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Chen P, Wei J, Ding R, Chen M, Zhao D, Li H, Chen L, Sun X, Qian X, Pu J, Chen Z, Wang L. Major adverse outcomes in patients with acute type A aortic dissection undergoing total arch replacement with frozen elephant trunk procedure. Int J Cardiol 2024:132254. [PMID: 38866109 DOI: 10.1016/j.ijcard.2024.132254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 05/04/2024] [Accepted: 06/09/2024] [Indexed: 06/14/2024]
Abstract
BACKGROUND The objective of this investigation was to identify the risk factors linked to major adverse outcomes (MAO) subsequent to total arch replacement with frozen elephant trunk procedure (TAR+FET) surgery among patients diagnosed with acute type A aortic dissection (ATAAD). Additionally, the study aimed to elucidate the influence of these adverse outcomes on the long-term prognosis of the patients. METHOD 670 ATAAD patients received the TAR+FET procedure. Multivariable logistic regression was used to investigate the risk factors associated with in-hospital MAO. Additionally, long-term survival outcomes were assessed through follow-up observations of all patients. RESULTS The overall in-hospital mortality was 4.33%. Among 670 patients, 169 patients (25.22%) developed postoperative MAO. Multivariate analysis showed that in-hospital MAO was positively associated with age (OR = 1.025, 95%CI: 1.005-1.045, P = 0.014), lower limb symptoms (OR = 2.562, 95%CI: 1.407-4.666, P = 0.002), involvement of coronary artery (OR = 2.027, 95%CI: 1.312-3.130, P = 0.001), involvement of left renal artery (OR = 1.998, 95%CI: 1.359-2.938, P < 0.001), CPB time (OR = 1.011, 95%CI: 1.007-1.015, P < 0.001) and WBC counts (OR = 1.045, 95%CI: 1.007-1.083, P = 0.019). MAO group showed a worse long-term prognosis than those non-MAO group (P = 0.002). CONCLUSIONS While TAR+FET can be an effective treatment option for ATAAD patients, careful patient selection and management are essential in minimizing the risk of MAO and ensuring long-term success.
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Affiliation(s)
- Pengfei Chen
- Cardiovascular Surgery Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovescular Diseases, Beijing, China
| | - Jinhua Wei
- Cardiovascular Surgery Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovescular Diseases, Beijing, China
| | - Runyu Ding
- Cardiovascular Surgery Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovescular Diseases, Beijing, China
| | - Mingjian Chen
- Cardiovascular Surgery Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovescular Diseases, Beijing, China
| | - Diming Zhao
- Cardiovascular Surgery Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovescular Diseases, Beijing, China
| | - Haochao Li
- Cardiovascular Surgery Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovescular Diseases, Beijing, China
| | - Liang Chen
- Cardiovascular Surgery Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovescular Diseases, Beijing, China
| | - Xiaogang Sun
- Cardiovascular Surgery Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovescular Diseases, Beijing, China
| | - Xiangyang Qian
- Cardiovascular Surgery Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovescular Diseases, Beijing, China
| | - Jundong Pu
- Intensive Care Unit, Dali Bai Autonomous Prefecture People's Hospital, Dali, Yunnan, China
| | - Zujun Chen
- Cardiovascular Surgery Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovescular Diseases, Beijing, China.
| | - Liqing Wang
- Cardiovascular Surgery Department, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, National Center for Cardiovescular Diseases, Beijing, China.
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Ahmad RA, Orelaru F, Titsworth M, Wu X, Kim KM, Fukuhara S, Patel H, Deeb GM, Yang B. Contemporary nonsurgical management of acute type A aortic dissection: Better outcomes? J Thorac Cardiovasc Surg 2024; 167:2027-2036.e1. [PMID: 36272767 DOI: 10.1016/j.jtcvs.2022.09.025] [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: 06/26/2022] [Revised: 08/25/2022] [Accepted: 09/15/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of this study was to evaluate outcomes of nonsurgically managed acute type A aortic dissection (ATAAD) in the contemporary era. METHODS From January 1996 to December 2021, 999 patients presented with ATAAD at our institution, of whom 839 patients underwent open aortic repair (surgical cohort) whereas 148 patients were managed nonoperatively (nonsurgical cohort) because of severe comorbidities, organ failure from malperfusion syndrome, and patients' wishes. Data were obtained from chart review, the Society of Thoracic Surgeons warehouse, the national death index, and Michigan death index database. RESULTS The combined in-hospital + 30-day mortality rate was 9 times higher in the nonsurgical cohort compared with the surgical cohort (70% vs 7.9%). In the nonsurgical cohort, compared with the first decade (1996-2010), patients during the second decade (2011-2021) had a lower in-hospital+30-day mortality rate (58% vs 87%; P<.001); lower incidence of aortic rupture (8% vs 21%; P=.008), and a higher 3-year survival rate (29% vs 13%; P=.005). Within the nonsurgical cohort, compared with patients without malperfusion syndrome, the patients with malperfusion syndrome had similar in-hospital + 30-day mortality but a greater incidence of aortic rupture (21% vs 6.1%, P=.01) with an odds ratio of 4.2 (P=.03); compared with classic type A dissection, the patients with intramural hematoma had a lower in-hospital+30-day mortality rate (52% vs 72%, P=.02) with an odds ratio of 0.36 (P=.02). CONCLUSIONS Surgery remained the mainstream treatment for ATAAD. Nonsurgical management still had a role for those who were not surgical candidates because of comorbidities or malperfusion syndrome, especially in those with acute type A intramural hematoma.
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Affiliation(s)
| | - Felix Orelaru
- Department of General Surgery, St Joseph Mercy, Ann Arbor, Mich
| | - Marc Titsworth
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Karen M Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | | | - Himanshu Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - G Michael Deeb
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich.
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3
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Yu W, Liang Y, Gao J, Xie D, Xiong J. Surgical choice for the treatment of partial intestinal ischemic necrosis caused by acute type a aortic dissection combined with malperfusion of superior mesenteric artery. J Cardiothorac Surg 2024; 19:286. [PMID: 38734628 PMCID: PMC11088173 DOI: 10.1186/s13019-024-02790-z] [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: 09/30/2023] [Accepted: 05/03/2024] [Indexed: 05/13/2024] Open
Abstract
Acute type A aortic dissection is a severe cardiovascular disease characterized by rapid onset and high mortality. Traditionally, urgent open aortic repair is performed after admission to prevent aortic rupture and death. However, when combined with malperfusion syndrome, the low perfusion of the superior mesenteric artery can further lead to intestinal necrosis, significantly impacting the surgery's prognosis and potentially resulting in adverse consequences, bringing. This presents great significant challenges in treatment. Based on recent domestic and international research literature, this paper reviews the mechanism, current treatment approaches, and selection of surgical methods for poor organ perfusion caused by acute type A aortic dissection. The literature review findings suggest that central aortic repair can be employed for the treatment of acute type A aortic dissection with inadequate perfusion of the superior mesenteric artery. The superior mesenteric artery can be windowed and (/or) stented, followed by delayed aortic repair. Priority should be given to revascularization of the superior mesenteric artery, followed by central aortic repair. During central aortic repair, direct blood perfusion should be performed on the distal true lumen of the superior mesenteric artery, leading to resulting in favorable therapeutic outcomes. The research results indicate that even after surgical aortic repair, intestinal ischemic necrosis may still occur. In such cases, prompt laparotomy and necessary necrotic bowel resection are crucial for saving the patient's life.
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Affiliation(s)
- Wenbo Yu
- The First Clinical Medical College of Gannan Medical University, Ganzhou, 341000, China
| | - Yuan Liang
- The First Clinical Medical College of Gannan Medical University, Ganzhou, 341000, China
| | - Jianfeng Gao
- The First Clinical Medical College of Gannan Medical University, Ganzhou, 341000, China
| | - Dilin Xie
- The First Clinical Medical College of Gannan Medical University, Ganzhou, 341000, China
| | - Jianxian Xiong
- First Affiliated Hospital of Gannan Medical University, Ganzhou, 341000, China.
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Hao J, Li J, Zhang H, Chen J, Fang M, Wu M, Gu B, Xiao Y, Lei L. Gastrointestinal bleeding risk factors in type A aortic dissection post-aortic arch replacement. J Thorac Dis 2024; 16:2314-2325. [PMID: 38738230 PMCID: PMC11087617 DOI: 10.21037/jtd-23-1752] [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: 11/14/2023] [Accepted: 03/07/2024] [Indexed: 05/14/2024]
Abstract
Background Gastrointestinal bleeding (GIB) is a notable complication in patients diagnosed with aortic dissection (AD). We evaluated the outcomes and identified the risk factors associated with GIB in patients with AD. Methods A retrospective case-control study was conducted on patients diagnosed with type A aortic dissection (TAAD) who underwent total aortic arch replacement (TAAR) at our institution from July 2021 to July 2023. Comprehensive clinical data, laboratory findings, and imaging results were meticulously gathered and analyzed to identify potential risk factors linked to GIB in this patient cohort. Results Of the 198 AD patients who underwent TAAR, 38 (19.2%) developed postoperative GIB (GIB group), with a median interval of 7 days between surgery and bleeding onset. The GIB group exhibited significantly higher mortality (26.3% vs. 3.1%, P<0.001), prolonged intensive care unit (ICU) stay {15 [interquartile range (IQR), 8-25] vs. 7 (IQR, 5-12) days, P<0.001}, and extended duration of ventilation [168 (IQR, 120-372) vs. 71 (IQR, 34-148) hours, P<0.001] compared to the control group (n=160, 80.8%). Logistic regression analysis identified age >54 years [odds ratio (OR): 3.529], intraoperative red blood cell (RBC) transfusion >600 mL (OR: 3.865), and concomitant celiac trunk and superior mesenteric artery (SMA) hypoperfusion (OR: 15.974) as independent risk factors for GIB in AD patients. Conclusions GIB subsequent to TAAR in AD patients is linked to adverse prognosis. Factors such as advanced age, extensive intraoperative transfusion, and gastrointestinal (GI) perfusion abnormalities may heighten the risk of GIB in this patient population.
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Affiliation(s)
- Junhai Hao
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
- School of Medicine, South China University of Technology, Guangzhou, China
| | - Jiaxin Li
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Hanxiao Zhang
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Jia Chen
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Miaoxian Fang
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Meifen Wu
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Bowen Gu
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Yingkai Xiao
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
| | - Liming Lei
- Department of Intensive Care Unit of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
- Guangdong Provincial Key Laboratory of South China Structural Heart Disease, Guangzhou, China
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Huang LC, Chen SK, Peng H, Wu XJ. A visceral organ function-focused therapeutic strategy using a 6-hour time window for patients with acute type a aortic dissection complicated by mesenteric malperfusion. J Cardiothorac Surg 2024; 19:183. [PMID: 38580973 PMCID: PMC10996210 DOI: 10.1186/s13019-024-02634-w] [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: 02/05/2023] [Accepted: 03/11/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Acute type A aortic dissection (ATAAD) complicated by mesenteric malperfusion is a critical and complicated condition. The optimal treatment strategy remains controversial, debate exists as to whether aortic dissection or mesenteric malperfusion should be addressed first, and the exact time window for mesenteric ischemia intervention is still unclear. To solve this problem, we developed a new concept based on the pathophysiological mechanism of mesenteric ischemia, using a 6-hour time window to divide newly admitted patients by the time from onset to admission, applying different treatment protocols to improve the clinical outcomes of patients with ATAAD complicated by mesenteric malperfusion. METHODS This was a retrospective study that covered a five-year period. From July 2018 to December 2020(phase I), all patients underwent emergency open surgery. From January 2021 to June 2023(phase II), patients with an onset within 6 h all underwent open surgical repair, followed by immediately postoperative examination if the malperfusion is suspected, while the restoration of mesenteric perfusion and visceral organ function was performed first, followed by open repair, in patients with an onset beyond 6 h. RESULTS There were no significant differences in baseline and surgical data. In phase I, eleven patients with mesenteric malperfusion underwent open surgery, while in phase II, our novel strategy was applied, with sixteen patients with an onset greater than 6 h and eleven patients with an onset less than 6 h. During the waiting period, none died of aortic rupture, but four patients died of organ failure, twelve patients had organ function improvement and underwent surgery successfully survived. The overall mortality rate decreased with the use of this novel strategy (54.55% vs. 18.52%, p = 0.047). Furthermore, the surgical mortality rate between the two periods showed even stronger statistical significance (54.55% vs. 4.35%, p = 0.022). Moreover, the proportions of patients with sepsis and multiorgan failure also showed differences. CONCLUSIONS Our novel strategy for patients with ATAAD complicated by mesenteric malperfusion not only improves the surgical success rate but also reduces the overall mortality rate.
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Affiliation(s)
- Ling-Chen Huang
- Department of Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, 167# Beilishi Road, Beijing, 100037, China
| | - Shuang-Kun Chen
- Department of Cardiac Surgery, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, 2999 Jinshan Road, Huli 25 District, Xiamen, 361008, China
| | - Hua Peng
- Department of Cardiac Surgery, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, 2999 Jinshan Road, Huli 25 District, Xiamen, 361008, China
| | - Xi-Jie Wu
- Department of Cardiac Surgery, School of Medicine, Xiamen Cardiovascular Hospital of Xiamen University, Xiamen University, 2999 Jinshan Road, Huli 25 District, Xiamen, 361008, China.
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6
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Yost G, Williams D, Yang B. Commentary: Acute type A dissection with malperfusion syndrome: Start your stopwatch? J Thorac Cardiovasc Surg 2024:S0022-5223(24)00185-5. [PMID: 38447868 DOI: 10.1016/j.jtcvs.2024.02.019] [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: 02/16/2024] [Accepted: 02/19/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Gardner Yost
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - David Williams
- Department of Interventional Radiology, University of Michigan, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
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7
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Lorenz V, Muzzi L, Neri E. Analysis of current mortality risk scores for acute type A aortic dissection: The Siena experience. Asian Cardiovasc Thorac Ann 2024; 32:116-122. [PMID: 38317575 DOI: 10.1177/02184923241230344] [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: 02/07/2024]
Abstract
OBJECTIVE In literature, various risk scores have been described to predict in-hospital mortality of patients undergoing surgery for acute type A dissection. We want to evaluate which factors are most correlated with a negative outcome and testing the validity of the current scores in literature analyzing our experience of over 20 years in the surgery of type A aortic dissections. MATERIALS AND METHODS A total of 324 patients were included in the study. Patients were divided into two groups according to 30-day survival or mortality. The preoperative variables analyzed are the parameters necessary for the calculation of scores: Penn Classification, Leipzig Halifax and adjusted Leipzig Halifax score, GERAADA score and EuroSCORE II. Intra- and post-operative mortality were 10.2% and 17.5%, respectively. In multivariate analysis, the preoperative predictors of 30-day mortality were age greater than 70 years, low eject fraction levels, visceral and coronary malperfusion. Both GERAADA and EuroSCORE II were statistically significant predictors of 30-day mortality. However, EuroSCORE II underestimates the mortality compared to GERAADA score probably due to the lack of evaluation of fundamental preoperative factors in the course of type A aortic dissection. RESULTS The study has demonstrated the efficacy of the GERAADA score in predicting the outcome of patients undergoing surgery and the underestimation of the mortality of EuroSCORE II in our population.
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Affiliation(s)
- Veronica Lorenz
- Cardiac Surgery - Aortic Unit, University of Study of Siena, Siena, Italy
| | - Luigi Muzzi
- Cardiac Surgery - Aortic Unit, University of Study of Siena, Siena, Italy
| | - Eugenio Neri
- Cardiac Surgery - Aortic Unit, University of Study of Siena, Siena, Italy
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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:S0003-4975(24)00077-8. [PMID: 38416090 DOI: 10.1016/j.athoracsur.2024.01.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [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
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Liu H, Zhang S, Zhang C, Gao Q, Liu Y, Liao F, Ge S. Risk factors for prolonged postoperative ICU stay in the patients with Stanford type A aortic dissection. J Cardiothorac Surg 2024; 19:46. [PMID: 38310273 PMCID: PMC10838431 DOI: 10.1186/s13019-024-02548-7] [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: 05/30/2023] [Accepted: 01/28/2024] [Indexed: 02/05/2024] Open
Abstract
OBJECTIVE To investigate the independent risk factors for postoperative prolonged ICU stay in patients with Stanford type A aortic dissection (TAAD) and assess the clinical outcomes of prolonged ICU stay. METHOD The clinical data of 100 patients with TAAD admitted to the Department of Cardiovascular Surgery, First Affiliated Hospital of Anhui Medical University from December 2018 to September 2022 were retrospectively collected and analyzed. Patients were divided into two groups, based on the postoperative ICU stay (7 days as the threshold), regular ICU stay group (< 7 days) and prolonged ICU stay group (≥ 7 days). First, preoperative and intraoperative materials were collected for univariate analysis. Then, the significant variables after univariate analysis were analyzed using logistic regression, and the final independent risk factors for prolonged ICU stay were determined. Meanwhile, the postoperative clinical outcomes were analyzed with the aim of assessing the clinical outcomes due to prolonged ICU stay. RESULTS There were 65 and 35 patients in the regular ICU stay group and the prolonged ICU stay group, respectively. In accordance with the result of univariate analysis in the two groups, emergency surgery (χ2 = 13.598; P < 0.001), preoperative urea nitrogen (t = 3.006; P = 0.004), cardiopulmonary bypass (CPB) time (t = 2.671; P = 0.001) and surgery time (t = 2.630; P = 0.010) were significant. All significant variates were analyzed through logistic regression, and it was found that emergency surgery (OR = 0.192; 95% CI: 0.065-0.561), preoperative urea nitrogen (OR = 0.775; 95% CI: 0.634-0.947) and cardiopulmonary time (OR = 0.988; 95% CI: 0.979-0.998) were independent risk factors for prolonged postoperative ICU stay. The Receiver Operating Characteristic (ROC) curves of these three factors were also effective in predicting postoperative prolonged ICU stay (Emergency surgery, AUC = 0.308, 95% CI: 0.201-0.415; Preoperative urea nitrogen, AUC = 0.288, 95% CI: 0.185-0.392; cardiopulmonary time, AUC = 0.340, 95% CI: 0.223-0.457). Moreover, compared with a single factor, the predictive value of combined factors was more significant (AUC = 0.810, 95% CI: 0.722-0.897). For the comparison of postoperative data in the two groups,, compared with the regular ICU stay group, the incidence of adverse events in the prolonged ICU stay group increased significantly, including limb disability of limbs (χ2 = 22.182; P < 0.001), severe organ injury (χ2 = 23.077; P < 0.001), tracheotomy (χ2 = 17.582; P < 0.001), reintubation (χ2 = 28.020; P < 0.001), 72 h tracheal extubation after surgery (χ2 = 29.335; P < 0.001), 12 h consciousness recovery after surgery (χ2 = 18.445; P < 0.001), ICU re-entering (χ2 = 9.496; P = 0.002) and irregular discharging (χ2 = 24.969; P < 0.001). CONCLUSION Emergency surgery, preoperative urea nitrogen, and CPB time are risk factors for postoperative prolonged ICU stay after TAAD surgery. Furthermore, prolonged ICU stay is associated with worse clinical outcomes. Hence, a reasonable strategy should be adopted proactively focusing on the risk factors to shorten ICU stays and improve clinical outcomes.
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Affiliation(s)
- Haiyuan Liu
- Department of Cardiovascular Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, 230061, Anhui Province, China
| | - Shuaipeng Zhang
- Department of Cardiovascular Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, 230061, Anhui Province, China
| | - Chengxin Zhang
- Department of Cardiovascular Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, 230061, Anhui Province, China
| | - Qinyun Gao
- Department of Cardiovascular Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, 230061, Anhui Province, China
| | - Yuyong Liu
- Department of Cardiovascular Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, 230061, Anhui Province, China
| | - Fangfang Liao
- Department of Infection Management, Second People's Hospital of Hefei, Hefei, 230011, Anhui Province, China
| | - Shenglin Ge
- Department of Cardiovascular Surgery, First Affiliated Hospital of Anhui Medical University, Hefei, 230061, Anhui Province, China.
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10
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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
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11
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Ahmad RA, Orelaru F, Arora A, Ling C, Kim KM, Fukuhara S, Patel H, Deeb GM, Yang B. Acute type A intramural hematoma: The less-deadly acute aortic syndrome? J Thorac Cardiovasc Surg 2024:S0022-5223(24)00090-4. [PMID: 38280668 DOI: 10.1016/j.jtcvs.2024.01.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 01/05/2024] [Accepted: 01/19/2024] [Indexed: 01/29/2024]
Abstract
OBJECTIVE To evaluate the short- and midterm outcomes of surgically managed acute type A intramural hematoma (IMH) versus classic acute type A aortic dissection (ATAAD). METHODS From 1996 to February 2023, a total of 106 patients with acute type A IMH and 795 patients with classic ATAAD presented for open aortic repair at our institution. Data were obtained from the local Society of Thoracic Surgeons' Data Warehouse and medical chart review. RESULTS Compared with the classic ATAAD group, the IMH group was older (65 vs 59 years, P < .001) and more likely to be female (45% vs 32%, P = .005), with fewer comorbidities such as severe aortic insufficiency (5.0% vs 25%, P < .001), acute stroke (2.8% vs 8.3%, P = .05), acute renal failure (5.7% vs 13%, P = .04), and malperfusion syndrome (8.5% vs 26%, P < .001) but more cardiac tamponade (18% vs 11%, P = .03). The IMH group had less aortic root replacement (15% vs 33%, P < .001), zone 2 arch replacements (9.4% vs 18%, P = .02), and shorter crossclamp times (120 minutes vs 150 minutes, P < .001). The operative mortality was significantly lower in the IMH group (0.9% vs 8.8%, P = .005) and a multivariable regression model showed IMH to be protective, odds ratio of 0.11, P = .03. The 10-year survival was similar between the 2 groups (65% vs 61%, P = .35). The hazard ratio of IMH for midterm mortality after surgery was 0.73, P = .12. CONCLUSIONS Acute type A IMH could be treated with emergency open aortic repair with excellent short- and midterm outcomes.
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Affiliation(s)
| | - Felix Orelaru
- Department of General Surgery, Trinity Health, Ann Arbor, Mich
| | - Akul Arora
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Carol Ling
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Karen M Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | | | - Himanshu Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - G Michael Deeb
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich.
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12
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Chen S, Peng H, Zhuang H, Wang J, Yan P, Zhang W, Zheng W, Li M, Wu X. Optimized strategy to improve the outcomes of acute type A aortic dissection with malperfusion syndrome. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00019-9. [PMID: 38218532 DOI: 10.1016/j.jtcvs.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/30/2023] [Accepted: 01/05/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND The mortality of acute type A aortic dissection (ATAAD) with malperfusion syndrome (MPS) is high. However, the management strategy remains controversial. We aimed to evaluate the strategy for MPS at our institution. METHODS Among 724 patients with ATAAD, 167 patients with MPS were treated with immediate central repair (first stage) or an optimized strategy (second stage). In the second stage, the optimized strategy used was based on 6-hour threshold from symptom onset. For MPS with symptom onset within 6 hours, immediate central repair was performed, followed by endovascular reperfusion if malperfusion persisted. With symptom onset beyond 6 hours, individualized delayed central repair was performed. We compared outcomes between the first and second stages. RESULTS The in-hospital mortality of ATAAD was significantly decreased when the optimized strategy was used (4.3% in the second stage vs 12.5% in the first stage; P < .01). In the second stage, the in-hospital mortality for MPS was decreased (10.2% vs 33.9%; P < .01). Moreover, the in-hospital mortality for MPS with symptom onset within 6 hours and beyond 6 hours decreased from 24% to 7.5% and from 41.2% to 11.8%, respectively. The operative mortality of MPS in the second stage was comparable to that in patients without MPS (4.0% vs 2.4%; P > .05). CONCLUSIONS The optimized strategy significantly improved the outcomes of MPS. The 6-hour threshold from symptom onset could be very useful in determining the timing of central repair. For patients with MPS symptom onset within 6 hours, immediate central repair is reasonable; for those with symptom onset beyond 6 hours, individualized delayed central repair should be considered.
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Affiliation(s)
- Shuangkun Chen
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Hua Peng
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Hui Zhuang
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Juxiang Wang
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Pianpian Yan
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Weiqun Zhang
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Weiliang Zheng
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Mingyu Li
- Fujian Provincial Key Laboratory of Innovative Drug Target Research, School of Pharmaceutical Sciences, Xiamen University, Xiamen, China
| | - Xijie Wu
- Department of Cardiac Surgery, Xiamen Cardiovascular Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China.
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13
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Garg K, Pergamo M, Jiang J, Smith D. Endovascular stenting of the ascending aorta for visceral malperfusion in a patient with type A aortic dissection. J Vasc Surg Cases Innov Tech 2023; 9:101341. [PMID: 37965114 PMCID: PMC10641677 DOI: 10.1016/j.jvscit.2023.101341] [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: 05/25/2023] [Accepted: 09/20/2023] [Indexed: 11/16/2023] Open
Abstract
A type A aortic dissection is a challenging condition for both cardiothoracic and vascular surgeons. Although open surgery remains the gold standard, there is considerable interest in the use of endovascular techniques for patients who present with malperfusion. We present the case of an unstable 55-year-old man with visceral malperfusion from a type A dissection who was stabilized using an endovascular technique as a bridge to open surgery. A bare metal thoracic endograft was used in the ascending aorta to rapidly restore perfusion. This hybrid approach to the problem of malperfusion in type A dissection could be useful for these patients with complicated cases.
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Affiliation(s)
- Karan Garg
- New York University Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Matthew Pergamo
- New York University Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Jeffrey Jiang
- New York University Grossman School of Medicine, NYU Langone Health, New York, NY
| | - Deane Smith
- New York University Grossman School of Medicine, NYU Langone Health, New York, NY
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14
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Minamidate N, Wakisaka H, Hachiro K, Miyashita F, Morimoto M, Kondo Y, Enomoto M, Takashima N, Suzuki T. Is central repair with coronary artery bypass grafting enough for multi-organ malperfusion in acute type A aortic dissection with coronary malperfusion? Asian J Surg 2023; 46:5449-5453. [PMID: 37311670 DOI: 10.1016/j.asjsur.2023.05.117] [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: 03/29/2023] [Revised: 05/22/2023] [Accepted: 05/25/2023] [Indexed: 06/15/2023] Open
Abstract
OBJECTIVES Acute type A aortic dissection with coronary malperfusion syndrome is rare but associated with high mortality. Multi-organ malperfusion is an independent predictor of acute type A aortic dissection. Coronary malperfusion requires treatment, but it is not feasible to treat all malperfusions. The adequacy of "central repair and coronary artery bypass grafting" for patients with coronary and other organ malperfusion is unknown. METHODS Of the 299 patients who underwent surgery between 2008 and 2018, 21 patients with coronary malperfusion, who received cental repair with coronary artery graft bypass, were analyzed retrospectively. They were divided; into Group M (n = 13, coronary and other organ malperfusion) and Group O (n = 8, coronary malperfusion only). The patient background, surgical content, details of malperfusion, surgical mortality and morbidity, and long-term outcome were compared. RESULTS There was no difference in operation time (205 ± 30 vs. 266 ± 88, p = 0.49), but the time from arrival to circulatory arrest tended to be shorter in Group M (81 vs. 134, p = 0.05). Among Group M, cerebral malperfusion was the most common at 92%. Two of the three cases with mesenteric malperfusion died. The mortality of Group M and Group O was 13% and 15% (P = 0.85), respectively. There was no difference in long-term mortality (p = 0.62). CONCLUSIONS Central repair and coronary artery bypass grafting is a sufficiently acceptable treatment for patients with acute type A aortic dissection and multi-organ malperfusion, including coronary malperfusion.
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Affiliation(s)
- Naoshi Minamidate
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan.
| | - Hodaka Wakisaka
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Kohei Hachiro
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Fumihiro Miyashita
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Masanori Morimoto
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Yasuo Kondo
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Masahide Enomoto
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Noriyuki Takashima
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
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15
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McClure RS, Lindsay TF, Keir M, Bayne JP, Berry RF, Chu MWA, Chung JCY, Dagenais F, Ducas RA, Duncan A, Horne G, Klass D, Mongeon FP, Richer J, Rommens KL. The Aortic Team Model and Collaborative Decision Pathways for the Management of Complex Aortic Disease: Clinical Practice Update From the Canadian Cardiovascular Society/Canadian Society of Cardiac Surgeons/Canadian Society for Vascular Surgery/Canadian Association for Interventional Radiology. Can J Cardiol 2023; 39:1484-1498. [PMID: 37949520 DOI: 10.1016/j.cjca.2023.07.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 07/30/2023] [Accepted: 07/31/2023] [Indexed: 11/12/2023] Open
Abstract
Disease of the aortic arch, descending thoracic, or thoracoabdominal aorta necessitates dedicated expertise across medical, endovascular, and surgical specialties. Cardiologists, cardiac surgeons, vascular surgeons, interventional radiologists, and others have expertise and skills that aid in the management of patients with complex aortic disease. No specialty is uniformly expert in all aspects of required care. Because of this dispersion of expertise across specialties, an aortic team model approach to decision-making and treatment is advocated. A nonhierarchical partnership across specialties within an interdisciplinary aortic clinic ensures that all treatment options are considered and promotes shared decision-making between the patient and all aortic experts. Furthermore, regionalization of care for aortic disease of increased complexity assures that the breadth of treatment options is available and that favourable volume-outcome ratios for high-risk procedures are maintained. An awareness of best practice care pathways for patient referrals for preventative management, acute care scenarios, chronic care scenarios, and pregnancy might facilitate a more organized management schema for aortic disease across Canada and improve lifelong surveillance initiatives.
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Affiliation(s)
- R Scott McClure
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada.
| | - Thomas F Lindsay
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Michelle Keir
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jason P Bayne
- Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Robert F Berry
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael W A Chu
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Jennifer C-Y Chung
- Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Francois Dagenais
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
| | - Robin A Ducas
- St Boniface Hospital, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Audra Duncan
- London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Gabrielle Horne
- QEII Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Darren Klass
- Vancouver Coastal Health, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Julie Richer
- University of Ottawa, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Kenton L Rommens
- Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
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16
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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: 2] [Impact Index Per Article: 2.0] [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.
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17
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Jassar AS. Care of patients with acute aortic syndromes: till death do us part. Eur J Cardiothorac Surg 2023; 64:ezad359. [PMID: 37882759 DOI: 10.1093/ejcts/ezad359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/25/2023] [Indexed: 10/27/2023] Open
Affiliation(s)
- Arminder S Jassar
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, USA
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18
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Lejot A, Ledieu G, Lenne X, Bruandet A, Delsart P, Girard A, Patterson B, Sobocinski J. Aortic dissection: results of the invasive treatment in France between 2012 and 2018 according to the French national database. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:526-533. [PMID: 37382212 DOI: 10.23736/s0021-9509.23.12570-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND To evaluate results of the invasive repair in the management of acute aortic dissection (AoD) in France. METHODS Patients admitted to hospital with acute AoD from 2012 to 2018 were identified. Patient demographics, severity score at admission, treatment strategy and in-hospital mortality were described. For patients undergoing intervention, perioperative complications rate was reported. A secondary analysis evaluating patients' outcome as regards of the annual caseload per center was conducted. RESULTS Overall, 14,706 patients with acute AoD were identified (male 64%, mean age 67, median modified Elixhauser score 5). The overall incidence increased during the study period (from 3.8 in 2012 to 4.4/100,000 in 2018) associated with a North-South gradient (respectively 3.6 vs. 4.7/100,000) and a winter peak; 45.5% (N.=6697) of patients received medical treatment alone. Among those with invasive repair, 6276 (78.3%) were defined as type A AoD (TAAD), whereas type B AoD (TBAD) accounted for 1733 patients (21.7%), of whom 1632 (94%) had TEVAR and 101 (6%) had other arterial procedures; 30-day mortality was respectively 18.9% in TAAD and 9.5% for TBAD. In high-volume centers (i.e. >20 AoD/year), a lower 3-month mortality of 22.3% was noted compared to 31.4% in the low-volume centres (P<0.001); 47% of patients reported ≥1 early major complication. TEVAR exhibited less complication (P<0.001) compared to other arterial reconstructions in TBAD. CONCLUSIONS The incidence of acute AoD increased in France over the period of the study and was associated with stable postoperative early mortality. Early postoperative mortality is significantly reduced in high-volume centers.
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Affiliation(s)
- Anais Lejot
- Department of Vascular Surgery, Aortic Center, University of Lille, Lille, France -
| | - Guillaume Ledieu
- Department of Cardiology, Aortic Center, University of Lille, Lille, France
| | - Xavier Lenne
- Department of Medical Information, University of Lille, Lille, France
- University of Lille, Lille, France
| | - Amelie Bruandet
- Department of Medical Information, University of Lille, Lille, France
- University of Lille, Lille, France
| | - Pascal Delsart
- Department of Cardiology, Aortic Center, University of Lille, Lille, France
| | - Audrey Girard
- Department of Medical Information, University of Lille, Lille, France
- University of Lille, Lille, France
| | - Benjamin Patterson
- Department of Vascular Surgery, University Hospital of Southampton, Southampton, UK
| | - Jonathan Sobocinski
- Department of Vascular Surgery, Aortic Center, University of Lille, Lille, France
- Department of Controlled Drug Delivery Systems and Biomaterials, University of Lille, Lille, France
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19
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Ogino H, Iida O, Akutsu K, Chiba Y, Hayashi H, Ishibashi-Ueda H, Kaji S, Kato M, Komori K, Matsuda H, Minatoya K, Morisaki H, Ohki T, Saiki Y, Shigematsu K, Shiiya N, Shimizu H, Azuma N, Higami H, Ichihashi S, Iwahashi T, Kamiya K, Katsumata T, Kawaharada N, Kinoshita Y, Matsumoto T, Miyamoto S, Morisaki T, Morota T, Nanto K, Nishibe T, Okada K, Orihashi K, Tazaki J, Toma M, Tsukube T, Uchida K, Ueda T, Usui A, Yamanaka K, Yamauchi H, Yoshioka K, Kimura T, Miyata T, Okita Y, Ono M, Ueda Y. JCS/JSCVS/JATS/JSVS 2020 Guideline on Diagnosis and Treatment of Aortic Aneurysm and Aortic Dissection. Circ J 2023; 87:1410-1621. [PMID: 37661428 DOI: 10.1253/circj.cj-22-0794] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Affiliation(s)
- Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Osamu Iida
- Cardiovascular Center, Kansai Rosai Hospital
| | - Koichi Akutsu
- Cardiovascular Medicine, Nippon Medical School Hospital
| | - Yoshiro Chiba
- Department of Cardiology, Mito Saiseikai General Hospital
| | | | | | - Shuichiro Kaji
- Department of Cardiovascular Medicine, Kansai Electric Power Hospital
| | - Masaaki Kato
- Department of Cardiovascular Surgery, Morinomiya Hospital
| | - Kimihiro Komori
- Division of Vascular and Endovascular Surgery, Department of Surgery, Nagoya University Graduate School of Medicine
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University
| | | | - Takao Ohki
- Division of Vascular Surgery, Department of Surgery, The Jikei University School of Medicine
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Graduate School of Medicine, Tohoku University
| | - Kunihiro Shigematsu
- Department of Vascular Surgery, International University of Health and Welfare Mita Hospital
| | - Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine
| | | | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University
| | - Hirooki Higami
- Department of Cardiology, Japanese Red Cross Otsu Hospital
| | | | - Toru Iwahashi
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Takahiro Katsumata
- Department of Thoracic and Cardiovascular Surgery, Osaka Medical College
| | - Nobuyoshi Kawaharada
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine
| | | | - Takuya Matsumoto
- Department of Vascular Surgery, International University of Health and Welfare
| | | | - Takayuki Morisaki
- Department of General Medicine, IMSUT Hospital, the Institute of Medical Science, the University of Tokyo
| | - Tetsuro Morota
- Department of Cardiovascular Surgery, Nippon Medical School Hospital
| | | | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University
| | - Kenji Okada
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | | | - Junichi Tazaki
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | - Masanao Toma
- Department of Cardiology, Hyogo Prefectural Amagasaki General Medical Center
| | - Takuro Tsukube
- Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital
| | - Keiji Uchida
- Cardiovascular Center, Yokohama City University Medical Center
| | - Tatsuo Ueda
- Department of Radiology, Nippon Medical School
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuo Yamanaka
- Cardiovascular Center, Nara Prefecture General Medical Center
| | - Haruo Yamauchi
- Department of Cardiac Surgery, The University of Tokyo Hospital
| | | | - Takeshi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medicine, Kyoto University
| | | | - Yutaka Okita
- Department of Surgery, Division of Cardiovascular Surgery, Kobe University Graduate School of Medicine
| | - Minoru Ono
- Department of Cardiac Surgery, Graduate School of Medicine, The University of Tokyo
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20
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Eranki A, Wilson-Smith AR, Williams ML, Gupta A, Flynn C, Iliopoulos J, Manganas C. The role of delayed aortic surgery in type A aortic dissection and mesenteric ischemia: a systematic review and meta-analysis. J Cardiothorac Surg 2023; 18:247. [PMID: 37596605 PMCID: PMC10439544 DOI: 10.1186/s13019-023-02341-y] [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: 11/23/2022] [Accepted: 07/21/2023] [Indexed: 08/20/2023] Open
Abstract
INTRODUCTION Approximately one third of patients with Acute Type A Aortic Dissection (ATAAD) present with pre-operative malperfusion syndromes (MPS). Of these, mesenteric malperfusion represents the greatest risk to patients with respect to increased short-term mortality. In select patients, it may be feasible to offer a staged approach by treating the mesenteric malperfusion first, optimizing the patient in the intensive care setting and then, following with a central aortic repair. The aim of this systematic review is to summarize cohort studies assessing the role of pre-operative interventions for mesenteric malperfusion. METHODS An electronic literature search of five databases was performed to identify all relevant studies providing studies examining short-term mortality on patients who underwent either endovascular or open revascularisation of mesenteric ischemia prior to central aortic repair. The primary outcome was all-cause, short-term mortality. Secondary outcomes were comparative mortality between a delayed repair vs. aortic repair first strategy, rates of postoperative laparotomy, bowel resection, and mortality following delayed aortic repair. RESULTS The search strategy identified 8 studies qualifying for inclusion, with a total of 180 patients who underwent delayed aortic surgery in the setting of mesenteric MPS. The weighted short-term mortality following a mesenteric revascularisation first, delayed aortic surgery strategy was 22.5%. This strategy was also associated with a significantly lower mortality than a central repair first strategy (OR 0.07, 95% CI 0.02-0.27), and a significantly lower rate of postoperative laparotomy/bowel resection (OR 0.05, 95% CI 0.02-0.14). If patients survive to receive central repair, the weighted short-term mortality postoperatively is low (2.1%). CONCLUSION A summary of this evidence reveals a lower short-term mortality in hemodynamically stable patients with mesenteric malperfusion, along with a reduction in postoperative laparotomy/bowel resections. Of those patients who survive to receive central repair, short-term mortality remains very low in the select group of hemodynamically stable patients. Further high-quality studies with randomized or propensity matched data are required to verify these results.
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Affiliation(s)
- Aditya Eranki
- Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.
- Department of Cardiothoracic Surgery, St George Hospital, Kograh, Sydney, 2217, Australia.
| | - Ashley R Wilson-Smith
- John Hunter Hospital, New Lambton Heights, Newcastle, Australia
- The Collaborative Research Group (CORE), Sydney, Australia
- The University of Sydney, Sydney, Australia
| | - Michael L Williams
- Department of Cardiothoracic Surgery, Gold Coast University Hospital, Gold Coast, Australia
| | - Aashray Gupta
- University of Adelaide, Adelaide, Australia
- Department of Cardiothoracic Surgery, St George Hospital, Kograh, Sydney, 2217, Australia
| | - Campbell Flynn
- Department of Cardiothoracic Surgery, St George Hospital, Kograh, Sydney, 2217, Australia
| | - Jim Iliopoulos
- Department of Vascular Surgery, St George Hospital, Kograh, Sydney, Australia
| | - Con Manganas
- Department of Cardiothoracic Surgery, St George Hospital, Kograh, Sydney, 2217, Australia
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21
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Ma M, Cao H, Li K, Pan J, Zhou Q, Tang X, Qin X, Zhu F, Wang D. Evaluation of Two Online Risk Prediction Models for the Mortality Rate of Acute Type A Aortic Dissection Surgery: The German Registry of Acute Aortic Dissection Type A Score and the European System for Cardiac Operative Risk Evaluation II. J Clin Med 2023; 12:4728. [PMID: 37510842 PMCID: PMC10381328 DOI: 10.3390/jcm12144728] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/26/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
EuroSCORE II is one of the most widely utilized cardiovascular surgery risk scoring systems. Recently, a new online score calculator, namely the German Registry of Acute Aortic Dissection Type A (GERAADA), was launched to predict 30-day surgical mortality for acute type A aortic dissection (ATAAD) patients. The aim of this study is to evaluate the predictive performance of these two scores. We calculated the two scores for 1346 ATAAD patients from January 2012 to December 2021. The overall performance was evaluated using Brier scores and Hosmer-Lemeshow statistics. Receiver Operating Characteristic (ROC) curves were employed to assess diagnostic ability, and the standardized mortality ratio (SMR) was utilized to evaluate calibration. The GERAADA score and EuroSCORE II predicted 30-day mortality rates of 14.7% and 3.1%, respectively, while the observed rate was 12.5%. The predictive ability of EuroSCORE II (AUC 0.708, 95% CI: 0.664-0.792) was superior to that of the GERAADA score (0.648, 95% CI: 0.605-0.692). The GERAADA score had higher sensitivity but lower specificity than EuroSCORE II. And the GERAADA score may overestimate mortality (0.76, 95% CI: 0.65-0.89), while EuroSCORE II may underestimate the mortality rate (3.17, 95% CI: 2.92-3.44). The EuroSCORE II was superior in predicting surgical mortality among ATAAD patients. But the observed 30-day mortality rate certified a good calibration for the GERAADA score.
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Affiliation(s)
- Ming Ma
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Hailong Cao
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Kai Li
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Jun Pan
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Qing Zhou
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Xinlong Tang
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Xichun Qin
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Feng Zhu
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Dongjin Wang
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
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22
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Ahmad RA, Orelaru F, Graham N, Titsworth M, Monaghan K, Wu X, Kim KM, Fukuhara S, Patel H, Deeb GM, Yang B. Progression of distal aorta after endovascular fenestration/stenting in acute type A aortic dissection with malperfusion syndrome. JTCVS OPEN 2023; 14:1-13. [PMID: 37425443 PMCID: PMC10328804 DOI: 10.1016/j.xjon.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 02/19/2023] [Accepted: 02/22/2023] [Indexed: 07/11/2023]
Abstract
Objective The study objective was to evaluate the progression of dissected distal aorta in patients with acute type A aortic dissection with malperfusion syndrome treated with endovascular fenestration/stenting and delayed open aortic repair. Methods From 1996 to 2021, 927 patients presented with acute type A aortic dissection. Of these, 534 had DeBakey I dissection with no malperfusion syndrome and underwent emergency open aortic repair (no malperfusion syndrome group), whereas 97 patients with malperfusion syndrome underwent fenestration/stenting and delayed open aortic repair (malperfusion syndrome group). Sixty-three patients with malperfusion syndrome treated with fenestration/stenting were excluded due to no open aortic repair, including death from organ failure (n = 31), death from aortic rupture (n = 16), and discharged alive (n = 16). Results Compared with the no malperfusion syndrome group, the malperfusion syndrome group had more patients with acute renal failure (60% vs 4.3%, P < .001). Both groups had similar aortic root and arch procedures. Postoperatively, the malperfusion syndrome group had similar operative mortality (5.2% vs 7.9%, P = .35) and permanent dialysis (4.7% vs 2.9%, P = .50), but more new-onset dialysis (22% vs 7.7%, P < .001) and prolonged ventilation (72% vs 49%, P < .001). The growth rate of the aortic arch (0.38 vs 0.35 mm/year, P = .81) was similar between the malperfusion syndrome and no malperfusion syndrome groups. The descending thoracic aorta growth rate (1.03 vs 0.68 mm/year, P = .001) and abdominal aorta growth rate (0.76 vs 0.59 mm/year, P = .02) were significantly higher in the malperfusion syndrome group. The cumulative incidence of reoperation over 10 years (18% vs 18%, P = .81) and 15-year survival outcome (50% vs 48%, P = .43) were similar between the malperfusion syndrome and no malperfusion syndrome groups. Conclusions Endovascular fenestration/stenting followed by delayed open aortic repair was a valid approach for patients with malperfusion syndrome.
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Affiliation(s)
| | - Felix Orelaru
- Department of General Surgery, St Joseph Mercy, Ann Arbor, Mich
| | - Nathan Graham
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Marc Titsworth
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Katelyn Monaghan
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Karen M. Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | | | - Himanshu Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - G. Michael Deeb
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
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23
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Carrel T, Sundt TM, von Kodolitsch Y, Czerny M. Acute aortic dissection. Lancet 2023; 401:773-788. [PMID: 36640801 DOI: 10.1016/s0140-6736(22)01970-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/04/2022] [Accepted: 09/27/2022] [Indexed: 01/13/2023]
Abstract
Although substantial progress has been made in the prevention, diagnosis, and treatment of acute aortic dissection, it remains a complex cardiovascular event, with a high immediate mortality and substantial morbidity in individuals surviving the acute period. The past decade has allowed a leap forward in understanding the pathophysiology of this disease; the existing classifications have been challenged, and the scientific community moves towards a nomenclature that is likely to unify the current definitions according to morphology and function. The most important pathophysiological pathway, namely the location and extension of the initial intimal tear, which causes a disruption of the media layer of the aortic wall, together with the size of the affected aortic segments, determines whether the patient should undergo emergency surgery, an endovascular intervention, or receive optimal medical treatment. The scientific evidence for the management and follow-up of acute aortic dissection continues to evolve. This Seminar provides a clinically relevant overview of potential prevention, diagnosis, and management of acute aortic dissection, which is the most severe acute aortic syndrome.
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Affiliation(s)
- Thierry Carrel
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland.
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts' General Hospital, Harvard Medical School, Boston, MA, USA
| | - Yskert von Kodolitsch
- Department of Vascular Medicine, German Aortic Center, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Germany; Faculty of Medicine, Albert Ludwig University Freiburg, Freiburg, Germany
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24
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Nakai C, Izumi S, Haraguchi T, Henmi S, Nakayama S, Mikami T, Tsukube T. Impact of time from symptom onset to operation on outcome of repair of acute type A aortic dissection with malperfusion. J Thorac Cardiovasc Surg 2023; 165:984-991.e1. [PMID: 33941373 DOI: 10.1016/j.jtcvs.2021.03.102] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 03/22/2021] [Accepted: 03/22/2021] [Indexed: 12/21/2022]
Abstract
OBJECTIVES We analyzed patients with acute type A aortic dissection complicated by malperfusion syndrome to establish whether the timing of operative treatment and the location of malperfusion are factors in determining outcomes. METHODS A total of 331 patients with acute type A aortic dissection were treated surgically between August 2003 and May 2019. Eighty-four patients (25%) presented with preoperative malperfusion syndrome. Fifty-eight patients with malperfusion syndrome (69%) were transferred to the operating room within 5 hours of the onset of symptoms (immediate repair); 26 patients (31%) were transferred after 5 hours (later repair). We analyzed the effects of immediate aortic repair on surgical outcomes. RESULTS There was no significant difference in the early mortality rates between patients with immediate and later aortic repair, which were 20.0% (n = 11/58) and 26.9% (n = 7/19), respectively (P = .12). Preoperative coronary malperfusion was the only predictor of early mortality. The cumulative 5-year survivals of patients with malperfusion syndrome in the immediate and later repair groups were 76.7% and 45.4%, respectively. A significant difference was noted in the long-term outcomes between the 2 groups (P = .02). On multivariable Cox survival analysis, coronary malperfusion and shock on arrival were associated with increased long-term mortality (P < .01 and P = .04). Conducting surgery within 5 hours of the onset of symptoms was a significant predictor of favorable long-term outcome (P = .03). CONCLUSIONS Although preoperative coronary malperfusion and shock on arrival worsened the long-term outcomes in patients undergoing aortic repair for acute type A aortic dissection with preoperative malperfusion syndrome, conducting an operation within 5 hours of the onset of symptoms significantly improved their long-term outcomes.
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Affiliation(s)
- Chikashi Nakai
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan
| | - So Izumi
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan
| | - Tomonori Haraguchi
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan
| | - Soichiro Henmi
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan
| | - Shinichi Nakayama
- Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center, Kobe, Japan
| | | | - Takuro Tsukube
- Division of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, Kobe, Japan.
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25
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Persistent malperfusion after central aortic repair in acute type I aortic dissections. J Vasc Surg 2023; 77:1618-1624. [PMID: 36796591 DOI: 10.1016/j.jvs.2023.02.004] [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: 01/06/2023] [Revised: 01/28/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Acute dissection involving the ascending aorta and extending beyond the innominate artery (DeBakey type I) may be associated with acute ischemic complications owing to branch artery malperfusion. The purpose of this study was to document the prevalence of noncardiac ischemic complications associated with type I aortic dissections that persisted after initial ascending aortic and hemiarch repair, necessitating vascular surgery intervention. METHODS Consecutive patients presenting with acute type I aortic dissections between 2007 and 2022 were studied. Patients who underwent initial ascending aortic and hemiarch repair were included in the analysis. Study end points included the need for additional interventions after ascending aortic repair and death. RESULTS There were 120 patients (70% men; mean age, 58 ± 13 years) who underwent emergent repair for acute type I aortic dissections during the study period. Forty-one patients (34%) presented with acute ischemic complications. These included 22 (18%) with leg ischemia, 9 (8%) with acute strokes, 5 (4%) with mesenteric ischemia, and 5 (4%) with arm ischemia. After proximal aortic repair, 12 patients (10%) had persistent ischemia. Nine patients (8%) required additional interventions for persistent leg ischemia (n = 7), intestinal gangrene (n = 1), or cerebral edema (craniotomy, n = 1). Three other patients with acute stroke had permanent neurologic deficits. All other ischemic complications resolved after the proximal aortic repair despite mean operative times exceeding 6 hours. Comparing patients with persistent ischemia with those whose symptoms resolved after central aortic repair, there were no differences in demographics, distal extent of dissection, mean operative time for aortic repair, or need for venous-arterial extracorporeal bypass support. Overall, 6 of the 120 patients (5%) suffered perioperative deaths. Hospital deaths occurred in 3 of the 12 patients (25%) with persistent ischemia vs none of 29 patients who had resolution of the ischemia after aortic repair (P = .02). Over a mean follow-up of 51 ± 39 months, no patient required an additional intervention for persistent branch artery occlusion. CONCLUSIONS One-third of patients with acute type I aortic dissections had associated noncardiac ischemia, prompting a vascular surgery consultation. Limb and mesenteric ischemia most often resolved after the proximal aortic repair and did not require further intervention. No vascular interventions were performed in patients with stroke. Although the presence of acute ischemia at presentation did not increase hospital or 5-year mortality rates, persistent ischemia after central aortic repair seems to be a marker for increased hospital mortality after type I dissections.
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26
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Jia B, Luo C, Li C, Ge Y, Zhong Y, Qiao Z, Hu H, Chen S, Zhu J. The Anzhen Risk Scoring System for Acute Type A Aortic Dissection: A Prospective Observational Study Protocol. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2023. [DOI: 10.15212/cvia.2023.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023] Open
Abstract
Introduction: Acute type A aortic dissection (ATAAD) is a catastrophic disease with fatal outcomes. Malperfusion syndrome (MPS) is a serious complication of ATAAD, with an incidence of 20–40%. Many studies have shown that MPS is the main risk factor for poor ATAAD prognosis. However, a risk scoring system for ATAAD based on MPS is lacking. Here, we designed a risk scoring system for ATAAD to assess mortality through quantitative assessment of relevant organ malperfusion and subsequently develop rational treatment strategies.
Methods and analysis: This was a prospective observational study. Patients’ perioperative clinical data were collected to establish a database of ATAAD (N≥3000) and determine whether these patients had malperfusion complications. The Anzhen risk scoring system was established on the basis of organ malperfusion by using a random forest survival model and a logistics model. The better method was then chosen to establish a revised risk scoring system.
Ethics and dissemination: This study received ethical approval from the Ethics Committees of Beijing Anzhen Hospital, Capital Medical University (KS2019034-1). Patient consent was waived because biological samples were not collected, and no patient rights were violated. Findings will be disseminated at scientific conferences and in peer-reviewed publications.
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Affiliation(s)
- Bo Jia
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Cheng Luo
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Chengnan Li
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Yipeng Ge
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Yongliang Zhong
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Zhiyu Qiao
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Haiou Hu
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Suwei Chen
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Capital Medical University Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center of Vascular Prostheses, Beijing, China
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Lee GH, Heo W, Lee Y, Kim TH, Huh H, Song SW, Ha H. Fluid-structure interaction simulation of visceral perfusion and impact of different cannulation methods on aortic dissection. Sci Rep 2023; 13:1116. [PMID: 36670162 PMCID: PMC9860063 DOI: 10.1038/s41598-023-27855-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 01/09/2023] [Indexed: 01/22/2023] Open
Abstract
Hemodynamics in aortic dissection (AD) is closely associated with the risk of aortic aneurysm, rupture, and malperfusion. Altered blood flow in patients with AD can lead to severe complications such as visceral malperfusion. In this study, we aimed to investigate the effect of cannulation flow on hemodynamics in AD using a fluid-structure interaction simulation. We developed a specific-idealized AD model that included an intimal tear in the descending thoracic aorta, a re-entry tear in the left iliac artery, and nine branches. Two different cannulation methods were tested: (1) axillary cannulation (AC) only through the brachiocephalic trunk and (2) combined axillary and femoral cannulation (AFC) through the brachiocephalic trunk and the right common iliac artery. AC was found to result in the development of a pressure difference between the true lumen and false lumen, owing to the difference in the flow rate through each lumen. This pressure difference collapsed the true lumen, disturbing blood flow to the celiac and superior mesenteric arteries. However, in AFC, the pressure levels between the two lumens were similar, and no collapse occurred. Moreover, the visceral flow was higher than that in AC. Lastly, the stiffness of the intimal flap affected the true lumen's collapse.
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Affiliation(s)
- Gyu-Han Lee
- Department of Interdisciplinary Program in Biohealth-Machinery Convergence Engineering, Kangwon National University, Chuncheon, Republic of Korea
| | - Woon Heo
- Vascular Access Center, Lifeline Clinic, Busan, Republic of Korea
| | - Youngjin Lee
- Department of Smart Health Science and Technology, Kangwon National University, 1 Gangwondaehak-Gil, Chuncheon, 24341, Republic of Korea
| | - Tae-Hoon Kim
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-Ro, Gangnam-Gu, Seoul, 06273, Republic of Korea
| | - Hyungkyu Huh
- Daegu-Gyeongbuk Medical Innovation Foundation, Medical Device Development Center, Daegu, Republic of Korea
| | - Suk-Won Song
- Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, 211 Eonju-Ro, Gangnam-Gu, Seoul, 06273, Republic of Korea.
| | - Hojin Ha
- Department of Smart Health Science and Technology, Kangwon National University, 1 Gangwondaehak-Gil, Chuncheon, 24341, Republic of Korea.
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28
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Shiiya N. Management of noncerebral malperfusion complicating acute type A dissection. Asian Cardiovasc Thorac Ann 2023; 31:26-31. [PMID: 35167355 DOI: 10.1177/02184923211069812] [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
Vital organ malperfusion in acute type A aortic dissection is associated with worse outcomes, especially when multiple organ systems are involved, and when coronary or mesenteric malperfusion is present. To achieve the two goals of central aortic repair and adequate and timely reperfusion, mechanism and organ-specific strategy in the methods and sequence of repair should be considered. For dynamic aortic malperfusion, reperfusion can be quickly achieved by femoral artery perfusion, and the fenestrated frozen elephant trunk operation, in which the proximal end of device is secured to zone 1 or 2 and distal 1 or 2 supra-aortic vessels are preserved by fenestration of the fabric, seems optimal as a method of central aortic repair. For coronary malperfusion, percutaneous coronary intervention before central aortic repair may have a role. However, it should be kept in mind that the door-to-unloading time is also important to reduce the area of myocardial infarction, and retrograde cardioplegia is not distributed to most of the right ventricle, which can be critical when right coronary malperfusion is present. Static mesenteric malperfusion should be addressed first, and second-look laparotomy should not be hesitated after central aortic repair. The use of a hybrid operating room may be an optimal solution to achieve both goals.
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Affiliation(s)
- Norihiko Shiiya
- First Department of Surgery, Hamamatsu University School of Medicine, Hamamatsu, Japan
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Dalal AR, Dossabhoy S, Heng E, Yasin A, Leipzig MM, Bonham SA, Fischbein MP, Lee JT, Woo YJ, Watkins AC. Midterm Outcomes in Type A Aortic Dissection Repair With and Without Malperfusion in a Hybrid Operating Room. Semin Thorac Cardiovasc Surg 2022:S1043-0679(22)00280-5. [PMID: 36567047 DOI: 10.1053/j.semtcvs.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
Treatment approach to type A aortic dissection with malperfusion, immediate open aortic repair vs upfront endovascular treatment, remains controversial. From January 2017 to July 2021, 301 consecutive type A repairs were evaluated at our institution. Starting in 2019, all type A aortic dissections were performed in a fixed-fluoroscopy, hybrid operating room. Propensity score matching was used to control baseline patient characteristics between traditional and hybrid operating room approaches. There were 144 patients in the traditional group and 157 in the hybrid group. In the hybrid group, 41% (64/157) underwent intraoperative angiograms, and of those, 58% (37/64) received at least 1 endovascular intervention. Following propensity matching, 125 patients remained in each the traditional and hybrid groups. Thirty-day survival was significantly improved in the hybrid cohort at 96.7% (122/125) as compared to the traditional cohort at 87.2% (109/125) (P = 0.002). There were no significant differences in perioperative paralysis (1.6% vs 1.6%, P > 0.9), new hemodialysis (12% vs 9.6%, P = 0.5), fasciotomy (2.4% vs 5.6%, P = 0.20, and exploratory laparotomy (1.6% vs 4.8%, P = 0.3). The hybrid operating room approach to type A aortic dissection, provides the ability to immediately assess distal malperfusion and perform endovascular interventions at the time of open aortic repair, and is associated with significantly higher 30-day and 2-year survival when compared to a stepwise repair approach in a traditional operating room.
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Affiliation(s)
- Alex R Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Shernaz Dossabhoy
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Elbert Heng
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Aleena Yasin
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Matthew M Leipzig
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Spencer A Bonham
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - Jason T Lee
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California
| | - A Claire Watkins
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, California.
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30
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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: 346] [Impact Index Per Article: 173.0] [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.
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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
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31
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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: 114] [Impact Index Per Article: 57.0] [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.
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32
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Chandra VM, Norton EL, Khaja MS, Herrera DG, Williams DM, Yang B. Surgical and endovascular repair for type B aortic dissections with mesenteric malperfusion syndrome: A systematic review of in-hospital mortality. JTCVS OPEN 2022; 12:37-50. [PMID: 36590716 PMCID: PMC9801243 DOI: 10.1016/j.xjon.2022.07.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 07/06/2022] [Accepted: 07/20/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVES Mesenteric malperfusion is a feared complication of aortic dissection, with high mortality. The purpose of this study was to systematically review in-hospital mortality (IHM) of endovascular and surgical management of acute and chronic Stanford type B aortic dissections (TBAD) complicated by mesenteric malperfusion (MesMP). METHODS A systematic search of English language articles was conducted in relevant databases. Data on patient demographics, procedure details, and survival outcomes were collected. Reports were classified by type of intervention performed. Studies that failed to report patient-level outcomes based on specific intervention performed or IHM were excluded. Retrospective chart review of previously published data from a single institution was also performed to further identify cases of TBAD that were managed endovascularly. The Fisher exact test was performed to determine statistical significance. RESULTS In total, 37 articles were suitable for inclusion in this systematic review, which yielded 149 patients with a median age 55.0 years (interquartile range, 46.5-65 years) and 79% being male. Overall, in-hospital mortality was 12.8% (19/149) and was similar between endovascular and open surgical interventions (13% vs 11%, P = .99). Among endovascular strategies, IHM was greater, although not statistically significant in the thoracic endovascular aortic repair group compared with the fenestration/stenting without thoracic endovascular aortic repair group (24% vs 11%, P = .15). CONCLUSIONS Multiple strategies exist for the management of TBAD with MesMP; however, a majority of cases were managed endovascularly. Despite advances in therapies, mortality remains high at 13%.
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Affiliation(s)
- Vishnu M. Chandra
- Division of Vascular and Interventional Radiology, Department of Radiology & Medical Imaging, University of Virginia Health, Charlottesville, Va
| | - Elizabeth L. Norton
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, Ga
| | - Minhaj S. Khaja
- Division of Vascular and Interventional Radiology, Department of Radiology & Medical Imaging, University of Virginia Health, Charlottesville, Va
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan, Ann Arbor, Mich
| | - Daniel Giraldo Herrera
- Division of Vascular and Interventional Radiology, Department of Radiology & Medical Imaging, University of Virginia Health, Charlottesville, Va
| | - David M. Williams
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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33
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Xu X, Wu Y, Wu Z. Revascularization-first strategy versus central repair-first strategy for acute type A aortic dissection complicated with mesenteric malperfusion syndrome: A meta-analysis. J Card Surg 2022; 37:4427-4433. [PMID: 36217990 DOI: 10.1111/jocs.17006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Revised: 08/03/2022] [Accepted: 09/07/2022] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The optimal therapeutic strategy for acute type A aortic dissection (ATAAD) accompanied by mesenteric malperfusion syndrome (mMPS) has not been fully elucidated. The intent of this meta-analysis was to analyze the effectiveness and safety of the revascularization-first strategy among patients with ATAAD complicated with mMPS through comprehensive comparisons with the central repair-first strategy. METHODS Studies relevant to the comparison of the outcomes of early reperfusion combined with delayed proximal aortic repair and initial central repair in the treatment of ATAAD complicated with mMPS, were systematacially searched using PubMed, Cochrane Library, Web of Science and Embase up to June 30, 2022. And the primary outcome was early mortality, with mesenteric complications, adverse aortic events and hypothermic circulatory arrest (HCA) time served as the secondary outcomes. Screening of the relevant studies, data extraction, and assessment of the included studies were conducted by two authors independently. Standard statistical procedures provided in Review Manager 5.3 were used to perform all statistical analyses. RESULTS Five studies comprising 72 patients in total were included into the quantitative synthesis. In-hospital/30-day mortality was significantly reduced in patients receiving the revascularization-first strategy than in those with the central repair-first strategy, with a pooled risk ratio (RR) of 0.46 (p = .04, 95% confidence interval [CI]: 0.22-0.95). The revascularization-first strategy resulted in a lower incidence of mesenteric complications compared with the central repair-first strategy, with a pooled RR of 0.15 (p = .0002, 95% CI: 0.05-0.41). Moreover, no significant difference was found in the comparison of the revascularization-first strategy and central repair-first strategy regarding adverse aortic events (p = .31, 95% CI: 0.44-12.78). Compared with central repair-first, a longer HCA time was observed in revascularization-first with mean difference of 9.91 (p = .02, 95% CI: 1.34-18.48). CONCLUSIONS The revascularization-first strategy presented a lower in-hospital/30-day mortality and mesenteric complications than the central repair-first strategy without increasing the incidence of adverse aortic events. However, the revascularization-first strategy indicated a longer HCA time than the central repair-first strategy.
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Affiliation(s)
- Xiaokang Xu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yunqiu Wu
- Department of Breast Surgery, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zhong Wu
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
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34
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Chang Y, Guo H, Yu C, Sun X, Yang K, Qian X. Visceral protection in total arch replacement for aortic dissection: Effect of lower body hypothermia. J Card Surg 2022; 37:4841-4849. [PMID: 36352779 DOI: 10.1111/jocs.17104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 10/12/2022] [Accepted: 10/27/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Optimal hypothermia strategy for total arch replacement in acute type A aortic dissection (ATAAD) is unclear. A higher temperature during circulatory arrest might reduce tolerance to ischemia for visceral organs. We sought to investigate the effect of hypothermia on visceral protection. METHODS From January 2010 to December 2019, 1138 consecutive patients underwent total arch replacement combined with frozen elephant trunk for acute type A aortic dissection. The data were retrospectively collected and analyzed. Visceral organ injury and visceral-related adverse outcomes were defined as acute renal failure or spinal cord injury or both. Multivariate logistic regression analysis and multivariate linear regression model were used. RESULTS The mean age of patient was 46.9 ± 10.0 years, with a male preponderance (79.6%). Operative mortality was 6.1% (69 patients). Spinal cord injury occurred in 55 (4.8%) patients and 133 (11.7%) patients had acute renal failure. In the multivariate logistic regression model, neither bladder temperature (odds ratio [OR] 0.971, 95% confidence interval [CI] 0.922-1.024, p = .278) nor circulatory arrest duration (OR 1.017, 95% CI 0.987-1.047, p = .267) significantly associated with visceral-related adverse outcomes. Female, lower limb malperfusion, age, cardiopulmonary bypass (CPB) duration and preoperative serum creatinine level were independent risk factors of visceral-related outcomes. There was a significant negative correlation between bladder temperature and CPB duration in multiple linear regression model (β = -3.67, p < .0001). CONCLUSIONS Bladder temperature had no effect on outcomes related to visceral protection under the premise of short circulatory arrest duration, but female gender, lower limb malperfusion, age, CPB duration, and preoperative serum creatinine level were independent risk factors. Bladder temperature negatively correlated to CPB duration.
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Affiliation(s)
- Yi Chang
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, P. R. China
| | - Hongwei Guo
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, P. R. China
| | - Cuntao Yu
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, P. R. China
| | - Xiaogang Sun
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, P. R. China
| | - Kan Yang
- Department of Cardiovascular Surgery, Nanyang central hospital, Nanyang, P. R. China
| | - Xiangyang Qian
- Department of Vascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, P. R. China
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35
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Acharya MN, Mariscalco G. Central aortic or mesenteric malperfusion repair first in acute type A aortic dissection: Still an unanswered question? J Card Surg 2022; 37:4434-4436. [PMID: 36217988 DOI: 10.1111/jocs.17010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/28/2022] [Indexed: 12/30/2022]
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36
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Kawaguchi Y, Fukumoto Y, Tamaki M, Kitamura H. Delayed bowel necrosis due to inferior mesenteric artery occlusion in Stanford type A acute aortic dissection. Interact Cardiovasc Thorac Surg 2022; 35:6772523. [PMID: 36282531 PMCID: PMC9641710 DOI: 10.1093/icvts/ivac265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 10/23/2022] [Indexed: 11/09/2022] Open
Abstract
Although inferior mesenteric artery occlusion due to acute aortic dissection sometimes occurs, it is usually not considered an important finding. Herein, we present an extremely rare case of delayed bowel ischaemia due to inferior mesenteric artery occlusion in Stanford type A acute aortic dissection that highlights the need for cardiac surgeons to be mindful of inferior mesenteric artery occlusion in patients with superior mesenteric artery dissection or vascular anomalies in the mesenteric arteries.
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Affiliation(s)
- Yasuhiko Kawaguchi
- Corresponding author. Department of Cardiovascular Surgery, Nagoya Heart Center, 1-1-14, Sunadabashi, Higashi-ward, Nagoya 4610045, Japan. Tel: +81-52-719-0810; fax: +81-52-719-0811; e-mail: (Y. Kawaguchi)
| | - Yuichiro Fukumoto
- Department of Cardiovascular Surgery, Nagoya Heart Center, Nagoya, Japan
| | - Mototsugu Tamaki
- Department of Cardiovascular Surgery, Nagoya Heart Center, Nagoya, Japan
| | - Hideki Kitamura
- Department of Cardiovascular Surgery, Nagoya Heart Center, Nagoya, Japan
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37
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Norton EL, Kim KM, Fukuhara S, Monaghan KP, Naeem A, Wu X, Ailawadi G, Patel HJ, Deeb GM, Yang B. Autologous blood transfusion in acute type A aortic dissection decreased blood product consumption and improved postoperative outcomes. JTCVS OPEN 2022; 12:20-29. [PMID: 36590717 PMCID: PMC9801237 DOI: 10.1016/j.xjon.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 06/02/2022] [Accepted: 06/22/2022] [Indexed: 01/04/2023]
Abstract
Objective To evaluate the effect of autologous blood use on blood product consumption and outcomes after acute type A aortic dissection repair. Methods From 2010 to October 2020, 497 patients underwent open acute type A aortic dissection repair, including those with autologous blood harvesting before cardiopulmonary bypass and transfusion after cardiopulmonary bypass (autologous blood transfusion [ABT], n = 397) and without autologous blood harvesting and transfusion (No-ABT, n = 100). The median ABT volume was 900 mL. Using propensity score matching, 89 matched pairs were identified based on age, sex, body mass index, preoperative hemoglobin, acute preoperative stroke, previous cardiac surgery, and cardiogenic shock. Results After propensity score matching, both groups were similar in demographic characteristics and aortic procedures. The ABT group required significantly less intraoperative transfusion of blood products (6 vs 11 units; P < .0001), including packed red blood cells (2 vs 4), fresh frozen plasma (2 vs 4), platelets (2 vs 2), and cryoprecipitate (0 vs 1); and combined intraoperative and postoperative transfusion (9 vs 13; P < .001). ABT was protective against intra- and postoperative blood product transfusion (odds ratio, 0.28; P = .01). The ABT group had significantly less sepsis, acute renal failure requiring dialysis, reintubation, and shorter intubation times and postoperative lengths of stay. Operative mortality was 6.7% in the ABT group versus 13% in the No-ABT group (P = .14). The midterm survival was similar between the 2 groups (5 year: 76% vs 74%). ABT had a hazard ratio of 0.81 for midterm mortality (P = .41). Conclusions Autologous blood transfusion was associated with better short-term outcomes and could be used routinely for acute type A aortic dissection repair. External multicenter prospective validation would be warranted.
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Affiliation(s)
- Elizabeth L. Norton
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Karen M. Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | | | | | - Aroma Naeem
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Gorav Ailawadi
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | | | - G. Michael Deeb
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich,Address for reprints: Bo Yang, MD, PhD, Department of Cardiac Surgery, Michigan Medicine, 5155 Frankel Cardiovascular Center, 1500 E Medical Center Dr, Ann Arbor, MI 48109.
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38
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Treating lower extremity malperfusion syndrome in acute type A aortic dissection with endovascular revascularization followed by delayed aortic repair. JTCVS OPEN 2022; 10:101-110. [PMID: 36408122 PMCID: PMC9667713 DOI: 10.1016/j.xjon.2022.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 02/17/2022] [Indexed: 11/23/2022]
Abstract
Objective To assess the outcomes of emergency revascularization with endovascular fenestration/stenting followed by delayed open aortic repair in patients with acute type A aortic dissection with lower extremity (LE) malperfusion syndrome (MPS); that is, necrosis and dysfunction of the lower extremity. Methods From 1996 to 2019, among 760 consecutive acute type A aortic dissection patients 512 patients had no malperfusion syndrome (Non-MPS), whereas 26 patients had LE-MPS with/without renal MPS and underwent endovascular fenestration/stenting, open aortic repair, or both. Patients with coronary, cerebral, mesenteric, and celiac MPS, or managed with thoracic endovascular aortic repair, were excluded (n = 222). All patients with LE-MPS underwent upfront endovascular fenestration/stenting except 1 patient (with signs of rupture) who initially underwent emergency open aortic repair. Results Among the LE-MPS patients, 17 (65%) had LE pain, 15 (58%) had abnormal motor function with 8 (31%) having paralysis, 10 (38%) had LE pallor, 17 (65%) had LE paresthesia, and 20 (77%) had LE pulselessness. Of the 25 patients undergoing upfront endovascular fenestration/stenting, 16 went on to open aortic repair, 3 survived to discharge without aortic repair, and 6 died before aortic repair (3-aortic rupture and 3-organ failure). In-hospital mortality among all patients was significantly higher in the LE-MPS group (31% vs 6.3%; P = .0003). Among those undergoing open aortic repair, postoperative outcomes were similar between groups, including operative mortality (18% vs 6.5%; P = .10). LE-MPS was a significant risk factor for in-hospital mortality (odds ratio, 6.0 [1.9, 19]; P = .002). Conclusions In acute type A aortic dissection, LE-MPS was associated with high in-hospital mortality. Emergency revascularization with endovascular fenestration/stenting followed by delayed open aortic repair may be a reasonable approach.
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Song M, Deng L, Shen H, Zhang G, Shi H, Zhu E, Xia Q, Han H. Th1, Th2, and Th17 cells are dysregulated, but only Th17 cells relate to C-reactive protein, D-dimer, and mortality risk in Stanford type A aortic dissection patients. J Clin Lab Anal 2022; 36:e24469. [PMID: 35522124 DOI: 10.1002/jcla.24469] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND T helper (Th) cells are closely involved in vascular inflammation, endothelial dysfunction, and atherogenesis, which are the hallmarks of aortic dissection (AD). This study aimed to evaluate the clinical value of Th1, Th2, and Th17 cell measurements in Stanford type A AD patients. METHODS Stanford type A AD patients (N=80) and non-AD patients with chest pain (N = 40) were recruited. Then, Th1, Th2, and Th17 cells in peripheral blood CD4+ T cells from all participants were detected by flow cytometry. The 30-day mortality of Stanford type A AD patients was recorded. RESULTS Th1 and Th17 cells were higher, while Th2 cells were lower in Stanford type A AD patients compared with non-AD patients (all p < 0.001). Meanwhile, Th1 cells (area under curve (AUC): 0.734, 95% confidence interval (CI): 0.640-0.828), Th2 cells (AUC: 0.841, 95% CI: 0.756-0.925), and Th17 cells (AUC: 0.898, 95% CI: 0.839-0.957) could distinguish Stanford type A patients from non-AD patients. Moreover, Th1 cells (p = 0.037) and Th17 cells (p = 0.001) were positively related to CRP, and Th17 cells (p = 0.039) were also positively associated with D-dimer in Stanford type A AD patients. Furthermore, Th17 cells were elevated in deaths compared with survivors (p = 0.001), also, it could estimate 30-day mortality risk in Stanford type A AD patients with an AUC of 0.741 (95% CI: 0.614-0.867), which was similar to the value of CRP (AUC: 0.771, 95% CI: 0.660-0.882), but lower than the value of D-dimer (AUC: 0.818, 95% CI: 0.722-0.913). CONCLUSION Th1, Th2, and Th17 cells are dysregulated, but only the Th17 cells relate to CRP, D-dimer, and 30-day mortality risk in Stanford type A AD patients.
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Affiliation(s)
- Mowei Song
- Department of Cardiology, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Li Deng
- Department of Extracorporeal Life Support, The People's Hospital of Gaozhou, Gaozhou, China
| | - Hongtao Shen
- Department of Orthopedic Surgery, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Guofu Zhang
- Department of Cardiovascular Surgery, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Hang Shi
- Department of Cardiovascular Surgery, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Erjun Zhu
- Department of Cardiovascular Surgery, The First Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Qingping Xia
- Department of Science and Education, The People's Hospital of Gaozhou, Gaozhou, China
| | - Hongguang Han
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China
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Wang D, Zhang H, Du L, Zhai Q, Hu G, Gao W, Zhang A, Wang S, Hao Y, Shang K, Liu X, Gao Y, Muyesai N, Ma Q. Early Prediction Model of Acute Aortic Syndrome Mortality in Emergency Departments. Int J Gen Med 2022; 15:3779-3788. [PMID: 35418773 PMCID: PMC8995175 DOI: 10.2147/ijgm.s357910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 03/23/2022] [Indexed: 11/26/2022] Open
Abstract
Purpose Acute aortic syndrome is a constellation of life-threatening medical conditions for which rapid assessment and targeted intervention are important for the prognosis of patients who are at high risk of in-hospital death. The current study aims to develop and externally validate an early prediction mortality model that can be used to identify high-risk patients with acute aortic syndrome in the emergency department. Patients and Methods This retrospective multi-center observational study enrolled 1088 patients with acute aortic syndrome admitted to the emergency departments of two hospitals in China between January 2017 and March 2021 for model development. A total of 210 patients with acute aortic syndrome admitted to the emergency departments of Peking University Third Hospital between January 2007 and December 2021 was enrolled for model validation. Demographics and clinical factors were collected at the time of emergency department admission. The predictive variables were determined by referring to the results of previous studies and the baseline analysis of this study. The study’s endpoint was in-hospital death. To assess internal validity, we used a fivefold cross-validation method. Model performance was validated internally and externally by evaluating model discrimination using the area under the receiver-operating characteristic curve (AUC). A nomogram was developed based on the binary regression results. Results In the development cohort, 1088 patients with acute aortic syndromes were included, and 88 (8.1%) patients died during hospitalization. In the validation cohort, 210 patients were included, and 20 (9.5%) patients died during hospitalization. The final model included the following variables: digestive system symptoms (OR=2.25; P=0.024), any pulse deficit (OR=7.78; P<0.001), creatinine (µmol/L)(OR=1.00; P=0.018), lesion extension to iliac vessels (OR=4.49; P<0.001), pericardial effusion (OR=2.67; P=0.008), and Stanford type A (OR=10.46; P<0.001). The model’s AUC was 0.838 (95% CI 0.784–0.892) in the development cohort and 0.821 (95% CI 0.750–0.891) in the validation cohort, and the Hosmer–Lemeshow test showed p=0.597. The fivefold cross-validation demonstrated a mean accuracy of 0.94, a mean precision of 0.67, and a mean recall of 0.13. Conclusion This risk prediction tool uses simple variables to provide robust prediction of the risk of in-hospital death from acute aortic syndrome and validated well in an independent cohort. The tool can help emergency clinicians quickly identify high-risk acute aortic syndrome patients, although further studies are needed for verifying the prospective data and the results of our study.
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Affiliation(s)
- Daidai Wang
- Department of Emergency Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Hua Zhang
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Lanfang Du
- Department of Emergency Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Qiangrong Zhai
- Department of Emergency Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Guangliang Hu
- Department of Emergency Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Wei Gao
- Department of Emergency Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Anyi Zhang
- Department of Emergency Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Sa Wang
- Department of Emergency Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Yajuan Hao
- Department of Emergency Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Kaijian Shang
- Department of Emergency Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
- Department of Emergency Medicine, Second hospital of Shanxi Medical University, Shanxi, People’s Republic of China
| | - Xueqing Liu
- Department of Emergency Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
| | - Yanxia Gao
- Department of Emergency Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, People’s Republic of China
| | - Nijiati Muyesai
- Department of Emergency Medicine, Xinjiang Ulger Municipal People’s Hospital, Urumqi, People’s Republic of China
| | - Qingbian Ma
- Department of Emergency Medicine, Peking University Third Hospital, Beijing, People’s Republic of China
- Correspondence: Qingbian Ma; Nijiati Muyesai, Tel +86 15611908229, Email ;
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Buech J, Radner C, Fabry TG, Horke KM, Ali A, Saha S, Hagl C, Pichlmaier MA, Peterss S. Visceral and renal malperfusion syndromes in acute aortic dissection type A: the fate of the branch vessel. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:117-123. [PMID: 35238524 DOI: 10.23736/s0021-9509.22.12276-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Malperfusion in acute aortic dissection is not uncommonly observed and associated with a highly significant increase in mortality and morbidity. Of the various malperfusion syndromes, visceral and renal involvement is the most challenging in terms of correct and timely diagnosis as well as the choice of management strategy. The aim of this study was to identify the pathology and associated fate of each visceral and renal vessel in acute type A dissections. METHODS Over a 12-year period, 167 consecutive patients with acute dissection type A extending into the thoracoabdominal aorta were included and radiographic images analyzed with a focus on individual branch vessel pathology and dependent organ perfusion. RESULTS Sixty-five patients (39%) were diagnosed with radiological signs of malperfusion on the CT Images. Of those, 20% expired during the hospital stay, compared to 8% without malperfusion. The left renal artery was the most frequently affected by dissection (31%) or false lumen supply (28%). False lumen perfusion was more often associated with manifest malperfusion than an extension of the dissection flap into the branch vessel. During the study period, there was no preference of surgical procedure treating the malperfusion. CONCLUSIONS Malperfusion of the visceral/renal branches of a dissected aorta represents a manifest indicator for postoperative mortality and morbidity. Neither clinical outcome, nor the fate of individual vessels can reliably be predicted prior to proximal reconstruction and thus, surgical strategy cannot generally be defined alone by radiological findings.
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Affiliation(s)
- Joscha Buech
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Caroline Radner
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Thomas G Fabry
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Konstanze M Horke
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Ahmad Ali
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Shekhar Saha
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
| | - Christian Hagl
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site of Munich Heart Alliance, Munich, Germany
| | | | - Sven Peterss
- Department of Cardiac Surgery, LMU University Hospital, Munich, Germany -
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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.
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Shetty V, Shetty DP, Rao PV, Hosabettu PK, Subramanian S, Vikneswaran G, Narayan P. Determinant of outcome in late presenting type A aortic dissection. J Card Surg 2022; 37:1654-1660. [DOI: 10.1111/jocs.16401] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Varun Shetty
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Devi Prasad Shetty
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Parachuri Venkat Rao
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Praveen Kumar Hosabettu
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Sendur Subramanian
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Gunaseelan Vikneswaran
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
| | - Pradeep Narayan
- Department of Cardiothoracic Surgery Narayana Institute of Cardiac Sciences Bengaluru Karnataka India
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Inoue Y, Inoue M, Koga M, Koizumi S, Yokawa K, Masada K, Seike Y, Sasaki H, Yoshitani K, Minatoya K, Matsuda H. Novel brain computed tomography perfusion for cerebral malperfusion secondary to acute type A aortic dissection. Interact Cardiovasc Thorac Surg 2022; 35:6537619. [PMID: 35218663 PMCID: PMC9336564 DOI: 10.1093/icvts/ivac046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Revised: 02/05/2022] [Accepted: 02/06/2022] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVES The management of acute type A aortic dissection with malperfusion syndrome remains challenging. To evaluate preoperative condition, symptoms might be subjective and objective evaluation of cerebral artery has not yet been established. For quantitative evaluation, this study focused on brain computed tomography perfusion (CTP), which has been recommended by several guidelines of acute ischaemic stroke. METHODS In the last 2 years, 147 patients hospitalized due to acute type A aortic dissection were retrospectively reviewed. Among the 23 (16%) patients with cerebral malperfusion, 14 who underwent brain CTP (6 preoperative and 8 postoperative) were enrolled. CTP parameters, including regional blood flow and time to maximum, were automatically computed using RApid processing of Perfusion and Diffusion software. The median duration from the onset to hospital arrival was 129 (31-659) min. RESULTS Among the 6 patients who underwent preoperative CTP, 4 with salvageable ischaemic lesion (penumbra: 8-735 ml) without massive irreversible ischaemic lesion (ischaemic core: 0-31 ml) achieved acceptable neurological outcomes after emergency aortic replacement regardless of preoperative neurological severity. In contrast, 2 patients with an ischaemic core of >50 ml (73, 51 ml) fell into a vegetative state or neurological death due to intracranial haemorrhage. CTP parameters guided postoperative blood pressure augmentation without additional supra-aortic vessel intervention in the 8 patients who underwent postoperative CTP, among whom 6 achieved normal neurological function regardless of common carotid true lumen stenosis severity. CONCLUSIONS CTP was able to detect irreversible ischaemic core, guide critical decisions in preoperative patients and aid in determining the blood pressure augmentation for postoperative management focusing on residual brain ischaemia.
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Affiliation(s)
- Yosuke Inoue
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shigeki Koizumi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koki Yokawa
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenta Masada
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshimasa Seike
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hiroaki Sasaki
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenji Yoshitani
- Department of Transfusion, Department of Anesthesiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenji Minatoya
- Department of Cardiovascular Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hitoshi Matsuda
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan,Corresponding author. Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 6-1 Kishibe-shimmachi, Suita, Osaka 564-8565, Japan. Tel: +81-6-6170-1070; fax: +81-6-6170-1782; e-mail: (H. Matsuda)
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Shetty V, Shales S, Narayan P. Lactate levels: A reliable tool to predict mortality in acute type A aortic dissections? J Card Surg 2022; 37:1212-1214. [PMID: 35172380 DOI: 10.1111/jocs.16322] [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: 01/26/2022] [Accepted: 01/27/2022] [Indexed: 11/28/2022]
Abstract
Lactate levels are surrogate markers of malperfusion in patients presenting with type A aortic dissections. Lactate measurement is simple, easy to perform, universally available, and thus can be an important tool for predicting mortality. However, the discriminatory power varies between studies and no cut-off point has been defined that can determine outcomes in the most reliable fashion. The risk prediction based on lactate levels can be improved when combined with other clinical and laboratory prognostic factors. Further studies with a much larger sample size, need to be carried out using serial measurements at well-defined time points to try and identify a cut-off value. The addition of lactate values to existing risk prediction scores or developing a new score based on it should be the subject of future research.
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Affiliation(s)
- Varun Shetty
- Department of Cardiac Surgery, Narayana Institute of Cardiac Sciences, Narayana Health, Bengaluru, Karnataka, India
| | - Sufina Shales
- Department of Cardiac Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India
| | - Pradeep Narayan
- Department of Cardiac Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, West Bengal, India
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Tanaka A, Trudell A, Smith-Washington A, Hoffstaetter T, Goldenberg R, Vemulapalli S, del Río-Solá L, Arnaoutakis GJ, Mussa F, Ota T. Knowledge Gaps in Surgical Management for Aortic Dissection. Semin Vasc Surg 2022; 35:35-42. [DOI: 10.1053/j.semvascsurg.2022.02.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 02/15/2022] [Accepted: 02/16/2022] [Indexed: 11/11/2022]
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Malperfusion in acute type A aortic dissection: how we handle the challenge? Indian J Thorac Cardiovasc Surg 2022; 38:122-131. [PMID: 35463696 PMCID: PMC8980967 DOI: 10.1007/s12055-021-01292-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 10/19/2022] Open
Abstract
Malperfusion syndrome (MPS) complicating acute type A aortic dissection (ATAAD) poses a continuing challenge and management dilemma for cardiovascular surgeons. MPS may involve any of the major arterial side branches resulting in myocardial, cerebral, spinal cord, visceral, and/or limb ischemia with varying frequency and severity. Despite the continuous improvement in diagnosis and management strategies for MPS with ATAAD, clinical outcomes remain poor and the optimal therapy is still debatable. The present review aimed to assess current evidence on ATAAD patients with MPS and how best to handle the challenge.
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King RW, Bonaca MP. Acute aortic syndromes: a review of what we know and future considerations. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2021; 10:1197-1203. [PMID: 34849689 DOI: 10.1093/ehjacc/zuab106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 10/26/2021] [Indexed: 12/27/2022]
Abstract
Acute aortic syndromes represent a spectrum of life-threatening aortic pathologies. Prompt diagnosis and proper management of these syndromes are important in reducing overall mortality and morbidity, which remains high. Acute aortic dissections represent most of these aortic wall pathologies, but intramural haematomas and penetrating atherosclerotic ulcers have been increasingly diagnosed. Type A dissections require prompt surgical treatment, with endovascular options on the horizon. Type B dissections can be complicated or uncomplicated, and treatment is determined based on this designation. Complicated Type B dissections require prompt repair with thoracic endovascular aortic repair (TEVAR) becoming the preferred method. Uncomplicated Type B dissections require medical management, but early TEVAR in the subacute setting is becoming more prominent. Proper surveillance for an uncomplicated Type B dissection is crucial in detecting aortic degeneration and need for intervention. Intramural haematomas and penetrating atherosclerotic ulcers are managed similarly to aortic dissections, but more research is needed to determine the proper management algorithms. Multi-disciplinary aortic programmes have been shown to improve patient outcomes and are necessary in optimizing long-term follow-up.
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Affiliation(s)
- R Wilson King
- CPC Clinical Research, 2115 N. Scranton St., Suite 2040 Aurora, CO, USA.,Department of Surgery, University of Colorado, Aurora, CO, USA
| | - Marc P Bonaca
- CPC Clinical Research, 2115 N. Scranton St., Suite 2040 Aurora, CO, USA.,Department of Medicine, University of Colorado, Aurora, CO, USA
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Heo W, Lee GH, Kim TH, Lee Y, Huh H, Ha H, Song SW, Yoo KJ. Quantification of visceral perfusion and impact of femoral cannulation: in vitro model of aortic dissection. Eur J Cardiothorac Surg 2021; 62:6469048. [PMID: 34921317 DOI: 10.1093/ejcts/ezab508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 10/18/2021] [Accepted: 11/01/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We aimed to simulate blood flow at an aortic dissection in an in vitro vascular model and assess the impact of the cannulation method on visceral perfusion. METHODS An aortic-dissection model with an acrylic aortic wall and silicone intimal flap was developed to study visceral perfusion under various cannulation conditions. The primary tear was placed in the proximal descending aorta and the re-entry site in the left common iliac artery. A cardiovascular pump was used to reproduce a normal pulsatile aortic flow and a steady cannulation flow. Axillary and axillary plus femoral cannulation were compared at flow rates of 3-7 l/min. Haemodynamics were analysed by using four-dimensional flow magnetic resonance imaging. RESULTS Axillary cannulation (AC) was found to collapse the true lumen at the coeliac and superior mesentery arteries, while combined axillary and femoral cannulation did not change the size of the true lumen. Combined axillary and femoral cannulation resulted in a larger visceral flow than did AC alone. When axillary plus femoral cannulation was used, the visceral flow increased by 125% at 3 l/min, by 89% at 4 l/min, by 67% at 5 L/min, by 98% at 6 l/min and by 101% at 7 l/min, respectively, compared to those with the AC only. CONCLUSIONS Our model was useful to understanding the haemodynamics in aortic dissection. In this specific condition, we confirmed that the intimal flap motion can partially block blood flow to the coeliac and superior mesenteric arteries and that additional femoral cannulation can increase visceral perfusion.
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Affiliation(s)
- Woon Heo
- Department of Medicine, Yonsei University Graduate School, Seoul, Republic of Korea.,Department of Thoracic and Cardiovascular Surgery, Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Gyu-Han Lee
- Department of Mechanical and Biomedical Engineering, Interdisciplinary Program in Biohealth-Machinery Convergence Engineering, Kangwon National University, Chuncheon, Republic of Korea
| | - Tae-Hoon Kim
- Department of Medicine, Yonsei University Graduate School, Seoul, Republic of Korea.,Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Youngjin Lee
- Department of Mechanical and Biomedical Engineering, Interdisciplinary Program in Biohealth-Machinery Convergence Engineering, Kangwon National University, Chuncheon, Republic of Korea
| | - Hyungkyu Huh
- Daegu-Gyeongbuk Medical Innovation Foundation, Medical Device development Center, Daegu, Republic of Korea
| | - Hojin Ha
- Department of Mechanical and Biomedical Engineering, Interdisciplinary Program in Biohealth-Machinery Convergence Engineering, Kangwon National University, Chuncheon, Republic of Korea
| | - Suk-Won Song
- Department of Medicine, Yonsei University Graduate School, Seoul, Republic of Korea.,Department of Thoracic and Cardiovascular Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung-Jong Yoo
- Department of Medicine, Yonsei University Graduate School, Seoul, Republic of Korea.,Department of Cardiovascular Surgery, Cardiovascular Hospital, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Addressing malperfusion first before repairing type A dissection. JTCVS Tech 2021; 10:1-5. [PMID: 34977693 PMCID: PMC8690294 DOI: 10.1016/j.xjtc.2021.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 04/21/2021] [Indexed: 11/29/2022] Open
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