972 PMCID: PMC11134620 DOI: 10.1186/s13019-024-02814-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/25/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND To assess whether retrograde cerebral perfusion reduces neurological injury and mortality in patients undergoing surgery for acute type A aortic dissection. METHODS Single-center, retrospective, observational study including all patients undergoing acute type A aortic dissection repair with deep hypothermic circulatory arrest between January 1998 and December 2022 with or without the adjunct of retrograde cerebral perfusion. 515 patients were included: 257 patients with hypothermic circulatory arrest only and 258 patients with hypothermic circulatory arrest and retrograde cerebral perfusion. The primary endpoints were clinical neurological injury, embolic lesions, and watershed lesions. Multivariable logistic regression was performed to identify independent predictors of the primary outcomes. Survival analysis was performed using Kaplan-Meier estimates. RESULTS Clinical neurological injury and embolic lesions were less frequent in patients with retrograde cerebral perfusion (20.2% vs. 28.4%, p = 0.041 and 13.7% vs. 23.4%, p = 0.010, respectively), but there was no significant difference in the occurrence of watershed lesions (3.0% vs. 6.1%, p = 0.156). However, after multivariable logistic regression, retrograde cerebral perfusion was associated with a significant reduction of clinical neurological injury (OR: 0.60; 95% CI 0.36-0.995, p = 0.049), embolic lesions (OR: 0.55; 95% CI 0.31-0.97, p = 0.041), and watershed lesions (OR: 0.25; 95%CI 0.07-0.80, p = 0.027). There was no significant difference in 30-day mortality (12.8% vs. 11.7%, p = ns) or long-term survival between groups. CONCLUSION In this study, we showed that the addition of retrograde cerebral perfusion during hypothermic circulatory arrest in the setting of acute type A aortic dissection repair reduced the risk of clinical neurological injury, embolic lesions, and watershed lesions.
Collapse
Affiliation(s)
- Jacob Ede
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden.
| | - Karl Teurneau-Hermansson
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Birgitta Ramgren
- Department of Clinical Sciences Lund, Department of Radiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Department of Neurology and Rehabilitation, Lund University, Skåne University Hospital, Lund, Sweden
| | - Daniel Oudin Åström
- Division of Occupational and Environmental Medicine, Department of Laboratory Medicine, Lund University, Lund, Sweden
- Division of Sustainable Health, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Mårten Larsson
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Johan Sjögren
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Per Wierup
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Shahab Nozohoor
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Igor Zindovic
- Department of Clinical Sciences Lund, Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| |
Collapse
|
5
|
Vervoort D, An KR, Deng MX, Elbatarny M, Fremes SE, Ouzounian M, Tarola C. The Call for the "Interventional/Hybrid" Aortic Surgeon: Open, Endovascular, and Hybrid Therapies of the Aortic Arch. Can J Cardiol 2024; 40:478-495. [PMID: 38052303 DOI: 10.1016/j.cjca.2023.11.038] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 11/29/2023] [Accepted: 11/29/2023] [Indexed: 12/07/2023] Open
Abstract
Aortic arch pathology is relatively rare but potentially highly fatal and associated with considerable comorbidity. Operative mortality and complication rates have improved over time but remain high. In response, aortic arch surgery is one of the most rapidly evolving areas of cardiac surgery in terms of surgical volume and improved outcomes. Moreover, there has been a surge in novel devices and techniques, many of which have been developed by or codeveloped with vascular surgeons and interventional radiologists. Nevertheless, the extent of arch surgery, the choice of nadir temperature, cannulation, and perfusion strategies, and the use of open, endovascular, or hybrid options vary according to country, centre, and surgeon. In this review article, we provide a technical overview of the surgical, total endovascular, and hybrid repair options for aortic arch pathology through historical developments and contemporary results. We highlight key information for surgeons, cardiologists, and trainees to understand the management of patients with aortic arch pathology. We conclude by discussing training paradigms, the role of aortic teams, and gaps in knowledge, arguing for the need for wire skills for the future "interventional aortic surgeon" and increased research into techniques and novel devices to continue improving outcomes for aortic arch surgery.
Collapse
Affiliation(s)
- Dominique Vervoort
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Kevin R An
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Mimi X Deng
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Malak Elbatarny
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Stephen E Fremes
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada.
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Tarola
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
6
|
Teurneau-Hermansson K, Ede J, Larsson M, Linton G, von Rosen D, Sjögren J, Wierup P, Nozohoor S, Zindovic I. Mortality after non-surgically treated acute type A aortic dissection is higher than previously reported. Eur J Cardiothorac Surg 2024; 65:ezae039. [PMID: 38310329 PMCID: PMC10871943 DOI: 10.1093/ejcts/ezae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 01/10/2024] [Accepted: 01/31/2024] [Indexed: 02/05/2024] Open
Abstract
OBJECTIVES It has been commonly accepted that untreated acute type A aortic dissection (ATAAD) results in an hourly mortality rate of 1-2% during the 1st 24 h after symptom onset. The data to support this statement rely solely on patients who have been denied surgical treatment after reaching surgical centres. The objective was to perform a total review of non-surgically treated (NST) ATAAD and provide contemporary mortality data. METHODS This was a regional, retrospective, observational study. All patients receiving one of the following diagnoses: International Classification of Diseases (ICD)-9 4410, 4411, 4415, 4416 or ICD-10 I710, I711, I715, I718 in an area of 1.9 million inhabitants in Southern Sweden during a period of 23 years (January 1998 to November 2021) were retrospectively screened. The search was conducted using all available medical registries so that every patient diagnosed with ATAAD in our region was identified. The charts and imaging of each screened patient were subsequently reviewed to confirm or discard the diagnosis of ATAAD. RESULTS Screening identified 2325 patients, of whom 184 NST ATAAD patients were included. The mortality of NST ATAAD was 47.3 ± 4.4%, 55.0 ± 4.4%, 76.7 ± 3.7% and 83.9 ± 4.3% at 24 h, 48 h, 14 days and 1 year, respectively. The hourly mortality rate during the 1st 24 h after symptom onset was 2.6%. CONCLUSIONS This study observed higher mortality than has previously been reported. It emphasizes the need for timely diagnosis, swift management and emergent surgical treatment for patients suffering an acute type A aortic dissection.
Collapse
Affiliation(s)
- Karl Teurneau-Hermansson
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Jacob Ede
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Mårten Larsson
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Gustaf Linton
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - David von Rosen
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Johan Sjögren
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Per Wierup
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Shahab Nozohoor
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Igor Zindovic
- Department of Clinical Sciences Lund, Skåne University Hospital, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| |
Collapse
|
7
|
Czerny M, Grabenwöger M, Berger T, Aboyans V, Della Corte A, Chen EP, Desai ND, Dumfarth J, Elefteriades JA, Etz CD, Kim KM, Kreibich M, Lescan M, Di Marco L, Martens A, Mestres CA, Milojevic M, Nienaber CA, Piffaretti G, Preventza O, Quintana E, Rylski B, Schlett CL, Schoenhoff F, Trimarchi S, Tsagakis K. EACTS/STS Guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg 2024; 65:ezad426. [PMID: 38408364 DOI: 10.1093/ejcts/ezad426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 09/15/2023] [Accepted: 12/19/2023] [Indexed: 02/28/2024] Open
Affiliation(s)
- Martin Czerny
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Martin Grabenwöger
- Department of Cardiovascular Surgery, Clinic Floridsdorf, Vienna, Austria
- Medical Faculty, Sigmund Freud Private University, Vienna, Austria
| | - Tim Berger
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Victor Aboyans
- Department of Cardiology, Dupuytren-2 University Hospital, Limoges, France
- EpiMaCT, Inserm 1094 & IRD 270, Limoges University, Limoges, France
| | - Alessandro Della Corte
- Department of Translational Medical Sciences, University of Campania "L. Vanvitelli", Naples, Italy
- Cardiac Surgery Unit, Monaldi Hospital, Naples, Italy
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Julia Dumfarth
- University Clinic for Cardiac Surgery, Medical University Innsbruck, Innsbruck, Austria
| | - John A Elefteriades
- Aortic Institute at Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
| | - Christian D Etz
- Department of Cardiac Surgery, University Medicine Rostock, University of Rostock, Rostock, Germany
| | - Karen M Kim
- Division of Cardiovascular and Thoracic Surgery, The University of Texas at Austin/Dell Medical School, Austin, TX, USA
| | - Maximilian Kreibich
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Mario Lescan
- Department of Thoracic and Cardiovascular Surgery, University Medical Centre Tübingen, Tübingen, Germany
| | - Luca Di Marco
- Cardiac Surgery Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Andreas Martens
- Department of Cardiac Surgery, Klinikum Oldenburg, Oldenburg, Germany
- The Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Carlos A Mestres
- Department of Cardiothoracic Surgery and the Robert WM Frater Cardiovascular Research Centre, The University of the Free State, Bloemfontein, South Africa
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Christoph A Nienaber
- Division of Cardiology at the Royal Brompton & Harefield Hospitals, Guy's and St. Thomas' NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Faculty of Medicine, Imperial College London, London, UK
| | - Gabriele Piffaretti
- Vascular Surgery Department of Medicine and Surgery, University of Insubria School of Medicine, Varese, Italy
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, VA, USA
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Bartosz Rylski
- Clinic for Cardiovascular Surgery, Department University Heart Center Freiburg Bad Krozingen, University Clinic Freiburg, Freiburg, Germany
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
| | - Christopher L Schlett
- Faculty of Medicine, Albert Ludwigs University Freiburg, Freiburg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Freiburg, Freiburg, Germany
| | - Florian Schoenhoff
- Department of Cardiac Surgery, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Santi Trimarchi
- Department of Cardiac Thoracic and Vascular Diseases, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Konstantinos Tsagakis
- Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Medicine Essen, Essen, Germany
| |
Collapse
|
8
|
Manchev G, Gegouskov V, Kornovski V, Yankov G, Goranovska V, Ilieva V, Petrova V. Can Open Distal Repair Be Safely Used in All Patients with Type A Acute Aortic Dissection? Ann Thorac Cardiovasc Surg 2024; 30:n/a. [PMID: 37730310 PMCID: PMC10902668 DOI: 10.5761/atcs.oa.23-00086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023] Open
Abstract
PURPOSE The distal suture line during aortic dissection repair can be performed by a closed technique or by an open technique. This study presents a retrospective comparison of both methods regarding their postoperative outcomes. PATIENTS AND METHODS 120 patients who underwent surgery for acute aortic dissection type A were divided into two groups. In group A (n = 81), open distal anastomosis was performed under hypothermic circulatory arrest and selective cerebral perfusion. In group B (n = 39), distal anastomosis was performed with the aorta cross-clamped under mildly hypothermic cardiopulmonary bypass. Primary outcomes were operative mortality, neurologic morbidity, and long-term survival. RESULTS Hospital mortality (17.3% for the open group vs. 12.8% for the closed group, p = 0.53), permanent neurologic dysfunction (8.7% vs. 8.3%, p = 1.0), and temporary neurologic dysfunction (31.9% vs. 22.2%, p = 0.298) were not significantly different between groups. No significant difference in actuarial 5- and 10-year survival was observed (88% vs. 86% and 53 vs. 73%, respectively, p = 0.396). After propensity-score adjustment, the technique of distal aortic repair was not found to be a predictor of the primary outcomes. CONCLUSION We conclude that the open repair can be used in most if not all cases of surgical repair of type A acute aortic dissection.
Collapse
Affiliation(s)
- Georgi Manchev
- Department of Cardiac Surgery, St. Anna University Hospital, Sofia, Bulgaria
- Medical University Pleven, Pleven, Bulgaria
| | - Vassil Gegouskov
- Department of Cardiac Surgery, St. Anna University Hospital, Sofia, Bulgaria
- Medical University Pleven, Pleven, Bulgaria
| | - Vladimir Kornovski
- Department of Cardiac Surgery, Heart and Brain University Hospital, Burgas, Bulgaria
| | - Georgi Yankov
- Department of Thoracic Surgery, Ivan Rilski University Hospital, Sofia, Bulgaria
| | - Valya Goranovska
- Department of Cardiac Surgery, St. Anna University Hospital, Sofia, Bulgaria
- Medical University Pleven, Pleven, Bulgaria
| | - Vicktoria Ilieva
- Department of Anesthesia and Intensive Care, Ivan Rilski University Hospital, Sofia, Bulgaria
| | - Vicktoria Petrova
- Department of Anesthesia and Intensive Care, Ivan Rilski University Hospital, Sofia, Bulgaria
| |
Collapse
|
9
|
Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
|
10
|
Nappi F, Alzamil A, Avtaar Singh SS, Spadaccio C, Bonnet N. Current Knowledge on the Interaction of Human Cytomegalovirus Infection, Encoded miRNAs, and Acute Aortic Syndrome. Viruses 2023; 15:2027. [PMID: 37896804 PMCID: PMC10611417 DOI: 10.3390/v15102027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Aortic dissection is a clinicopathological entity caused by rupture of the intima, leading to a high mortality if not treated. Over time, diagnostic and investigative methods, antihypertensive therapy, and early referrals have resulted in improved outcomes according to registry data. Some data have also emerged from recent studies suggesting a link between Human Cytomegalovirus (HCMV) infection and aortic dissection. Furthermore, the use of microRNAs has also become increasingly widespread in the literature. These have been noted to play a role in aortic dissections with elevated levels noted in studies as early as 2017. This review aims to provide a broad and holistic overview of the role of miRNAs, while studying the role of HCMV infection in the context of aortic dissections. The roles of long non-coding RNAs, circular RNAs, and microRNAs are explored to identify changes in expression during aortic dissections. The use of such biomarkers may one day be translated into clinical practice to allow early detection and prognostication of outcomes and drive preventative and therapeutic options in the future.
Collapse
Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (N.B.)
| | - Almothana Alzamil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (N.B.)
| | | | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Mayo Clinic, Rochester, Rochester, MN 55905, USA;
| | - Nicolas Bonnet
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (N.B.)
| |
Collapse
|
11
|
Nappi F, Alzamil A, Salsano A, Avtaar Singh SS, Gambardella I, Santini F, Fiore A, Perocchio G, Demondion P, Mesnildrey P, Schoell T, Bonnet N, Leprince P. Lactate-Based Difference as a Determinant of Outcomes following Surgery for Type A Acute Aortic Dissection: A Multi-Centre Study. J Clin Med 2023; 12:6177. [PMID: 37834821 PMCID: PMC10573384 DOI: 10.3390/jcm12196177] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023] Open
Abstract
Type A acute aortic dissection (TAAAD) is a serious condition within the acute aortic syndromes that demands immediate treatment. Despite advancements in diagnostic and referral pathways, the survival rate post-surgery currently sits at almost 20%. Our objective was to pinpoint clinical indicators for mortality and morbidity, particularly raised arterial lactate as a key factor for negative outcomes. METHODS All patients referred to the three cardiovascular centres between January 2005 and December 2022 were included in the study. The inclusion criteria required the presence of a lesion involving the ascending aorta, symptoms within 7 days of surgery, and referral for primary surgical repair of TAAAD based on recommendations, with consideration for other concomitant major cardiac surgical procedures needed during TAAAD and retrograde extension of TAAAD. We conducted an analysis of both continuous and categorical variables and utilised predictive mean matching to fill in missing numeric features. For missing binary variables, we used logistic regression to impute values. We specifically targeted early postoperative mortality and employed LASSO regression to minimise potential collinearity of over-fitting variables and variables measured from the same patient. RESULTS A total of 633 patients were recruited for the study, out of which 449 patients had complete preoperative arterial lactate data. The average age of the patients was 64 years, and 304 patients were male (67.6%). The crude early postoperative mortality rate was 24.5% (110 out of 449 patients). The mortality rate did not show any significant difference when comparing conservative and extensive surgeries. However, malperfusion had a significant impact on mortality [48/131 (36.6%) vs. 62/318 (19.5%), p < 0.001]. Preoperative arterial lactates were significantly elevated in patients with malperfusion. The optimal prognostic threshold of arterial lactate for predicting early postoperative mortality in our cohort was ≥2.6 mmol/L. CONCLUSION The arterial lactate concentration in patients referred for TAAAD is an independent factor for both operative mortality and postoperative complications. In addition to mortality, patients with an upper arterial lactate cut-off of ≥2.6 mmol/L face significant risks of VA ECMO and the need for dialysis within the first 48 h after surgery. To improve recognition and facilitate rapid transfer and surgical treatment protocol, more diligent efforts are required in the management of malperfusion in TAAAD.
Collapse
Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Almothana Alzamil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Italy DISC Department, University of Genoa, 16145 Genoa, Italy; (A.S.); (F.S.); (G.P.)
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Weill Cornell Medicine–New York, Presbyterian Medical Center, 505 E 70th St., New York, NY 10065, USA;
| | | | - Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Italy DISC Department, University of Genoa, 16145 Genoa, Italy; (A.S.); (F.S.); (G.P.)
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Créteil, France;
| | - Giacomo Perocchio
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Italy DISC Department, University of Genoa, 16145 Genoa, Italy; (A.S.); (F.S.); (G.P.)
| | - Pierre Demondion
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47–83, 75013 Paris, France; (P.D.); (P.L.)
| | - Patrick Mesnildrey
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Thibaut Schoell
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Nicolas Bonnet
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Pascal Leprince
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47–83, 75013 Paris, France; (P.D.); (P.L.)
| |
Collapse
|
12
|
Nappi F, Avtaar Singh SS, Gambardella I, Alzamil A, Salsano A, Santini F, Biancari F, Schoell T, Bonnet N, Folliguet T, Fiore A. Surgical Strategy for the Repair of Acute Type A Aortic Dissection: A Multicenter Study. J Cardiovasc Dev Dis 2023; 10:253. [PMID: 37367418 DOI: 10.3390/jcdd10060253] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/24/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023] Open
Abstract
Type A acute aortic dissection is associated with significant morbidity and mortality, with prompt referral imaging and management to tertiary referral centers needed urgently. Surgery is usually needed emergently, but the choice of surgery often varies depending on the patient and the presentation. Staff and center expertise also play a major role in determining the surgical strategy employed. The aim of this study was to compare the early- and medium-term outcomes of patients undergoing a conservative approach extended only to the ascending aorta and the hemiarch to those of patients subjected to extensive surgery (total arch reconstruction and root replacement) across three European referral centers. A retrospective study was conducted across three sites between January 2008 and December 2021. In total, 601 patients were included within the study, of which 30% were female, and the median age was 64.4 years. The most common operation was ascending aorta replacement (n = 246, 40.9%). The aortic repair was extended proximally (i.e., root n = 105; 17.5%) and distally (i.e., arch n = 250; 41.6%). A more extensive approach, extending from the root to the arch, was employed in 24 patients (4.0%). Operative mortality occurred in 146 patients (24.3%), and the most common morbidity was stroke (75, 12.6%). An increased length of ICU admission was noted in the extensive surgery group, which comprised younger and more frequently male patients. No significant differences were noted in surgical mortality between patients managed with extensive surgery and those managed conservatively. However, age, arterial lactate levels, "intubated/sedated" status on arrival, and "emergency or salvage" status at presentation were independent predictors of mortality both within the index hospitalization and during the follow-up. The overall survival was similar between the groups.
Collapse
Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
| | | | - Ivancarmine Gambardella
- Department of Cardiothoracic Surgery, Weill Cornell Medicine-New York, Presbyterian Medical Center, New York, NY 10065, USA
| | - Almothana Alzamil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
| | - Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, DISC Department, University of Genoa, 16126 Genoa, Italy
| | - Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, DISC Department, University of Genoa, 16126 Genoa, Italy
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00231 Helsinki, Finland
| | - Thibaut Schoell
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
| | - Nicolas Bonnet
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
| | - Thierry Folliguet
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France
| |
Collapse
|
13
|
Nappi F, Petiot S, Salsano A, Avtaar Singh SS, Berger J, Kostantinou M, Bonnet S, Gambardella I, Biancari F, Almazil A, Santini F, Chaara R, Fiore A. Sex-Based Difference in Aortic Dissection Outcomes: A Multicenter Study. J Cardiovasc Dev Dis 2023; 10:jcdd10040147. [PMID: 37103025 PMCID: PMC10143202 DOI: 10.3390/jcdd10040147] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
Background: Type A Acute Aortic Dissection (TAAAD) repair is a surgical emergency associated with high morbidity and mortality. Registry data have noted several sex-specific differences in presentation with TAAAD which may account for the differences in men and women undergoing surgery for this condition. Methods: A retrospective review of data from three departments of cardiac surgery (Centre Cardiologique du Nord, Henri-Mondor University Hospital, San Martino University Hospital, Genoa) between January 2005 and 31 December 2021 was conducted. Confounders were adjusted using doubly robust regression models, a combination of regression models with inverse probability treatment weighting by propensity score. Results: 633 patients were included in the study, of which 192 (30.3%) were women. Women were significantly older with reduced haemoglobin levels and pre-operative estimated glomerular filtration rate compared to men. Male patients were more likely to undergo aortic root replacement and partial or total arch repair. Operative mortality (OR 0.745, 95% CI: 0.491–1.130) and early postoperative neurological complication results were comparable between the groups. The adjusted survival curves using IPTW by propensity score confirmed the absence of a significant impact of gender on long-term survival (HR 0.883, 95% CI 0.561–1.198). In a subgroup analysis of women, preoperative levels of arterial lactate (OR 1.468, 95% CI: 1.133–1.901) and mesenteric ischemia after surgery (OR 32.742, 95% CI: 3.361–319.017) were significantly associated with increased operative mortality. Conclusions: The advancing age of female patients alongside raised preoperative level of arterial lactate may account for the increasing preponderance among surgeons to perform more conservative surgery compared to their younger male counterparts although postoperative survival was similar between the groups.
Collapse
|
14
|
Okada K. Total arch replacement: When and how? Asian Cardiovasc Thorac Ann 2023; 31:42-47. [PMID: 35509182 DOI: 10.1177/02184923211073374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Acute type A aortic dissection (ATAAD) is a life-threatening disease, which often causes cardiac tamponade, rupture, and malperfusion. ATAAD is associated with a high hospital mortality rate. Open aortic surgery for ATAAD is always required to save the patient, particularly elderly patients. Tear-oriented surgery is recommended as the frontline treatment for ATAAD, and hemiarch replacement (HAR) is sufficient because the primary entry is often observed in the ascending aorta (60%-70%). However, HAR has some drawbacks, such as new creation of an anastomotic entry and unfavorable distal aortic remodeling during long-term follow-up. Although total arch replacement (TAR) is a demanding procedure, it is another useful option for ATAAD. Proper patient selection for TAR is controversial. Standardized procedure for TAR, including the optimal brain protection methods and the use of excellent sealed vascular prosthetic grafts, has been established over the past decades. Therefore, TAR is increasingly being selected for HAR in patients who are young or have enlarged aortic arch, severely dissected supra-aortic arch vessels, or hereditary thoracic aortic disorders. The emerging technology of commercially available frozen elephant trunk accelerated the application of TAR, facilitates distal anastomosis, and improves distal aortic remodeling. Although further evidence is required, TAR could be the best choice for HAR for selected patients. Currently, appropriate selection of the surgical technique is important to maximize the benefits of open surgery for ATAAD.
Collapse
Affiliation(s)
- Kenji Okada
- Division of Cardiovascular Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| |
Collapse
|
15
|
Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 446] [Impact Index Per Article: 223.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Y Joseph Woo
- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
| |
Collapse
|
16
|
Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
Collapse
|
17
|
Larsson M, Zindovic I, Sjögren J, Svensson PJ, Strandberg K, Nozohoor S. A prospective, controlled study on the utility of rotational thromboelastometry in surgery for acute type A aortic dissection. Sci Rep 2022; 12:18950. [PMID: 36347972 PMCID: PMC9643344 DOI: 10.1038/s41598-022-23701-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 11/03/2022] [Indexed: 11/11/2022] Open
Abstract
To evaluate the hemostatic system with ROTEM in patients undergoing surgery for acute type aortic dissection (ATAAD) using elective aortic procedures as controls. This was a prospective, controlled, observational study. The study was performed at a tertiary referral center and university hospital. Twenty-three patients with ATAAD were compared to 20 control patients undergoing elective surgery of the ascending aorta or the aortic root. ROTEM (INTEM, EXTEM, HEPTEM and FIBTEM) was tested at 6 points in time before, during and after surgery for ATAAD or elective aortic surgery. The ATAAD group had an activated coagulation coming into the surgical theatre. The two groups showed activation of both major coagulation pathways during surgery, but the ATAAD group consistently had larger deficiencies. Reversal of the coagulopathy was successful, although none of the groups reached elective baseline until postoperative day 1. ROTEM did not detect low levels of clotting factors at heparin reversal nor low levels of platelets. This study demonstrated that ATAAD is associated with a coagulopathic state. Surgery causes additional damage to the hemostatic system in ATAAD patients as well as in patients undergoing elective surgery of the ascending aorta or the aortic root. ROTEM does not adequately catch the full coagulopathy in ATAAD. A transfusion protocol in ATAAD should be specifically created to target this complex coagulopathic state and ROTEM does not negate the need for routine laboratory tests.
Collapse
Affiliation(s)
- Mårten Larsson
- grid.411843.b0000 0004 0623 9987Department of Clinical Sciences, Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, 221 85 Lund, Sweden
| | - Igor Zindovic
- grid.411843.b0000 0004 0623 9987Department of Clinical Sciences, Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, 221 85 Lund, Sweden
| | - Johan Sjögren
- grid.411843.b0000 0004 0623 9987Department of Clinical Sciences, Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, 221 85 Lund, Sweden
| | - Peter J. Svensson
- grid.411843.b0000 0004 0623 9987Department of Coagulation Disorders, Skåne University Hospital, Lund University, Malmö, Sweden
| | - Karin Strandberg
- University and Regional Laboratories, Region Skåne, Malmö, Sweden
| | - Shahab Nozohoor
- grid.411843.b0000 0004 0623 9987Department of Clinical Sciences, Department of Cardiothoracic Surgery, Skåne University Hospital, Lund University, 221 85 Lund, Sweden
| |
Collapse
|
18
|
Segers J, Gutermann H, Mesotten D, Beran M. Recognition and diagnosis of acute type A aortic dissection in a large Belgian referral center – can we do better? ACTA ANAESTHESIOLOGICA BELGICA 2022. [DOI: 10.56126/73.3.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background: Acute type A aortic dissection (ATAAD) has a poor prognosis unless promptly diagnosed and surgically treated. As ATAAD is relatively rare and clinical presentation may mimic other pathologies, diagnosis can be challenging.
Objectives: The aim of this study is to evaluate the difficulties in diagnosing ATAAD.
Methods: A monocentric, retrospective analysis was conducted of all patients undergoing surgical repair for acute type A aortic dissection in our hospital (a large Belgian referral center) between the 1st of January 2016 and the 31st of December 2020. Data were collected regarding patient’s demographics i.e. age and gender, time of first medical contact, referral from other hospitals, presenting symptoms, initial diagnosis, inappropriate antiplatelet or antithrombotic therapy, time to the correct diagnosis, time to initiate surgical repair, and one- year mortality.
Results: Thirty-three patients were included. We found that a correct initial diagnosis was only made in twelve percent of patients with ATAAD. In twenty-one percent of patients, misdiagnoses led to inappropriate administration of antiplatelet or antithrombotic drugs pre-operatively. There was a difference in time from first medical contact to initiation of surgical repair between referred and non-referred patients. This time interval tended to be shorter in the latter group.
Conclusions: The main finding of this analysis is the delayed diagnosis of ATAAD in the majority of patients. This trend is slightly higher in patients referred from other hospitals. To improve outcome in ATAAD, efforts should be made to increase awareness for the presenting symptoms, and appropriate diagnostic imaging should be performed in a timely manner.
Collapse
|
19
|
Bayamin K, Power A, Chu MWA, Dubois L, Valdis M. Malperfusion syndrome in acute type A aortic dissection: Thinking beyond the proximal repair. J Card Surg 2022; 37:3827-3834. [PMID: 35989530 DOI: 10.1111/jocs.16872] [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: 05/03/2022] [Revised: 07/15/2022] [Accepted: 07/23/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Malperfusion syndrome (MPS) is associated with the highest mortality and major morbidity risk in patients with acute Type A aortic dissection (TAAD). The timing of the open proximal aortic repair in the presence of MPS remains debatable given variability in clinical presentation and different local treatment algorithms. This paper provides an up to date and comprehensive overview of published outcomes and available techniques for addressing malperfusion in the setting of acute TAAD. METHODS We have reviewed published data from the major aortic dissection registries including the International Registry of Acute Aortic Dissection, the German Registry for Acute Aortic Dissection In Type A, and the Nordic Consortium for Acute Type A Aortic Dissection, as well as the most up to date literature involving malperfusion in the setting of acute TAAD. This data highlights unique strategies that have been adopted at aortic centers internationally to address malperfusion in this setting pre-, intra-, and postoperatively, which are summarized here and may be of great clinical benefit to other centers treating this disease with more traditional methods. RESULTS The review of the available data has definitively shown an increased mortality up to 43% and morbidity in patients presenting with MPS in the setting of acute TAAD. More specifically, preoperative MPS has been shown to be an independent predictor of mortality with mesenteric malperfusion associated with the worst mortality outcomes from 70% to 100%. Addressing MPS pre or intraoperatively is associated with significantly reduced mortality outcomes down to 4%-13%. CONCLUSION Adapting a dynamic and easily accessible diagnostic method for the comprehensive assessment of different forms of malperfusion (dynamic/static) and incorporating it within the surgical plan is the first step toward early diagnosis and prevention of malperfusion related complications.
Collapse
Affiliation(s)
- Karama Bayamin
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Center, London, Ontario, Canada
| | - Adam Power
- Division of Vascular Surgery, Department of Surgery, Western University, London Health Sciences Center, London, Ontario, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Center, London, Ontario, Canada
| | - Luc Dubois
- Division of Vascular Surgery, Department of Surgery, Western University, London Health Sciences Center, London, Ontario, Canada
| | - Matthew Valdis
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Center, London, Ontario, Canada
| |
Collapse
|
20
|
Dimagli A, Angelini GD. "Time is aorta?": Timeliness of surgical repair in type A aortic dissection. J Card Surg 2022; 37:1661-1663. [PMID: 35340069 PMCID: PMC9314949 DOI: 10.1111/jocs.16412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/03/2022] [Indexed: 11/28/2022]
Abstract
Acute type A aortic dissection is a life‐threatening event that requires prompt management, a complex interaction among the timing of aortic surgical repair, presence or absence of organ malperfusion, and surgical outcomes exists. Whether resection of intimal entry tear should be deferred after reversal of malperfusion and end‐organ ischemia is a matter of controversy. In fact, the timing of aortic repair should be considered within the clinical presentation and baseline characteristics of each patient. Moreover, every effort should be made to minimize times between symptom onset, diagnosis, and surgery.
Collapse
|
21
|
Tong G, Sun Z, Wu J, Zhao S, Chen Z, Zhuang D, Liu Y, Yang Y, Liang Z, Fan R, Sun T. Aortic Balloon Occlusion Technique Does Not Improve Peri-Operative Outcomes for Acute Type A Acute Aortic Dissection Patients With Lower Body Malperfusion. Front Cardiovasc Med 2022; 9:835896. [PMID: 35360012 PMCID: PMC8962400 DOI: 10.3389/fcvm.2022.835896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/26/2022] [Indexed: 12/04/2022] Open
Abstract
Background The management of malperfusion is vital to improve the outcomes of surgery for acute type A acute aortic dissection (ATAAD). Open arch repair under hypothermic circulatory arrest with selective antegrade cerebral perfusion (HCA/sACP) is safe and efficient but associated with inevitable hypothermia and ischemia-reperfusion injury. The aortic balloon occlusion (ABO) technique is shown to be organ protective by allowing higher temperature and shorter circulatory arrest time. In this study, we aimed to evaluate the safety and efficacy of this new technique for ATAAD patients with lower body malperfusion. Methods Between January 2013 and November 2020, 355 ATAAD patients with lower body malperfusion who underwent arch repair in our institute were enrolled. The patients were divided into 2 groups: ABO group (n = 85) and HCA/sACP group (n = 271). Propensity score matching was performed to correct baseline differences. Results Using the propensity score matching, 85 pairs were generated. Circulatory arrest time was significantly lower in the ABO group compared with the HCA/sACP group (median, 8 vs. 22 min; p < 0.001). The incidence of in-hospital mortality (10.6 vs. 12.9%; p = 0.812), stroke (7.1 vs. 7.1%; p = 1.000), dialysis (25.9 vs. 32.9%; p = 0.183), hepatic dysfunction (52.9 vs. 57.6%; p = 0.537), tracheostomy (4.7 vs. 2.4%; p = 0.682), paraplegia (1.2 vs. 4.7%; p = 0.368) were comparable between ABO and HCA/sACP groups. Other outcomes and major adverse events were comparable. The multivariable logistic analysis did not recognize ABO technique protective against any major adverse outcomes. Conclusions For ATAAD patients with lower body malperfusion, the ABO technique allows the performance of arch repair with frozen elephant trunk (FET) under higher temperature and shorter circulatory arrest time. However, ABO technique did not improve perioperative outcomes. Future studies are warranted to evaluate the efficacy of this technique.
Collapse
Affiliation(s)
- Guang Tong
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiac Surgery, Ganzhou Municipal Hospital, Ganzhou, China
| | - Zhongchan Sun
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Ganzhou Municipal Hospital, Ganzhou, China
| | - Jinlin Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shuang Zhao
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zerui Chen
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Donglin Zhuang
- Department of Cardiovascular Surgery, National Center for Cardiovascular Disease, China and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Structural Heart Disease, National Center for Cardiovascular Disease, China and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Cardiovascular Apparatus Innovation, Beijing, China
| | - Yaorong Liu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yongchao Yang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhichao Liang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ruixin Fan
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Tucheng Sun
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- *Correspondence: Tucheng Sun
| |
Collapse
|
22
|
Uimonen M, Olsson C, Jeppsson A, Geirsson A, Chemtob R, Khalil A, Hjortdal V, Hansson EC, Nozohoor S, Zindovic I, Gunn J, Wickbom A, Ahlsson A, Gudbjartsson T, Mennander A. Outcome after surgery for acute type A aortic dissection with or without primary tear resection. Ann Thorac Surg 2021; 114:492-501. [PMID: 34774491 DOI: 10.1016/j.athoracsur.2021.09.067] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 08/25/2021] [Accepted: 09/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The outcome in patients after surgery for acute type A aortic dissection without replacement of the part of the aorta containing the primary tear is undefined. METHODS Data of 1122 patients who underwent surgery for acute type A aortic dissection in eight Nordic centers from Jan 2005 to Dec 2014 were retrospectively analyzed. The patients with primary tear location either unfound, unknown, not confirmed or not recorded (n=243, 21.7%) were excluded from the analysis. The patients were divided into two groups according to whether the aortic reconstruction encompassed the portion of the primary tear (TR group, n=730) or not (TNR group, n=149). The restricted mean survival time ratios adjusted for patient characteristics and surgical details between the groups were calculated for all-cause mortality and aortic reoperation-free survival. The median follow-up time was 2.57 (inter-quartile range 0.53-5.30) years. RESULTS For the majority of the patients in the TR group, the primary tear was located in the ascending aorta (83.6%). The reconstruction encompassed both aortic root and the aortic arch in 7.4% in the TR group as compared with 0.7% in the TNR patients (P<0.001). There were no significant differences in all-cause mortality (adjusted restricted mean survival time ratio 1.01, 95% confidence interval 0.92-1.12, P=0.799) or reoperation-free survival (adjusted restricted mean survival time ratio 0.98, 95% confidence interval 0.95-1.02, P=0.436) between the TR group and TNR groups. CONCLUSIONS Primary tear resection alone does not determine the mid-term outcome after surgery for acute type A aortic dissection.
Collapse
Affiliation(s)
- Mikko Uimonen
- Tampere University Heart Hospital and Tampere University, Tampere, Finland
| | | | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden and Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Raphaelle Chemtob
- Department of Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | | | | | - Emma C Hansson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden and Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Shahab Nozohoor
- Department of Cardiothoracic Surgery, Skane University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - Igor Zindovic
- Department of Cardiothoracic Surgery, Skane University Hospital, Clinical Sciences, Lund University, Lund, Sweden
| | - Jarmo Gunn
- Turku University Hospital, Turku, Finland
| | | | | | - Tomas Gudbjartsson
- Landspitali University Hospital, Faculty of Medicine University of Iceland, Reykjavik Iceland
| | - Ari Mennander
- Tampere University Heart Hospital and Tampere University, Tampere, Finland,.
| |
Collapse
|
23
|
The role of philosophy of life approaching type A acute aortic dissection. Trends Cardiovasc Med 2021; 32:462-463. [PMID: 34508848 DOI: 10.1016/j.tcm.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/02/2021] [Indexed: 11/21/2022]
|
24
|
Benedetto U, Dimagli A, Kaura A, Sinha S, Mariscalco G, Krasopoulos G, Moorjani N, Field M, Uday T, Kendal S, Cooper G, Uppal R, Bilal H, Mascaro J, Goodwin A, Angelini G, Tsang G, Akowuah E. Determinants of outcomes following surgery for type A acute aortic dissection: the UK National Adult Cardiac Surgical Audit. Eur Heart J 2021; 43:44-52. [PMID: 34468733 PMCID: PMC8720141 DOI: 10.1093/eurheartj/ehab586] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/21/2021] [Accepted: 08/17/2021] [Indexed: 01/16/2023] Open
Abstract
Aims Operability of type A acute aortic dissections (TAAAD) is currently based on non-standardized decision-making process, and it lacks a disease-specific risk evaluation model that can predict mortality. We investigated patient, intraoperative data, surgeon, and centre-related variables for patients who underwent TAAAD in the UK. Methods and results We identified 4203 patients undergoing TAAAD surgery in the UK (2009–18), who were enrolled into the UK National Adult Cardiac Surgical Audit dataset. The primary outcome was operative mortality. A multivariable logistic regression analysis was performed with fast backward elimination of variables and the bootstrap-based optimism-correction was adopted to assess model performance. Variation related to hospital or surgeon effects were quantified by a generalized mixed linear model and risk-adjusted funnel plots by displaying the individual standardized mortality ratio against expected deaths. Final variables retained in the model were: age [odds ratio (OR) 1.02, 95% confidence interval (CI) 1.02–1.03; P < 0.001]; malperfusion (OR 1.79, 95% CI 1.51–2.12; P < 0.001); left ventricular ejection fraction (moderate: OR 1.40, 95% CI 1.14–1.71; P = 0.001; poor: OR 2.83, 95% CI 1.90–4.21; P < 0.001); previous cardiac surgery (OR 2.29, 95% CI 1.71–3.07; P < 0.001); preoperative mechanical ventilation (OR 2.76, 95% CI 2.00–3.80; P < 0.001); preoperative resuscitation (OR 3.36, 95% CI 1.14–9.87; P = 0.028); and concomitant coronary artery bypass grafting (OR 2.29, 95% CI 1.86–2.83; P < 0.001). We found a significant inverse relationship between surgeons but not centre annual volume with outcomes. Conclusions Patient characteristics, intraoperative factors, cardiac centre, and high-volume surgeons are strong determinants of outcomes following TAAAD surgery. These findings may help refining clinical decision-making, supporting patient counselling and be used by policy makers for quality assurance and service provision improvement.
Collapse
Affiliation(s)
- Umberto Benedetto
- Bristol Heart Institute, University of Bristol, Senate House, Tyndall Avenue, Bristol BS8 1TH, UK
| | - Arnaldo Dimagli
- Bristol Heart Institute, University of Bristol, Senate House, Tyndall Avenue, Bristol BS8 1TH, UK
| | - Amit Kaura
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, The Bays, South Wharf Road, St Mary's Hospital, London W21NY, UK
| | - Shubhra Sinha
- Bristol Heart Institute, University of Bristol, Senate House, Tyndall Avenue, Bristol BS8 1TH, UK
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, Groby Rd, Leicester LE3 9QP, UK
| | - George Krasopoulos
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Papworth Rd, Trumpington, Cambridge CB2 0AY, UK
| | - Mark Field
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Thomas Dr, Liverpool L14 3PE, UK
| | - Trivedi Uday
- Sussex Cardiac Center, Brighton and Sussex University Hospitals NHS Trust, Barry Building, Eastern Rd, Brighton BN2 5BE, UK
| | - Simon Kendal
- South Tees Hospitals NHS Trust, Marton Road, Middlesbrough TS4 3BW, UK
| | - Graham Cooper
- Sheffield Teaching Hospitals Foundation Trust, Royal Hallamshire Hospital, Glossop Rd, Broomhall, Sheffield S10 2JF, UK
| | - Rakesh Uppal
- Barts Heart Centre, William Harvey Research Institute, W Smithfield, London EC1A 7BE, UK
| | - Haris Bilal
- Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Rd, Manchester M13 9WL, UK
| | - Jorge Mascaro
- University Hospital Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - Andrew Goodwin
- South Tees Hospitals NHS Trust, Marton Road, Middlesbrough TS4 3BW, UK
| | - Gianni Angelini
- Bristol Heart Institute, University of Bristol, Senate House, Tyndall Avenue, Bristol BS8 1TH, UK
| | - Geoffry Tsang
- Wessex Cardiothoracic Center, University Hospital Southampton NHS Trust, Tremona Road Southampton, Hampshire SO16 6YD, UK
| | - Enoch Akowuah
- South Tees Hospitals NHS Trust, Marton Road, Middlesbrough TS4 3BW, UK
| | | |
Collapse
|
25
|
Malaisrie SC, Szeto WY, Halas M, Girardi LN, Coselli JS, Sundt TM, Chen EP, Fischbein MP, Gleason TG, Okita Y, Ouzounian M, Patel HJ, Roselli EE, Shrestha ML, Svensson LG, Moon MR. 2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg 2021; 162:735-758.e2. [PMID: 34112502 DOI: 10.1016/j.jtcvs.2021.04.053] [Citation(s) in RCA: 130] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 01/16/2023]
Affiliation(s)
- S Christopher Malaisrie
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill.
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa
| | - Monika Halas
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC
| | | | - Thomas G Gleason
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Hospitals, Ann Arbor, Mich
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Malakh L Shrestha
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
| | | |
Collapse
|
26
|
Jakob H, Moughal S, Bashir M. Frozen elephant trunk with straight vascular prosthesis: single-center experience with a review of current trends. THE JOURNAL OF CARDIOVASCULAR SURGERY 2020; 61:301-307. [DOI: 10.23736/s0021-9509.20.11401-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
27
|
Abstract
Double aortic arch (DAA) is extremely rare in adults. A 71-year-old woman suffered from syncope, and an acute-type aortic dissection with a DAA accompanied by a massive pericardial effusion was shown in a non-enhanced computed tomography (CT). Enhanced CT was not performed because of her hemodynamic instability. She was rushed to the operating theater after immediate pericardiocentesis without more precise morphological evaluation. Ascending aortic replacement was performed by clamping both aortic arches without systemic circulatory arrest. She survived the operation, but her respiratory function was affected by tracheomalacia and remaining DAA with residual dissection.
Collapse
Affiliation(s)
- Katsuaki Tsukioka
- Department of Cardiovascular Surgery, Iida Municipal Hospital, Iida, Nagano, Japan
| | - Tetsuya Kono
- Department of Cardiovascular Surgery, Suwa Red Cross Hospital, Suwa, Nagano, Japan
| | - Kohei Takahashi
- Department of Cardiovascular Surgery, Iida Municipal Hospital, Iida, Nagano, Japan
| |
Collapse
|
28
|
Gudbjartsson T, Ahlsson A, Geirsson A, Gunn J, Hjortdal V, Jeppsson A, Mennander A, Zindovic I, Olsson C. Acute type A aortic dissection - a review. SCAND CARDIOVASC J 2019; 54:1-13. [PMID: 31542960 DOI: 10.1080/14017431.2019.1660401] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute type A aortic dissection (ATAAD) is still one of the most challenging diseases that cardiac surgeons encounter. This review is based on the current literature and includes the results from the Nordic Consortium for Acute Type-A Aortic Dissection (NORCAAD) database. It covers different aspects of ATAAD and concentrates on the outcome of surgical repair. The diagnosis is occasionally delayed, and ATAAD is usually lethal if prompt repair is not performed. The dynamic nature of the disease, the variation in presentation and clinical course, and the urgency of treatment require significant attentiveness. Many surgical techniques and perfusion strategies of varying complexity have been described, ranging from simple interposition graft to total arch replacement with frozen elephant trunk and valve-sparing root reconstruction. Although more complex techniques may provide long-term benefit in selected patients, they require significant surgical expertise and experience. Short-term survival is first priority so an expedited operation that fits in with the surgeon's level of expertise is in most cases appropriate.
Collapse
Affiliation(s)
- Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Anders Ahlsson
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Jarmo Gunn
- Department of Cardiothoracic Surgery, Turku University Hospital, University of Turku, Turku, Finland
| | - Vibeke Hjortdal
- Department of Cardiothoracic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Anders Jeppsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Sweden and Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ari Mennander
- Tampere University Heart Hospital and Tampere University, Tampere, Finland
| | - Igor Zindovic
- Lund University, Skåne University Hospital, Department of Clinical Sciences, Department of Cardiothoracic Surgery, Lund, Sweden
| | - Christian Olsson
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
29
|
Chivasso P, Bruno VD. Commentary: Open versus clamp-on distal anastomosis techniques in acute type A aortic dissection: The ship has already left the port. J Thorac Cardiovasc Surg 2019; 157:1761-1762. [DOI: 10.1016/j.jtcvs.2018.09.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 09/26/2018] [Indexed: 11/29/2022]
|
30
|
Baciewicz FA. Commentary: Clamp-on…clamp-off. J Thorac Cardiovasc Surg 2018; 157:1759-1760. [PMID: 30396729 DOI: 10.1016/j.jtcvs.2018.09.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 09/21/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Frank A Baciewicz
- Department of Cardiothoracic Surgery and Michael and Marian Ilitch Department of Surgery, Wayne State University School of Medicine, Detroit, Mich.
| |
Collapse
|