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Kitamura T, Fukuzumi M, Mishima T, Shikata F, Motoji Y, Tamura Y, Horikoshi R, Yokozuka H, Ishiwaki D, Miyaji K. Watch-and-wait strategy for selected patients with type A intramural hematoma. Gen Thorac Cardiovasc Surg 2024; 72:225-231. [PMID: 37592167 DOI: 10.1007/s11748-023-01967-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: 05/16/2023] [Accepted: 08/03/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE This single-center retrospective study evaluated early and midterm outcomes of 100 consecutive patients with type A intramural hematoma. METHODS Initial watch-and-wait strategy was indicated if the maximum aortic diameter was < 50 mm, pain score was < 3/10 on the numerical rating scale, and no ulcer-like projection was observed in the ascending aorta. The primary endpoints of this study were all-cause and aorta-related deaths, and the secondary endpoint was aortic events. RESULTS Initial watch-and-wait strategy was indicated in 52 patients. Emergency aortic repair was indicated in the remaining 48 patients; 2, 31, and 15 patients died before surgery, underwent emergency surgery, and declined emergency surgery, respectively. Among the watch-and-wait group, 11 (21%) patients underwent aortic repair during hospitalization. In-hospital mortality rates, 5-year survival rates, and 5-year freedom from aorta-related death were not significantly different between the initial watch-and-wait strategy and emergency surgery (2% vs. 6%, 92% vs. 82%, and 100% vs. 94%, respectively). In the initial watch-and-wait strategy group, 5-year freedom from aortic events and freedom from aortic events involving the ascending aorta were 60% and 66%, respectively. CONCLUSIONS The early and midterm outcomes with the initial watch-and-wait strategy in patients with type A intramural hematoma with a maximum aortic diameter of ≤ 50 mm, pain score of ≤ 3/10, and no ulcer-like projection in the ascending aorta were favorable with no aorta-related death.
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Affiliation(s)
- Tadashi Kitamura
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan.
| | - Masaomi Fukuzumi
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Toshiaki Mishima
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Fumiaki Shikata
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yusuke Motoji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Yoshimi Tamura
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Rihito Horikoshi
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Hikaru Yokozuka
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Daiki Ishiwaki
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
| | - Kagami Miyaji
- Department of Cardiovascular Surgery, Kitasato University School of Medicine, 1-15-1 Kitasato, Minami, Sagamihara, Kanagawa, 252-0374, Japan
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Kaufeld T, Beckmann E, Rudolph L, Krüger H, Natanov R, Arar M, Korte W, Schilling T, Haverich A, Martens A, Shrestha M. Preoperative pericardial hematoma in patients with acute type A aortic dissection (AAAD): Do we need an adjusted treatment? J Cardiothorac Surg 2023; 18:67. [PMID: 36759866 PMCID: PMC9909972 DOI: 10.1186/s13019-023-02152-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 01/24/2023] [Indexed: 02/11/2023] Open
Abstract
OBJECTIVE An acute type A aortic dissection (AAAD) is a critical emergency and remains one of the most challenging diseases in cardiothoracic surgery. The existence of a pericardial hematoma caused by an aortic rupture can dramatically reduce the chances of survival (Jerzewski and Kulik in J Card Surg 29(4):529-530, 2014; Mehta et al. in Circulation 105(2):200-206, 2002; Gilon et al. in Am J Cardiol 103(7):1029-1031, 2009; Isselbacher et al. in Circulation 90(5):2375-2378, 1994). We assessed the surgical outcome of a high-risk group of patients with AAAD and a pericardial hematoma. METHODS In this study we included 430 Patients (67% male; median age: 64 years) who received surgical treatment between January 2000 and January 2018 at our facility for acute aortic dissection DeBakey type I. We divided the cohort in two groups: Group A consisted of high-risk patients with a pericardial hematoma (n = 162) and Group B of patients without pericardial hematoma (n = 268). RESULTS Patients with a preoperative pericardial hematoma had a significantly higher requirement for preoperative mechanical resuscitation (A: 21%; B: 1.5%; P: < 0.001) and were relevantly more frequently admitted to the operation theater with an intubated status (A: 19.8%; B: 8.6%; P: < 0.001). The incidence of visceral malperfusion differed significantly between both groups (A. 11.7%, B. 6:0%; P: 0.034). Limited aortic arch repair (proximal aortic arch replacement) was preferred in the high-risk group (A: 51.9%; B: 40.3%; P: 0.020). However, survival time was generally reduced in these patients (A: 7.5 y; B: 9.9 y). CONCLUSION AAAD patients with preoperative pericardial hematoma present themselves in potentially lethal conditions, with a significantly higher rate of visceral malperfusion. Despite the existence of this risk factor, a limited arch repair was favored. We have proven that cardiac compression is associated with preoperative intubation and mechanical resuscitation. Patients with pericardial hematoma must be further evaluated for preoperative pericardial drainage. In the event of long transfer times to an aortic center a slow drainage should be discussed to prevent early mortality.
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Affiliation(s)
- Tim Kaufeld
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Carl - Neuberg Str.1, 30625, Hannover, Germany.
| | - Erik Beckmann
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Carl - Neuberg Str.1, 30625, Hannover, Germany.,Minneapolis Heart Institute, Abbott Northwester Hospital, 920E 28th St., Minneapolis, MN, 55417, USA
| | - Linda Rudolph
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Carl - Neuberg Str.1, 30625, Hannover, Germany
| | - Heike Krüger
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Carl - Neuberg Str.1, 30625, Hannover, Germany
| | - Ruslan Natanov
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Carl - Neuberg Str.1, 30625, Hannover, Germany
| | - Morsi Arar
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Carl - Neuberg Str.1, 30625, Hannover, Germany
| | - Wilhelm Korte
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Carl - Neuberg Str.1, 30625, Hannover, Germany
| | - Tobias Schilling
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Carl - Neuberg Str.1, 30625, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Carl - Neuberg Str.1, 30625, Hannover, Germany
| | - Andreas Martens
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Carl - Neuberg Str.1, 30625, Hannover, Germany
| | - Malakh Shrestha
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hanover Medical School, Carl - Neuberg Str.1, 30625, Hannover, Germany.,Cardiovascular Medicine, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
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Sromicki J, Van Hemelrijck M, Schmiady MO, Krüger B, Morjan M, Bettex D, Vogt PR, Carrel TP, Mestres CA. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6544114. [PMID: 35258082 PMCID: PMC9252133 DOI: 10.1093/icvts/ivac037] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 01/20/2022] [Accepted: 01/31/2022] [Indexed: 11/21/2022] Open
Affiliation(s)
- Juri Sromicki
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Corresponding author. Department of Cardiac Surgery, University Hospital Zürich, Rämistrasse 100, CH-8091 Zürich, Switzerland. Tel: +41 44 255 95 82; fax: +41 44 255 44 67; e-mail:
| | | | - Martin O Schmiady
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Bernard Krüger
- Institute of Anesthesiology. University Hospital Zurich, Zurich, Switzerland
| | - Mohammed Morjan
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
- Department of Cardiac Surgery, Herzzentrum Duisburg, Duisburg, Germany
| | - Dominique Bettex
- Institute of Anesthesiology, University Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Paul R Vogt
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Thierry P Carrel
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Carlos-A Mestres
- Department of Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland
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