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Wu Z, Li Y, Xu Z, Liu H, Liu K, Qiu P, Chen T, Lu X. Prediction of preoperative in-hospital mortality rate in patients with acute aortic dissection by machine learning: a two-centre, retrospective cohort study. BMJ Open 2023; 13:e066782. [PMID: 37012019 PMCID: PMC10083797 DOI: 10.1136/bmjopen-2022-066782] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2023] Open
Abstract
OBJECTIVES To conduct a comprehensive analysis of demographic information, medical history, and blood pressure (BP) and heart rate (HR) variability during hospitalisation so as to establish a predictive model for preoperative in-hospital mortality of patients with acute aortic dissection (AD) by using machine learning techniques. DESIGN Retrospective cohort study. SETTING Data were collected from the electronic records and the databases of Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine and the First Affiliated Hospital of Anhui Medical University between 2004 and 2018. PARTICIPANTS 380 inpatients diagnosed with acute AD were included in the study. PRIMARY OUTCOME Preoperative in-hospital mortality rate. RESULTS A total of 55 patients (14.47%) died in the hospital before surgery. The results of the areas under the receiver operating characteristic curves, decision curve analysis and calibration curves indicated that the eXtreme Gradient Boosting (XGBoost) model had the highest accuracy and robustness. According to the SHapley Additive exPlanations analysis of the XGBoost model, Stanford type A, maximum aortic diameter >5.5 cm, high variability in HR, high variability in diastolic BP and involvement of the aortic arch had the greatest impact on the occurrence of in-hospital deaths before surgery. Moreover, the predictive model can accurately predict the preoperative in-hospital mortality rate at the individual level. CONCLUSION In the current study, we successfully constructed machine learning models to predict the preoperative in-hospital mortality of patients with acute AD, which can help identify high-risk patients and optimise the clinical decision-making. Further applications in clinical practice require the validation of these models using a large-sample, prospective database. TRIAL REGISTRATION NUMBER ChiCTR1900025818.
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Affiliation(s)
- Zhaoyu Wu
- Department of Vascular Surgery, Shanghai Jiao Tong University School of Medicine Affiliated to Ninth People's Hospital, Shanghai, China
| | - Yixuan Li
- Big Data Research Lab, University of Waterloo, Waterloo, Ontario, Canada
- Department of Economics, University of Waterloo, Waterloo, Ontario, Canada
| | - Zhijue Xu
- Department of Vascular Surgery, Shanghai Jiao Tong University School of Medicine Affiliated to Ninth People's Hospital, Shanghai, China
| | - Haichun Liu
- Department of Automation, Shanghai Jiao Tong University, Shanghai, China
| | - Kai Liu
- Big Data Research Lab, University of Waterloo, Waterloo, Ontario, Canada
- School of Mathematical and Computational Sciences, University of Prince Edward Island, Charlottetown, Prince Edward Island, Canada
| | - Peng Qiu
- Department of Vascular Surgery, Shanghai Jiao Tong University School of Medicine Affiliated to Ninth People's Hospital, Shanghai, China
- Big Data Research Lab, University of Waterloo, Waterloo, Ontario, Canada
| | - Tao Chen
- Big Data Research Lab, University of Waterloo, Waterloo, Ontario, Canada
- Department of Economics, University of Waterloo, Waterloo, Ontario, Canada
| | - Xinwu Lu
- Department of Vascular Surgery, Shanghai Jiao Tong University School of Medicine Affiliated to Ninth People's Hospital, Shanghai, China
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Meng X, Han J, Wang L, Wu Q. Aortic dissection during pregnancy and postpartum. J Card Surg 2021; 36:2510-2517. [PMID: 33928681 DOI: 10.1111/jocs.15575] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/21/2021] [Accepted: 03/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with aortic dissection during pregnancy and postpartum period exhibit a high mortality. At present, a complete overview of aortic dissection during pregnancy and postpartum period is lacking. Methods: This systematic review included 80 reports published from 2000 to 2020, comprising a total study population of 103 patients with aortic dissection. Results: We found that Stanford Type A aortic dissection was more common in prepartum cases, especially in the third trimester, while postpartum cases of aortic dissection were more common in Stanford Type B. The most common risk factor was connective tissue disease, with no other known risk factors. The mode of delivery had no significant effect on the type of postpartum aortic dissection. Reduced maternal and fetal mortality was observed when patients with Stanford Type A aortic dissection occurring after 28 gestational weeks underwent cesarean section followed by aortic replacement. Patients with Stanford Type B aortic dissection were treated mainly with medication and/or endovascular repair. Conclusion: Contemporary management of patients during pregnancy and within 12 weeks postpartum requires multidisciplinary cooperation and includes serial, noninvasive imaging, biomarker testing, and genetic risk profiling for aortopathy. Early diagnosis and accurate treatment are essential to reduce maternal and fetal mortality.
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Affiliation(s)
- Xiangli Meng
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Jijing Han
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Li Wang
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Qingqing Wu
- Department of Ultrasound, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
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Patel C, Akhtar H, Gupta S, Harky A. Pregnancy and cardiac interventions: What are the optimal management options? J Card Surg 2020; 35:1589-1596. [PMID: 32484993 DOI: 10.1111/jocs.14637] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Cardiac disease is the leading cause of maternal mortality in the United Kingdom. Major causes of cardiac death in pregnant women include cardiomyopathies, myocardial infarction, ischemic heart disease, and aortic dissection. Uncorrected congenital heart disease and women who have had corrective or palliative surgery may have complicated pregnancies as well. Some women with significant cardiac disease are unable to meet the increased physiological demands of pregnancy. Of these, those who do not respond to medical treatment may require surgical correction such as coronary artery bypass grafting. The risk of cardiac operations for pregnant women is similar to that for nonpregnant women but the fetal mortality rate remains high. Contributing factors to high fetal mortality rates include timing, urgency of operation, and the fetal/fetoplacental response to cardiopulmonary bypass. The aim of this review is to summarize current evidence in utilizing the different management approaches of cardiac issues during pregnancy.
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Affiliation(s)
- Chandni Patel
- Department of Medicine, St George's University of London, London, UK
| | - Hubba Akhtar
- Department of Medicine, St George's University of London, London, UK
| | - Shubhi Gupta
- Department of Medicine, University of Liverpool, Liverpool, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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Silvestri V, Mazzesi G, Mele R. Postpartum aortic dissection. A case report and review of literature. Int J Surg Case Rep 2019; 56:101-106. [PMID: 30870737 PMCID: PMC6425083 DOI: 10.1016/j.ijscr.2019.02.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 02/05/2019] [Accepted: 02/08/2019] [Indexed: 02/08/2023] Open
Abstract
Cardiovascular comorbidities may complicate pregnancy. Pregnancy carries a 25-fold relative risk for aortic dissection. Dissection may occur in pregnancies without known genetic or anatomical risk factors (non syndromic sporadic aortic dissection). Dissection may occur in the postpartum period. Given the high mortality for both mother and foetus, a high clinical suspicion for aortic dissection is needed in an emergency setting in postpartum.
Introduction Aortic dissection is a rare cardiovascular complication in pregnancy. Most of the cases occur during the third trimester of pregnancy, whilst 33% of cases are reported during the postpartum period. Presentation of case We report the case of a multiparous 35-year-old patient with gestational hypertension treated for a type A aortic dissection on the second postpartum day. A review of literature on non-syndromic sporadic aortic dissection during the postpartum period is presented. Discussion Aortic complications in pregnancy have been described in genetic syndromes or congenital aortic malformations but may also be non -syndromic and occur in the absence of any other risk factor. Pregnancy carries a 25-fold increase in relative risk for dissection. A review of the 16 cases published in literature from 1995 to December 2016 of non-syndromic, sporadic aortic dissections in pregnancy showed that the event may occur more frequently in the first week post-partum, be symptomatic for thoracic pain or dyspnoea. Type A aortic dissection accounts to 75% of cases. Mortality, despite surgical treatment, has been reported in 4 cases. Conclusions Even though rarely reported, given the increasing incidence and the high mortality of aortic dissection in pregnancy, along with the potential challenge for two lives, clinician must consider aortic dissection in post-partum while dealing with differential diagnosis in post-partum patients in the emergency setting.
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Affiliation(s)
- Valeria Silvestri
- Surgical Science Department, Policlinico Umberto I, University of Rome "La Sapienza", Rome, Italy; Cardiac Surgery Unit, Cardiovascular, Respiratory, Nefrologic and Geriatric Department, Policlinico Umberto I, University of Rome "La Sapienza", Rome, Italy.
| | - Giuseppe Mazzesi
- Surgical Science Department, Policlinico Umberto I, University of Rome "La Sapienza", Rome, Italy; Cardiac Surgery Unit, Cardiovascular, Respiratory, Nefrologic and Geriatric Department, Policlinico Umberto I, University of Rome "La Sapienza", Rome, Italy
| | - Rita Mele
- Surgical Science Department, Policlinico Umberto I, University of Rome "La Sapienza", Rome, Italy; Cardiac Surgery Unit, Cardiovascular, Respiratory, Nefrologic and Geriatric Department, Policlinico Umberto I, University of Rome "La Sapienza", Rome, Italy
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Patel PA, Fernando RJ, Augoustides JG, Yoon J, Gutsche JT, Feinman JW, Zhou E, Weiss SJ, Hamburger J, Evans AS, Aljure O, Fabbro M. Acute Type-B Aortic Dissection in Pregnancy: Therapeutic Challenges in a Multidisciplinary Setting. J Cardiothorac Vasc Anesth 2017; 31:2268-2276. [DOI: 10.1053/j.jvca.2017.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Indexed: 01/16/2023]
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Smith K, Gros B. Pregnancy-related acute aortic dissection in Marfan syndrome: A review of the literature. CONGENIT HEART DIS 2017; 12:251-260. [PMID: 28371362 DOI: 10.1111/chd.12465] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Revised: 03/08/2017] [Accepted: 03/10/2017] [Indexed: 11/25/2022]
Abstract
A well-established association exists between acute aortic dissection and pregnancy, particularly in women with Marfan syndrome. However, there is debate regarding appropriate management guidelines. In particular, there are differing opinions regarding when prophylactic aortic root repair should be recommended as well as the efficacy of beta blockers in this clinical scenario. The current study evaluated 10 years of published literature (2005-2015) in the PubMed/Medline database. Fifty articles, describing 72 cases of women who presented with aortic dissection in the antepartum or postpartum period were identified. Comparisons on demographic variables and clinical outcomes between cases of women with Marfan syndrome (n = 36) and without Marfan syndrome (n = 36) were conducted. There were no significant differences in demographics (age, gravidity, parity) between the Marfan and non-Marfan cases. Marfan patients presented with antepartum dissections significantly earlier in pregnancy than those without Marfan syndrome (P = .002). However, there were no significant difference between the 2 groups in maternal mortality, fetal mortality, or obstetric outcomes (mode of delivery and gestational age at delivery). Eight cases described events in Marfan women with an aortic root diameter ≤40 mm. Six events occurred in Marfan women who were managed with beta blockers. Current guidelines rely on aortic root diameter for stratification of Marfan women into risk categories, but we identified several cases that would be missed by these guidelines. Specifically, the existing literature suggest that women with Marfan syndrome should take precautions throughout pregnancy, rather than the third trimester.
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Affiliation(s)
| | - Bernard Gros
- University of Central Florida College of Medicine
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A successful cesarean section followed with endovascular stent-graft implantation for a 36-week twin pregnancy with acute aortic dissection: a case report. Ir J Med Sci 2015; 185:735-739. [DOI: 10.1007/s11845-015-1260-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 01/17/2015] [Indexed: 10/24/2022]
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Rajagopalan S, Nwazota N, Chandrasekhar S. Outcomes in pregnant women with acute aortic dissections: a review of the literature from 2003 to 2013. Int J Obstet Anesth 2014; 23:348-56. [PMID: 25223644 DOI: 10.1016/j.ijoa.2014.05.001] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 04/07/2014] [Accepted: 05/05/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND Acute aortic dissection in pregnant women is a rare but potentially life-threatening event. Our aim was to evaluate maternal and fetal outcomes of acute aortic dissection during pregnancy. METHODS We conducted a review of literature of the PubMed database to identify publications related to pregnant women with acute aortic dissections during the period 2003-2013: 59 articles were included in the study. RESULTS A total of 75 patients were included in the analyses. Stanford type A dissections were the most common form, accounting for 77% of all cases. The majority (78%) occurred in the third trimester and immediate postpartum period. Inherited connective tissue disorders were causative in 49% of patients. Maternal mortality was not statistical different between type A and type B dissections (21% vs. 23%), but fetal outcomes were worse in type B dissections (35% vs. 10.3%; P<0.05). Fetal mortality in type A dissections was dependent on the timing of aortic repair, with antepartum aortic repair associated with a higher mortality (36%). CONCLUSION Despite advances in diagnostic and surgical techniques, maternal and fetal mortalities in pregnant patients with aortic dissection remain high. Patients undergoing combined cesarean section with aortic repair had favorable fetal outcomes.
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Affiliation(s)
- S Rajagopalan
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA.
| | - N Nwazota
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
| | - S Chandrasekhar
- Department of Anesthesiology, Baylor College of Medicine, Houston, TX, USA
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Abstract
Postpartum aortic dissection is a rare but lethal event. Until now, only a limited number of cases have been reported, and a comprehensive literature review from 1988 to 2012 yielded 27 cases. Postpartum aortic dissection occurred between Day 1 and Day 42 after delivery, either vaginally or by cesarean section. Pregnancy alone without underlying contributing risk factors and Marfan syndrome were the two main risk factors for postpartum aortic dissection, accounting for 44.4% and 40.7% of cases, respectively. Late presentation and delayed diagnosis may lead to sudden death. Improving prenatal and peripartum care is, therefore, crucial in preventing the development of aortic dissection. Prompt diagnosis and timely treatment of postpartum aortic dissection may prevent patient death.
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Affiliation(s)
- Shi-Min Yuan
- Department of Cardiothoracic Surgery, First Hospital of Putian, Teaching Hospital, Fujian Medical University, Putian, Fujian Province, China.
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Shu C, Fang K, Dardik A, Li X, Li M. Pregnancy-Associated Type B Aortic Dissection Treated With Thoracic Endovascular Aneurysm Repair. Ann Thorac Surg 2014; 97:582-7. [DOI: 10.1016/j.athoracsur.2013.09.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Revised: 08/22/2013] [Accepted: 09/04/2013] [Indexed: 12/11/2022]
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Abstract
We report a case of acute aortic dissection (Stanford type B) that occurred in pregnant woman at 34-week gestation. She had no systemic characteristics of Marfan syndrome, however she exhibited a mutation of FBN1, Arg 545 Cys, which has been found to correlate with ectopia lentis but not with aortic dissection.
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