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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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2
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Hoell NG, Beck CJ, Laczynski D, Lyden SP, Kirksey L, Rowse JW, Quatromoni JG, Bena J, Caputo FJ. Late Referral and Patient Transfer is Associated with Worse Outcomes for Patients Presenting with Initially Uncomplicated Type B Aortic Dissections. Ann Vasc Surg 2024; 98:131-136. [PMID: 37356655 DOI: 10.1016/j.avsg.2023.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Acute type B aortic dissections (TBADs) can become complicated at any time point, necessitating surgical repair. We sought to investigate the effect of interhospital transfer on the development of delayed complications in acute type B aortic dissection (dcTBAD). METHODS All patients who presented with acute TBAD to a tertiary aortic center from 2015 to 2019 were analyzed. Patients were divided into initially complicated type B aortic dissection (icTBAD) (0-24 hours from symptom onset), dcTBAD (25 hours to 14 days), and uncomplicated type B aortic dissection (ucTBAD) groups. Criteria for complicated dissection were aortic rupture, malperfusion, or rapid aortic growth. Demographics, patient history, the timing of presentation, imaging findings, and clinical outcomes were compared between groups. RESULTS Of 120 acute TBADs included, 27 (22%) were initially complicated (aortic rupture, n = 9; malperfusion, n = 18). Twenty-one (18%) developed delayed complications (aortic rupture, n = 3; malperfusion, n = 14; rapid growth, n = 4) at a median of 7.0 [4.0, 9.0] days from symptom onset. Seventy-two (60%) remained uncomplicated. Overall, 111 (93%) presented as transfers from outside hospitals (icTBAD, n = 25; dcTBAD, n = 21; ucTBAD, n = 65). Of those, dcTBADs were more likely to have a prolonged delay between presentation to the outside hospital and referral to the tertiary center compared to ucTBADs (median = 1.00 [0.0, 5.0] days delayed vs. 0.00 [0.0, 0.0] days delayed; P < 0.001). Initially uncomplicated patients referred for transfer ≥24 hours from presentation went on to develop dcTBAD more often than those transferred in <24 hours (73% vs 13%; P < 0.001). Of dcTBADs, 38% had no high-risk features on initial imaging. Patients with dcTBAD had significantly longer length of stay (median = 12 vs 7 days; P = 0.006). In-hospital mortality was significantly higher in dcTBADs than ucTBADs (9.5% vs 0%; P = 0.047). In-hospital mortality was not significantly different between dcTBADs and icTBADs (9.5% vs. 11%; P > 0.05). CONCLUSIONS The incidence and consequence of dcTBADsare not insignificant. Late referral and transfer to a tertiary aortic center (≥24 hours from initial presentation) was associated with dcTBADsrequiring surgical intervention. The development of dcTBADwas associated with increased length of stay and increased in-hospital mortality.
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Affiliation(s)
- Nicholas G Hoell
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
| | - Cassandra J Beck
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - David Laczynski
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sean P Lyden
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Levester Kirksey
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jarrad W Rowse
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jon G Quatromoni
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - James Bena
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Francis J Caputo
- Department of Vascular Surgery, Aortic Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
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3
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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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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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5
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Ginzberg SP, Roberson JL, Nehemiah A, Ballester JMS, Warshauer AK, Wachtel H, Erdman MS, Dlugosz KL, George LJ, Lynn JC, Martin ND, Myers JS. Time to Transfer as a Quality Improvement Imperative: Implications of a Hub-and-Spoke Health System Model on the Timing of Emergency Procedures. Jt Comm J Qual Patient Saf 2023; 49:539-546. [PMID: 37422425 DOI: 10.1016/j.jcjq.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 07/10/2023]
Abstract
BACKGROUND In the increasingly prevalent hub-and-spoke health system model, specialized services are centralized at a hub hospital, while spoke hospitals offer more limited services and transfer patients to the hub as needed. In one urban, academic health system, a community hospital without procedural capabilities was recently incorporated as a spoke. The goal of this study was to assess the timeliness of emergent procedures for patients presenting to the spoke hospital under this model. METHODS The authors performed a retrospective cohort study of patients transferred from the spoke hospital to the hub hospital for emergency procedures after the health system restructuring (April 2021-October 2022). The primary outcome was the proportion of patients who arrived within their goal transfer time. Secondary outcomes were time from transfer request to procedure start and whether procedure start occurred within guideline-recommended treatment time frames for ST-elevation myocardial infarction (STEMI), necrotizing soft tissue infection (NSTI), and acute limb ischemia (ALI). RESULTS A total of 335 patients were transferred for emergency procedural intervention during the study period, most commonly for interventional cardiology (23.9%), endoscopy or colonoscopy (11.0%), or bone or soft tissue debridement (10.7%). Overall, 65.7% of patients were transferred within the goal time. 23.5% of patients with STEMI met goal door-to-balloon time, and more patients with NSTI (55.6%) and ALI (100%) underwent intervention within the guideline-recommended time frame. CONCLUSION A hub-and-spoke health system model can provide access to specialized procedures in a high-volume, resource-rich setting. However, ongoing performance improvement is required to ensure that patients with emergency conditions receive timely intervention.
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Mehta CK, Chiu S, Hoel AW, Vassallo P, Whippo B, Andrei AC, Schmidt MJ, Pham DT, Johnston DR, Churyla A, Malaisrie SC. Implementation of a direct-to-operating room aortic emergency transfer program: Expedited management of type A aortic dissection. Am J Emerg Med 2023; 70:113-118. [PMID: 37270850 DOI: 10.1016/j.ajem.2023.05.036] [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: 04/21/2023] [Revised: 05/10/2023] [Accepted: 05/23/2023] [Indexed: 06/06/2023] Open
Abstract
INTRODUCTION Type A Aortic Dissection (TAAD) is a surgical emergency with a time-dependent rate of mortality. We hypothesized that a direct-to-operating room (DOR) transfer program for patients with TAAD would reduce time to intervention. METHODS A DOR program was started at an urban tertiary care hospital in February 2020. We performed a retrospective study of adult patients undergoing treatment for TAAD before (n = 42) and after (n = 84) implementation of DOR. Expected mortality was calculated using the International Registry of Acute Aortic Dissection risk prediction model. RESULTS Median time from acceptance of transfer from emergency physician to operating room arrival was 1.37 h (82 min) faster in DOR compared to pre-DOR (1.93 h vs 3.30 h, p < 0.001). Median time from arrival to operating room was 1.14 h (72 min) faster after DOR compared to pre-DOR (0.17 h vs 1.31 h, p < 0.001). In-hospital mortality was 16.2% in pre-DOR, with an observed-to-expected (O/E) ratio of 1.03 (p = 0.24) and 12.0% in the DOR group, with an O/E ratio of 0.59 (p < 0.001). CONCLUSION Creation of a DOR program resulted in decreased time to intervention. This was associated with a decrease in observed-to-expected operative mortality. The transfer of patients with acute type A aortic dissection to centers with direct-to-OR programs may result in decreased time from diagnosis to surgery.
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Affiliation(s)
- Christopher K Mehta
- Division of Cardiac Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA.
| | - Stephen Chiu
- Division of Cardiac Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - Andrew W Hoel
- Division of Vascular Surgery, Department of Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - Patricia Vassallo
- Division of Cardiology, Department of Medicine, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - Beth Whippo
- Division of Cardiology, Department of Medicine, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - Adin Cristian Andrei
- Division of Biostatistics, Department of Preventative Medicine, Northwestern University, Chicago, IL, USA
| | - Michael J Schmidt
- Department of Emergency Medicine, Northwestern University, Chicago, IL, USA
| | - Duc Thinh Pham
- Division of Cardiac Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - Douglas R Johnston
- Division of Cardiac Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - Andrei Churyla
- Division of Cardiac Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
| | - S Chris Malaisrie
- Division of Cardiac Surgery, Northwestern Feinberg School of Medicine and Northwestern Medicine, Chicago, IL, USA
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7
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Greve* D, Werner* D, Stroux A, Möckel M, Falk V, Dominik Kurz S. Air Rescue of Patients With Acute Aortic Syndromes. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:483-484. [PMID: 37661319 PMCID: PMC10487669 DOI: 10.3238/arztebl.m2023.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 11/09/2022] [Accepted: 02/09/2023] [Indexed: 09/05/2023]
Affiliation(s)
- Dustin Greve*
- *These authors are co-first authors
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin; Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Daniel Werner*
- *These authors are co-first authors
- ADAC Luftrettung gGmbH, Munich; Hospital of the Ludwig-Maximilians-University Munich (LMU), Department of Anesthesiology, Munich, Germany
| | - Andrea Stroux
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Berlin, Germany
| | - Martin Möckel
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin; Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Volkmar Falk
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin; Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Swiss Federal Institute of Technology, Department of Health Science and Technology, Zurich, Switzerland
| | - Stephan Dominik Kurz
- Deutsches Herzzentrum der Charité – Medical Heart Center of Charité and German Heart Institute Berlin, Department of Cardiothoracic and Vascular Surgery, Berlin; Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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8
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Narita M, Tsutsui M, Ushioda R, Kikuchi Y, Shirasaka T, Ishikawa N, Kamiya H. Proximal and extended aortic arch replacement in acute DeBakey type I aortic dissection. Front Surg 2023; 10:1081167. [PMID: 36860951 PMCID: PMC9968786 DOI: 10.3389/fsurg.2023.1081167] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023] Open
Abstract
Objective This study aimed to compare the short- and long-term outcomes of proximal repair vs. extensive arch surgery for acute DeBakey type I aortic dissection. Subjects From April 2014 to September 2020, 121 consecutive patients with acute type A dissection were surgically treated at our institute. Of these patients, 92 had dissections extending beyond the ascending aorta. Methods Of the 92 patients, 58 underwent proximal repair, including aortic root and/or hemiarch replacement, and 34 underwent extended repair, including partial and total arch replacement. Perioperative variables and early and late postoperative results were statistically analyzed. Results The duration of surgery, cardiopulmonary bypass, and circulatory arrest was significantly shorter in the proximal repair group (p < 0.01). The overall operative mortality rate was 10.3% in the proximal repair group and 14.7% in the extended repair group (p = 0.379). The mean follow-up period was 31.1 ± 26.7 months in the proximal repair group and 35.3 ± 26.8 months in the extended repair group. During follow-up, the cumulative survival and freedom from reintervention rates at 5 years were 66.4% and 92.9% in the proximal repair group, and 76.1% and 72.6% in the extended repair group, respectively (p = 0.515 and p = 0.134). Conclusions No significant differences were found in the rates of long-term cumulative survival and freedom from aortic reintervention between the two surgical strategies. These findings suggest limited aortic resection achieves acceptable patient outcomes.
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Affiliation(s)
- Masahiko Narita
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | | | - Ryouhei Ushioda
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Yuta Kikuchi
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Tomonori Shirasaka
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Natsuya Ishikawa
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
| | - Hiroyuki Kamiya
- Department of Cardiac Surgery, Asahikawa Medical University, Asahikawa, Japan
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9
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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: 368] [Impact Index Per Article: 184.0] [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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10
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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: 129] [Impact Index Per Article: 64.5] [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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11
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Segers J, Gutermann H, Mesotten D, Beran M. Recognition and diagnosis of acute type A aortic dissection in a large Belgian referral center – can we do better? ACTA ANAESTHESIOLOGICA BELGICA 2022. [DOI: 10.56126/73.3.21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background: Acute type A aortic dissection (ATAAD) has a poor prognosis unless promptly diagnosed and surgically treated. As ATAAD is relatively rare and clinical presentation may mimic other pathologies, diagnosis can be challenging.
Objectives: The aim of this study is to evaluate the difficulties in diagnosing ATAAD.
Methods: A monocentric, retrospective analysis was conducted of all patients undergoing surgical repair for acute type A aortic dissection in our hospital (a large Belgian referral center) between the 1st of January 2016 and the 31st of December 2020. Data were collected regarding patient’s demographics i.e. age and gender, time of first medical contact, referral from other hospitals, presenting symptoms, initial diagnosis, inappropriate antiplatelet or antithrombotic therapy, time to the correct diagnosis, time to initiate surgical repair, and one- year mortality.
Results: Thirty-three patients were included. We found that a correct initial diagnosis was only made in twelve percent of patients with ATAAD. In twenty-one percent of patients, misdiagnoses led to inappropriate administration of antiplatelet or antithrombotic drugs pre-operatively. There was a difference in time from first medical contact to initiation of surgical repair between referred and non-referred patients. This time interval tended to be shorter in the latter group.
Conclusions: The main finding of this analysis is the delayed diagnosis of ATAAD in the majority of patients. This trend is slightly higher in patients referred from other hospitals. To improve outcome in ATAAD, efforts should be made to increase awareness for the presenting symptoms, and appropriate diagnostic imaging should be performed in a timely manner.
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Samanidis G, Kanakis M, Georgiou C, Perreas K. Association of dissected ascending aorta diameter with preoperative adverse events in patients with acute type A aortic dissection. World J Cardiol 2022; 14:231-238. [PMID: 35582464 PMCID: PMC9048272 DOI: 10.4330/wjc.v14.i4.231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/02/2022] [Accepted: 04/04/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute type A aortic dissection (ATAAD) is a life-threatening disease associated with high morbidity and mortality.
AIM To evaluate the diameter of dissected ascending aorta in patients diagnosed with ATAAD and whether the aortic diameter is associated with preoperative adverse events.
METHODS A total of 108 patients diagnosed with ATAAD who underwent emergency operation under hypothermic circulatory arrest were enrolled in this study. Demographic characteristics and perioperative data were recorded. In all patients, preoperative chest and abdomen computed tomography (CT) scans were performed.
RESULTS Median age of the patients was 61.5 (52.5-70.5) years and median body mass index (BMI) was 28.2 (25.1-32.6) cm2. The number of female patients was 37 (25%). Median diameter of the ascending aorta was 5.0 (4.5-6) cm and 53.8% of the patients had an aortic diameter < 5.0 cm, while 32.3% of the patients had an aortic diameter of 4.5cm and 72.0% had an ascending aorta diameter < 5.5 cm. The diameter of the ascending aorta did not differ in patients with vs without preoperative adverse events: Preoperative neurological dysfunction (P = 0.53) and hemodynamic instability (P = 0.43). Median age of patients with preoperative hemodynamic instability was 65 (57.5-74) years, while it was 60 (51-68) years in patients without (P = 0.04)
CONCLUSION Although current guidelines suggest replacing the ascending aorta with a diameter > 5.5 cm, most of the patients with ATAAD had an aortic diameter of less than 5.5 cm. The diameter of the ascending aorta in patients diagnose with ATAAD is not associated with preoperative adverse events.
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Affiliation(s)
- George Samanidis
- Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Meletios Kanakis
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Charalampos Georgiou
- Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens 17674, Greece
| | - Konstantinos Perreas
- Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens 17674, Greece
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Schattner A. The Reply. Am J Med 2021; 134:e470. [PMID: 34340758 DOI: 10.1016/j.amjmed.2021.03.040] [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: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Ami Schattner
- The Faculty of Medicine, Hebrew University and Hadassah Medical School, Ein Kerem, Jerusalem 91120, Israel.
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