1
|
Ishizue N, Fukaya H, Oikawa J, Sato N, Ogiso S, Murayama Y, Nakamura H, Kishihara J, Niwano S, Ako J. Prognostic impact of oral anticoagulation therapy and atrial fibrillation in patients with type B acute aortic dissection. J Arrhythm 2024; 40:297-305. [PMID: 38586850 PMCID: PMC10995604 DOI: 10.1002/joa3.13020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 04/09/2024] Open
Abstract
Background The prognostic impact of atrial fibrillation (AF) and oral anticoagulation (OAC) therapy in patients with type B acute aortic dissection (AAD) remains unclear. Therefore, we investigated the prognostic impact of AF and OAC therapy in patients with type B AAD. Methods Consecutive patients diagnosed with AAD were included in this single-center, retrospective study. Patients with type B AAD were selected from the study population and divided into three groups: AF(+)/OAC(+), AF(+)/OAC(-), and AF(-)/OAC(-). The primary end point was major adverse cardiovascular and cerebrovascular events (MACCE), including all-cause death, progressive aortic events, cerebral infarction, and organ malperfusion. Results In total, 139 patients diagnosed with type B AAD were analyzed. AF was observed in 27 patients (19%). Among them, 13 patients (9%) received OAC therapy for AF. MACCE occurred in 32 patients (23%) during the observation period: all-cause death in four patients, progressive aortic events in 24 patients, cerebral infarction events in two patients, and malperfusion events in two patients. The incidence of MACCE was higher in the AF(+)/OAC(+) group than in the AF(+)/OAC(-) group (hazard ratio[HR]: 3.875; 95% confidence interval [CI]: 1.153-17.496). In contrast, there was no significant difference in the incidence of MACCE between the AF(+)/OAC(-) and AF(-)/OAC(-) groups (HR: 1.001, 95% CI: 0.509-1.802). Conclusion Among patients with type B AAD, the use of OAC for AF was associated with a higher risk of MACCE.
Collapse
Affiliation(s)
- Naruya Ishizue
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Hidehira Fukaya
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Jun Oikawa
- Department of Kitasato Clinical Research CenterKitasato University School of MedicineSagamiharaJapan
| | - Nobuhiro Sato
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Sho Ogiso
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Yusuke Murayama
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Hironori Nakamura
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Jun Kishihara
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Shinichi Niwano
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| | - Junya Ako
- Department of Cardiovascular MedicineKitasato University School of MedicineSagamiharaJapan
| |
Collapse
|
2
|
Ibraheem A, Abdullah A, Priyam K, Fakhruddin R. Type B Aortic Dissection Masquerading As Acute Pyelonephritis: Think Beyond Measures. Cureus 2024; 16:e54343. [PMID: 38500931 PMCID: PMC10948085 DOI: 10.7759/cureus.54343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 03/20/2024] Open
Abstract
Aortic dissection (AD) is a life-threatening medical emergency with a high mortality rate if misdiagnosed; therefore, an urgent and precise diagnosis is crucial for prompt treatment. This article presents a rare case report of AD with an atypical clinical presentation that led to delayed diagnosis and a complicated clinical course. Herein, we aim to contribute to the existing literature by providing insights into the varied presentations of AD and offering valuable lessons for clinicians faced with similar diagnostic scenarios. A 64-year-old female with an extended history of hypertension and other comorbidities presented to the emergency department with a one-day duration of right-sided loin pain and fever. Her blood investigations demonstrated evidence of leukocytosis and high c-reactive protein (CRP) levels. She was preliminarily treated as a case of acute pyelonephritis since, initially, clinical and radiographic evidence did not yield an alternative diagnosis. Despite antibiotics, her condition deteriorated, and her urine output became less than 0.5 mL/kg/hour for six consecutive hours. Additionally, the obtained urine culture was negative on the third day of admission, which made the medical team repeat her history taking and clinical examination, revealing a previously overlooked weight loss. This red flag prompted the medical team to conduct thorough chest and abdominal imaging studies in search of any hidden malignancy, especially when her thyroid function test returned normal. Surprisingly, a contrast-enhanced abdominal CT scan demonstrated an infarcted right kidney by thromboembolism that originated from the partially obstructive thrombus in the proximal abdominal aorta, which was later confirmed to be a type B AD by a CT angiogram. A multidisciplinary team guided her treatment, which included carefully controlling her blood pressure, using anticoagulants, and closely monitoring the patient. The take-home messages of this case report underscore the critical importance of recognizing atypical clinical presentations of AD, overcoming diagnostic challenges through comprehensive approaches, tailoring treatments to individual patient needs, and advocating for a multidisciplinary and patient-centered approach to enhance overall clinical outcomes.
Collapse
Affiliation(s)
- Anas Ibraheem
- Internal Medicine, Imamein Kadhimein Medical City, Baghdad, IRQ
- Internal Medicine/Clinical Hematology, Al Karama Teaching Hospital, Baghdad, IRQ
| | - Abdullah Abdullah
- General Medicine, Frimley Health NHS Foundation Trust, Wexham Park Hospital, Slough, GBR
| | - Kumari Priyam
- General Medicine, Frimley Health NHS Foundation Trust, Wexham Park Hospital, Slough, GBR
| | - Rebin Fakhruddin
- Acute Medicine, Pilgrim Hospital, United Lincolnshire Hospitals Trust, Boston, GBR
| |
Collapse
|
3
|
Masumoto A, Azumi Y, Kaji S, Miyoshi Y, Kim K, Kitai T, Furukawa Y. Impact of antithrombotic therapy on clinical outcomes in patients with type B acute aortic syndrome. JTCVS OPEN 2023; 14:36-45. [PMID: 37425476 PMCID: PMC10328807 DOI: 10.1016/j.xjon.2023.02.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 02/14/2023] [Accepted: 02/28/2023] [Indexed: 07/11/2023]
Abstract
Objective Antithrombotic therapy has the potential to interfere with false lumen thrombosis. In type B acute aortic syndrome, the degree of false lumen thrombosis affects clinical outcomes. We aimed to explore the association of antithrombotic therapy with the prognosis of patients with type B acute aortic syndrome. Methods We reviewed 406 patients with type B acute aortic syndrome who were discharged alive with and without antithrombotic therapy. The primary outcome was aorta-related adverse events, defined as a composite of aorta-related death, aortic rupture, aortic repair, and progressive aortic dilation. Results Of the 406 patients, 64 (16%) were discharged with antithrombotic therapy and 342 (84%) were discharged without antithrombotic therapy. A total of 249 patients (61%) presented with intramural hematoma with complete thrombosis of the false lumen, and 157 patients (39%) presented with aortic dissection. During a median follow-up of 4.6 years, 32 patients (50%) in the antithrombotic group and 93 patients (27%) in the nonantithrombotic group had a primary outcome event. Cumulative incidence of aorta-related events at 1 and 3 years with death as the competing risk was higher in the antithrombotic group than in the nonantithrombotic group (19% ± 5% vs 9% ± 2% at 1 year and 40% ± 7% vs 17% ± 2% at 3 years, P < .001). Conclusions Antithrombotic therapy might be associated with an increased risk of aorta-related events in patients with type B acute aortic syndrome.
Collapse
Affiliation(s)
| | | | - Shuichiro Kaji
- Address for reprints: Shuichiro Kaji, MD, PhD, Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima-minamimachi, Chuo-ku 650-0047, Kobe, Japan.
| | | | | | | | | |
Collapse
|
4
|
Gong X, Lang Q, Qin C, Meng W, Xiao Z. The effect of postoperative anticoagulation on acute aortic dissection: a systematic review and meta-analysis. Front Cardiovasc Med 2023; 10:1173945. [PMID: 37234372 PMCID: PMC10206123 DOI: 10.3389/fcvm.2023.1173945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 04/24/2023] [Indexed: 05/27/2023] Open
Abstract
Background and aim The evolution of the false lumen after the repair of acute aortic dissection has been linked to numerous adverse clinical outcomes, including increased late mortality and a higher risk of reoperation. Despite the widespread use of chronic anticoagulation in patients who have undergone repair for acute aortic dissection, the effects of this therapy on false lumen evolution and its subsequent consequences are yet to be fully understood. This meta-analysis aimed to investigate the impact of postoperative anticoagulation on patients with acute aortic dissection. Methods In PubMed, Cochrane Libraries, Embase, and Web of Science, we performed a systematic review of nonrandomized studies, comparing outcomes with postoperative anticoagulation vs. non-anticoagulation on aortic dissection. We investigated the status of false lumen (FL), aorta-related death, aortic reintervention, and perioperative stroke in aortic dissection patients with anticoagulation and non-anticoagulation. Results After screening 527 articles, seven non-randomized studies were selected, including a total of 2,122 patients with aortic dissection. Out of these patients, 496 received postoperative anticoagulation while 1,626 served as controls. Meta-analyses of 7 studies revealed significantly higher FL patency in Stanford type A aortic dissection (TAAD) postoperative anticoagulation with an OR of 1.82 (95% CI: 1.22 to 2.71; Z = 2.95; I²=0%; P = 0.93). Moreover, there was no statistically significant difference between the two groups in aorta-related death, aortic reintervention, and perioperative stroke with an OR of 1.31 (95% CI: 0.56 to 3.04; Z = 0.62; I² = 0%; P = 0.40), 0.98 (95% CI: 0.66 to 1.47; Z = 0.09; I² = 23%; P = 0.26), 1.73 (95% CI: 0.48 to 6.31; Z = 0.83; I² = 8%; P = 0.35), respectively. Conclusions Postoperative anticoagulation was associated with higher FL patency in Stanford type A aortic dissection patients. However, there was no significant difference between the anticoagulation and non-anticoagulation groups in terms of aorta-related death, aortic reintervention, and perioperative stroke.
Collapse
Affiliation(s)
- Xiangfeng Gong
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Qianlei Lang
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Chaoyi Qin
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
- Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, China
| | - Wei Meng
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
- Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, China
| | - Zhenghua Xiao
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Chengdu, China
- Cardiovascular Surgery Research Laboratory, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
5
|
Morello F, Bima P, Castelli M, Nazerian P. Acute aortic syndromes: An internist's guide to the galaxy. Eur J Intern Med 2022; 106:45-53. [PMID: 36229285 DOI: 10.1016/j.ejim.2022.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/05/2022] [Accepted: 10/05/2022] [Indexed: 11/03/2022]
Abstract
Acute aortic syndromes (AASs) are severe conditions defined by dissection, hemorrhage, ulceration or rupture of the thoracic aorta. AASs share etiological and pathophysiological features, including long-term aortic tissue degeneration and mechanisms of acute aortic damage. The clinical signs and symptoms of AASs are unspecific and heterogeneous, requiring large differential diagnosis. When evaluating a patient with AAS-compatible symptoms, physicians need to integrate clinical probability assessment, bedside imaging techniques such as point-of-care ultrasound, and blood test results such as d-dimer. The natural history of AASs is dominated by engagement of ischemic, coagulative and inflammatory pathways at large, causing multiorgan damage. Medical treatment, multiorgan monitoring and outcome prognostication are therefore paramount, with internal medicine playing a key role in non-surgical management of AASs.
Collapse
Affiliation(s)
- Fulvio Morello
- S.C. Medicina d'Urgenza U (MECAU), A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy; Dipartimento di Scienze Mediche, Università degli Studi di Torino, Italy
| | - Paolo Bima
- S.C. Medicina d'Urgenza U (MECAU), A.O.U. Città della Salute e della Scienza di Torino, Torino, Italy; Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
| | - Matteo Castelli
- Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy
| | - Peiman Nazerian
- Department of Emergency Medicine, Careggi University Hospital, Firenze, Italy.
| |
Collapse
|
6
|
Kamaltdinov RR, Akhmetzianov RV, Bredikhin RA, Dzhordzhikiya RK. Outpatient management of patients after surgical operations for acute aortic dissection of type A. AMBULATORNAYA KHIRURGIYA = AMBULATORY SURGERY (RUSSIA) 2022. [DOI: 10.21518/1995-1477-2022-19-2-44-49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Acute aortic dissection of type A is still one of the most difficult diseases faced by doctors of all specialties. The current review is based on an analysis of current literature data and clinical guidelines. It covers various aspects of outpatient patient management and focuses on conservative therapy. The lack of an adequate diagnostic algorithm often leads to complications and, ultimately, death. The dynamic nature of the disease, the variability of clinical manifestations and the course of the pathological process require special attention. Both short-term and long-term survival of the patient depends on careful observation. Postoperative management of patients with acute aortic dissection of type A is entirely entrusted to the outpatient unit, which, due to the absence of the main aspects of the strategy in modern clinical recommendations, is not always prepared for the curation of this complex cohort of patients. The lack of experience in managing this pathology by outpatient hospital doctors causes significant difficulties in interpreting instrumental diagnostic methods, which leads to further erroneous tactics with the development of long-term complications. Due to the lack of a unified scheme of drug therapy, the question of prescribing drugs in these patients, who often receive a fairly large range of medications for concomitant pathology, remains open. These factors contribute to polyprogmasia or vice versa – insufficient volume of drug therapy, which further leads to the progression of the disease. As a result of insufficient emphasis on the basics of outpatient management of this cohort of patients, a whole complex of problems arises, leading to unsatisfactory treatment results and increased healthcare costs for their subsequent solution. The purpose of the review is to highlight the main problems of this issue from the point of view of evidence-based medicine.
Collapse
Affiliation(s)
- R. R. Kamaltdinov
- Kazan State Medical University; Interregional Clinical Diagnostic Center
| | - R. V. Akhmetzianov
- Kazan State Medical University; Interregional Clinical Diagnostic Center
| | - R. A. Bredikhin
- Kazan State Medical University; Interregional Clinical Diagnostic Center
| | | |
Collapse
|
7
|
Larsson M, Bozovic G, Sjögren J, Zindovic I, Ragnarsson S, Nozohoor S. The effect of postoperative anticoagulation on false lumen patency after surgery for acute type A aortic dissection. J Cardiothorac Surg 2021; 16:279. [PMID: 34583738 PMCID: PMC8480047 DOI: 10.1186/s13019-021-01661-1] [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: 12/13/2020] [Accepted: 09/19/2021] [Indexed: 12/04/2022] Open
Abstract
Background Patent false lumen has been shown to have a negative impact on prognosis after surgery for acute type A aortic dissection (ATAAD). We aimed to assess the effect of postoperative anticoagulation on false lumen patency and clinical outcomes in relation to false lumen status. Methods Postoperative computed tomographies of 156 patients undergoing ATAAD DeBakey type I surgery were retrospectively evaluated for false lumen patency. The patients were divided into groups determined by anticoagulation treatment at discharge. Uni- and multivariable logistic regression was used for analysing the effect of anticoagulation on the false lumen, and Kaplan–Meier estimates were used to assess the association of a patent false lumen with the incidence of reoperation and long-term survival. Results A patent false lumen was present in 81% of the patients. Postoperative anticoagulants were not associated with a patent false lumen (p = 0.48) in univariable analysis. In multivariable analysis, both hemiarch replacement (OR 0.15, CI95% 0.05–0.49, p = 0.001) and the use of betablockers had a protective effect (OR 0.29, CI95% 0.10–0.85, p = 0.023). The Kaplan–Meier estimates for survival and the composite endpoint of survival and freedom from distal reintervention indicated no difference in outcome between patients in regard to anticoagulation treatment (survival p = 0.43, composite p = 0.82) or false lumen status (survival p = 0.21, composite p = 0.09). Conclusion This study could not show negative effects from the postoperative use of anticoagulants on false lumen status, nor that false lumen patency was associated with poorer prognosis. A hemiarch procedure was shown to be associated with reduced risk of false lumen patency.
Collapse
Affiliation(s)
- Mårten Larsson
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden.
| | - Gracijela Bozovic
- Department of Medical Imaging and Clinical Physiology, Lund University and Skåne University Hospital, Lund, Sweden
| | - Johan Sjögren
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - Igor Zindovic
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - Sigurdur Ragnarsson
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| | - Shahab Nozohoor
- Department of Clinical Sciences Lund, Cardiothoracic Surgery, Lund University and Skåne University Hospital, Getingevägen 4, 221 85, Lund, Sweden
| |
Collapse
|
8
|
Do oral anticoagulants impact outcomes and false lumen patency after repair of acute type A aortic dissection? J Thorac Cardiovasc Surg 2021:S0022-5223(21)01312-X. [PMID: 34583844 DOI: 10.1016/j.jtcvs.2021.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 08/21/2021] [Accepted: 09/03/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The study objective was to analyze the effects of chronic oral anticoagulation on long-term outcomes after repair of type A acute aortic dissection and its influence on false lumen fate. METHODS We studied 188 patients (median age, 62 years; 74% were male) who underwent repair of type A aortic dissection; patients receiving postoperative chronic oral anticoagulation (n = 59) were compared with those receiving antiplatelet therapy alone (n = 129). RESULTS Median age was similar: 60 years (18-79 years; OAC group) versus 64 years (22-86; no-OAC group) (P = .11); patients taking anticoagulants were more frequently male (88% vs 67%, P = .003). After a median follow-up of 8.4 years (2 months to 30 years), 58 patients died, 18 of aortic-related causes, and 37 patients underwent aortic reintervention. After multivariable adjustment, anticoagulation showed no significant effect on long-term survival (hazard ratio, 0.85; 95% confidence interval, 0.41-1.76; P = .66) or risk of reintervention (hazard ratio, 0.55; 95% confidence interval, 0.27-1.15; P = .11). Analysis of 127 postoperative computed tomography scans showed a patent false lumen in 53% of anticoagulated patients versus 38% of nonanticoagulated patients (P = .09): partially thrombosed in 8% versus 28% (P = .01) and thrombosed in 39% versus 34% (P = .63), respectively. In patients with a control computed tomography, there were 6 late aortic-related deaths, 1 among anticoagulated patients and 5 in those who were not. CONCLUSIONS Chronic anticoagulation after repair of type A acute aortic dissection favors persistent late false lumen patency, which is not a risk factor for late mortality or reoperation. Chronic anticoagulation can be administered safely to patients with repaired type A acute aortic dissection regardless of its specific indication.
Collapse
|
9
|
Aboyans V, Bauersachs R, Mazzolai L, Brodmann M, Palomares JFR, Debus S, Collet JP, Drexel H, Espinola-Klein C, Lewis BS, Roffi M, Sibbing D, Sillesen H, Stabile E, Schlager O, De Carlo M. Antithrombotic therapies in aortic and peripheral arterial diseases in 2021: a consensus document from the ESC working group on aorta and peripheral vascular diseases, the ESC working group on thrombosis, and the ESC working group on cardiovascular pharmacotherapy. Eur Heart J 2021; 42:4013-4024. [PMID: 34279602 DOI: 10.1093/eurheartj/ehab390] [Citation(s) in RCA: 63] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/27/2021] [Accepted: 06/03/2021] [Indexed: 12/24/2022] Open
Abstract
The aim of this collaborative document is to provide an update for clinicians on best antithrombotic strategies in patients with aortic and/or peripheral arterial diseases. Antithrombotic therapy is a pillar of optimal medical treatment for these patients at very high cardiovascular risk. While the number of trials on antithrombotic therapies in patients with aortic or peripheral arterial diseases is substantially smaller than for those with coronary artery disease, recent evidence deserves to be incorporated into clinical practice. In the absence of specific indications for chronic oral anticoagulation due to concomitant cardiovascular disease, a single antiplatelet agent is the basis for long-term antithrombotic treatment in patients with aortic or peripheral arterial diseases. Its association with another antiplatelet agent or low-dose anticoagulants will be discussed, based on patient's ischaemic and bleeding risk as well therapeutic paths (e.g. endovascular therapy). This consensus document aims to provide a guidance for antithrombotic therapy according to arterial disease localizations and clinical presentation. However, it cannot substitute multidisciplinary team discussions, which are particularly important in patients with uncertain ischaemic/bleeding balance. Importantly, since this balance evolves over time in an individual patient, a regular reassessment of the antithrombotic therapy is of paramount importance.
Collapse
Affiliation(s)
- Victor Aboyans
- Department of Cardiology, Dupuytren University Hospital, and INSERM 1094 & IRD, University of Limoges, 2, Martin Luther King ave, 87042, Limoges, France
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt Germany, and Center for Thrombosis and Hemostasis, University of Mainz, Mainz, Germany
| | - Lucia Mazzolai
- Division of Angiology, Heart and Vessel Department, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - José F Rodriguez Palomares
- Department of Cardiology, Vall d'Hebron Institut de Recerca (VHIR), Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Centro de Investigación Biomédica en RedCV, CIBER CV, Barcelona, Spain
| | - Sebastian Debus
- Department of Vascular Medicine, University Heart Centre Hamburg, University Medical Centre HamburgEppendorf, Hamburg, Germany
| | - Jean-Philippe Collet
- Sorbonne Université, ACTION Study Group (www.actioncoeur.org), INSERM UMRS 1166, Institut de Cardiologie, Hôpital PitiéSalpêtrière (APHP), Paris, France
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Landeskrankenhaus Feldkirch, Austria
| | - Christine Espinola-Klein
- Section Angiology, Department of Cardiology, Cardiology I, University Medical Center Mainz, Mainz, Germany
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, TechnionIsrael Institute of Technology, Haifa, Israel
| | - Marco Roffi
- Division of Cardiology, University Hospitals, Geneva, Switzerland
| | - Dirk Sibbing
- Ludwig Maximilians Universität München and Privatklinik Lauterbacher Mühle am Ostersee, Munich, Germany
| | - Henrik Sillesen
- Department of Vascular Surgery, Rigshospitalet, University of Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Eugenio Stabile
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples 'Federico II', Naples, Italy
| | - Oliver Schlager
- Division of Angiology, 2nd Department of Medicine, Medical University of Vienna, Austria
| | - Marco De Carlo
- Cardiothoracic and Vascular Department, Azienda OspedalieroUniversitaria Pisana, Pisa, Italy
| |
Collapse
|
10
|
Bjørnstad JL, Khan AM, Røed-Undlien H, Bendz B, Nygård S, Hoel TN, Lingaas PS. Operative survival in patients with acute aortic disease in the era of newer oral anticoagulants. Open Heart 2020; 7:openhrt-2020-001278. [PMID: 32675298 PMCID: PMC7368483 DOI: 10.1136/openhrt-2020-001278] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 04/16/2020] [Accepted: 05/18/2020] [Indexed: 12/12/2022] Open
Abstract
Aims The aim of this study was the analysis of the risk associated with direct oral anticoagulants (DOACs) in patients undergoing non-elective operations on the proximal aorta due to aortic disease. Methods and results Data from the department’s register of cardiac surgery was analysed retrospectively with emphasis on operative mortality. 135 non-elective operations for proximal aortic disease (October 2016 to 2018) were identified, of which 19 died during the first 90 days. DOAC use was the top-ranked risk factor in the univariate analysis with a HR of 9.6 (3.1 to 29), p=0.00007. Using a Cox proportional hazards model including the most relevant risk factors, the risk associated with DOAC use remained significant with a HR of 6.1 (1.4 to 26.3), p=0.015. We did not find increased risk associated with warfarin use. Conclusion In patients undergoing non-elective operations on the proximal aorta due to aortic disease, the use of DOAC is associated with increased operative mortality.
Collapse
Affiliation(s)
- Johannes Lagethon Bjørnstad
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway .,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Adil Mahboob Khan
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | | | - Bjørn Bendz
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Ståle Nygård
- Department of Biostatistics, Oslo Centre for Biostatistics and Epidemiology, University of Oslo, Oslo, Norway
| | - Tom Nilsen Hoel
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| | - Per Snorre Lingaas
- Department of Cardiothoracic Surgery, Oslo University Hospital, Oslo, Norway
| |
Collapse
|
11
|
Gouran A, Safdari H, Pouraliakbar H, Shafe O, Moosavi J, Mohebbi B, Sadeghipour P. Double Whammy: Concomitant Acute Type B Aortic Dissection and Acute Pulmonary Embolism. Vasc Specialist Int 2020; 36:158-162. [PMID: 32759465 PMCID: PMC7531301 DOI: 10.5758/vsi.200025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 07/04/2020] [Accepted: 07/12/2020] [Indexed: 11/20/2022] Open
Abstract
The concomitant occurrence of acute type B aortic dissection (TBAD) and acute pulmonary embolism (PE) is a rare but challenging condition. Although anticoagulation therapy is essential in the treatment of PE, it may increase the risk of aortic rupture and bleeding complications. We herein describe a patient with acute TBAD complicated by PE, which was successfully treated with early thoracic endovascular aortic repair (TEVAR) followed by anticoagulation. The present case report demonstrates that early TEVAR not only treats the aortic pathology but also allows the safe initiation of anticoagulation therapy.
Collapse
Affiliation(s)
- Amirkhosro Gouran
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hassan Safdari
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Pouraliakbar
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Omid Shafe
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Jamal Moosavi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Bahram Mohebbi
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Parham Sadeghipour
- Cardiovascular Intervention Research Center, Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
12
|
Salmasi MY, Panda A, Hartley P, Abdulkhader A, Osman A, Nienaber C, Athanasiou T, Asimakopoulos G. Aortic root replacement to treat type A aortic dissection: A comparison of midterm outcomes between composite valve grafts and porcine aortic roots. J Card Surg 2020; 35:1840-1847. [PMID: 32643831 DOI: 10.1111/jocs.14712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Porcine aortic roots (PAR) have been reported in the literature with acceptable short- and long-term outcomes for the treatment of aortic root aneurysms. However, their efficacy in type A aortic dissection (TAAD) is yet to be defined. METHODS Using data from a locally collated aortic dissection registry, we compared the outcomes in patients undergoing aortic root replacement for TAAD using either of two surgical options: (a) PAR or (b) composite valve grafts (CVG). A retrospective analysis was conducted for all procedures in the period from 2005 to 2018. RESULTS A total of 252 patients underwent procedures for TAAD in the time period. Sixty-five patients had aortic root replacements (PAR n = 30, CVG n = 35). Between-group comparisons identified a younger CVG group (50.5 vs 64.5, P < .05) although all other covariates were comparable. Operative parameters were comparable between the two groups. The use of PAR did not significantly impact operative mortality (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.22-3.61; P = .992), stroke (OR, 2.91, 0.25-34.09, P = .395), reoperation (OR, 0.91; 95% CI, 0.22-3.62; P = .882) or length of stay (coeff 2.33, -8.23 to 12.90; P = .659) compared to CVG. Five-year survival was similar between both groups (PAR 59% vs CVG 69%; P = .153) and reoperation was negligible. Echocardiography revealed significantly lower aortic valve gradients in the PAR group (8.69 vs 15.45mm Hg; P < .0001), and smaller left ventricular dimensions both at 6-week and 1-year follow-up (P < .05). CONCLUSIONS This study highlights the comparable short- and midterm outcomes of PAR in cases of TAAD, in comparison to established therapy.
Collapse
Affiliation(s)
| | - Abinash Panda
- Royal Brompton and Harefield Foundation Trust, London, UK
| | - Philip Hartley
- Royal Brompton and Harefield Foundation Trust, London, UK
| | | | - Ahmed Osman
- Royal Brompton and Harefield Foundation Trust, London, UK
| | | | | | | |
Collapse
|
13
|
Bocchino PP, De Filippo O, Piroli F, Scacciatella P, Imazio M, D'Ascenzo F, De Ferrari GM. Anticoagulant and anti-thrombotic therapy in acute type B aortic dissection: when real-life scenarios face the shadows of the evidence-based medicine. BMC Cardiovasc Disord 2020; 20:29. [PMID: 31973746 PMCID: PMC6977351 DOI: 10.1186/s12872-020-01342-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 01/16/2020] [Indexed: 11/10/2022] Open
Abstract
Background Evidence-based recommendations about anticoagulation in acute type B aortic dissection (TBAD) are completely missing, but there is a diffuse conviction that it could prevent the healing process of the dissected aorta’s false lumen. However, several clinical conditions may lead to the necessity to start anticoagulant therapy among patients with acute type B aortic dissection, ranging from atrial fibrillation to more complicated clinical scenarios and the correct management in this kind of patients is still an open issue. Case presentation We are presenting a 51-years-old man with multi-infarct encephalopathy referred to us for an acute TBAD and a first diagnosis of ischemic cardiomyopathy complicated by left ventricular (LV) thrombus formation. Coronary angiography revealed a critical stenosis of left anterior descending artery (LAD) treated with drug-eluting stent deployment. The patient was addressed to triple antithrombotic therapy with acetylsalicylic acid, clopidogrel and warfarin with target INR 2.0–2.5. After 6 months, computed tomography angiography revealed the stability of the dissection flap. Cardiac magnetic resonance imaging, however, confirmed the persistence of a small thrombotic formation in LV apex, thus double antithrombotic therapy with warfarin and clopidogrel was instituted. The patient remained asymptomatic during the follow-up period but was advised to suspend his job and physical activities. Conclusion Current guidelines do not discuss anticoagulant therapy in the setting of TBAD and large randomized trials are lacking. Despite it is generally considered unsafe to administer anticoagulants in patients with TBAD, we present a case in which triple antithrombotic therapy was well tolerated and did not lead to progression of the intimal flap after 6 months.
Collapse
Affiliation(s)
- Pier Paolo Bocchino
- Division of Cardiology, Department of Medical Sciences, 'Città della Salute e della Scienza' Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Ovidio De Filippo
- Division of Cardiology, Department of Medical Sciences, 'Città della Salute e della Scienza' Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Francesco Piroli
- Division of Cardiology, Department of Medical Sciences, 'Città della Salute e della Scienza' Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Paolo Scacciatella
- Division of Cardiology, Department of Medical Sciences, 'Città della Salute e della Scienza' Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Massimo Imazio
- Division of Cardiology, Department of Medical Sciences, 'Città della Salute e della Scienza' Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, 'Città della Salute e della Scienza' Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy.
| | - Gaetano Maria De Ferrari
- Division of Cardiology, Department of Medical Sciences, 'Città della Salute e della Scienza' Hospital, University of Turin, Corso Bramante 88, 10126, Turin, Italy
| |
Collapse
|
14
|
Zschaler S, Schmidt G, Kukucka M, Syrmas G, Zaschke L, Kurz SD. How to prevent inadvertent emergency anticoagulation in acute type A aortic dissection: when in doubt, don't. Cardiovasc Diagn Ther 2018; 8:805-810. [PMID: 30740328 DOI: 10.21037/cdt.2018.10.13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Inadvertent emergency anticoagulation in patients with acute type A aortic dissection (ATAAD) has been sparsely reported. There are case reports bringing this potential critical incident to attention, however, little is known about the number of undetected and unreported cases. We approach this issue based on a case report of inadvertent emergency anticoagulation in ATAAD and attempt to shed light on aspects that may have contributed to the critical incident: The challenge of distinguishing an ATAAD from an acute coronary syndrome (ACS) and the potential underestimation of incidents of ATAAD. We also discuss errors and biases in medical decision making, and provide suggestions that may help raise awareness of how ATAAD can be mimicking ACS in clinical practice.
Collapse
Affiliation(s)
- Silke Zschaler
- Institute for Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Gerard Schmidt
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Marian Kukucka
- Institute for Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Georg Syrmas
- Department of Emergency Medicine, Campus Benjamin Franklin (CBF), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Lisa Zaschke
- Institute for Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | | |
Collapse
|
15
|
The impact of oral anticoagulation on false lumen patency in acute type A aortic dissections. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 26:345-350. [PMID: 32082762 DOI: 10.5606/tgkdc.dergisi.2018.15013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 03/29/2018] [Indexed: 01/16/2023]
Abstract
Background In this study, the effect of postoperative oral anticoagulation on the false lumen patency of the distal aorta in patients with acute type A aortic dissection was investigated. Methods Forty-one patients (32 male, 9 female; mean age 56.8±13.6 years; range, 30 to 84 years) who were diagnosed with acute type A aortic dissection and underwent surgical treatment in our clinic, and whose entire data of both control computed tomographic assessments and all postoperative follow-up visits could be accessed were enrolled. The patients were divided into two groups according to the type of surgical intervention that was performed. Computed tomography imaging of the patients were scanned and false lumen patency rates were evaluated. Besides oral anticoagulation, preoperative, intraoperative, and postoperative risk factors that may have affected false lumen patency secondary to acute type A aortic dissection were evaluated and statistically analyzed. Results Twenty-one patients (51.2%) had concomitant hypertension. Thirty five (85.4%) of the patients had the main symptom of angina. Sixteen patients (39%) in Group 1 underwent ascending aortic replacement combined with aortic valve replacement (Bentall procedure); while 25 patients (61%) in Group 2 underwent isolated ascending aortic replacement. Mean follow-up was 43.9±26.3 (range: 5-120) months. No statistically significant difference was found between the study subgroups in any of the operation parameters except for cardiopulmonary bypass time (p=0.035) and cross-clamp time (p=0.002). Evaluation of the control contrast-enhanced tomographic imaging of the patients showed false lumen patency in the thorax in 34 patients (82.9%) and in the abdominal region in 33 patients (80.5%). When analyzing subgroups according to the type of surgical procedure, or indirectly anticoagulant use, no statistically significant difference was found in false lumen patency prevalence between the thoracic and abdominal groups (p=0.534 and p=0.922). Conclusion No potential effect of postoperative anticoagulation on false lumen patency was found in cases with acute type A aortic dissection.
Collapse
|