Case Report: Are We Witnessing an Increase of Chronic Ascending Aortic Dissection as a Collateral Effect to the COVID-19 Pandemic?

Clinical Presentation and Emergency Department Management Checkpoints of Acute Aortic Syndromes during the First Two Waves of the COVID-19 Pandemic

The COVID-19 pandemic has deeply affected the activity and patient flows of Emergency Departments (EDs), and concern for the worsening outcome of cardiovascular emergencies has been raised. However, the impact of COVID-19 on all subtypes of acute aortic syndromes (AASs) has not been evaluated so far. Cases of AASs managed in the ED of three hub hospitals in a large area of Northern Italy were retrospectively analyzed, comparing those registered during the pandemic (March 2020 to May 2021) with corresponding pre-COVID-19 periods. A total of 124 patients with AAS were managed during the COVID-19 period vs. 118 pre-COVID-19 (p = 0.70), despite a -34.6% change in ED visits. Posterior chest pain at presentation was the only clinical variable with a different prevalence (46.0% vs. 32.2%, p = 0.03). Surgery and endovascular treatment rates were unchanged. Time intervals influenced by patient transfer to the hub center were longer during the COVID-19 period and longest during high viral circulation periods. Ninety-day mortality was unchanged, with a higher mortality trend during the pandemic surges. In conclusion, ED presentation and care of AASs were marginally affected by COVID-19, but efforts are needed to preserve efficient patient transfer to specialized centers and prevent mortality, especially during pandemic peaks.

Outcomes of acute type A aortic dissection during the COVID-19 pandemic: An analysis of the Society of Thoracic Surgeons Database

PURPOSE

There have been reported reductions of hospital presentation for acute cardiovascular conditions such as myocardial infarction and acute type A aortic dissection (ATAAD) in the United States during the COVID-19 pandemic. This study examined presentation patterns and outcomes of ATAAD in North America immediately before, and during, the COVID-19 pandemic.

METHODS

The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD) was queried to identify patients presenting with ATAAD in the 12 months pre-pandemic (March 2019-February 2020), and during the early pandemic (March through June 2020). Demographics and operative characteristics were compared using χ² test and Wilcoxon Rank-sum test. The median annual case volume designated low-volume centers versus high-volume centers (>10 cases per month). Step-wise variable selection was used to create a risk set used for adjustment of all multivariable models.

RESULTS

There were 5480 patients identified: 4346 pre-pandemic and 1134 during pandemic. There was significantly lower volume of median cases per month during the COVID-19 pandemic period (286 interquartile range [IQR]: 256-306 vs. 372 IQR: 291-433,p = .0152). In historically low-volume centers (<10 cases per year), there was no difference in volume between the two periods (142 IQR: 133-166 vs. 177 IQR: 139-209, p = NS). In high-volume centers, there was a decline during the pandemic (140 IQR: 123-148 vs. 212 IQR: 148-224, p = .0052). There was no difference in overall hospital-to-hospital transfers during the two time periods (54% of cases pre-pandemic, 55% during). Patient demographics, operative characteristics, malperfusion rates, and cardiac risk factors were similar between the two time periods. There was no difference in unadjusted operative mortality (19.01% pre-pandemic vs. 18.83% during, p = .9) nor major morbidity (52.42% pre-pandemic vs. 51.24% during, p = .5). Risk-adjusted multivariable models showed no difference in either operative mortality nor major morbidity between time periods.

CONCLUSIONS

For patients presenting to the hospital with ATAAD during the first surge of the pandemic, operative outcomes were similar to pre-pandemic despite a 30% reduction in volume. Out-of-hospital mortality from ATAAD during the pandemic remains unknown. Further understanding these findings will inform management of ATAAD during future pandemics.

Impact of COVID-19 on Emergency Management of Acute Type A Aortic Dissection: A Single-Center Historic Control Study

Background

The present study aimed to clarify the impact of the 2020 COVID-19 pandemic on emergency management of acute type A aortic dissection.

Methods

We consecutively enrolled 337 acute type A aortic dissection (ATAAD) patients at emergency room in Fuwai Hospital (Beijing, China) from January to June during the 2020 COVID-19 epidemic (n = 148) and the same period in 2019 as the historical control (n = 189). The primary outcome was defined as in-hospital death. Other outcomes included automatic discharge during emergency admission. The factors with significant differences before and after the epidemic were compared and analyzed by stages with the study endpoint to clarify their changes in different stages of the epidemic.

Results

There was no significant difference in in-hospital mortality (35 (20.5%) vs. 23 (17.4%), p = 0.472). Compared with year 2019, proportion of patients receiving surgical treatment decreased significantly (74 (50.0%) vs. 129 (68.25%), p < 0.001). The surgery time of ATAAD patients in 2020 was significantly shorter (6.46 [5.52, 7.51] vs. 7.33 [6.00, 8.85] hours, p = 0.01). The length of stay in the emergency department significantly differed at each stage.

Conclusions

Our study demonstrated a significant reduction in the number of ATAAD patients and surgical treatment during COVID-19 outbreak. The surgical strategy of patients changed, but the overall mortality was largely the same. Patients undergoing surgery had a trend toward longer interval from the onset to the operating room, but they tended to be normal at the end of the epidemic. Proper epidemic prevention policies may avoid COVID-19 hitting patients who are not infected with the virus to the greatest extent.

A Case of Chronic Aortic Dissection With Hemopericardium and Tamponade

Type A aortic dissection involves the separation of the wall of the ascending aorta into a true lumen and a false lumen. The finding of an aortic dissection in a patient experiencing mild to moderate symptoms for several weeks may be surprising for clinicians, given the severity of the underlying process. Here, we present an 88-year-old patient who was admitted to our hospital due to orthopnea and leg swelling for the past two to three weeks and was found to have a chronic dissection of the ascending aorta, complicated by hemopericardium and tamponade. The existing literature very rarely reports chronic type A aortic dissection with tamponade on presentation.