Outcomes of Early-Onset Acute Type A Aortic Dissection - Influence of Etiologic Factors

Impact of Residual Entry Tears in the Descending Aorta After Type A Dissection

BACKGROUND

Aggressive resection/exclusion of the primary entry in the descending aorta remains controversial in older patients with acute type A aortic dissection (ATAAD). We investigated the effect of residual primary entry in the descending aorta in younger and older groups.

METHODS

Patients with ATAAD who underwent emergency operation (n = 1103) were divided into younger (<70 years; n = 681) and older (≥70 years; n = 422) cohorts. Each cohort was further divided into groups with or without residual primary entry in the descending aorta. After propensity score matching, 179 and 71 matched pairs were obtained in the younger and older cohorts, respectively. Surgical outcomes were compared between the residual and nonresidual groups in each age cohort.

RESULTS

In the younger cohort, the cumulative incidence rate of distal aortic events was significantly higher in the residual than in the nonresidual group at 10 years (35% [95% CI, 27%-44%] vs 22% [95% CI, 15%-31%], P = .001). However, in the older group, residual or nonresidual primary entry did not affect the rates at 10 years (11% [95% CI, 5%-20%] vs 9% [95% CI, 4%-17%], P = .75). Multivariate analysis identified age <70 years (hazard ratio, 2.188; 95% CI, 1.493-3.205; P < .001) and residual primary entry at the descending aorta (hazard ratio, 2.142; 95% CI, 1.559-2.943; P < .001) as significant predictors for distal aortic events.

CONCLUSIONS

Aggressive resection/exclusion of the primary entry in the descending aorta should be considered for patients aged <70 years to avoid distal aortic events; however, it might not always be appropriate for the older patients ≥70 years.

Cerebral infarction and risk factors in acute type A aortic dissection with arch branch extension

OBJECTIVE

Stanford type A aortic dissection (AAD) may affect the supra-aortic arteries, which are associated with acute ischemic stroke (AIS) or transient ischemic attack (TIA). This study aimed to investigate cerebral perfusion, the infarction incidence and risk factors in AAD patients.

METHODS

A total of 156 consecutive AAD patients were enrolled and divided into two groups according to whether the aortic arch branches were involved: the affected group (n = 90) and the unaffected group (n = 66). Clinical, echocardiographic/carotid Doppler data and cerebral infarction morbidity were compared between the groups. Independent predictors of 30-day AAD mortality were identified through multivariable Cox regression, and perioperative risk factors were analyzed.

RESULTS

In total, 57.7% of AAD patients had aortic arch branch involvement. Abnormal Doppler waveforms were more common in the affected group (p < 0.05). Regarding intracranial perfusion, the blood flow volumes (BFVs) of the bilateral internal carotid arteries (ICAs) and right vertebral artery (RVA) in the affected group were significantly reduced (p < 0.05). The incidence of cerebral infarction in the affected group was significantly higher than that in the unaffected group (35.6% vs. 19.7%, p = 0.031). Multivariable analysis revealed that age >45 years old, right internal carotid artery (RICA) involvement and reduced left ventricular ejection fraction (LVEF) were significant predictors of perioperative death.

CONCLUSIONS

Aortic arch branch involvement is common in patients with AAD and is associated with reduced cerebral blood flow (especially on the right side) and a higher incidence of cerebral infarction. Age, extension of the RICA dissection and LVEF impairment are independent risk factors for AAD-related death.

Fibrillin-1 Gene Polymorphisms (rs145233125, rs11070646, rs201170905) Are Associated With the Susceptibility and Clinical Prognosis of DeBakey Type III Aortic Dissection in Chinese Han Population

ABSTRACT

We aim to investigate whether genetic variants of the Fibrillin-1 (FBN1) gene were associated with DeBakey type III aortic dissection (AD) and its clinical prognosis in Chinese Han population. Three single-nucleotide polymorphisms (SNPs) (rs145233125, rs11070646, rs201170905) in FBN1 were analyzed in patients with DeBakey type III AD (159) and healthy subjects (216). Gene-environment interactions were evaluated to use generalized multifactor dimensionality reduction. Haplotype analysis of the 3 SNPs in the FBN1 gene was performed by Haploview software. Patients were followed up for average 4 years. G carriers of rs11070646 and rs201170905 in FBN1 have an increased risk of DeBakey type III AD. The interaction of FBN1 and environmental factors facilitated to the increased risk of DeBakey type III AD (cross-validation consistency = 10/10, P = 0.001). One of the most common haplotypes revealed an increased risk of DeBakey type III AD (CGG, P = 0.009). Recessive models of rs145233125 CC genotype ( P < 0.05) and rs201170905 GG genotype ( P < 0.001) were associated with an increased risk of death and recurrent chest pain of DeBakey type III AD. In conclusions, FBN1 gene polymorphisms contribute to DeBakey type III AD susceptibility. The interactions of gene and environment are related with the risk of DeBakey type III AD. C carriers of rs145233125 and G carriers of rs201170905 may be the adverse prognostic indicators of death and recurrent chest pain in DeBakey type III AD.

Frozen Elephant Trunk: Technical Overview and Our Experience with a Patient-Tailored Approach

Ever since the first hybrid prosthesis was used for a total aortic arch replacement, many other techniques have been developed to comply with the need for the treatment of a wide spectrum of patients and their clinical pictures. We hereby provide an overview of the most popular surgical techniques to perform a frozen elephant trunk, including our tailored approach revolving around the antegrade deployment of a Gore C-TAG endovascular stent graft sutured to a four-branched vascular prosthesis. This technique was applied to three cases of acute type A aortic dissection. Although our small series of patients consists of acute aortic dissections only, this technique could be applied to any other aortic arch pathology, such as chronic dissections or aneurysms. Moreover, we believe that, because of the individually tailored approach and widespread availability of the necessary materials, this technique can reveal itself useful in many different operative scenarios.

An increased prothrombin time-international normalized ratio in patients with acute type A aortic dissection: contributing factors and their influence on outcomes

PURPOSE

We investigated factors contributing to coagulopathy in patients with acute type A aortic dissection (ATAAD) and coagulopathy's influence on patient outcomes.

METHODS

We grouped 420 patients who underwent ATAAD repair-none under anticoagulation therapy or with liver disease-by the prothrombin time-international normalized ratio (PT-INR) at admission:  <  1.2 (no coagulopathy, n  =  371), 1.2-1.49 (mild coagulopathy, n  =  33), or  ≥  1.5 (severe coagulopathy, n  =  16). We then compared the clinical presentation, dissection morphology, and outcomes among the groups. We assessed the PT-INR in relation to the preoperative hemodynamics and searched for factors predictive of a PT-INR  ≥  1.2.

RESULTS

The transfusion volume and operation time were increased among patients with coagulopathy (P  <  0.05). The in-hospital mortality (15.2-37.5% vs. 5.1%, P  < 0.001) and 5-year survival (61.1-74.4% vs. 87.6%) were relatively poor for these patients. The median PT-INR was 1.03 (0.97-1.1) for patients with stable hemodynamics (n  =  318), 1.11 (1.02-1.21) for those in shock (blood pressure  <  80 mmHg) not given cardiopulmonary resuscitation (CPR) (n  =  81), and 1.1 (1.0-1.54) for those in shock given CPR (n  =  21) (P  < 0.001). A multivariable analysis identified shock (P  <  0.001), a partially thrombosed false lumen (P  =  0.006), and mesenteric malperfusion (P  =  0.016) as predictive variables.

CONCLUSIONS

Shock, a partially thrombosed false lumen, and mesenteric malperfusion appear to be predictive of dissection-related coagulopathy, which influences outcomes negatively.

Outcomes of urgent aortic wrapping for acute type A aortic dissection

OBJECTIVE

Standard surgical repair of acute type A aortic dissection is associated with high mortality rates, especially in high-risk patients. In an attempt to improve survival in frail patients, we evaluated the outcomes after ascending aorta wrapping in a high-risk patient cohort.

METHODS

This single-center retrospective cohort study included all consecutive patients treated using ascending aorta wrapping for an acute type A aortic dissection from 2008 to 2019. The primary end points included 30-day mortality, survival during follow-up, and dissection-related mortality. Secondary end points included assessment of aortic remodeling after ascending aorta wrapping. Patients with an aortic anatomy suitable for adjunctive endografting of the ascending aorta were also identified.

RESULTS

Thirty-five consecutive patients who underwent ascending aorta wrapping were included. Their median age was 77 years (range, 46-96 years). The 30-day all-cause mortality rate was 9%. Major complications occurred in 7 patients (21%), including early reinterventions in 11 (31%). Median follow-up was 36 months (range, 2.4-106.6; interquartile range, 72). The actuarial survival at 36 months was 82%. The dissection-related mortality was 11.4%. The median aortic growth of the nonwrapped descending thoracic aorta was 3.4 mm. Computed tomography scan analysis depicted that 88% of survivors were theoretical candidates for an additional endovascular procedure to exclude the primary entry tear.

CONCLUSIONS

Aortic wrapping is associated with favorable early outcomes and a low rate of aortic events during follow-up. This therapeutic option should be considered for patients considered too fragile for standard surgical repair.

Effects of Obesity on Outcomes of Acute Type A Aortic Dissection Repair in Japan

Background: The prevalence of obesity among Japanese acute type A aortic dissection (ATAAD) patients and its effect on repair outcomes remain to be elucidated.

Methods and Results: The prevalence of obesity (body mass index [BMI] ≥30.0 kg/m²) among 1,059 patients (mean [±SD] age 64.3±12.7 years) who underwent ATAAD repair between 1990 and 2018 was compared with that among the general Japanese population (National Health and Nutrition Survey data). The prevalence of obesity among male patients (17.1% [6/35], 20.0% [18/90], and 14.4% [20/139] for those aged 20–39, 40–49, and 50–59 years, respectively) was significantly higher than that among the age- and sex-matched general population. The 1,059 patients were divided into groups according to weight (normal [BMI <25.0 kg/m²; n=742], overweight [BMI 25.0–29.9 kg/m²; n=248], or obese [BMI ≥30.0 kg/m²; n=69]). Comparing the normal weight, overweight, and obese groups revealed significant differences among the 3 groups in median cardiopulmonary bypass time (143, 167, and 183 min, respectively), ventilation >48 h (44.5%, 60.1%, and 78.3%, respectively), and in-hospital mortality (7.0%, 7.3%, and 17.4%, respectively), but not in 30-day survival. Shock, visceral malperfusion, operation time >360 min, obesity, and coronary malperfusion were identified as predictors of in-hospital mortality.

Conclusions: The prevalence of obesity is increased among Japanese male patients with ATAAD aged ≤59 years. Obesity may increase these patients’ operative risk; overweight does not.

Endo-Bentall for proximal aortic dissection: from conception to application

The endovascular treatment of pathologies of the ascending aorta has not been incorporated into routine clinical practice. The aim of this article is to provide an overview of the endovascular treatment of pathologies of the ascending aorta, particularly type A aortic dissection. A thorough analysis and discussion of anatomical, physiological, clinical and technical challenges, and obstacles is performed. Conventional straight stent-grafts alone are not capable of fixing the entire complex underlying problem in the vast majority of patients with acute type A aortic dissection. An endovascular valve-carrying conduit consisting of a proximal transcatheter aortic valve connected to a covered stent-graft would be able to close a primary entry tear in the ascending aorta, ensure coronary perfusion, initiate true lumen expansion, treat malperfusion, treat aortic regurgitation, drain any pericardial effusion through a transapical approach, and possibly stabilize the distal aorta. Two thirds of all patients with acute aortic dissection are potential candidates for endovascular treatment, and the concept may help to significantly improve survival in patients with acute aortic dissection.

Aortic progression and reintervention in patients with pathogenic variants after a thoracic aortic dissection

OBJECTIVE

To evaluate aortic disease progression and reintervention after an initial thoracic aortic dissection in pathogenic variant carriers.

METHODS

Of 175 participants diagnosed with thoracic aortic dissection, 31 had a pathogenic variant (pathogenic group) across 6 genes (COL3A1, FBN1, LOX, PRKG1, SMAD3, TGFBR2) identified by whole exome sequencing. Those with benign or normal variants (benign/normal group, n = 144) comprised the control group. Clinical data were collected through medical record review (1985-2018) and supplemented with the National Death Index database (December 2018).

RESULTS

The entire cohort (n = 175) consisted of 108 type A aortic dissections and 67 type B aortic dissections, similarly distributed between groups. The pathogenic group was significantly younger (43 vs 56 years, P < .0001) and had significantly more aortic root replacements and similar extents of arch replacement at initial type A aortic dissection repair. The median follow-up time was 7.5 (4.6-12) years. After initial treatment, the pathogenic group required significantly more aortic reinterventions (median 1 vs 0, P < .0001) and mean cumulative aortic reinterventions for each patient (10 years: 1 vs 0.5, P = .029). Both incidence rate (12%/year vs 1.2%/year, P = .0001) and cumulative incidence of reinterventions (9 years: 70% vs 6%, P < .0001) for the preserved native aortic root were significantly higher in the pathogenic group, but were similar for the preserved native aortic arch and distal aorta between groups. Ten-year survival was similar in the pathogenic and benign/normal groups (92% vs 85%).

CONCLUSIONS

Aggressive aortic root replacement and similar arch management should be considered in pathogenic variant carriers at initial type A aortic dissection repair compared with benign/normal variant carriers.