1
|
Murana G, Gliozzi G, Rucci P, Votano D, Orioli V, Rosa S, Folesani G, Buia F, Lovato L, Pacini D. Survival and reoperation in acute aortic syndromes-a single-centre experience of 912 patients. Eur J Cardiothorac Surg 2023; 64:ezad350. [PMID: 37878821 PMCID: PMC10722879 DOI: 10.1093/ejcts/ezad350] [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: 04/29/2023] [Revised: 08/21/2023] [Accepted: 10/23/2023] [Indexed: 10/27/2023] Open
Abstract
OBJECTIVES Acute aortic syndromes are associated with poor outcomes, despite diagnostic and therapeutic advances. We analysed trends in volumes and outcomes from 2000 to 2021. METHODS The study population includes 494 type A acute aortic syndromes (TAAAS) (54.2%) and 418 type B acute aortic syndromes (TBAAS) (45.8%). Primary outcomes were in-hospital mortality, long-term survival and freedom from aortic reoperation. RESULTS Regardless the type of acute aortic syndrome, patient volumes increased over time. Patients with TBAAS were older, more likely to have comorbid conditions and previous cardiac surgery (P < 0.001), while cerebrovascular accidents were more frequent in TAAAS (P < 0.05). Among TAAAS, 143 (28.9%) required total arch and 351 (71.1%) hemiarch replacement. TBAAS management was medical therapy in 182 (43.5%), endovascular in 198 (47.4%) and surgical in 38 (9.1%) cases. Overall in-hospital mortality was 14.6% [18.2% in TAAAS (95% confidence interval (CI) 14.4-21.2%) vs 10.7% in TBAAS (95% CI 7.8%-13.7%); P = 0.0027]. After propensity score adjustment, in-hospital mortality exhibited a significantly decreasing trend from 2000 to 2021 (P < 0.001) in TAAAS and TBAAS. 1-, 5- and 10-year survival was 74.2%, 62.2% and 45.5% in TAAAS and 75.4%, 60.7% and 41.0% in TBAAS (P = 0.975), with no differences among treatment strategies. The adjusted cumulative reoperation risk at 10 years was more than two-fold in TBAAS versus TAAAS (9.5% vs 20.5%, hazard ratio (HR) = 2.30, 95% I 1.31-4.04). CONCLUSIONS In the last decades, better patient triage and surgical/endovascular techniques led to substantial improvements in the management of acute aortic syndrome, with reduction in early mortality and reoperation rate. However, long-term mortality is still >50%.
Collapse
Affiliation(s)
- Giacomo Murana
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Gregorio Gliozzi
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Daniela Votano
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Valentina Orioli
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Simona Rosa
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Gianluca Folesani
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Francesco Buia
- Cardiovascular Radiology Unit, Cardio-Thoraco-Vascular Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Luigi Lovato
- Cardiovascular Radiology Unit, Cardio-Thoraco-Vascular Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Davide Pacini
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| |
Collapse
|
2
|
Roselli EE, Kramer B, Germano E, Toth A, Vargo PR, Bakaeen F, Menon V, Blackstone EH. The modified frozen elephant trunk may outperform limited and extended-classic repair in acute type I dissection. Eur J Cardiothorac Surg 2023; 63:ezad122. [PMID: 37018150 PMCID: PMC10234761 DOI: 10.1093/ejcts/ezad122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/16/2023] [Accepted: 04/04/2023] [Indexed: 04/06/2023] Open
Abstract
OBJECTIVES A better surgical approach for acute DeBakey type I dissection has been sought for decades. We compare operative trends, complications, reinterventions and survival after limited versus extended-classic versus modified frozen elephant trunk (mFET) repair for this condition. METHODS From 1 January 1978 to 1 January 2018, 879 patients underwent surgery for acute DeBakey type I dissection at Cleveland Clinic. Repairs were limited to the ascending aorta/hemiarch (701.79%) or extended through the arch [extended classic (88.10%) or mFET (90.10%)]. Weighted propensity score matched established comparable groups. RESULTS Among weighted propensity-matched patients, mFET repair had similar circulatory arrest times and postoperative complications to limited repair, except for postoperative renal failure, which was twice as high in the limited group [25% (n = 19) vs 12% (n = 9), P = 0.006]. Lower in-hospital mortality was observed following limited compared to extended-classic repair [9.1% (n = 7) vs 19% (n = 16), P = 0.03], but not after mFET repair [12% (n = 9) vs 9.5% (n = 8), P = 0.6]. Extended-classic repair had higher risk of early death than limited repair (P = 0.0005) with no difference between limited and mFET repair groups (P = 0.9); 7-year survival following mFET repair was 89% compared to 65% after limited repair. Most reinterventions following limited or extended-classic repair underwent open reintervention. All reinterventions following mFET repair were completed endovascularly. CONCLUSIONS Without increasing in-hospital mortality or complications, less renal failure and a trend towards improved intermediate survival, mFET may be superior to limited or extended-classic repair for acute DeBakey type I dissections. mFET repair facilitates endovascular reintervention, potentially reducing future invasive reoperations and warranting continued study.
Collapse
Affiliation(s)
- Eric E Roselli
- Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Benjamin Kramer
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Emidio Germano
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrew Toth
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Patrick R Vargo
- Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Faisal Bakaeen
- Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Venu Menon
- Aorta Center, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|