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Biancari F, Dell'Aquila AM, Onorati F, Rossetti C, Demal T, Rukosujew A, Peterss S, Buech J, Fiore A, Folliguet T, Perrotti A, Hervé A, Nappi F, Conradi L, Pinto AG, Lega JR, Pol M, Kacer P, Wisniewski K, Mazzaro E, Gatti G, Vendramin I, Piani D, Ferrante L, Rinaldi M, Quintana E, Pruna-Guillen R, Gerelli S, Di Perna D, Acharya M, Mariscalco G, Field M, Kuduvalli M, Pettinari M, Rosato S, Mustonen C, Kiviniemi T, Roberts CS, Mäkikallio T, Juvonen T. Classification of the Urgency of the Procedure and Outcome of Acute Type A Aortic Dissection. Am J Cardiol 2024; 217:59-67. [PMID: 38401652 DOI: 10.1016/j.amjcard.2024.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/09/2024] [Accepted: 01/29/2024] [Indexed: 02/26/2024]
Abstract
Surgery for type A aortic dissection (TAAD) is associated with a high risk of early mortality. The prognostic impact of a new classification of the urgency of the procedure was evaluated in this multicenter cohort study. Data on consecutive patients who underwent surgery for acute TAAD were retrospectively collected in the multicenter, retrospective European Registry of TAAD (ERTAAD). The rates of in-hospital mortality of 3,902 consecutive patients increased along with the ERTAAD procedure urgency grades: urgent procedure 10.0%, emergency procedure grade 1 13.3%, emergency procedure grade 2 22.1%, salvage procedure grade 1 45.6%, and salvage procedure grade 2 57.1% (p <0.0001). Preoperative arterial lactate correlated with the urgency grades. Inclusion of the ERTAAD procedure urgency classification significantly improved the area under the receiver operating characteristics curves of the regression model and the integrated discrimination indexes and the net reclassification indexes. The risk of postoperative stroke/global brain ischemia, mesenteric ischemia, lower limb ischemia, dialysis, and acute heart failure increased along with the urgency grades. In conclusion, the urgency of surgical repair of acute TAAD, which seems to have a significant impact on the risk of in-hospital mortality, may be useful to improve the stratification of the operative risk of these critically ill patients. This study showed that salvage surgery for TAAD is justified because half of the patients may survive to discharge.
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Affiliation(s)
- Fausto Biancari
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland; Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
| | - Angelo M Dell'Aquila
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Cecilia Rossetti
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Till Demal
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Andreas Rukosujew
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, LMU University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Joscha Buech
- Department of Cardiac Surgery, LMU University Hospital, Ludwig Maximilian University, Munich, Germany; German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France
| | - Thierry Folliguet
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France
| | - Andrea Perrotti
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Amélie Hervé
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Angel G Pinto
- Cardiovascular Surgery Department, University Hospital Gregorio Marañón, Madrid, Spain
| | - Javier Rodriguez Lega
- Cardiovascular Surgery Department, University Hospital Gregorio Marañón, Madrid, Spain
| | - Marek Pol
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Kacer
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Konrad Wisniewski
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Enzo Mazzaro
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Igor Vendramin
- Cardiothoracic Department, University Hospital, Udine, Italy
| | - Daniela Piani
- Cardiothoracic Department, University Hospital, Udine, Italy
| | - Luisa Ferrante
- Cardiac Surgery, Molinette Hospital, University of Turin, Turin, Italy
| | - Mauro Rinaldi
- Cardiac Surgery, Molinette Hospital, University of Turin, Turin, Italy
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clínic de Barcelona, University of Barcelona, Barcelona Spain
| | - Robert Pruna-Guillen
- Department of Cardiovascular Surgery, Hospital Clínic de Barcelona, University of Barcelona, Barcelona Spain
| | - Sebastien Gerelli
- Department of Cardiac Surgery, Centre Hospitalier Annecy Genevois, Epagny Metz-Tessy, France
| | - Dario Di Perna
- Department of Cardiac Surgery, Centre Hospitalier Annecy Genevois, Epagny Metz-Tessy, France
| | - Metesh Acharya
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, United Kingdom
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, United Kingdom
| | - Mark Field
- Liverpool Centre for Cardiovascular Sciences, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Manoj Kuduvalli
- Liverpool Centre for Cardiovascular Sciences, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Matteo Pettinari
- Department of Cardiac Surgery, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Stefano Rosato
- National Center for Global Health, Istituto Superiore di Sanitá, Rome, Italy
| | - Caius Mustonen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | | | - Timo Mäkikallio
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland
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Biancari F, Demal T, Nappi F, Onorati F, Francica A, Peterss S, Buech J, Fiore A, Folliguet T, Perrotti A, Hervé A, Conradi L, Rukosujew A, Pinto AG, Lega JR, Pol M, Rocek J, Kacer P, Wisniewski K, Mazzaro E, Vendramin I, Piani D, Ferrante L, Rinaldi M, Quintana E, Pruna-Guillen R, Gerelli S, Di Perna D, Acharya M, Mariscalco G, Field M, Kuduvalli M, Pettinari M, Rosato S, D’Errigo P, Jormalainen M, Mustonen C, Mäkikallio T, Dell’Aquila AM, Juvonen T, Gatti G. Baseline risk factors of in-hospital mortality after surgery for acute type A aortic dissection: an ERTAAD study. Front Cardiovasc Med 2024; 10:1307935. [PMID: 38288052 PMCID: PMC10822912 DOI: 10.3389/fcvm.2023.1307935] [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: 10/05/2023] [Accepted: 12/31/2023] [Indexed: 01/31/2024] Open
Abstract
Background Surgery for type A aortic dissection (TAAD) is associated with high risk of mortality. Current risk scoring methods have a limited predictive accuracy. Methods Subjects were patients who underwent surgery for acute TAAD at 18 European centers of cardiac surgery from the European Registry of Type A Aortic Dissection (ERTAAD). Results Out of 3,902 patients included in the ERTAAD, 2,477 fulfilled the inclusion criteria. In the validation dataset (2,229 patients), the rate of in-hospital mortality was 18.4%. The rate of composite outcome (in-hospital death, stroke/global ischemia, dialysis, and/or acute heart failure) was 41.2%, and 10-year mortality rate was 47.0%. Logistic regression identified the following patient-related variables associated with an increased risk of in-hospital mortality [area under the curve (AUC), 0.755, 95% confidence interval (CI), 0.729-0.780; Brier score 0.128]: age; estimated glomerular filtration rate; arterial lactate; iatrogenic dissection; left ventricular ejection fraction ≤50%; invasive mechanical ventilation; cardiopulmonary resuscitation immediately before surgery; and cerebral, mesenteric, and peripheral malperfusion. The estimated risk score was associated with an increased risk of composite outcome (AUC, 0.689, 95% CI, 0.667-0.711) and of late mortality [hazard ratio (HR), 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403]. In the validation dataset (248 patients), the in-hospital mortality rate was 16.1%, the composite outcome rate was 41.5%, and the 10-year mortality rate was 49.1%. The estimated risk score was predictive of in-hospital mortality (AUC, 0.703, 95% CI, 0.613-0.793; Brier score 0.121; slope 0.905) and of composite outcome (AUC, 0.682, 95% CI, 0.614-0.749). The estimated risk score was predictive of late mortality (HR, 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403), also when hospital deaths were excluded from the analysis (HR, 1.024, 95% CI, 1.018-1.031; Harrell's C 0.630; Somer's D 0.261). Conclusions The present analysis identified several baseline clinical risk factors, along with preoperative estimated glomerular filtration rate and arterial lactate, which are predictive of in-hospital mortality and major postoperative adverse events after surgical repair of acute TAAD. These risk factors may be valuable components for risk adjustment in the evaluation of surgical and anesthesiological strategies aiming to improve the results of surgery for TAAD. Clinical Trial Registration https://clinicaltrials.gov, identifier NCT04831073.
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Affiliation(s)
- Fausto Biancari
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Till Demal
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Alessandra Francica
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Sven Peterss
- LMU University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Joscha Buech
- LMU University Hospital, Ludwig Maximilian University, Munich, Germany
- German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France
| | - Thierry Folliguet
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France
| | - Andrea Perrotti
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Amélie Hervé
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Andreas Rukosujew
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Angel G. Pinto
- Cardiovascular Surgery Department, University Hospital Gregorio Marañón, Madrid, Spain
| | - Javier Rodriguez Lega
- Cardiovascular Surgery Department, University Hospital Gregorio Marañón, Madrid, Spain
| | - Marek Pol
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Jan Rocek
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Kacer
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Konrad Wisniewski
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Enzo Mazzaro
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Igor Vendramin
- Cardiothoracic Department, University Hospital, Udine, Italy
| | - Daniela Piani
- Cardiothoracic Department, University Hospital, Udine, Italy
| | - Luisa Ferrante
- Cardiac Surgery, Molinette Hospital, University of Turin, Turin, Italy
| | - Mauro Rinaldi
- Cardiac Surgery, Molinette Hospital, University of Turin, Turin, Italy
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Robert Pruna-Guillen
- Department of Cardiovascular Surgery, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Sebastien Gerelli
- Department of Cardiac Surgery, Centre Hospitalier Annecy Genevois, Annecy, France
| | - Dario Di Perna
- Department of Cardiac Surgery, Centre Hospitalier Annecy Genevois, Annecy, France
| | - Metesh Acharya
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, United Kingdom
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, United Kingdom
| | - Mark Field
- Liverpool Centre for Cardiovascular Sciences, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Manoj Kuduvalli
- Liverpool Centre for Cardiovascular Sciences, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Matteo Pettinari
- Department of Cardiac Surgery, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Stefano Rosato
- National Center for Global Health, Istituto Superiore di Sanitá, Rome, Italy
| | - Paola D’Errigo
- National Center for Global Health, Istituto Superiore di Sanitá, Rome, Italy
| | - Mikko Jormalainen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Caius Mustonen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Timo Mäkikallio
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
| | - Angelo M. Dell’Aquila
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
- Department of Cardiac Surgery, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
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