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Ulkucu A, Altay S. A Fatal Disaster: Accompanying Aortic Dissection Obscured by Acute Coronary Syndrome. Angiology 2024; 75:954-967. [PMID: 37501377 DOI: 10.1177/00033197231191167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
The present study investigated the characteristics of rare but often fatal cases of acute coronary syndrome and aortic dissection and the factors affecting mortality. HEART score, aortic dissection detection risk score, and Global Registry of Acute Coronary Event (GRACE) Score were calculated by evaluating biochemical tests and symptoms/signs of the 20 patients who were admitted to our clinic with a preliminary diagnosis of acute myocardial infarction and subsequently diagnosed with aortic dissection. The assumption of normal distribution was checked with the Shapiro-Wilk test, and independent group comparisons were made with the t test or the Mann-Whitney U test. Relationships between qualitative variables were analyzed with chi-square tests. Relationships between quantitative variables were analyzed with Pearson or Spearman correlation coefficients. Patients with conditions like hypertension and diabetes are at higher risk for aortic dissection. We recommend the use of the GRACE Score with the risk parameters we have determined for the prediction of operative mortality. We suggest that the axillary region and antegrade cerebral perfusion may be preferred as the cannulation area in dissection repair. We emphasize preliminary risk assessment according to the aortic dissection detection risk score and remind physicians that ECG ST-T and troponin changes may be misleading.
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Affiliation(s)
- Attila Ulkucu
- Digestive Disease & Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Servet Altay
- Department of Cardiology, School of Medicine, Trakya University, Edirne, Turkey
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2
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Chen T, Kholova I, Paavonen T, Mennander A. The proximal extension of acute type A aortic dissection is associated with ascending aortic wall degeneration. J Thorac Dis 2024; 16:4155-4164. [PMID: 39144334 PMCID: PMC11320277 DOI: 10.21037/jtd-24-206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/26/2024] [Indexed: 08/16/2024]
Abstract
Background Aortic root involvement during acute type A aortic dissection (ATAAD) may depend on ascending aortic wall degeneration. Surgical decision-making for extended resection of the aortic root is clinically made without histopathology. The aim of the study was to investigate whether the degree of degeneration of the ascending aortic wall found in patients with ATAAD is associated with the aortic root involvement. Methods Collectively, 141 consecutive patients undergoing ATAAD surgery at Tampere University Heart Hospital were investigated. The ascending aortic wall resected in surgery was processed for 11 different variables that describe medial and adventitial degeneration. In addition, atherosclerosis and inflammation were separately evaluated. Patients undergoing aortic root replacement were compared with those with supracoronary reconstruction of the ascending aorta with/without aortic valve surgery (root-sparing surgery) during a mean 4.9-year follow-up. Results Aortic root replacement together with the ascending aortic replacement was performed in 39% of the patients (n=55). The mean age for all patients was 65 years [standard deviation (SD 13)]. Many patients with aortic root replacement had moderate to severe aortic valve regurgitation (85.5%). Most of the patients with aortic root-sparing surgery included a supracoronary tube prosthesis (89.5%), while nine patients also had aortic valve replacement. The degree of mucoid extracellular matrix accumulation was more prominent in patients with aortic root replacement compared to patients with root-sparing surgery (2.1 SD 0.4 vs. 1.9 SD 0.4, P=0.04, respectively). During follow-up, there were 52 deaths among patients (log rank P=0.79). Conclusions Histopathology of the ascending aorta during ATAAD reveals distinctive aortic wall degeneration in patients with aortic root involvement vs. not. The degree of mucoid extracellular matrix accumulation assessed postoperatively is associated with the choice of surgical procedure in many patients.
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Affiliation(s)
- Trina Chen
- Department of Cardiothoracic Surgery, Tampere University Heart Hospital and Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
- Department of Pathology, Fimlab Laboratories, Tampere University Hospital and Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | - Ivana Kholova
- Department of Pathology, Fimlab Laboratories, Tampere University Hospital and Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | - Timo Paavonen
- Department of Pathology, Fimlab Laboratories, Tampere University Hospital and Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
| | - Ari Mennander
- Department of Cardiothoracic Surgery, Tampere University Heart Hospital and Tampere University, Faculty of Medicine and Health Technology, Tampere, Finland
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3
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Wolfe SB, Sundt TM, Isselbacher EM, Cameron DE, Trimarchi S, Bekeredjian R, Leshnower B, Bavaria JE, Brinster DR, Sultan I, Pai CW, Kachroo P, Ouzounian M, Coselli JS, Myrmel T, Pacini D, Eagle K, Patel HJ, Jassar AS. Survival after operative repair of acute type A aortic dissection varies according to the presence and type of preoperative malperfusion. J Thorac Cardiovasc Surg 2024; 168:37-49.e6. [PMID: 36333247 DOI: 10.1016/j.jtcvs.2022.09.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 09/07/2022] [Accepted: 09/20/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE Approximately one-quarter of patients with acute type A aortic dissection (TAAD) present with concomitant malperfusion of coronary arteries, mesenteric circulation, lower extremities, kidneys, brain, and/or coma. It is generally accepted that TAAD patients who present with malperfusion experience higher mortality rates than patients without, although how specific malperfusion syndromes, alone or in combination, affect mortality is not well described. METHODS The International Registry of Acute Aortic Dissection database was queried for patients who underwent surgical repair of TAAD. Patients were stratified according to the presence/absence of malperfusion at presentation. Multivariable logistic regression was used to evaluate in-hospital mortality according to malperfusion type. Kaplan-Meier estimates were used to estimate 30-day postoperative survival. RESULTS Six thousand four hundred thirty-seven patients underwent surgical repair of acute TAAD, of whom 2642 (41%) had 1 or more preoperative malperfusion syndromes. Mesenteric malperfusion (adjusted odds ratio [AOR], 4.84; P < .001) was associated with the highest odds of in-hospital mortality, followed by coma (AOR, 1.88; P = .007), limb ischemia (AOR, 1.73; P = .008), and coronary malperfusion (AOR, 1.51; P = .02). Renal malperfusion (AOR, 1.37; P = .24) and neurologic deficit (AOR, 1.35; P = .28) were not associated with increased in-hospital mortality. In patients who survived to discharge, there was no difference in 1-year postdischarge survival in the malperfusion and no malperfusion cohorts (P = .36). CONCLUSIONS Survival during the index admission after TAAD repair varies according to the presence and type of malperfusion syndromes, with mesenteric malperfusion being associated with the highest odds of in-hospital death. Not only the presence of malperfusion but rather specific malperfusion syndromes should be considered when assessing a patient's risk of undergoing TAAD repair.
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Affiliation(s)
- Stanley B Wolfe
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Mass
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Mass
| | - Eric M Isselbacher
- Division of Cardiology, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Mass
| | - Duke E Cameron
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Mass
| | - Santi Trimarchi
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, University of Milan, Milan, Italy
| | - Raffi Bekeredjian
- Department of Internal Medicine, University Hospital of Heidelberg, Heidelberg, Germany
| | - Bradley Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Derek R Brinster
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Center for Thoracic Aortic Disease, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Chih-Wen Pai
- International Registry of Acute Aortic Dissection, University of Michigan, Ann Arbor, Mich
| | - Puja Kachroo
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St Louis, Mo
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Truls Myrmel
- Department of Thoracic and Cardiovascular Surgery, Tromso University Hospital, Tromso, Norway
| | - Davide Pacini
- Division of Cardiac-Surgery, Istituto di Ricovero e Cura a Carattere Scientifico, Azienda-Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Kim Eagle
- Division of Cardiology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Mich
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Arminder S Jassar
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Mass.
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Doukas P, Dalibor N, Keszei A, Frankort J, Krabbe J, Zayat R, Jacobs MJ, Gombert A, Akhyari P, Mehdiani A. Factors Associated with Early Mortality in Acute Type A Aortic Dissection-A Single-Centre Experience. J Clin Med 2024; 13:1023. [PMID: 38398336 PMCID: PMC10889250 DOI: 10.3390/jcm13041023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 01/31/2024] [Accepted: 02/08/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Acute aortic dissection type A (AADA) is a surgical emergency with relevant mortality and morbidity despite improvements in current management protocols. Identifying patients at risk of a fatal outcome and controlling the factors associated with mortality remain of paramount importance. METHODS In this retrospective observational study, we reviewed the medical records of 117 patients with AADA, who were referred to our centre and operated on between 2005 and 2021. Preoperative, intraoperative, and postoperative variables were analysed and tested for their correlation with in-hospital mortality. RESULTS The overall survival rate was 83%. Preoperatively, factors associated with mortality were age (p = 0.02), chronic hypertension (p = 0.02), any grade of aortic valve stenosis in the patient's medical history (p = 0.03), atrial fibrillation (p = 0.04), and oral anticoagulation (p = 0.04). Non-survivors had significantly longer operative times (p = 0.002). During the postoperative phase, mortality was strongly associated with acute kidney injury (AKI) (p < 0.001), acute heart failure (p < 0.001), stroke (p = 0.02), focal neurological deficits (p = 0.02), and sepsis (p = 0.001). In the multivariate regression analysis, the onset of postoperative focal neurological deficits was the best predictor of a fatal outcome after adjusting for ARDS (odds ratio: 5.8, 95%-CI: 1.2-41.7, p = 0.04). CONCLUSIONS In this retrospective analysis, atrial fibrillation, oral anticoagulation, hypertension, and age were significantly correlated with mortality. Postoperatively, acute kidney injury, acute heart failure, sepsis, and focal neurological deficits were correlated with in-hospital mortality, and focal neurological deficit has been identified as a significant predictor of fatal outcomes. Early detection and interdisciplinary management of at-risk patients remain crucial throughout the postoperative phase.
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Affiliation(s)
- Panagiotis Doukas
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (N.D.); (J.F.); (M.J.J.); (A.G.)
| | - Nicola Dalibor
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (N.D.); (J.F.); (M.J.J.); (A.G.)
| | - András Keszei
- Center for Translational & Clinical Research Aachen (CTC-A), RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany;
| | - Jelle Frankort
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (N.D.); (J.F.); (M.J.J.); (A.G.)
| | - Julia Krabbe
- Institute of Occupational, Social and Environmental Medicine, Medical Faculty, RWTH Aachen University, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Rachad Zayat
- Clinic for Cardiac Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (R.Z.); (P.A.); (A.M.)
| | - Michael J. Jacobs
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (N.D.); (J.F.); (M.J.J.); (A.G.)
| | - Alexander Gombert
- European Vascular Center Aachen-Maastricht, Department of Vascular Surgery, RWTH University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (N.D.); (J.F.); (M.J.J.); (A.G.)
| | - Payam Akhyari
- Clinic for Cardiac Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (R.Z.); (P.A.); (A.M.)
| | - Arash Mehdiani
- Clinic for Cardiac Surgery, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (R.Z.); (P.A.); (A.M.)
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Chen T, Kholova I, Paavonen T, Mennander A. Aortic elastic fiber degeneration during acute type a aortic dissection and reverse aortic remodeling. J Cardiothorac Surg 2024; 19:80. [PMID: 38336717 PMCID: PMC10858525 DOI: 10.1186/s13019-024-02577-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 01/30/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Progression of proximal or distal aortic dilatation is defined as reverse aortic remodeling after surgery for acute type A aortic dissection (ATAAD) that may be dependent on aortic wall degeneration. METHODS We investigated whether aortic wall degeneration is associated with reverse aortic remodeling leading to aortic reoperation after surgery for ATAAD. Altogether, 141 consecutive patients undergoing surgery for ATAAD at Tampere were evaluated. The resected ascending aortic wall at surgery was processed for 42 degenerative, atherosclerotic and inflammatory histological variables. Patients undergoing aortic reoperations (Redos) were compared with those without aortic reoperations (Controls) during a mean 4.9-year follow-up. RESULTS Redos were younger than Controls (56 and 66 years, respectively, P < 0.001), and had less frequently previous cardiac surgery prior to ATAAD. Initial surgery encompassed replacement of the ascending aorta in the majority. There were 21 Redos in which one patient died during follow-up as compared with 51 deaths in Controls (log Rank P = 0.002). Histology of the aortic wall revealed increased elastic fiber fragmentation, loss, and disorganization in Redos as compared with Controls (2.1 ± 0.5 vs. 1.9 ± 0.5, Point score unit (PSU), P = 0.043 and 1.7 ± 0.8 vs. 1.2 ± 0.8, PSU, P = 0.016, respectively). Moderate atherosclerosis occurred less often in Redos vs. Controls (9.5% vs. 33%, PSU, P = 0.037, respectively). CONCLUSIONS According to this exploratory study, histopathology reveals distinctive aortic wall degeneration during ATAAD. Reverse aortic remodeling after ATAAD is associated with the presence of ascending aortic wall elastic fiber fragmentation, loss and disorganization during ATAAD.
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Affiliation(s)
- Trina Chen
- Tampere University Heart Hospital, Tampere University Medical School, SDSKIR, Elämänaukio 1, P.O. Box 2000, Tampere, FI-33521, Finland
- Department of Pathology, Fimlab Laboratories, Tampere University Hospital, Tampere University Medical School, Tampere, Finland
| | - Ivana Kholova
- Department of Pathology, Fimlab Laboratories, Tampere University Hospital, Tampere University Medical School, Tampere, Finland
| | - Timo Paavonen
- Department of Pathology, Fimlab Laboratories, Tampere University Hospital, Tampere University Medical School, Tampere, Finland
| | - Ari Mennander
- Tampere University Heart Hospital, Tampere University Medical School, SDSKIR, Elämänaukio 1, P.O. Box 2000, Tampere, FI-33521, Finland.
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Jankovic N, Matkovic M, Bilbija I, Milicevic V, Zlatkovic M, Aleksic N, Cvetic V, Milin-Lazovic J, Putnik S. The Clinical Impact of the Extension of Acute Type A Aortic Surgery on Long-Term Outcomes: Should We Tend to Be Conservative? MEDICINA (KAUNAS, LITHUANIA) 2023; 60:35. [PMID: 38256296 PMCID: PMC10821435 DOI: 10.3390/medicina60010035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024]
Abstract
Background and Objectives: Despite advances in surgical techniques, industry adjuncts, and cerebral perfusion techniques, the in-hospital mortality rate of type A acute dissection (TAAD) remains at 15-30%. This study aimed to investigate the influence of different extents of aortic resection on survival and quality of life (QoL) after long-term follow-up. Materials and Methods: A retrospective observational trial was performed, including 165 patients operated upon for TAAD. Patients were divided into two groups according to the extent of their aortic repair: the first group comprised patients who had ascending aorta replacement and the second included patients who had hemiarch or total arch replacement. The groups were compared with regard to their baseline characteristics, operative characteristics, survival, complications, and QoL during nine years of follow-up. Results: The mean follow-up time was 75.6 months (1-108 months). The mean survival in the ascending aorta repair group was 89.651 (81.242-98.061) months and was 54.801 (40.053-69.548) months in the hemiarch and arch group; the difference between the groups was significant (log-rank p < 0.001). The rate of new postoperative neurological deficits was statistically higher in the hemiarch and arch group (17.5% vs. 8.4%, p = 0.045), the most common being stroke, and was also more frequent in the hemiarch and arch group than in the ascending aorta group (with statistical significance (15.7% vs. 6.5%)). The mean SF-12 physical score from the QoL questionnaire was higher in the ascending aorta replacement group than in the hemiarch and arch group (50.1 ± 7.3 vs. 44.0 ± 11.9, p = 0.017). Additionally, the mean SF-12 mental score was higher in the ascending aorta replacement group (52.3 ± 7.3 vs. 47.1 ± 12.8, p = 0.032). Conclusions: A more aggressive approach involving aortic arch repair means a lower survival rate and lesser quality of life after long-term follow-up in comparison with the replacement of the ascending aorta. If clinically applicable, a more defensive strategy may be considered.
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Affiliation(s)
- Natasa Jankovic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
| | - Milos Matkovic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
| | - Ilija Bilbija
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
| | - Vladimir Milicevic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
| | - Mina Zlatkovic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
| | - Nemanja Aleksic
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
| | - Vladimir Cvetic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
- Department for Cardiovascular Radiology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Jelena Milin-Lazovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
- Department of Biostatistics, Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Svetozar Putnik
- Department for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia; (M.M.); (I.B.); (V.M.); (M.Z.); (N.A.); (S.P.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (V.C.); (J.M.-L.)
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Zea-Vera R, Green SY, Amarasekara HS, Orozco-Sevilla V, Preventza O, LeMaire SA, Coselli JS. Contemporary Midterm Outcomes After Primary Repair of Chronic Type A Aortic Dissection. Ann Thorac Surg 2023; 116:459-466. [PMID: 36528124 DOI: 10.1016/j.athoracsur.2022.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 10/21/2022] [Accepted: 12/06/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Without surgical repair, acute type A aortic dissection (TAAD) is usually fatal. However, some patients survive without an early operation and progress to the chronic phase. Contemporary outcomes of primary surgical repair of chronic TAAD are unclear, so we evaluated them at our single-practice service. METHODS During 1990 to 2021, 205 patients underwent repair of TAAD in the chronic phase (>60 days after onset). The 2 relevant DeBakey classifications were nearly equally represented: type I, 52% (n = 107), and type II, 48% (n = 98). The median interval between dissection onset and repair was 7 months (interquartile range, 3-25 months). Kaplan-Meier and competing-risk analyses provided time-dependent outcomes. RESULTS At the time of intervention, most patients (40%) had chronic symptoms. Type I patients were younger than type II patients; however, comorbidities were similar. Most patients (n = 183 [87%]) underwent hemiarch or total arch repair, although total arch replacement was more common in type I dissection (P < .001). There were 15 operative deaths (7%), and 7 strokes (3%) persisted to the time of death or discharge. No patient had persistent paraplegia. Median follow-up was 5 years (interquartile range, 2-11 years). The 5-year reoperation-free survival was 61% (95% CI, 54%-68%), and the incidence of reoperation was 3% (95% CI, 0.4%-5%). Patients with type I and type II dissection did not differ significantly in survival (P = .2). CONCLUSIONS Durable repair can be achieved with reasonable operative risk. Treatment is individualized and is associated with low rates of persistent neurologic complications. Despite differing operative approaches by DeBakey type, early and late outcomes were similar.
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Affiliation(s)
- Rodrigo Zea-Vera
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, Catholic Health Initiatives (CHI) St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas; Texas Heart Institute, Houston, Texas
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, Catholic Health Initiatives (CHI) St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas; Texas Heart Institute, Houston, Texas
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, Catholic Health Initiatives (CHI) St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas; Texas Heart Institute, Houston, Texas; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas.
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Cardiovascular Surgery, Catholic Health Initiatives (CHI) St. Luke's Health-Baylor St. Luke's Medical Center, Houston, Texas; Texas Heart Institute, Houston, Texas; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas
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8
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Feier H, Grigorescu A, Braescu L, Falnita L, Sintean M, Luca CT, Mocan M. Systematic Innominate Artery Cannulation Strategy in Acute Type A Aortic Dissection: Better Perfusion, Better Results. J Clin Med 2023; 12:jcm12082851. [PMID: 37109188 PMCID: PMC10141089 DOI: 10.3390/jcm12082851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/09/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
(1) Background: Arterial cannulation in type A acute aortic dissection (TAAAD) is still subject to debate. We describe a systematic approach of using the innominate artery for arterial perfusion (2) Methods: The hospital records of 110 consecutive patients with acute TAAAD operated on between January 2014 and December 2022 were retrospectively analyzed. The effect of the cannulation site on early and late mortality, as well as on cardio-pulmonary perfusion indices (lactate and base excess levels, and cooling and rewarming speed) were investigated. (3) Results: There was a significant difference in early mortality (8.82% vs. 40.79%, p < 0.01) but no difference in long-term survival beyond the first 30 days. Using the innominate artery enabled the use of approximately 20% higher CPB flows (2.73 ± 0.1 vs. 2.42 ± 0.06 L/min/m2 BSA, p < 0.01), which resulted in more rapid cooling (1.89 ± 0.77 vs. 3.13 ± 1.62 min/°C/m2 BSA, p < 0.01), rewarming (2.84 ± 1.36 vs. 4.22 ± 2.23, p < 0.01), lower mean base excess levels during CPB (-5.01 ± 2.99 mEq/L vs. -6.66 ± 3.37 mEq/L, p = 0.01) and lower lactate levels at the end of the procedure (4.02 ± 2.48 mmol/L vs. 6.63 ± 4.17 mmol/L, p < 0.01). Postoperative permanent neurologic insult (3.12% vs. 20%, p = 0.02) and acute kidney injury (3.12% vs. 32.81%, p < 0.01) were significantly reduced. (4) Conclusions: systematic use of the innominate artery enables better perfusion and superior results in TAAAD repair.
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Affiliation(s)
- Horea Feier
- Institute for Cardiovascular Diseases, 300310 Timisoara, Romania
- Department of Cardiology, University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Andrei Grigorescu
- Institute for Cardiovascular Diseases, 300310 Timisoara, Romania
- Department of Cardiology, University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Laurentiu Braescu
- Institute for Cardiovascular Diseases, 300310 Timisoara, Romania
- Department of Cardiology, University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Lucian Falnita
- Institute for Cardiovascular Diseases, 300310 Timisoara, Romania
- Department of Cardiology, University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Marius Sintean
- Institute for Cardiovascular Diseases, 300310 Timisoara, Romania
| | - Constantin Tudor Luca
- Institute for Cardiovascular Diseases, 300310 Timisoara, Romania
- Department of Cardiology, University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Mihaela Mocan
- Department of Internal Medicine, University of Medicine and Pharmacy Iuliu Hatieganu, 400012 Cluj-Napoca, Romania
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9
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Norton EL, Kim KM, Fukuhara S, Wu X, Patel HJ, Deeb GM, Yang B. Differences among sexes in presentation and outcomes in acute type A aortic dissection repair. J Thorac Cardiovasc Surg 2023; 165:972-981. [PMID: 33902911 PMCID: PMC8478983 DOI: 10.1016/j.jtcvs.2021.03.078] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 03/13/2021] [Accepted: 03/16/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Female sex is a known risk factor in most cardiac surgery, including coronary and valve surgery, but unknown in acute type A aortic dissection repair. METHODS From 1996 to 2018, 650 patients underwent acute type A aortic dissection repair; 206 (32%) were female, and 444 (68%) were male. Data were collected through the Cardiac Surgery Data Warehouse, medical record review, and National Death Index database. RESULTS Compared with men, women were significantly older (65 vs 57 years, P < .0001). The proportion of women and men inverted with increasing age, with 23% of patients aged less than 50 years and 65% of patients aged 80 years or older being female. Women had significantly less chronic renal failure (2.0% vs 5.4%, P = .04), acute myocardial infarction (1.0% vs 3.8%, P = .04), and severe aortic insufficiency. Women underwent significantly fewer aortic root replacements with similar aortic arch procedures, shorter cardiopulmonary bypass times (211 vs 229 minutes, P = .0001), and aortic crossclamp times (132 vs 164 minutes, P < .0001), but required more intraoperative blood transfusion (4 vs 3 units) compared with men. Women had significantly lower operative mortality (4.9% vs 9.5%, P = .04), especially in those aged more than 70 years (4.4% vs 16%, P = .02). The significant risk factors for operative mortality were male sex (odds ratio, 2.2), chronic renal failure (odds ratio, 3.4), and cardiogenic shock (odds ratio, 6.8). The 10-year survival was similar between sexes. CONCLUSIONS Physicians and women should be cognizant of the risk of acute type A aortic dissection later in life in women. Surgeons should strongly consider operations for acute type A aortic dissection in women, especially in patients aged 70 years or more.
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Affiliation(s)
| | - Karen M Kim
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | | | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Himanshu J Patel
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - G Michael Deeb
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich
| | - Bo Yang
- Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich.
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10
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Pedroza AJ, Dalal AR, Krishnan A, Yokoyama N, Nakamura K, Tognozzi E, Woo YJ, Macarthur JW, Fischbein MP. Outcomes of Reoperative Aortic Root Replacement After Previous Acute Type A Dissection Repair. Semin Thorac Cardiovasc Surg 2023; 36:292-300. [PMID: 36758660 DOI: 10.1053/j.semtcvs.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 02/01/2023] [Indexed: 02/11/2023]
Abstract
Limited aortic root repair for acute type A dissection is associated with greater risk of proximal reoperations compared to full aortic root replacement. Surgical outcomes for patients undergoing reoperative root replacement after previous dissection repair are unknown. This study seeks to determine outcomes for these patients to further inform the debate surrounding optimal upfront management of the aortic root in acute dissection. Retrospective record review of all patients who underwent full aortic root replacement after a previous type A dissection repair operation at a tertiary academic referral center from 2004-2020 was performed. Among 57 cases of reoperative root replacement after type A repair, 35 cases included concomitant aortic arch replacements, and 21 cases involved coronary reconstruction (unilateral or bilateral modified Cabrol grafts). There were 3 acute postoperative strokes and 4 operative mortalities (composite 30-day and in-hospital deaths, 7.0%). Mid-term outcomes were equivalent for patients who required arch replacement compared to isolated proximal repairs (81.8% vs 80.6% estimated 5-year survival, median follow-up 5.53 years. Reoperative root replacement after index type A dissection repairs, including those with concomitant aortic arch replacement and/or coronary reconstruction is achievable with acceptable outcomes at an experienced aortic center.
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Affiliation(s)
- Albert J Pedroza
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Alex R Dalal
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Aravind Krishnan
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Nobu Yokoyama
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Ken Nakamura
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Emily Tognozzi
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - John W Macarthur
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford California..
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11
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Unilateral versus bilateral antegrade cerebral perfusion during surgical repair for patients with acute type A aortic dissection. JTCVS OPEN 2022; 11:37-48. [PMID: 36172412 PMCID: PMC9510789 DOI: 10.1016/j.xjon.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 04/01/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022]
Abstract
Objectives To compare unilateral versus bilateral antegrade cerebral perfusion (ACP) techniques on cerebral protection during acute type A aortic dissection repair. Methods Using an institutional database, we retrospectively reviewed patients who underwent acute type A aortic dissection repair with selective ACP techniques from October 2008 to December 2019. Primary end point was the detection of neurologic dysfunctions. The secondary end point was mortality. For baseline adjustment, the propensity score matching method was used. Multivariable logistic regression analysis was performed to determine the predictor of neurologic events. Results Among 522 patients (aged 62.0 ± 14.9 years; 45.7% women), unilateral and bilateral ACP techniques were used in 357 (64.7%) and 165 (35.3%) patients, respectively. Transient (19.6% vs 21.2%; P = .65) and permanent (7.0% vs 10.3%; P = .70) neurologic dysfunction rates were not significantly different in patients with unilateral versus bilateral ACP, respectively. Observed mortality rate was higher in the patients with bilateral ACP (hazard ratio, 2.05; 95% CI, 1.33-3.14; P = .001). Propensity-score matching yielded 94 pairs of patients. In matched analysis, bilateral ACP did not significantly lower the risks for transient (odds ratio, 0.87; 95% CI, 0.42-1.81; P = .71) and permanent (odds ratio, 1.42; 95% CI, 0.55-3.85; P = .47) neurologic dysfunction or death (hazard ratio, 1.65; 95% CI, 0.87-3.15; P = .13). In the multivariable analysis, the ACP technique was not significantly associated with perioperative neurologic deficit. Conclusions Despite additional supply, the patients undergoing bilateral ACP during acute type A aortic dissection repair did not have superior outcomes in neurologic and death events compared with the patients undergoing unilateral ACP.
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12
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Right Heart Failure as an Atypical Presentation of Chronic Type A Aortic Dissection - Multimodality Imaging for Accurate Diagnosis and Treatment. A case report and mini-review of literature. J Crit Care Med (Targu Mures) 2022; 8:204-213. [PMID: 36062037 PMCID: PMC9396954 DOI: 10.2478/jccm-2022-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/12/2022] [Indexed: 11/21/2022] Open
Abstract
Background An intrapericardial organized haematoma secondary to chronic type A aortic dissection is an extremely rare cause of right heart failure. Imaging studies are essential in recognising and diagnosis of this distinctive medical condition and guiding the anticipated treatment. Case presentation A 70-year-old male patient was admitted for progressive symptoms of right heart failure. His cardiovascular history exposed an aortic valve replacement 22 years before with a Medtronic Hall 23 tilting valve with no regular follow-up. Classical signs of congestion were recognized at physical examination. Transthoracic two-dimensional echocardiography and thoraco-abdominal computed tomography angiography, as essential parts of multimodality imaging algorithm, established the underlying cause of right heart failure. Under total cardiopulmonary bypass and cardiac arrest, surgical removal of the haematoma and proximal repair of the ascending aorta with a patient-matched vascular graft were successfully performed. The patient was discharged in good condition with appropriate pharmacological treatment, guideline-directed; no imagistic signs of acute post-surgery complications were ascertained. Conclusion This paper highlights the importance of recognizing and providing a timely clinical and imagistic diagnosis of this very rare, potentially avoidable cause of right heart failure in patients with previous cardiac surgery.
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13
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Giambuzzi I, Bonalumi G, Parolari A, Di Mauro M. Commentary: Do not close a door that opens a window! JTCVS Tech 2021; 9:11-12. [PMID: 34647043 PMCID: PMC8501188 DOI: 10.1016/j.xjtc.2021.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 10/31/2022] Open
Affiliation(s)
- Ilaria Giambuzzi
- Department of Cardiac Surgery, IRCCS Monzino Cardiology Center, Milan, Italy
- Dipartimento Scienze Cliniche e di Comunità, University of Milan, Milan, Italy
| | - Giorgia Bonalumi
- Department of Cardiac Surgery, IRCCS Monzino Cardiology Center, Milan, Italy
| | - Alessandro Parolari
- Unit of Cardiac Surgery and Translational Research, IRCCS Policlinico S. Donato, University of Milan, Milan, Italy
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Unit, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
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14
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Vendramin I, Lechiancole A, Piani D, Deroma L, Tullio A, Sponga S, Milano AD, Onorati F, Bortolotti U, Livi U. Type A acute aortic dissection with ≥40-mm aortic root: results of conservative and replacement strategies at long-term follow-up. Eur J Cardiothorac Surg 2021; 59:1115-1122. [PMID: 33367649 DOI: 10.1093/ejcts/ezaa456] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/04/2020] [Accepted: 11/15/2020] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES We evaluated the long-term results of aortic root (AR) preservation and replacement in patients operated on for acute type A aortic dissection. METHODS Out of 302 patients discharged after repair of acute aortic dissection (1977-2019), 124 patients had an AR ≥40 mm, which was preserved in 84 (68%, group A) patients and replaced in 40 (32%, group B) patients. Group B patients were younger (mean age 57 ± 12 vs 62 ± 11 years, P = 0.07), with a mean AR of 47 vs 43 mm and ≥moderate aortic insufficiency in 65% vs 30%. Survival, causes of death and reoperations were analysed at mean follow-up of 9 ± 8 years (6 months to 40 years). RESULTS Actuarial survival of discharged patients at 5, 10 and 15 years was 97% (0.89-0.99), 78% (0.67-0.90) and 75% (0.64-0.88) in group A, and 85% (0.71-0.95), 62% (0.44-0.78) and 57% (0.39-0.76) in group B (log-rank test P = 0.2). Nine patients in group A (7 patients for aortic insufficiency and dilatation of the root and 2 patients for pseudoaneurysm) and 1 patient of group B (pseudoaneurysm of the right coronary button) required proximal reoperation without deaths. At 5, 10 and 15 years, the cumulative incidence of proximal aortic reoperations was 5%, 9% and 25% in group A, and 0%, 3% and 3% in group B (P = 0.02). At multivariable analysis AR >45 mm [hazard ratio (HR) 6.8, P = 0.026] and age (HR 0.9, P = 0.016) were independently associated with proximal reoperation. CONCLUSIONS AR preservation in acute type A dissection showed acceptable long-term outcomes. Nevertheless, a more aggressive approach appears a valid option, especially in patients with AR diameter >45 mm.
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Affiliation(s)
- Igor Vendramin
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Andrea Lechiancole
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Daniela Piani
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Laura Deroma
- Health Management Department, University Hospital of Udine, Udine, Italy
| | - Annarita Tullio
- Department of Hygiene and Clinical Epidemiology, University Hospital of Udine, Udine, Italy
| | - Sandro Sponga
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Aldo D Milano
- Division of Cardiac Surgery, Department of Emergencies and organ transplantation, University of Bari, Bari, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona Medical School, Verona, Italy
| | - Uberto Bortolotti
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
| | - Ugolino Livi
- Division of Cardiac Surgery, Cardiothoracic Department, University Hospital of Udine, Udine, Italy
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15
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Belluschi I, Glauber M, Miceli A. Commentary: Fate Revealed: How Simulation Predicts False Lumen Evolution. Semin Thorac Cardiovasc Surg 2021; 34:449-450. [PMID: 34116199 DOI: 10.1053/j.semtcvs.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Igor Belluschi
- Department of Cardiac Surgery, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Mattia Glauber
- Department of Cardiac Surgery, Sant'Ambrogio Hospital, Milan, Italy
| | - Antonio Miceli
- Department of Cardiac Surgery, Sant'Ambrogio Hospital, Milan, Italy.
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16
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Shad R, Kong S, Fong R, Quach N, Kasinpila P, Bowles C, Lee A, Hiesinger W. Computational Fluid Dynamics Simulations to Predict False Lumen Enlargement After Surgical Repair of Type-A Aortic Dissection. Semin Thorac Cardiovasc Surg 2021; 34:443-448. [PMID: 34091015 DOI: 10.1053/j.semtcvs.2021.05.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 05/11/2021] [Indexed: 11/11/2022]
Abstract
We aim to use computational fluid dynamics to investigate the hemodynamic conditions that may predispose to false lumen enlargement in this patient population. Nine patients who received surgical repairs of their type-A aortic dissections between 2017-2018 were retrospectively identified. Multiple contrast-enhanced post-operative CT scans were used to construct 3D models of aortic geometries. Computational fluid dynamics simulations of the models were run on a high-performance computing cluster using SimVascular - an open-source simulation package. Physiological pulsatile flow conditions (4.9 L/min) were used at the aortic true lumen inlet, and physiological vascular resistances were applied at the distal vascular ends. Exploratory analyses showed no correlation between rate of false lumen growth and blood pressure, immediate post-op aortic diameter, or the number of fenestrations (p = 0.2). 1-year post-operative CT scans showed a median false lumen growth rate of 4.31 (3.66, 14.67) mm/year Median (Interquartile range) peak systolic, mid-diastolic, and late diastolic velocity magnitudes were 0.90 (1.40); 0.10 (0.16); and 0.06 (0.06) cm/s respectively. Spearman's ranked correlations between fenestration velocity and 1-year false lumen growth rates were found to be statistically significant: Velocity magnitude at peak systolic (p = 0.025; rho = 0.75), mid diastolic (p = 0.025; rho = 0.75) and late diastolic phases of the cardiac cycle (p = 0.006; rho = 0.85). We have shown that false lumen growth is strongly correlated to fenestration flow velocity, which has potential implications for post-operative surveillance and risk stratification.
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Affiliation(s)
- Rohan Shad
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California
| | - Sandra Kong
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California
| | - Robyn Fong
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California
| | - Nicolas Quach
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California
| | - Patpilai Kasinpila
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California
| | - Cayley Bowles
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California
| | - Anson Lee
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California
| | - William Hiesinger
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, California.
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17
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Saran N, Pochettino A. Cannulation strategies & circulation management in type-A aortic dissection. J Card Surg 2021; 36:1793-1798. [PMID: 33728710 DOI: 10.1111/jocs.15456] [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: 12/13/2020] [Accepted: 12/26/2020] [Indexed: 11/30/2022]
Abstract
Type A aortic dissection most often requires emergent surgery to prevent malperfusion, stroke, and/or rupture of aorta. To achieve the structural goals of the operation, the conduct of the surgery is targeted from it inception at restoring true lumen flow. In this regard, institution of cardiopulmonary bypass and circulation management is key to allow adequate systemic flow, perfusion of brain and visceral organs and comprehensive systemic cooling to achieve circulatory arrest when needed. Different strategies have been used to establish adequate true lumen perfusion with varying success rates, with the most common still being femoral cannulation. More recently axillary and central cannulation strategies have shown satisfactory results by allowing more reliable true lumen flow. Cannulation approach should, therefore, depend on individual patient characteristics, presentation, and true lumen anatomy.
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Affiliation(s)
- Nishant Saran
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Alberto Pochettino
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota, USA
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18
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O’Hara D, McLarty A, Sun E, Itagaki S, Tannous H, Chu D, Egorova N, Chikwe J. Type-A Aortic Dissection and Cerebral Perfusion: The Society of Thoracic Surgeons Database Analysis. Ann Thorac Surg 2020; 110:1461-1467. [DOI: 10.1016/j.athoracsur.2020.04.144] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 04/06/2020] [Accepted: 04/30/2020] [Indexed: 10/24/2022]
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19
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Lu Y, Xue Y, Zhang H, Xie W, Zhao W, Wang D, Zhou Q. Management strategy of Type A Aortic Dissection in a developing center from China: 16 years experiences. J Thorac Dis 2020; 12:6780-6788. [PMID: 33282379 PMCID: PMC7711430 DOI: 10.21037/jtd-20-1866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background Type A Aortic Dissection (TAAD) remains a lethal disease of increasing incidence. However the incidence, standardized treatment and survival rates of TAAD is still a lack in China. This study aims to share the management strategy of TAAD from a developing center of this country. Methods All subjects identified with TAAD in Nanjing Drum Tower Hospital, China, from Jan. 2002 to Dec. 2018 were included in this study. Of 1,037 individuals, 932 (89.9%) were underwent surgery. Based on annual case volume patients underwent surgery were stratified into three operative stages: Early, Middle and Current stage, and patient characteristics, operative trends and outcomes across the operative stages were assessed. Results The annual admissions of patients increased from approximately 20 during 2002–2013 (early era), 100 during 2014–2016 (middle era) to 200 during 2017–2018 (current era). The median age of patients increased from 49.0 to 53.0 among different eras (P<0.001). The overall in-hospital mortality was 16.5%, which significantly decreased from 21.3% to 13.1% with eras (P=0.023). The median time from admission to surgery was remarkedly shorted from 30.4 h during the early era to 14.0 h during the current era. Compared with in the early era, the percentages of aortic arch repair were increased in middle or current eras, while total arch replacement decreased. Conclusions During the last 16 years, the prevalence of TAAD was increasing, and the annual number of operations increased substantially in China. Hospital survival improved over time was challenging prompt management and suitable operations.
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Affiliation(s)
- Yuzhou Lu
- Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Yunxing Xue
- Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - He Zhang
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Wei Xie
- Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Weiwei Zhao
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Dongjin Wang
- Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China.,Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
| | - Qing Zhou
- Department of Cardiothoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.,Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing, China
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20
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Helder MR, Schaff HV, Day CN, Pochettino A, Bagameri G, Greason KL, Lansman SL, Girardi LN, Storlie CB, Habermann EB. Regional and Temporal Trends in the Outcomes of Repairs for Acute Type A Aortic Dissections. Ann Thorac Surg 2020; 109:26-33. [DOI: 10.1016/j.athoracsur.2019.06.058] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 06/03/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
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21
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Thoracic Endovascular Aortic Repair for Type A Intramural Hematoma and Retrograde Thrombosed Type A Aortic Dissection: A Single-Center Experience. Ann Vasc Surg 2019; 65:224-231. [PMID: 31743779 DOI: 10.1016/j.avsg.2019.11.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 11/10/2019] [Accepted: 11/11/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND The aim of this study is to present our experience of thoracic endovascular aortic repair (TEVAR) for type A intramural hematoma (TAIMH) and retrograde thrombosed type A aortic dissection (rt-TAAD) with the entry tear in the descending aorta or the abdominal aorta and discuss the outcomes. METHODS We retrospectively reviewed total 6 patients who underwent TEVAR for TAIMH (n = 2) or rt-TAAD (n = 4) in our hospital between September 2017 and July 2019. The mean age of the patients (5 men and 1 woman) was 74 ± 13 years, and the mean follow-up duration was 13 ± 7 months. RESULTS TEVAR was successfully performed in the acute phase in all patients without relevant complications. After TEVAR, the shrinkage of enlarged thoracic aorta and complete resorptions of the false lumen of the entire thoracic aorta were achieved in 4 patients. In the remaining 2 patients, one had residual thrombosed false lumen of the ascending aorta due to a new development of PAU at the distal aortic arch and another needed additional endovascular intervention for ascending aorta hematoma progression. Late aorta-related adverse event was observed in one patient, who needed open aortic repair. There was no death during follow-up. CONCLUSIONS Tear-oriented endovascular aortic repair is a potential option in selected patients of TAIMH and rt-TAAD and has shown favorable immediate outcomes and aortic remodeling. However, the late aorta-related adverse event is not negligible, and their long-term outcome has not been fully clarified. More research is warranted.
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Faure EM, El Batti S, Sutter W, Bel A, Julia P, Achouh P, Alsac JM. Stent-assisted balloon-induced intimal disruption and relamination of distal remaining aortic dissection after acute DeBakey type I repair. J Thorac Cardiovasc Surg 2019; 157:2159-2165. [DOI: 10.1016/j.jtcvs.2018.10.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/01/2018] [Accepted: 10/02/2018] [Indexed: 11/16/2022]
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23
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Qin J, Zhao Z, Liu G, Ye K, Yin M, Cui C, Shi H, Peng Z, Jiang M, Liu X, Li W, Lu X. In situ diode laser fenestration of aortic arch stent grafts during thoracic endovascular aortic repair of Stanford type A aortic dissection. EUROINTERVENTION 2019; 14:e1854-e1860. [PMID: 30719978 DOI: 10.4244/eij-d-18-00710] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The aim of the study was to evaluate the feasibility, safety, and effectiveness of in situ diode laser fenestration of thoracic endovascular aortic repair (TEVAR) stent grafts to treat Stanford type A aortic dissection. METHODS AND RESULTS Fifty-eight patients with acute or subacute Stanford type A aortic dissection treated with in situ diode laser fenestration during TEVAR under cerebral circulation protection with an extracorporeal bypass were reviewed retrospectively. Routine postoperative outcomes were recorded and assessed. Computed tomography angiography (CTA) was performed during the follow-up after 3, 6 and 12 months. Procedural success was achieved in 53 patients (91.4%). The average procedure time was 162±36 minutes. One patient died of pericardial tamponade during intervention, and one died of severe pneumonia after the intervention. Except for two minor strokes, no more fenestration-related complications occurred at 30 days and 12 months after the intervention. CTA imaging demonstrated 100% primary patency for the left subclavian artery and carotid arteries with favourable aortic remodelling after TEVAR during the follow-up. Two patients had a type Ia endoleak and one other a type II endoleak. CONCLUSIONS In situ diode laser fenestration during TEVAR for type A aortic dissection was found to be feasible, safe, and effective, and may be beneficial as a less invasive approach.
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Affiliation(s)
- Jinbao Qin
- Department of Vascular Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
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Physician-Modified Thoracic Stent Grafts for the Arch After Surgical Treatment of Type A Dissection. Ann Thorac Surg 2019; 108:491-498. [PMID: 30898563 DOI: 10.1016/j.athoracsur.2019.02.026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 01/31/2019] [Accepted: 02/11/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND This study evaluated the outcome of physician-modified thoracic stent grafts for the treatment of dissecting aortic arch aneurysms after surgical treatment of acute type A dissection. METHODS From August 2016 through February 2018, 13 patients (8 men and 5 women) underwent thoracic endovascular aortic repair in which physician-modified thoracic stent grafts were used to treat dissecting aortic arch aneurysms after surgical treatment of acute type A dissection. Patients were a mean age of 70.7 ± 10 years (range, 43 to 82 years). Four patients were treated in an emergent setting for a symptomatic aortic arch aneurysm. The aneurysmal disease involved zone 0 in 10 patients and zone 2 in 3. Seven patients (48%) were treated using an aortic arch stent graft with a single fenestration, combined with cervical debranching in 4 patients. Six patients underwent total endovascular aortic arch repair using a double-fenestrated stent graft. Additional planned endovascular procedures were performed in 3 patients. RESULTS Median time for stent graft modifications was 18 minutes (range, 14 to 21 minutes). All the proximal entry tears in the arch were successfully excluded. The 30-day mortality rate was 0%. One patient (7.6%) had a stroke without permanent sequelae. The median length of stay was 5 days (range, 1 to 17 days). During follow up of 8 ± 6 months, there were no conversions to open repair, aortic rupture, paraplegia, or retrograde dissection. CONCLUSIONS The use of physician-modified thoracic stent grafts for the treatment of dissecting aortic arch aneurysm after surgical treatment of acute type A dissection is feasible and effective. Durability concerns will need to be assessed in future studies.
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Ertugay S, Apaydın A, Baysal B. Kronik tip a aort diseksiyonunun cerrahi tedavisi: Erken dönem sonuçlar. EGE TIP DERGISI 2019. [DOI: 10.19161/etd.418028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Kim JH, Choi JB, Kim TY, Kim KH, Kuh JH. Simplified surgical approach to improve surgical outcomes in the center with a small volume of acute type A aortic dissection surgery. Technol Health Care 2019; 26:675-685. [PMID: 29966210 PMCID: PMC6218144 DOI: 10.3233/thc-171169] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND: Despite recent advances in surgical techniques and perioperative management, the surgical mortality of acute type A aortic dissection remains high. OBJECTIVE: In a hospital with few acute type A aortic dissection operations, we retrospectively investigated whether simplified surgical approach could obtain proper surgical outcomes. METHODS: Between October 2007 and December 2016, we performed emergency surgery in 99 patients who had acute type A aortic dissection, including replacement of the hemi-arch in 62 patients (63%) and total arch in 32 patients (32%) and aortic root surgery in 7 patients (7%). Surgical strategy has been simplified over time. RESULTS: We performed right axillary artery perfusion in 61 patients (62%) and antegrade cerebral perfusion in 78 patients (79%). During the last 3 years, in-hospital mortality was decreased to 4% (2/47). Preoperative unresolved shock was an independent predictor of hospital death. Although the patients with total arch replacement or aortic root surgery had a mean significantly long cardiopulmonary bypass or circulatory arrest time, in-hospital mortality or neurologic complications was not increased. CONCLUSIONS: Simplified surgical approach could provide a reasonable surgical outcome in acute type A aortic dissection surgery in a center with a small volume of acute aortic dissection surgery.
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Affiliation(s)
- Jong Hun Kim
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea.,Research Institute of Clinical Medicine of Chonbuk National University, Jeonju, Chonbuk, Korea.,Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Chonbuk, Korea.,Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea
| | - Jong Bum Choi
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea.,Research Institute of Clinical Medicine of Chonbuk National University, Jeonju, Chonbuk, Korea.,Biomedical Research Institute of Chonbuk National University Hospital, Jeonju, Chonbuk, Korea.,Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea
| | - Tae Youn Kim
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea.,Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea
| | - Kyung Hwa Kim
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea.,Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea
| | - Ja Hong Kuh
- Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea.,Department of Thoracic and Cardiovascular Surgery, Chonbuk National University Medical School, Jeonju, Chonbuk, Korea
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Engin M, Göncü MT, Güvenç O, Savran M, Özyazıcıoğlu AF. Tip A Aort Diseksiyonlarında Operasyon Sonrası Erken Dönem Mortalite Ve Morbidite Üzerine Etki Eden Faktörlerin Retrospektif İncelenmesi. DICLE MEDICAL JOURNAL 2018. [DOI: 10.5798/dicletip.497890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Merkle J, Sabashnikov A, Deppe AC, Zeriouh M, Maier J, Weber C, Eghbalzadeh K, Schlachtenberger G, Shostak O, Djordjevic I, Kuhn E, Rahmanian PB, Madershahian N, Rustenbach C, Liakopoulos O, Choi YH, Kuhn-Régnier F, Wahlers T. Impact of ascending aortic, hemiarch and arch repair on early and long-term outcomes in patients with Stanford A acute aortic dissection. Ther Adv Cardiovasc Dis 2018; 12:327-340. [PMID: 30295137 DOI: 10.1177/1753944718801568] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND: Stanford A acute aortic dissection (AAD) is a life-threatening emergency associated with major morbidity and mortality. The aim of this study was to compare outcomes of three different surgical approaches in patients with Stanford A AAD. METHODS: From January 2006 to March 2015 a total of 240 consecutive patients with diagnosed Stanford A AAD underwent elective, isolated surgical aortic repair in our centre. Patients were divided into three groups according to the extent of surgical repair: isolated replacement of the ascending aorta, hemiarch replacement and total arch replacement. Patients were followed up for up to 9 years. After univariate analysis multinomial logistic regression was performed for subgroup analysis. Baseline characteristics and endpoints as well as long-term survival were analysed. RESULTS: There were no statistically significant differences among the three groups in terms of demographics and preoperative baseline and clinical characteristics. Incidence of in-hospital stroke ( p = 0.034), need for reopening due to bleeding ( p = 0.031) and in-hospital mortality ( p = 0.017) increased significantly with the extent of the surgical approach. There was no statistical difference in terms of long-term survival ( p = 0.166) among the three groups. Applying multinomial logistic regression for subgroup analysis significantly higher odds for stroke ( p = 0.023), reopening for bleeding ( p = 0.010) and in-hospital mortality ( p = 0.009) for the arch surgery group in comparison to the ascending aorta surgery group as well as significantly higher odds for stroke ( p = 0.029) for the total arch surgery group in comparison to the hemiarch surgery group were identified. CONCLUSIONS: With Stanford A AAD the incidence of perioperative complications increased significantly with the extent of the surgical approach. Subgroup analysis and long-term follow up in patients undergoing isolated ascending or hemiarch surgery showed a lower incidence of cerebrovascular events compared with surgery for total arch replacement.
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Affiliation(s)
- Julia Merkle
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Kerpener Strasse 62, 50937 Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Johanna Maier
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Olga Shostak
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Ilija Djordjevic
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Parwis B Rahmanian
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Navid Madershahian
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Christian Rustenbach
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Oliver Liakopoulos
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
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Houben IB, Patel HJ. Acute Type A Aortic Dissection: Managing More Than Just the Entry-Tear. Semin Thorac Cardiovasc Surg 2018; 31:122-128. [PMID: 30205145 DOI: 10.1053/j.semtcvs.2018.08.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 08/31/2018] [Indexed: 11/11/2022]
Abstract
As emergency repair for acute type A aortic dissection is improving, the reintervention rate increases. Over 10% of cases require an aortic reintervention, which should ideally be performed in an early stage to allow for positive aortic remodeling and to prevent limitations by the stiffened aortic flap. These reinterventions remain a surgical challenge and may come with complications. We provide a comprehensive overview of different management strategies and their success in treating aortic adverse remodelling, based on current evidence of the literature. Two meta-analyses and an additional literature search yielded comparable mortality rates between limited repair and extensive repair. Cardiopulmonary bypass time, cross clamping time and cardiac arrest time were significantly shorter in limited repairs. Reintervention rate was generally lower in extensive repair, although not always significant. In conclusion, the early aggressive approach may be useful to lower reintervention rates. However, it has not yet been proven to be more beneficial. It will be imperative to develop a patient-specific early stage prediction model for residual aortic reintervention.
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Affiliation(s)
- Ignas B Houben
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan Health Center, Ann Arbor, Michigan
| | - Himanshu J Patel
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan Health Center, Ann Arbor, Michigan.
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Chen IM, Chen PL, Weng SH, Hsu CP, Shih CC, Chang HH, Wei J. Clinical Outcomes of VasoRing Connector in Patients With Acute Type A Aortic Dissection. Ann Thorac Surg 2018; 106:764-770. [DOI: 10.1016/j.athoracsur.2018.03.056] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 02/23/2018] [Accepted: 03/19/2018] [Indexed: 11/28/2022]
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Merkle J, Sabashnikov A, Weber C, Schlachtenberger G, Maier J, Spieker A, Eghbalzadeh K, Deppe AC, Zeriouh M, Rahmanian PB, Madershahian N, Rustenbach C, Choi YH, Kuhn-Régnier F, Liakopoulos O, Wahlers T. Impact of age on early outcomes and long-term survival of patients undergoing aortic repair with Stanford A dissection. Perfusion 2018; 33:687-695. [DOI: 10.1177/0267659118786332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Objectives: Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in older patients and requiring immediate surgical repair. The aim of this study was to evaluate early outcome and short- and long-term survival of patients under and above 65 years of age. Methods: Two hundred and forty patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015 in our center. After statistical analysis and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up, comprising patients under and above 65 years of age. Results: The proportion of patients above 65 years of age suffering from Stanford A AAD was 50% (n=120). The group of patients above 65 years of age compared to the group under 65 years of age showed statistically significant differences in terms of higher odds ratios (OR) for hypertension (p=0.012), peripheral vascular disease (p=0.026) and tachyarrhythmia absoluta (p=0.004). Patients over 65 years of age also showed significantly poorer short- and long-term survival. Our subgroup analysis revealed that male patients (Breslow p=0.001, Log-Rank p=0.001) and patients suffering with hypertension (Breslow p=0.003, Log-Rank p=0.001) were reasonable for these results whereas younger and older female patients showed similar short- and long-term outcome (Breslow p=0.926, Log-Rank p=0.724). After stratifying all patients into 4 age groups (<45; 55-65; 65-75; >75years), short-term survival of the patients appeared to be significantly poorer with increasing age (Breslow p=0.026, Log-Rank p=0.008) whereas long-term survival of patients free from cerebrovascular events (Breslow p=0.0494, Log-Rank p=0.489) remained similar. Conclusions: All patients referred to our hospital for repair of Stanford A AAD with higher age had poorer short- and long-term survival, caused by male patients and patients suffering from hypertension, whereas survival of women and survival free from cerebrovascular events of the entire patient cohort was similar, irrespective of age.
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Affiliation(s)
- Julia Merkle
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Johanna Maier
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Anna Spieker
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Parwis B. Rahmanian
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Navid Madershahian
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Christian Rustenbach
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Oliver Liakopoulos
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
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Providing Culturally Competent Acute Care Physical Therapy for a Complex Medical Patient of Amish Heritage. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2018. [DOI: 10.1097/jat.0000000000000080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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Zhao H, Wen D, Duan W, An R, Li J, Zheng M. Identification of CTA-Based Predictive Findings for Temporary and Permanent Neurological Dysfunction after Repair in Acute Type A Aortic Dissection. Sci Rep 2018; 8:9740. [PMID: 29950715 PMCID: PMC6021413 DOI: 10.1038/s41598-018-28152-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 05/24/2018] [Indexed: 11/09/2022] Open
Abstract
The aim of this study was to determine CT risk findings predictive of temporary neurological dysfunction (TND) and permanent neurological dysfunction (PND) after surgical repair for acute type A aortic dissection (ATAAD). A total of 255 patients (41 ± 16 years, 79% male) with ATAAD underwent aortic CT angiography (CTA) and surgical repair consecutively from January 2013 to June 2016. The CTA findings of the 255 patients for the thoracic aorta and carotid artery were analysed to identify risk factors predictive of TND and PND. Thirty-eight patients (15%) suffered TND, and 18 (7%) exhibited PND. Common carotid artery (CCA) dissection (OR = 4.63), lower enhancement of unilateral ICA (OR = 3.02) and aortic arch tears (OR = 2.83) were predictors of postoperative TND, while PND was best predicted by retrograde ascending aorta (aAO) dissection (OR = 5.62) and aortic arch tears (OR = 6.74). In CCA dissection, the extent of the entire CCA and proximal ICA (P = 0.014), a low-enhancement false lumen with re-entry (P = 0.000) and a severely narrowed true lumen without re-entry (P = 0.005) significantly increased the risk of postoperative TND. In patients with ATAAD, specific CT findings allow the individual risk of postoperative TND and PND to be identified and may guide subsequent surgical management.
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Affiliation(s)
- Hongliang Zhao
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Didi Wen
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Weixun Duan
- Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Rui An
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Jian Li
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Minwen Zheng
- Department of Radiology, Xijing Hospital, Fourth Military Medical University, Xi'an, China.
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Siti D, Abudesimu A, Ma X, Yang L, Ma X, Ma YT. Incidence and risk factors of recurrent pain in acute aortic dissection and in-hospital mortality. VASA 2018; 47:301-310. [PMID: 29808775 DOI: 10.1024/0301-1526/a000704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND We investigated the prevalence of recurrent pain and its relationship with in-hospital mortality in acute aortic dissection (AAD). PATIENTS AND METHODS Between 2011 and 2016, 234 AAD patients were selected. Recurrent pain was defined as a mean of VAS > 3, within 48 hours following hospital admission or before emergency operation. Patients with and without recurrent pain were divided into group I and group II, respectively into type A AAD and type B AAD patients. Our primary outcome was in-hospital mortality. RESULTS The incidence of recurrent pain was 24.4 % in AAD patients. Incidence of recurrent pain was higher in type A AAD patients than type B AAD patients (48.9 vs. 9.6 %). Overall in-hospital mortality was 25.6 %. Type A AAD had a higher in-hospital mortality than type B AAD patients (47.7 vs. 12.3 %). Group I had significantly higher in-hospital mortality than group II (type A: 79.1 vs. 17.8 %; type B: 57.1 vs. 7.6 %, all P < 0.001), as was the case with medical managed patients (type A: 72.1 vs. 13.3 %; type B: 35.7 vs. 2.3 %, all P < 0.001). Logistic regression analysis showed that use of one drug alone and waist pain were predictive factors for recurrent pain in type A AAD and type A AAD patients, respectively (OR 3.686, 95 % CI: 1.103~12.316, P = 0.034 and OR 14.010, 95 % CI: 2.481~79.103, P = 0.003). Recurrent pains were the risk factors (type A: OR 11.096, 95 % CI: 3.057~40.280, P < 0.001; type B: OR 14.412, 95 % CI: 3.662~56.723, P < 0.001), while invasive interventions were protective (type A: OR 0.133, 95 % CI: 0.035~0.507, P < 0.001; type B: OR 0.334, 95 % CI: 0.120~0.929, P = 0.036) for in-hospital mortality in AAD patients. CONCLUSIONS Approximately one-fourth of AAD patients presented with recurrent pains, which might increase in-hospital mortality. Thus, interventional strategies at early stages are important.
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Affiliation(s)
- Dilixiati Siti
- 1 Department of Cardiovascular Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Asiya Abudesimu
- 1 Department of Cardiovascular Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiaojie Ma
- 1 Department of Cardiovascular Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Lei Yang
- 1 Department of Cardiovascular Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xiang Ma
- 1 Department of Cardiovascular Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yi-Tong Ma
- 1 Department of Cardiovascular Medicine, the First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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Merkle J, Sabashnikov A, Deppe AC, Zeriouh M, Eghbalzadeh K, Weber C, Rahmanian P, Kuhn E, Madershahian N, Kroener A, Choi YH, Kuhn-Régnier F, Liakopoulos O, Wahlers T. Impact of hypertension on early outcomes and long-term survival of patients undergoing aortic repair with Stanford A dissection. Perfusion 2018; 33:463-471. [PMID: 29629837 DOI: 10.1177/0267659118768147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Stanford A acute aortic dissection (AAD) is a life-threatening emergency, typically occurring in hypertensive patients, requiring immediate surgical repair. The aim of this study was to evaluate early outcomes and long-term survival of hypertensive patients in comparison to normotensive patients suffering from Stanford A AAD. METHODS In our center, 240 patients with Stanford A AAD underwent aortic surgical repair from January 2006 to April 2015. After statistical and logistic regression analysis, Kaplan-Meier survival estimation was performed, with up to 9-year follow-up. RESULTS The proportion of hypertensive patients suffering from Stanford A AAD was 75.4% (n=181). There were only few statistically significant differences in terms of basic demographics, comorbidities, preoperative baseline and clinical characteristics of hypertensive patients in comparison to normotensive patients. Hypertensive patients were significantly older (p=0.008), more frequently received hemi-arch repair (p=0.028) and selective brain perfusion (p=0.001). Our study showed similar statistical results in terms of 30-day mortality (p=0.196), long-term overall cumulative survival of patients (Log-Rank p=0.506) and survival of patients free from cerebrovascular events (Log-Rank p=0.186). Furthermore, subgroup analysis for long-term survival in terms of men (Log-Rank p=0.853), women (Log-Rank p=0.227), patients under and above 65 years of age (Log-Rank p=0.188 and Log-Rank p=0.602, respectively) and patients undergoing one of the three types of aortic repair surgery showed similar results for normotensive and hypertensive patient groups. Subgroup analysis for long-term survival of patients free from cerebrovascular events for women, patients under 65 years of age and patients undergoing aortic arch repair showed significant differences between the two groups in favor of hypertensive patients. CONCLUSIONS Hypertensive patients suffering from Stanford A AAD were older, more frequently received hemi-arch replacement and were not associated with increased risk of 30-day mortality and poorer long-term survival compared to normotensive patients.
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Affiliation(s)
- Julia Merkle
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Antje-Christin Deppe
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Kaveh Eghbalzadeh
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Carolyn Weber
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Parwis Rahmanian
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Elmar Kuhn
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Navid Madershahian
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Axel Kroener
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | | | - Oliver Liakopoulos
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, University Hospital of Cologne, Cologne, Germany
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Chiu P, Trojan J, Tsou S, Goldstone AB, Woo YJ, Fischbein MP. Limited root repair in acute type A aortic dissection is safe but results in increased risk of reoperation. J Thorac Cardiovasc Surg 2017; 155:1-7.e1. [PMID: 29042100 DOI: 10.1016/j.jtcvs.2017.08.137] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/28/2017] [Accepted: 08/24/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Management of the aortic root is a challenge for surgeons treating acute type A aortic dissection. METHODS We performed a retrospective review of the acute type A aortic dissection experience at Stanford Hospital between 2005 and 2015 and identified patients who underwent either limited root repair or aortic root replacement. Differences in baseline characteristics were balanced with inverse probability weighting to estimate the average treatment effect on the controls. Weighted logistic regression was used to evaluate in-hospital mortality. Weighted Cox proportional hazards regression was used to evaluate differences in the hazard for mid-term death. Reoperation was evaluated with death as a competing risk with the Fine-Gray subdistribution hazard. RESULTS After we excluded patients managed either nonoperatively or with definitive endovascular repair, there were 293 patients without connective tissue disease who underwent either limited root repair or aortic root replacement. There was no difference in weighted perioperative mortality, odds ratio 0.89 (95% confidence interval [CI], 0.44-1.76, P = .7), and there was no difference in weighted survival, hazard ratio 1.12 (95% CI, 0.54-2.31, P = .8). Risk of reoperation was greater in limited root repair (11.8%, 95% CI, 0.0%-23.8%) than for root replacement (0%), P < .001. CONCLUSIONS Limited root repair was associated with increased risk of late reoperation after repair of acute type A aortic dissection. Surgeons with adequate experience may consider aortic root replacement in well-selected patients. However, given good outcomes after limited root repair, surgeons should not feel compelled to perform this more-complex operation.
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Affiliation(s)
- Peter Chiu
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif; Division of Health Research and Policy, Stanford University, School of Medicine, Stanford, Calif
| | - Jeffrey Trojan
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - Sarah Tsou
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - Andrew B Goldstone
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif; Division of Health Research and Policy, Stanford University, School of Medicine, Stanford, Calif
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif
| | - Michael P Fischbein
- Department of Cardiothoracic Surgery, Stanford University, School of Medicine, Stanford, Calif.
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Hawkins RB, Mehaffey JH, Downs EA, Johnston LE, Yarboro LT, Fonner CE, Speir AM, Rich JB, Quader MA, Ailawadi G, Ghanta RK. Regional Practice Patterns and Outcomes of Surgery for Acute Type A Aortic Dissection. Ann Thorac Surg 2017; 104:1275-1281. [PMID: 28599962 DOI: 10.1016/j.athoracsur.2017.02.086] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 02/19/2017] [Accepted: 02/27/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND The surgical management of acute type A aortic dissection is evolving, and many aortic centers of excellence are reporting superior outcomes. We hypothesize that similar trends exist in a multiinstitutional regional consortium. METHODS Records for 884 consecutive patients who underwent aortic operations (2003 to 2015) for acute type A aortic dissection were extracted from a regional The Society of Thoracic Surgeons database. Patients were stratified into three equal operative eras. Differences in outcomes and risk factors for morbidity and mortality were determined. RESULTS Surgical procedures for type A aortic dissection are increasing in extent and complexity. Aortic root repair was performed in 16% of early era cases compared with 67% currently (p < 0.0001). Similarly, aortic arch repair increased from 27% to 37% cases (p < 0.0001). Cerebral perfusion is currently used in 85% of circulatory arrest cases, most frequently antegrade (57%). Total circulatory arrest times increased (29 minutes vs 31 minutes vs 36 minutes; p = 0.005), but times without cerebral perfusion were stable (12 minutes vs 6 minutes; p = 0.68). Although the operative mortality rate remained stable at 18.9% during the 3 operative eras, there were significant decreases in pneumonia and reoperations (p < 0.05). Predictors of operative mortality and major morbidity are age (odds ratio [OR], 1.04; p < 0.0001), previous stroke (OR, 2.09; p = 0.03), and elevated creatinine (OR, 1.31; p = 0.01). Importantly, the extent of aortic operation did not increase risk for morbidity or mortality. CONCLUSIONS Operative morbidity and mortality remain significant for type A aortic dissection, but lower than historical outcomes. The extent of aortic surgery has increased, resulting in adaptive cerebral protection changes in contemporary "real-world" practice.
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Affiliation(s)
- Robert B Hawkins
- Department of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Department of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Emily A Downs
- Department of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Lily E Johnston
- Department of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Leora T Yarboro
- Department of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Clifford E Fonner
- Virginia Cardiac Services Quality Initiative, Falls Church, Virginia
| | - Alan M Speir
- INOVA Heart and Vascular Institute, Falls Church, Virginia
| | - Jeffrey B Rich
- Virginia Cardiac Services Quality Initiative, Falls Church, Virginia
| | - Mohammed A Quader
- Division of Cardiothoracic Surgery, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
| | - Gorav Ailawadi
- Department of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Ravi K Ghanta
- Department of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia.
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