Surgical results in acute type A aortic dissection with preoperative cardiopulmonary resuscitation: Survival and neurological outcome

Cardiopulmonary resuscitation at operating room entry in acute aortic dissection type A patients: is surgery contraindicated?

Background

This study aimed to compare the short-term outcomes of surgical treatment for acute type A aortic dissection between patients undergoing cardiopulmonary arrest at the time of entry into the operating room and patients who received successful preoperative cardiopulmonary resuscitation before entering the operating room or patients who had cardiopulmonary arrest on the operating room table after entering the operating room without cardiopulmonary arrest. In the present study, we focused on the circulatory status at the time of entering the operating room because it is economically and emotionally difficult to cease intervention once the patient has entered the operating room, where surgeons, anesthesiologists, nurses, and perfusionists are already present, all necessary materials are packed off and cardiopulmonary bypass have already been primed.

Methods

Twenty (5.5%) of 362 patients who underwent surgical treatment for acute type A aortic dissection between January 2016 and March 2022 had preoperative cardiopulmonary arrest. To compare the early operative outcomes, the patients were divided into the spontaneous circulation group (n = 14, 70.0%) and the non-spontaneous circulation group (n = 6, 30.0%) based on the presence or absence of spontaneous circulation upon entering the operating room. The primary endpoint was postoperative 30-day mortality. The secondary endpoints included in-hospital complications and persistent neurological disorders.

Results

Thirty-day mortality was 65% (n = 13/20) in the entire cohort; 50% (n = 7/14) in the spontaneous circulation group and 100% (n = 6/6) in the non-spontaneous circulation group. The major cardiopulmonary arrest causes were aortic rupture and cardiac tamponade (n = 16; 80.0%), followed by coronary malperfusion (n = 4; 20.0%). Seven patients (50.0%) survived in the spontaneous circulation group, and none survived in the non-spontaneous circulation group (P = .044). Five survivors walked unaided and were discharged home; the remaining two were comatose and paraplegic.

Conclusions

The outcomes were extremely poor in patients with acute type A aortic dissection who had preoperative cardiopulmonary arrest and received ongoing cardiopulmonary resuscitation at entry into the operating room. Therefore, surgical treatment might be contraindicated in such patients.

Analysis of outcomes and prognostic factor in acute type A aortic dissection complicated with preoperative shock: A single-center study

BACKGROUND

Acute type A aortic dissection (ATAAD) is a critical cardiovascular emergency that requires prompt surgical intervention for preserving life, particularly in patients with critical preoperative status. This retrospective study aimed to investigate the clinical features, early and late outcomes, and prognostic factors in patients undergoing aortic repair surgery for ATAAD complicated with preoperative shock.

METHODS

Between April 2007 and July 2020, 694 consecutive patients underwent emergency ATAAD repair at our institution, including 162 (23.3%) presenting with preoperative shock (systolic blood pressure <90 mm Hg), who were classified into the survivor (n = 125) and non-survivor (n = 37) groups according to whether they survived to hospital discharge. The clinical demographics, surgical information, and postoperative complications were compared. Five-year survival and freedom from reoperation rates of survivors were analyzed using the Kaplan-Meier actuarial method. Multivariate logistic regression analysis was used to identify independent risk factors for in-hospital mortality.

RESULTS

The in-hospital surgical mortality rate in patients with ATAAD and shock was 22.8%. The non-survivor group showed higher rates of preoperative cardiopulmonary resuscitation, acute myocardial infarction, and cerebral infarction, and was associated with longer cardiopulmonary bypass time, higher rates of total arch replacement and intraoperative extracorporeal membrane oxygenation implementation. The non-survivor group had higher blood transfusion volumes and rates of malperfusion-related complications. Multivariate analysis revealed that preoperative cardiopulmonary resuscitation, prolonged cardiopulmonary bypass time, and total arch replacement were risk factors for in-hospital mortality. For patients who survived to discharge, the 5-year cumulative survival and freedom from aortic reoperation rates were 75.6% (95% confidence interval, 67.6%-83.6%) and 82.6% (95% confidence interval, 74.2%-91.1%), respectively.

CONCLUSIONS

Preoperative shock in ATAAD is associated with a high risk of in-hospital mortality, particularly in patients who undergo cardiopulmonary resuscitation and complex aortic repair procedures with extended cardiopulmonary bypass. However, late outcomes are acceptable for patients who were stabilized through surgical treatment and survived to discharge.

Acute type a aortic intramural hematoma complicated with preoperative hemopericardium: early and late surgical outcome analyses

BACKGROUND

Acute type A aortic intramural hematoma (ATAIMH) is a variant of acute type A aortic dissection (ATAAD), exhibiting an increased risk of hemopericardium and cardiac tamponade. It can be life-threatening without emergency treatment. However, comprehensive studies of the clinical features and surgical outcomes of preoperative hemopericardium in patients with ATAIMH remain scarce. This retrospective study aims to investigate the clinical features and early and late outcomes of patients who underwent aortic repair surgery for ATAIMH complicated with preoperative hemopericardium.

METHODS

We investigated 132 consecutive patients who underwent emergency ATAIMH repair at this institution between February 2007 and August 2020. These patients were dichotomized into the hemopericardium (n = 58; 43.9%) and non-hemopericardium groups (n = 74; 56.1%). We compared the clinical demographics, surgical information, postoperative complications, 5-year cumulative survival rates, and freedom from reoperation rates. Furthermore, multivariable logistic regression analysis was utilized to identify independent risk factors for patients who underwent re-exploration for bleeding.

RESULTS

In the hemopericardium group, 36.2% of patients presented with cardiac tamponade before surgery. Moreover, the hemopericardium group showed higher rates of preoperative shock and endotracheal intubation and was associated with an elevated incidence of intractable perioperative bleeding, necessitating delayed sternal closure for hemostasis. The hemopericardium group exhibited higher blood transfusion volumes and rates of re-exploration for bleeding following surgery. However, the 5-year survival (59.5% vs. 75.0%; P = 0.077) and freedom from reoperation rates (93.3% vs. 85.5%; P = 0.416) were comparable between both groups. Multivariable analysis revealed that hemopericardium, cardiopulmonary bypass time, and delayed sternal closure were the risk factors for bleeding re-exploration.

CONCLUSIONS

The presence of hemopericardium in patients with ATAIMH is associated with an elevated incidence of cardiac tamponade and unstable preoperative hemodynamics, which could lead to perioperative bleeding tendencies and high complication rates. However, patients of ATAIMH complicated with hemopericardium undergoing aggressive surgical intervention exhibited long-term surgical outcomes comparable to those without hemopericardium.

Analysis of factors affecting outcome in acute type A aortic dissection complicated by preoperative cardiopulmonary resuscitation

OBJECTIVES

Cardiopulmonary resuscitation (CPR) aggravates the pre-existing dismal prognosis of patients suffering from acute type A aortic dissection (ATAAD). We aimed to identify factors affecting survival and outcome in ATAAD patients requiring CPR at presentation at 2 European aortic centres.

METHODS

Data on 112 surgical candidates and undergoing preoperative CPR were retrospectively evaluated. Patients were divided into 2 groups according to 30-day mortality. A multivariable model identified predictors for 30-day mortality.

RESULTS

Preoperative death occurred in 23 patients (20.5%). In the remaining 89 surgical patients (79.5%) circulatory arrest time (41 ± 20 min in 30-day non-survivors vs 30 ± 13 min in 30-day survivor, P = 0.003) as well as cardiopulmonary bypass time (320 ± 132 min in 30-day non-survivors vs 252 ± 140 min in 30-day survivor, P = 0.020) time was significantly longer in patients with worse outcome. Thirty-day mortality of the total cohort was 61.6% (n = 69) with cardiac failure in 48% and aortic rupture or haemorrhagic shock (28%) as predominant reasons of death. Age [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.09, P = 0.034], preoperative coronary (OR 3.42, 95% CI 1.34-9.26, p = 0.012) and spinal malperfusion (OR 12.49, 95% CI 1.83-225.02, P = 0.028) emerged as independent predictors for 30-day mortality while CPR due to tamponade was associated with improved early survival (OR 0.29, 95% CI 0.091-0.81, P = 0.023).

CONCLUSIONS

Assessment of underlying cause for CPR is mandatory. Pericardial tamponade, rapidly resolved with pericardial drainage, is a predictor for improved survival, while age and presence of coronary and spinal malperfusion are associated with dismal outcome in this high-risk patient group.

Delayed sternal closure for intractable bleeding after acute type A aortic dissection repair: outcomes and risk factors analyses

BACKGROUND

Perioperative coagulopathy and intractable bleeding are severe complications in acute type A aortic dissection (ATAAD) repair surgery. Mediastinal packing with delayed sternal closure (DSC) is a commonly adapted technique to stabilize the hemorrhagic tendency. This retrospective study aims to investigate the early and late outcomes and risk factors in patients who underwent DSC procedure during ATAAD repair surgery.

METHODS

This study investigated 704 consecutive patients who underwent ATAAD repair at this institution between January 2007 and September 2020. These patients were dichotomized into the DSC (n = 109; 15.5%) and primary sternal closure (PSC) groups (n = 595; 84.5%). The clinical features, surgical information, postoperative complications, 5-years cumulative survival, and freedom from reoperation rates were compared. A multivariate logistic regression analysis was used to identify the independent risk factors for patients who underwent DSC.

RESULTS

The DSC group showed a higher rate of hemopericardium and preoperative malperfusion, and was associated with longer cardiopulmonary bypass and aortic clamping times and a higher rate of intraoperative extracorporeal membrane oxygenation (ECMO) support. The DSC group showed higher blood transfusion volumes and rate of reexploration for bleeding after surgery. However, the in-hospital mortality rates (17.4% vs. 13.3%; P = 0.249), 5-year survival rates (66.9% vs. 68.2%; P = 0.635), and freedom from reoperation rates (89.1% vs. 82.5%; P = 0.344) were comparable between the DSC and PSC groups. Multivariate analysis revealed that hemopericardium, preoperative malperfusion, and intraoperative ECMO support were risk factors for implementing DSC.

CONCLUSIONS

DSC is an efficient life-saving technique to stabilize patients with intractable bleeding after undergoing ATAAD repair surgery, which leads to acceptable short- and long-term outcomes. Patients who were at risk for intractable bleeding should have early decision-making for implementing DSC.

Surgical outcomes of DeBakey type I and type II acute aortic dissection: a propensity score-matched analysis in 599 patients

Background

The DeBakey classification divides Stanford acute type A aortic dissection (ATAAD) into DeBakey type I (D1) and type II (D2) according to the extent of acute aortic dissection (AAD). This retrospective study aimed to compare the early and late outcomes of D1-AAD and D2-AAD through a propensity score-matched analysis.

Methods

Between January 2009 and April 2020, 599 consecutive patients underwent ATAAD repair at our institution, and were dichotomized into D1 (n = 543; 90.7%) and D2 (n = 56; 9.3%) groups. Propensity scoring was performed with a 1:1 ratio, resulting in a matched cohort of 56 patients per group. The clinical features, postoperative complications, 5-year cumulative survival and freedom from reoperation rates were compared.

Results

In the overall cohort, the D1 group had a lower rate of preoperative shock and more aortic arch replacement with longer cardiopulmonary bypass time. The D1 group had a higher in-hospital mortality rate than the D2 group in overall (15.8% vs 5.4%; P = 0.036) and matched cohorts (19.6% vs 5.4%; P = 0.022). For patients that survived to discharge, the D1 and D2 groups demonstrated similar 5-year survival rates in overall (77.0% vs 85.2%; P = 0.378) and matched cohorts (79.1% vs 85.2%; P = 0.425). The 5-year freedom from reoperation rates for D1 and D2 groups were 80.0% and 97.1% in overall cohort (P = 0.011), and 93.6% and 97.1% in matched cohort (P = 0.474), respectively.

Conclusions

Patients with D1-AAD had a higher risk of in-hospital mortality than those with D2-AAD. However, for patients who survived to discharge, the 5-year survival rates were comparable between both groups.