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Qanadli SD, Malekzadeh S, Villard N, Jouannic AM, Bodenmann D, Tozzi P, Rotzinger DC. A New Clinically Driven Classification for Acute Aortic Dissection. Front Surg 2020; 7:37. [PMID: 32656225 PMCID: PMC7324626 DOI: 10.3389/fsurg.2020.00037] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 05/20/2020] [Indexed: 12/20/2022] Open
Abstract
Objectives: To report a new classification scheme for acute aortic dissection (AAD) that considers the aortic arch as a separate entity and integrates patterns of malperfusion syndrome (MPS). The proposed classification was evaluated retrospectively in a large population. Materials and Methods: We retrospectively reviewed pre-therapy CT angiograms of 226 consecutive patients (mean ± SD age: 64 ± 12 years) with AAD. AADs were reclassified with a new classification scheme that included three aortic dissection types (A, involving at least the ascending aorta; B, involving exclusively the descending aorta; and C, involving the aortic arch with/without the descending aorta) and four malperfusion grades (0: no MPS; 1: dynamic MPS; 2: static MPS; 3: static and dynamic MPS). AAD features were assessed and correlated to patient outcomes. Results: According to the new classification, we identified 152 type A dissections (92 A0, 11 A1, 38 A2, 11 A3); 50 type B (38 B0, 5 B1, 6 B2, 1 B3); and 24 type C (17 C0, 6 C2, 1 C3). Type C represented 11% of all AADs. MPS occurred in 39, 24, and 29% in type A, B, and C, respectively. Type C was treated with significantly more endovascular or hybrid interventions (37%) than in types A (3%) and B (20%) (p < 0.001). Conclusion: The new AAD classification was feasible, and type C was easily identified (“non-A, non-B”). Preliminary findings supported the usefulness of this classification for the decision-making process and subsequent treatments.
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Affiliation(s)
- Salah D Qanadli
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Sonaz Malekzadeh
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Nicolas Villard
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Anne-Marie Jouannic
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Daniel Bodenmann
- Department of Radiology, Kantonsspital Frauenfeld, Frauenfeld, Switzerland
| | - Piergiorgio Tozzi
- Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland.,Department of Heart and Vessels, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - David C Rotzinger
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland.,Faculty of Biology and Medicine (FBM), University of Lausanne (UNIL), Lausanne, Switzerland
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Utility of neuromonitoring in hypothermic circulatory arrest cases for early detection of stroke: Listening through the noise. J Thorac Cardiovasc Surg 2020; 162:1035-1045.e5. [PMID: 32204911 DOI: 10.1016/j.jtcvs.2020.01.090] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 12/30/2019] [Accepted: 01/04/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Stroke remains a potentially devastating complication of aortic arch intervention. The value of neurophysiologic intraoperative monitoring (NIOM) in the early identification of stroke is unclear. We evaluated the utility of NIOM for early stroke detection in aortic arch surgery. METHODS Across 8 years at our institution, 365 patients underwent aortic arch surgery with hypothermic circulatory arrest, and 224 cases utilized NIOM. One patient was excluded for intraoperative death. In the remaining cohort, we reviewed the incidence, timing, and location of strokes, and the incidence and nature of NIOM alerts. RESULTS Hemiarch was performed in 154 patients and total arch replacement in 69 patients. Stroke occurred in 6.3% of all cases (14 out of 223), 15.9% of total arches (11 out of 69), and 2.0% of hemiarches (3 out of 154). There were 33 NIOM alerts (14.8%), and 9 patients had both alerts and stroke. Of these, NIOM deficits plausibly correlated with imaging findings in 7 cases (78%). Of the 5 stroke patients without NIOM alerts, 2 developed neurologic symptoms 3 days or more postoperatively, and infarcts in 3 patients did not result in sensory or motor deficits. Excluding 2 patients with late stroke, the sensitivity of NIOM for stroke detection was 75%, specificity was 88.5%, positive predictive value was 27.3%, and negative predictive value was 97.4%. CONCLUSIONS Despite a low positive predictive value requiring a high level of discrimination when interpreting abnormal findings, NIOM has high sensitivity and specificity for the early stroke detection. Furthermore, its high negative predictive valve is reassuring for low risk of stroke in the absence of alerts.
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Gutsche JT, Patel PA, Cobey FC, Ramakrishna H, Gordon EK, Riha H, Sophocles A, Ghadimi K, Fabbro M, Al-Ghofaily L, Chern SYS, Cisler S, Sahota GS, Valentine E, Weiss SJ, Andritsos M, Silvay G, Augoustides JGT. The year in Cardiothoracic and Vascular Anesthesia: selected highlights from 2014. J Cardiothorac Vasc Anesth 2014; 29:1-7. [PMID: 25481390 DOI: 10.1053/j.jvca.2014.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2014] [Indexed: 02/06/2023]
Affiliation(s)
- Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Harish Ramakrishna
- Mayo Clinic, Scottsdale, Arizona; §Cardiothoracic Anesthesiology and Intensive Care, Department of Anesthesiology and Intensive Care Medicine, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Emily K Gordon
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Hynek Riha
- Department of Anesthesiology and Critical Care, Duke University, Durham, North Carolina
| | - Aris Sophocles
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Ohio State University, Columbus, Ohio
| | - Michael Fabbro
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lourdes Al-Ghofaily
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sy-Yeu S Chern
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sophia Cisler
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gurmukh S Sahota
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth Valentine
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - George Silvay
- Department of Anesthesiology and Critical Care, Icahn School of Medicine, Mount Sinai Hospital, New York, New York
| | - John G T Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
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Tagarakis GL, Whitlock RP, Gutsche JT, Diegeler A, Patel PA, Daskalopoulos ME, Vernick WJ, Anastasiadis K, Augoustides JG. New frontiers in aortic therapy: focus on deliberate hypotension during thoracic aortic endovascular interventions. J Cardiothorac Vasc Anesth 2014; 28:843-7. [PMID: 24746338 DOI: 10.1053/j.jvca.2014.01.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Georgios L Tagarakis
- Department of Surgery, AHEPA Hospital, Aristotle University, Thessaloniki, Greece
| | | | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Prakash A Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - William J Vernick
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - John G Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
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Lanigan MJ, Chaney MA, Gologorsky E, Chavanon O, Augoustides JG. CASE 2—2014. J Cardiothorac Vasc Anesth 2014; 28:398-407. [DOI: 10.1053/j.jvca.2013.05.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2013] [Indexed: 01/16/2023]
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Tan CNH, Fraser AG. Perioperative transesophageal echocardiography for aortic dissection. Can J Anaesth 2014; 61:362-78. [PMID: 24477464 DOI: 10.1007/s12630-014-0113-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 01/14/2014] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Aortic dissection is an infrequent but serious condition that often requires immediate operative intervention. We explore recent developments in the classification of aortic dissection and perioperative transesophageal echocardiography that assist with quantifying the severity of disease and facilitate its management. PRINCIPAL FINDINGS We describe the pivotal role of echocardiography in relation to key surgical considerations such as cannulation, aortic root surgery, perfusion in the aortic arch vessels, stenting in hybrid arch repair, and timing of preventative surgery. CONCLUSION Developments in the classification of aortic dissection have improved our perspective and understanding of the key presenting features that affect mortality. Improvements in patient outcome may be achieved in part by appropriately timed echocardiography-guided surgery.
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Affiliation(s)
- Christine N H Tan
- Department of Anaesthesia, Critical Care and Pain Management, B3, University Hospital of Wales, Cardiff, CF 14 4XW, UK,
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Perreas K, Samanidis G, Dimitriou S, Kalogris P, Balanika M, Antzaka C, Khoury M, Michalis A. Outcomes after ascending aorta and proximal aortic arch repair using deep hypothermic circulatory arrest with retrograde cerebral perfusion: analysis of 207 patients. Interact Cardiovasc Thorac Surg 2012; 15:456-61. [PMID: 22687431 DOI: 10.1093/icvts/ivs252] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Correction of ascending aorta and proximal aortic arch pathology with numerous surgical techniques having been proposed over the years remains a surgical challenge. This study was undertaken to identify risk factors influencing outcome after aortic arch operations, requiring deep hypothermic circulatory arrest (DHCA). METHODS Between 1993 and 2010, 207 consecutive patients were operated for ascending aorta and proximal arch correction with the use of deep hypothermic circulatory arrest with retrograde cerebral perfusion. All patients were followed up with regular out-patient clinics, transthoracic echocardiography and, when required, chest computed tomography. RESULTS There were 102 (49.3%) emergencies (acute type A dissection) and 105 (50.7%) elective cases. Mean age: 63.5 ± 12 years. Mean circulatory arrest time was 25.4 ± 13 min. Unadjusted analysis of factors associated with 30-day mortality revealed emergency status, preoperative hemodynamic instability, acute dissection, reoperation, increased circulatory arrest time, postoperative bleeding, postoperative creatinine levels and presence of neurological dysfunction. Multi-adjusted analysis revealed duration of circulatory arrest as the only and main factor related to death. Thirty-day mortality was 2.4% for the elective and 7.2% for emergencies cases. Survival during long-term follow-up was 93, 82 and 53% at 1, 5 and 10 years, respectively. CONCLUSIONS Ascending aorta and proximal aortic arch replacement with brief duration of deep hypothermic circulatory arrest combined with retrograde cerebral perfusion is a safe method with acceptable short- and long-tem results.
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Affiliation(s)
- Konstantinos Perreas
- Second Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
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Pires de Morais G, Rodrigues A, Gama V. Treatment of type-a aortic dissection using endoprosthesis occurring after coronary artery bypass surgery. Catheter Cardiovasc Interv 2012; 80:1099-104. [DOI: 10.1002/ccd.23462] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2011] [Accepted: 10/31/2011] [Indexed: 11/11/2022]
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Current world literature. Curr Opin Cardiol 2011; 26:165-73. [PMID: 21307667 DOI: 10.1097/hco.0b013e328344b569] [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: 11/26/2022]
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Andritsos M, Singh N, Patel P, Sinha A, Fassl J, Wyckoff T, Riha H, Roscher C, Subramaniam B, Ramakrishna H, Augoustides JG. The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2010. J Cardiothorac Vasc Anesth 2011; 25:6-15. [DOI: 10.1053/j.jvca.2010.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2010] [Indexed: 12/14/2022]
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Andritsos M, Desai ND, Grewal A, Augoustides JG. Innovations in Aortic Disease Management: The Descending Aorta. J Cardiothorac Vasc Anesth 2010; 24:523-9. [DOI: 10.1053/j.jvca.2010.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Indexed: 11/11/2022]
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