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Chandiramani A, Al-Tawil M, Rajasekar T, Elleithy A, Kakar S, Haneya A, Zeinah M, Harky A. Incidence Rates of Penn Classes and Class-Specific Mortality in Acute Type A Aortic Dissection Patients: An Epidemiologic Systematic Review and Meta-Analysis. J Cardiothorac Vasc Anesth 2024; 38:1558-1568. [PMID: 38644098 DOI: 10.1053/j.jvca.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 02/28/2024] [Accepted: 03/13/2024] [Indexed: 04/23/2024]
Abstract
Acute type A aortic dissection (ATAAD) is a life-threatening emergency that is associated with a high morbidity and mortality rate. One of the complications is end-organ ischemia, a known predictor of mortality. The primary aims of this meta-analysis were to summarize the findings of observational studies investigating the utility of the Penn classification system and to analyze the incidence rates and mortality patterns within each class. The electronic databases PubMed, MEDLINE, and Embase were searched through to April 2023. These were filtered by multiple reviewers to give 10 studies that met the inclusion criteria. The extracted data included patient characteristics, and primary outcomes were the incidence rates of different Penn classes, along with the corresponding mortality for each class. Out of 1,512 studies identified during the initial search, 10 studies, including 4,494 patients, met the inclusion criteria. The pooled incidence of Penn A was highest at 0.55 (95% CI 0.52, 0.58), followed by Penn B at 0.21 (95% CI 0.17, 0.25), and finally Penn C at 0.14 (95% CI 0.11, 0.17). Patients with Penn BC were found to be at the highest risk of death, as their early mortality rates were 0.36 (95% CI 0.31, 0.41). Within those populations, the subtype with the highest individual mortality was Penn C at 0.21 (95% CI 0.15, 0.27), followed by Penn B at 0.19 (95% CI 0.15, 0.23) and Penn A at 0.07 (95% CI 0.05, 0.10). Among patients presenting with ATAAD, class A was most frequently observed, followed by classes B, C, and BC. These findings indicate an incremental increase in mortality rates with the progression of Penn classification.
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Affiliation(s)
| | | | | | | | - Sahil Kakar
- Department of Ear, Nose, and Throat Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Mohamed Zeinah
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.
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Ishikawa N, Narita M, Shirasaka T, Ushioda R, Tsutsui M, Azuma N, Kamiya H. Role of Helicopter Transfer and Cloud-Type Imaging for Acute Type A Aortic Dissection. Thorac Cardiovasc Surg 2024; 72:105-117. [PMID: 36758638 PMCID: PMC10914492 DOI: 10.1055/a-2031-3763] [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: 07/26/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND This study explored if long-distance transfer was safe for patients suffering from acute aortic dissection type A (AADA) and also analyzed the effectiveness of helicopter transfer and cloud-type imaging transfer systems for such patients in northern Hokkaido, Japan. METHODS AND RESULTS The study included 112 consecutive patients who underwent emergency surgical treatment for AADA from April 2014 to September 2020. The patients were divided into two groups according to the location of referral source hospitals: the Asahikawa city group (group A, n = 49) and the out-of-the-city group (group O, n = 63). Use of helicopter transfer (n = 13) and cloud-type telemedicine (n = 20) in group O were reviewed as subanalyses.Transfer distance differed between groups (4.2 ± 3.5 km in group A vs 107.3 ± 69.2 km in group O; p = 0.0001), but 30-day mortality (10.2% in group A vs 7.9% in group O; p = 0.676) and hospital mortality (12.2% in group A vs 9.5% in group O; p = 0.687) did not differ. Operative outcomes did not differ with or without helicopter and cloud-type telemedicine, but diagnosis-to-operation time was shorter with helicopter (240.0 ± 70.8 vs 320.0 ± 78.5 minutes; p = 0.031) and telemedicine (242.0 ± 75.2 vs 319.0 ± 83.8 minutes; p = 0.007). CONCLUSION We found that long-distance transfer did not impair surgical outcomes in AADA patients, and both helicopter transfer and cloud-type telemedicine system could contribute to the reduction of diagnosis-to-operation time in the large Hokkaido area. Further studies are mandatory to investigate if both the systems will improve clinical outcomes.
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Affiliation(s)
- Natsuya Ishikawa
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Masahiko Narita
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Tomonori Shirasaka
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Ryouhei Ushioda
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Masahiro Tsutsui
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Nobuyoshi Azuma
- Department of Vascular Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Hokkaido, Japan
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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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Ghoneim A, Ouzounian M, Peterson MD, El-Hamamsy I, Dagenais F, Chu MWA. Commentary: Timely repair of acute aortic dissection: Every minute counts. J Thorac Cardiovasc Surg 2023; 165:993-994. [PMID: 33972110 DOI: 10.1016/j.jtcvs.2021.04.026] [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: 04/11/2021] [Revised: 04/11/2021] [Accepted: 04/12/2021] [Indexed: 10/21/2022]
Affiliation(s)
| | | | | | - Ismail El-Hamamsy
- Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Francois Dagenais
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Quebec City, Quebec, Canada
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Asai T. Commentary: Swift reaction to malperfusion saves lives. J Thorac Cardiovasc Surg 2023; 165:992-993. [PMID: 33994000 DOI: 10.1016/j.jtcvs.2021.04.017] [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: 04/07/2021] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 11/22/2022]
Affiliation(s)
- Tohru Asai
- Department of Cardiovascular Surgery, Juntendo University, Tokyo, Japan.
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Hui L, Wang D, Liu T, Liu B, Wang Y, Liu B. Diagnostic performance of transthoracic echocardiography in screening acute type A aortic dissection from ST-segment elevated myocardial infarction. Cardiovasc Diagn Ther 2022; 12:603-613. [PMID: 36329963 PMCID: PMC9622407 DOI: 10.21037/cdt-22-59] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 09/05/2022] [Indexed: 07/25/2023]
Abstract
BACKGROUND When patients with type A acute aortic dissection (TAAAD) present with changes to their ST-segment, diagnostic and treatment delays increase significantly. The performance of transthoracic echocardiography (TTE) screening of TAAAD in patients with ST-segment elevated myocardial infarction (STEMI) is yet to be validated. METHODS The diagnostic performance of TTE alone and combined with the aortic dissection risk score (ADRS) in TAAAD was evaluated. In this retrospective study (ChiCTR, No. 2000031291), TTE was reviewed to detect direct/indirect signs of TAAAD. The ADRS of each patient was calculated according to guidelines. Case adjudication was based on advanced imaging and surgery. RESULTS Among a total of 442 patients, TAAAD was diagnosed in 146 (33.0%). The presence of direct TTE signs had a sensitivity of 43.0% [95% confidence interval (CI): 35.0% to 52.0%] and specificity of 97.0% (95% CI: 95.0% to 99.0%), and the presence of any TTE sign had a sensitivity of 97.0% (95% CI: 93.0% to 99.0%) and specificity of 78.0% (95% CI: 73.0% to 82.0%) for TAAAD. The additive value of TTE was most evident in patients with low clinical probability for TAAAD (ADRS ≤1). The presence of ADRS ≤1 plus an absence of direct TTE signs for TAAAD rule-out had a sensitivity of 98.4% (95% CI: 96.1% to 99.6%). CONCLUSIONS The use of TTE adds value in the screening of TAAAD in STEMI patients. In patients with low clinical probability for TAAAD, direct TTE signs can be used to rapidly identify those who require advanced imaging.
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Affiliation(s)
- Lili Hui
- Department of Cardiology, Shanghai General Hospital, Nanjing Medical University, Shanghai, China
- Department of Cardiology, Suzhou Kowloon Hospital, School of Medicine, Shanghai Jiao Tong University, Suzhou, China
| | - Di Wang
- Department of Cardiology, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
| | - Tao Liu
- Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Bingjie Liu
- Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, Nanchong, China
| | - Yi Wang
- Department of Cardiology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bei Liu
- Department of Cardiology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Sugiyama K, Watanuki H, Tochii M, Futamura Y, Kitagawa Y, Makino S, Ohashi W, Matsuyama K. Impact of GERAADA score in patients with acute type A aortic dissection. J Cardiothorac Surg 2022; 17:127. [PMID: 35606857 PMCID: PMC9128089 DOI: 10.1186/s13019-022-01858-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/24/2022] [Indexed: 11/24/2022] Open
Abstract
Background Despite continuous developments and advances in the perioperative management of patients suffering from acute aortic dissection type A (AADA), the associated postoperative morbidity and mortality remain high and strongly depend on the preoperative clinical status. The associated postoperative mortality is still hard to predict prior to the surgical procedure. The so-called German Registry of Acute Aortic Dissection Type A (GERAADA) score uses very basic and easily retrievable parameters and was specifically designed for predicting the 30-day mortality rate in patients undergoing surgery for AADA. This study evaluated impact of the GERAADA score in the authors’ institutional results. Methods Among 101 acute type A aortic dissection patients treated at our hospital during August 2015–March 2021, the GERAADA was calculated individually and retrospectively. Predicted and actual mortalities were assessed, and independent predicted factors were searched. The primary endpoint was defined as comparison of GERAADA scores and early mortality, and the secondary endpoints were defined as comparison of GERAADA scores and other postoperative results, and comparison of preoperative factors and postoperative results regardless to GERAADA scores.
Results While the overall 30-day mortality for the entire study cohort calculated by the GERAADA score was 14.3 (8.1–77.6)%, the actual mortality rate was 6%. However, the GERAADA score was significantly high in some postoperative complications and showed significant correlation with some peri- and post-operative factors. In addition, factors not belonging to GERAADA score such as time from onset to arrival at the hospital, time from onset to arrival at the operation room, spouse presence, and hemodialysis were significantly associated with 30-day mortality. Conclusions Although the actual mortality was lower than predicted, GERAADA score may impact on the postoperative course. In addition, it would be desirable to add parameters such as the time from onset to arrival, family background, and hemodialysis for further accuracy.
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Affiliation(s)
- Kayo Sugiyama
- Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi, 480-1195, Japan.
| | - Hirotaka Watanuki
- Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi, 480-1195, Japan
| | - Masato Tochii
- Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi, 480-1195, Japan
| | - Yasuhiro Futamura
- Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi, 480-1195, Japan
| | - Yuka Kitagawa
- Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi, 480-1195, Japan
| | - Satoshi Makino
- Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi, 480-1195, Japan
| | - Wataru Ohashi
- Clinical Research Center, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi, 480-1195, Japan
| | - Katsuhiko Matsuyama
- Department of Cardiac Surgery, Aichi Medical University Hospital, 1-1 Yazako Karimata, Nagakute, Aichi, 480-1195, Japan
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