Quality of life following surgical repair of acute type A aortic dissection: a systematic review

Organ-specific malperfusion in acute type A aortic dissection: epidemiological meta-analysis of incidence rates

BACKGROUND

Acute type A aortic dissection is a life-threatening clinical emergency that necessitates immediate surgical intervention with an estimated mortality rate of approximately 1-2% per hour. When complicated by malperfusion, the perioperative mortality rate is reported to be increased by up to 39%. Malperfusion can affect many vascular beds with varying incidence and severity, resulting in coronary, cerebral, visceral, peripheral, renal or spinal malperfusion. The primary aim of this systematic review and meta-analysis is to investigate the epidemiology of specific types of organ malperfusion in acute type A aortic dissection and to analyse the impact on the survival outcomes associated with each malperfusion type.

METHODS

Electronic databases PubMed, MEDLINE and Embase were searched through to September 2024 to identify original studies that presented data on the incidence and the survival outcome of organ malperfusion in association with acute type A aortic dissection. The extracted data included patient characteristics and incidence of organ-specific malperfusion. Primary outcomes were the respective in-hospital mortality rate associated with each organ-specific malperfusion and a proportional meta-analysis was conducted to pool results. Quality assessment was performed using the modified National Institutes of Health quality assessment tool for single-arm observational studies.

RESULTS

A total of 40 studies met the inclusion criteria, including a total of 35 361 patients. Peripheral limb malperfusion was the most prevalent with a pooled incidence of 12% (95% c.i. 10 to 14). This was followed by lower limb or iliofemoral with 11% (95% c.i. 9 to 14). Spinal malperfusion was the lowest with 1% (95% c.i. 1 to 2). The pooled mortality rate with organ malperfusion varied between 18 and 36%. Within this population the highest mortality rate was associated with mesenteric malperfusion with 36% (95% c.i. 28 to 45). Following this the highest mortality rate was found with coronary at 33% (95% c.i. 26 to 40) and cerebral at 28% (95% c.i. 24 to 33) malperfusion.

CONCLUSION

Survival during hospital admission after acute type A aortic dissection can vary depending on the presence and type of malperfusion, with mesenteric, coronary and cerebral malperfusion being associated with the highest in-hospital mortality rates. Organ-specific malperfusion syndromes should be considered when assessing the perioperative risk and surgical planning of patients undergoing surgical repair for acute type A aortic dissection.

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.

Quality of Life after Type A Aortic Dissection Surgery in the United Kingdom: The QUADS Study

BACKGROUND

 Acute Type A aortic dissection (TAAD) is a life-threatening condition that carries significant mortality and morbidity; a proportion of the survivors might require further aortic procedures in the mid-/long-term follow-up. Quality of life (QoL) after TAAD is not well studied. Quality of life after Type A Aortic Dissection Surgery (QUADS) is the first multicentre study to assess QoL in survivors of surgically treated TAAD.

METHODS

 A tailored questionnaire for survivors of TAAD was designed with patient and public involvement. Patients who underwent surgery from 2018 to 2022 in eight United Kingdom centres were invited to participate. Preoperative, intraoperative, and postoperative prospectively collected data were collated and analyzed retrospectively. The data were analyzed with SPSS v29. Patient's questionnaire was validated with a Cronbach's alpha analysis, exploratory factor analysis, and AMOS confirmatory factor analysis. Three groups were created according to QoL (Good, Fair, Poor).

RESULTS

 A total of 162 patients were recruited. Majority were male with a mean age of 63 years (24-92). Surgical procedures for TAAD were root and ascending aorta replacement (n = 61, 38%), ascending (n = 81, 50%), and/or arch replacement (n = 20, 12%). Eleven patients (7%) required later intervention. Patient's answers regarding overall QoL were good (n = 67, 41%), fair (n = 89, 55%), and poor (n = 6, 4%). Neurological complications, circulatory arrest duration, reoperation for bleeding, postoperative myocardial infraction, arrhythmias, wound infection, and patient destination at discharge have been identified as main variables impacting on QoL after TAAD surgery across different domains of this questionnaire.

CONCLUSION

 QUADS questionnaire is the first tailored and validated questionnaire for TAAD survivors. Results in the United Kingdom population suggest that it is a useful tool to assess QoL after TAAD surgery.

Long-Term Health-Related Quality of Life following Acute Type A Aortic Dissection with a Focus on Male-Female Differences: A Cross Sectional Study

Objectives: Acute type A aortic dissection (ATAAD) is a life-threatening cardiovascular emergency, of which the long-term impact on health-related quality of life (HRQoL) and male-female-specific insights remain inadequately clarified. Methods: Consecutive adult ATAAD patients who underwent surgery were retrospectively included between 2007 and 2017 in four referral centers in the Netherlands, and baseline data were collected. The 36-Item Short-Form (SF-36) Health Survey was sent to all survivors between 2019 and 2021 and compared to validated SF-36 scores of the Dutch general population stratified by age group and sex. Results: In total, 324/555 surviving patients returned the SF-36 questionnaire (response rate 58%), of which 40.0% were female; the median follow-up was 6.5 years (range: 1.7-13.9, IQR: 4.0-9.4) after surgery for ATAAD. In comparison to the general population, ATAAD patients scored significantly lower on 6/8 SF-36 subdomains and higher on bodily pain. Differences in HRQoL domains compared to the sex-matched data were largely comparable between sexes, apart from bodily pain. In the age-matched subgroups impaired HRQoL was most pronounced in younger patients aged 41-60 (5/8 impaired domains). Female ATAAD patients scored significantly worse on 5/8 SF-36 subdomains and the physical component summary (PCS) scores than male patients. Age at ATAAD, female sex, hypertension, COPD, and prior thoracic aortic aneurysm were associated with worse PCS scores. Conclusions: Long-term HRQoL was impaired in both male and female ATAAD patients when compared to the general population. Further studies on the nature of this impairment and on interventions to improve HRQoL after ATAAD are clearly warranted, with special attention to females and younger patients.

Health-related quality of life in patients with aortic dissection: An unmet need

Knowledge about the Health-related Quality of Life (HR-QoL) after Type A (TA-AAD) and Type B acute aortic dissection (TB-AAD) is still insufficient. Through this systematic review, including 22 studies (16 for TA-AAD and 6 TB-AAD -1998-2023), the entire literature on HR-QoL after surgical and/or endovascular and/or medical interventions has been investigated. In TA-AAD patients, despite overall SF-36 score was similar to the standard population, with > 80 years patients displaying a better emotional domain, the SF-12 was significant lower to controls in physical and mental well-being domains. Exercise-based cardiac rehabilitation improved HR-QoL. In TB-AAD, vitality and mental health SF-36 scores improved after thoracic endovascular aortic repair (TEVAR); long-term QoL was similar in the open surgery group compared to TEVAR. Overall, HR-QoL after AAD seems adequate irrespective of age or sex, except for some specific domains. Physical exercise and cardiac rehabilitation may improve HR-QoL in these patients. PROSPERO registry ID: CRD42023421130.

What Really Matters to Survivors of Acute Type A Aortic Dissection-A Survey of Patient-Reported Outcomes in the Dutch National Aortic Dissection Advocacy Group

(1) Background: Type A acute aortic dissection (TAAAD) almost always requires emergency surgery, and postoperative complications are common. Quality assurance systems tend to measure only the hard outcomes, e.g., complications and mortality. Our aim was to assess the health-related quality of life of TAAAD survivors. (2) Methods: An anonymized, Dutch language, web-based survey was sent out to all of the participants of the 2022 Annual Meeting of the Dutch National Aortic Dissection (DNAD) advocacy group via their own representatives. The survey was divided into five sections: patient information, global satisfaction, surgery, including complications, and the recovery period. (3) Results: Ninety members of the DNAD group attended the meeting. Seventy-five (83%) participated in the survey, and the responses from 61 (81%) were available for analysis. Despite hindrances in their daily life (complications, changes in physical, cognitive, and social functioning), patients were satisfied with their treatment, and all would undergo the procedure again. In addition they requested better post-discharge guidance and communication (4) Conclusion: The emphasis lies in equipping patients with knowledge about potential outcomes and effective coping strategies. This underscores the importance of communication and expectation management, in line with established literature.

The Long-Term Outcome and Quality of Life after Replacement of the Ascending Aorta

(1) Background: Despite optimal surgical therapy, replacement of the ascending aorta leads to a significant reduction in the quality of life (QoL). However, an optimal result includes maintaining and improving the QoL. The aim of our study was to evaluate the long-term outcome and the QoL in patients with aneurysms in the ascending aorta; (2) Methods: Between 2014 and 2020, 121 consecutive patients who underwent replacement of the ascending aorta were included in this study. Acute aortic pathologies were excluded. A standard short form (SF)-36 questionnaire was sent to the 112 survivors. According to the surgical procedure, patients were divided into two groups (A: supracoronary replacement of the aorta, n = 35 and B: Wheat-, David- or Bentall-procedures, n = 86). The QoL was compared within these groups and to the normal population, including myocardial infarction (MI), coronary artery disease (CAD) and cancer (CAN) patients; (3) Results: 83 patients were males (68.6%) with a mean age of 62.0 ± 12.5 years. Early postoperative outcomes showed comparable results between groups A and B, with a higher re-thoracotomy rate in B (A: 0.0% vs. B: 22.1%, p = 0.002). The 30-day mortality was zero. Overall, mortality during the follow-up was 7.4%. The SF-36 showed a significant decay in both the Physical (PCS) and Mental Component Summary (MCS) in comparison to the normal population (PCS: 41.1 vs. 48.4, p < 0.001; MCS: 42.1 vs. 50.9, p < 0.001) but without significant difference between both groups. Compared to the MI and CAD patients, significantly higher PCS but lower MCS scores were detected (p < 0.05); (4) Conclusions: Replacement of the ascending aorta shows low risk regarding the operative and postoperative outcomes with satisfying long-term results in the QoL. The extent of the surgical procedure does not influence the postoperative QoL.

How to help aortic dissection survivors with recovery?: A health promotion program based on the comprehensive theory of health behavior change and literature review

For aortic dissection survivors, health promotion can help them recover from the disease, which requires systematic program support. The aim of this study was to construct a health promotion program for aortic dissection survivors. Literature search, group discussion, and expert consultation were used. The Integrated Theory of Health Behavior Change was the theoretical basis of the program. Multiple medical-related databases were searched. Based on a literature search and group discussion, 3 primary items, 8 secondary items, and 34 tertiary items were formed. After 2 rounds of expert consultation (number of experts = 25), 3 primary items, 16 secondary items, and 54 tertiary items were retained. The authority coefficients of the 2 rounds of experts were 0.890 and 0.905, respectively. The Kendall W coefficient of the 2 rounds were 0.210 to 0.370 (P < .05) and 0.221 to 0.378 (P < .05), respectively. The mean importance value and coefficient of variation of each item were >3.5 and <0.25, respectively. The health promotion program constructed in this study was reasonable and scientific, which could provide a reference for clinical work.