Acute aortic dissection type A: Impact of aortic specialists on short and long term outcomes

Long-Term Results and Quality of Life after Surgery for Acute Aortic Dissection Type A: Contemporary Single-Centre Experience

Background: Aortic dissection is still afflicted with significant morbidity and mortality. This research seeks to assess long-term outcomes and quality of life after emergency surgery for acute aortic dissection type A. Methods: A total of 413 patients were analysed, who had been operated upon between 2000 and 2016 at our centre. We compared our results of the early (2000-2007) versus late (2008-2016) period with regards to 30-day and follow-up mortality and need for reoperation, including risk factor analysis. Quality of life was assessed via the SF-36 survey. Results: Calculated perioperative risk by EuroSCORE increased significantly from early, 24.9%, to late, 38.0%, p < 0.001. Thirty-day rates of mortality decreased significantly from 26.7% to 17.4%, p = 0.03. Survival at 1-, 5-, and 10-years was 92.3% vs. 91.8% (p = 0.91), 75.2% vs. 81.0% (p = 0.29), and 53.4% vs. 69.7% (p = 0.04). Freedom from reoperation was comparable between groups at follow-up: 74.0% vs. 85.7%, p = 0.28. Quality of life was impaired. Conclusions: Despite more complex severity of disease and operative procedures, the results of surgery for type A aortic dissection improved significantly over time at 30-day and 10-year follow-up. Quality of life was significantly impaired compared to a healthy reference population.

Impact of preoperative malperfusion on postoperative outcomes in type A aortic dissection - importance of serum lactate estimation in ongoing malperfusion

INTRODUCTION

Acute type A aortic dissection (ATAAD) is one of the most critical emergencies in cardiovascular surgery. Additional complications such as organ malperfusion can significantly decrease the chances of survival. Despite promptly performed surgical treatment, impaired organ perfusion may persist, thus close postoperative monitoring is recommended. But, is there a surgical consequence due to the existence of a preoperatively known malperfusion and is there a correlation between pre-, peri- and postoperative levels of serum lactate and proven malperfusion?

METHODS

Between 2011 and 2018, 200 patients (66% male; median age: 62.5 years; interquartile range: +/-12.4 years) that received surgical treatment at our institution for an acute dissection DeBakey type I were enrolled in this study. The cohort was divided into two groups according to the preoperative existence of malperfusion and non-malperfusion. At least one kind of malperfusion occurred in 74 patients (Group A: 37%), while 126 patients (Group B: 63%) showed no evidence of malperfusion. Furthermore, lactate levels of both cohorts were differentiated into four periods: preoperative, intraoperative, 24 hours after surgery, and 2-4 days after surgery.

RESULTS

The patients' status differed significantly prior to surgery. Group A (malperfusion) showed an elevated requirement for mechanical resuscitation (A: 10.8%; B: 5.6%; p: 0.173), were significantly more often admitted in an intubated state (A: 14.9%; B: 2.4%; p: 0.001) and showed higher incidences of stroke (A: 18.9% (n = 149); B: 3.2% (n = 4); p: 0.001). Levels of serum lactate from the preoperative period until days 2-4 were significantly increased in the malperfusion cohort at all times.

CONCLUSIONS

Preexisting malperfusion due to ATAAD may significantly increase the chance of early mortality in patients with ATAAD. Serum lactate levels were a reliable marker for inadequate perfusion from admission until day 4 after surgery. Despite this, early intervention survival in this cohort remains limited.

Acute Aortic Syndromes from Diagnosis to Treatment-A Comprehensive Review

This work aims to provide a comprehensive description of the characteristics of a group of acute aortic diseases that are all potentially life-threatening and are collectively referred to as acute aortic syndromes (AASs). There have been recent developments in the care and diagnostic plan for AAS. A substantial clinical index of suspicion is required to identify AASs before irreversible fatal consequences arise because of their indefinite symptoms and physical indicators. A methodical approach to the diagnosis of AAS is addressed. Timely and suitable therapy should be started immediately after diagnosis. Improving clinical outcomes requires centralising patients with AAS in high-volume centres with high-volume surgeons. Consequently, the management of these patients benefits from the increased use of aortic centres, multidisciplinary teams and an "aorta code". Each acute aortic entity requires a different patient treatment strategy; these are outlined below. Finally, numerous preventive strategies for AAS are discussed. The keys to good results are early diagnosis, understanding the natural history of these disorders and, where necessary, prompt surgical intervention. It is important to keep in mind that chest pain does not necessarily correspond with coronary heart disease and to be alert to the possible existence of aortic diseases because once antiplatelet drugs are administered, a blocked coagulation system can complicate aortic surgery and affect prognosis. The management of AAS in "aortic centres" improves long-term outcomes and decreases mortality rates.

Improving outcomes of surgery for acute type A aortic dissection

Background. It remains equivocal if acute type A aortic dissection (ATAAD) surgical outcomes are improving. We analyzed current outcome trends to evaluate improvements and to identify predicting variables. Methods. From 2015 to 2020, 204 patients underwent surgery for ATAAD and were divided into recent (n = 102) and earlier (n = 102) groups. Uni- and multivariable statistical analysis was performed to identify predictors of 30-day mortality. Results. Thirty-day mortality decreased significantly in the recent group (3.9% vs 14.6%, p = .014). Prevalence of neurological insult also decreased significantly (13% vs 25%, p = .028). Other major complications remained unchanged. There was no statistically significant difference in overall 30-day mortality between low-volume vs high-volume surgeons (12.3% vs 7.3%, p = .21). The number of surgeons performing ATAAD procedures decreased from nine in 2015 to five in 2020. Preoperative lactate (OR 1.24, 95%CI 1.03-1.51), dissection of any arch vessel (OR 14.2, 95%CI 1.79-113), non-normal left ventricular ejection fraction (OR 12.5, 95%CI 2.54-61.6), biological composite graft (OR 19.1, 95%CI 2.75-133), concomitant coronary artery bypass grafting (OR 38.8, 95%CI 2.91-517) and intraoperative adverse event (OR 9.5, 95%CI 2.22-40.9) were statistically significant independent predictors of mortality. Conclusions. Early outcomes after ATAAD improved in the most recent experience. Part of the explanation may be fewer surgeons performing more procedures annually, a relatively conservative approach to the extent of aortic resection and ensuring adequate cerebral protection. Major complications remain prevalent and require attention to be further reduced.

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

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.

Onset of pain to surgery time in acute aortic dissections type A: a mandatory factor for evaluating surgical results?

Objective

An acute aortic dissection type A (AADA) is a rare but life-threatening event. The mortality rate ranges between 18% to 28% and mortality is often within the first 24 h and up to 1%-2% per hour. Although the onset of pain to surgery time has not been a relevant factor in terms of research in the field of AADA, we hypothesize that a patient's preoperative conditions depend on the length of this time.

Methods

Between January 2000 and January 2018, 430 patients received surgical treatment for acute aortic dissection DeBakey type I at our tertiary referral hospital. In 11 patients, the exact time point of initial onset of pain was retrospectively not detectable. Accordingly, a total of 419 patients were included in the study. The cohort was categorized into two groups: Group A with an onset of pain to surgery time < 6 h (n = 211) and Group B > 6 h (n = 208), respectively.

Results

Median age was 63.5 years (y) ((IQR: 53.3-71.4 y); (67.5% male)). Preoperative conditions differed significantly between the cohorts. Differences were detected in terms of malperfusion (A: 39.3%; B: 23.6%; P: 0.001), neurological symptoms (A: 24.2%; B: 15.4%; P: 0.024), and the dissection of supra-aortic arteries (A: 25.1%; B: 16.8%; P: 0.037). In particular, cerebral malperfusion (A 15.2%: B: 8.2%; P: 0.026) and limb malperfusion (A: 18%, B: 10.1%; P: 0.020) were significantly increased in Group A. Furthermore, Group A showed a decreased median survival time (A: 1,359.0 d; B: 2,247.5 d; P: 0.001), extended ventilation time (A: 53.0 h; B: 44.0 h; P: 0.249) and higher 30-day mortality rate (A: 25.1%; B: 17.3%; P: 0.051).

Conclusions

Patients with a short onset of pain to surgery time in cases of AADA present themselves not only with more severe preoperative symptoms but are also the more compromised cohort. Despite early presentation and emergency aortic repair, these patients show increased chances of early mortality. The "onset of pain to surgery time" should become a mandatory factor when making comparable surgical evaluations in the field of AADA.

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

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.

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

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.

Early Results of a Novel Hybrid Prosthesis for Treatment of Acute Aortic Dissection Type A With Distal Anastomosis Line Beyond Aortic Arch Zone Zero

Introduction

Acute aortic dissection type A (AADA) is associated with high perioperative morbidity and mortality. A novel non-covered hybrid prosthesis (Ascyrus Medical Dissection Stent (AMDS) Hybrid Prosthesis, Cryolife/Jotec, Hechingen, Germany) can be easily implanted to stabilize the true lumen (TL), improve remodeling, and preserve organ perfusion. Although developed for implantation in aortic zone 0, occasionally, partial replacement of the aortic arch and further distal implantation of AMDS may appear favorable. Implantation of AMDS with anastomosis line beyond zone 0 has not been described yet.

Materials and Methods

Between 08/2019 and 12/2020, a total of n = 97 patients were treated due to AADA at a single University hospital. Of those, n = 28 received an AMDS hybrid prosthesis, of whom in eight patients, due to intraoperative finding the distal anastomosis line was placed distal to the brachiocephalic trunk. Three patients had AMDS implantation in zone I and four were treated by implantation of the prostheses in zone II, and one patient had the implantation performed in zone III. Clinical outcome and the development of a proportional area of TL and false lumen (FL) at defined levels of the thoracic aorta were analyzed.

Results

None of the surviving patients (87.5%) showed signs of clinical malperfusion (i.e., stroke, spinal cord injury, and need for dialysis). A postoperative CT scan showed an open TL in all patients. The proportion of TL with respect to total aortic diameter (TL+FL) was postoperatively significantly higher in zone III (p = 0.016) and at the level of T11 (p = 0.009). The mean area of TL+FL was comparable between pre- and postoperative CT-scan (p = n.s.). One patient with preoperative resuscitation died of multiple organ failure on extracorporeal life support on postoperative day 3.

Conclusion

Implantation of AMDS can be safely performed in patients who need partial replacement of the aortic arch beyond zone 0. The advantages of the AMDS can be combined with those of the total arch repair (remodeling of the arch and prevention of TL collapse) without the possible disadvantages (risk of spinal cord injury).

Th1, Th2, and Th17 cells are dysregulated, but only Th17 cells relate to C-reactive protein, D-dimer, and mortality risk in Stanford type A aortic dissection patients

BACKGROUND

T helper (Th) cells are closely involved in vascular inflammation, endothelial dysfunction, and atherogenesis, which are the hallmarks of aortic dissection (AD). This study aimed to evaluate the clinical value of Th1, Th2, and Th17 cell measurements in Stanford type A AD patients.

METHODS

Stanford type A AD patients (N=80) and non-AD patients with chest pain (N = 40) were recruited. Then, Th1, Th2, and Th17 cells in peripheral blood CD4⁺ T cells from all participants were detected by flow cytometry. The 30-day mortality of Stanford type A AD patients was recorded.

RESULTS

Th1 and Th17 cells were higher, while Th2 cells were lower in Stanford type A AD patients compared with non-AD patients (all p < 0.001). Meanwhile, Th1 cells (area under curve (AUC): 0.734, 95% confidence interval (CI): 0.640-0.828), Th2 cells (AUC: 0.841, 95% CI: 0.756-0.925), and Th17 cells (AUC: 0.898, 95% CI: 0.839-0.957) could distinguish Stanford type A patients from non-AD patients. Moreover, Th1 cells (p = 0.037) and Th17 cells (p = 0.001) were positively related to CRP, and Th17 cells (p = 0.039) were also positively associated with D-dimer in Stanford type A AD patients. Furthermore, Th17 cells were elevated in deaths compared with survivors (p = 0.001), also, it could estimate 30-day mortality risk in Stanford type A AD patients with an AUC of 0.741 (95% CI: 0.614-0.867), which was similar to the value of CRP (AUC: 0.771, 95% CI: 0.660-0.882), but lower than the value of D-dimer (AUC: 0.818, 95% CI: 0.722-0.913).

CONCLUSION

Th1, Th2, and Th17 cells are dysregulated, but only the Th17 cells relate to CRP, D-dimer, and 30-day mortality risk in Stanford type A AD patients.

Association of dissected ascending aorta diameter with preoperative adverse events in patients with acute type A aortic dissection

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.

Acute Aortic Syndrome Revisited: JACC State-of-the-Art Review

The purpose of this paper is to describe all available evidence on the distinctive features of a group of 4 life-threatening acute aortic pathologies gathered under the name of acute aortic syndrome (AAS). The epidemiology, diagnostic strategy, and management of these patients has been updated. The authors propose a new and simple diagnostic algorithm to support clinical decision making in cases of suspected AAS, thereby minimizing diagnostic delays, misdiagnoses, and unnecessary advanced imaging. AAS-related entities are reviewed, and a guideline to avoid imaging misinterpretation is provided. Centralization of patients with AAS in high-volume centers with high-volume surgeons is key to improving clinical outcomes. Thus, the role of multidisciplinary teams, an "aorta code" (streamlined emergent care pathway), and aortic centers in the management of these patients is boosted. A tailored patient treatment approach for each of these acute aortic entities is needed, and as such has been summarized. Finally, a set of prevention measures against AAS is discussed.

Femoral versus axillary cannulation in acute type A aortic dissections: A meta-analysis

OBJECTIVE

There has been a growing interest in antegrade cannulation techniques in type A aortic dissection surgery. Axillary cannulation has previously been reported to provide better outcomes in terms of short-term mortality and neurological event. Consensus regarding the best cannulation strategy still remains controversial.

METHOD

The MEDLINE and EMBASE databases were conducted up until October 3, 2020. Data regarding mortality, stroke, reoperation for bleeding and length of hospital stay, wound infection and cardiopulmonary bypass time were extracted and submitted to a meta-analysis using random-effects modelling and the I² -test for heterogeneity. Fourteen retrospective observational studies were included, enrolling a total of 2621 patients.

RESULTS

There were a total of 2621 patients (1327 axillary cannulation and 874 femoral cannulation). Axillary cannulation was associated with reduced short term mortality (pooled odds ratio [OR] = +0.42, 95% confidence interval [CI] = +0.25 to +0.70; p = .0009) compared to femoral cannulation. Axillary cannulation was also associated with a lower incidence of neurological events (pooled OR = +0.63, 95% CI = +0.42 to +0.94; p = .02).

CONCLUSION

Our meta-analyses suggests that axillary cannulation has superior outcomes in terms of mortality and stroke following emergency surgery for type A aortic dissection. However, the lack of high quality randomized controlled trials does not make this recommendation generalisable to all units.