Results of late-onset type A aortic dissection after previous cardiac surgery: Does prior coronary artery bypass grafting affect survival?

Risk factor analysis for aortic dissection after aortic valve replacement in patients with tricuspid aortic valve

OBJECTIVE

Aortic dilatation concurrent with aortic valve disease is a common condition. However, the incidence of aortic dissection after aortic valve replacement for tricuspid aortic valve has not been fully investigated. Therefore, we performed a risk factor analysis for the incidence of aortic dissection after aortic valve replacement in patients with tricuspid aortic valve.

METHODS

We retrospectively reviewed 599 patients who underwent aortic valve replacement at our hospital between January 2000 and December 2020. We performed a risk factor analysis for the incidence of aortic dissection after aortic valve replacement in patients with tricuspid aortic valve.

RESULTS

Seven patients developed late aortic dissections during the follow-up period. All patients with aortic dissection underwent aortic valve replacement for aortic regurgitation. Multivariable analysis revealed that aortic regurgitation was an independent predictor of aortic dissection (p < 0.0001). The mean ascending aortic diameter at aortic valve replacement for aortic regurgitation was significantly greater in patients with aortic dissection than in those without aortic dissection (46 [43.5-46] mm vs. 39 [36-42] mm, p < 0.001). The predictive cutoff value of ascending aortic diameter was indicated using receiver operating characteristic curve analysis; 46.0 mm (area under the curve: 0.8987). Freedom rates from aortic dissection in patients with aortic regurgitation and an ascending aortic diameter ≥ 46 mm were significantly lower than those in patients with an ascending aortic diameter < 46 mm (66.7% vs. 100% at 5 years, p < 0.0001).

CONCLUSION

Aortic regurgitation combined with ascending aortic dilatation at aortic valve replacement could be a significant risk factor for late aortic dissection.

Type A aortic dissection after Coronary Artery Bypass Grafting

BACKGROUND Aortic dissection is rare after coronary artery bypass grafting (CABG). It is a potentially fatal complication of cardiac surgery. Reoperation may pose problems with thoracotomy, adhesiolysis, and myocardial protection. No standard treatment guidelines exist for chronic aortic dissection after CABG. We present a case of chronic type A aortic dissection after cardiac surgery, which was successfully treated. CASE REPORT A 65-year-old female patient presented with a medical background of hypertension, type 2 diabetes mellitus, and hyperlipidemia.No connective tissue disorders were diagnosed. The aortic valve was tricuspid. Three years ago, she had undergone coronary artery bypass grafting involving four branches at a different medical facility. She was complaining of chest pain weeks after bypass surgery, which gradually increased. Aortic dissection was observed in the latest contrast-enhanced CT scan. Beginning from just above the sinotubular junction and reaching below the brachiocephalic trunk.  Two grafts from the saphenous vein were patent, and one was lying just below the sternum. Cardiopulmonary support was initiated by cannulating the right femoral artery and vein. An opening in the ascending aorta exposed an intimal tear near the proximal anastomosis of the two great saphenous vein grafts. Antegrad Del-Nido cardioplegia was given through native ostia and functional bypass grafts. Proximal and then distal anastomosis of graft prosthesis was performed. A new venous graft was anastomosed to the apical part of the left anterior descending artery (LAD). This saphenous vein and the buttons of the two previous vein grafts were anastomosed to the prosthesis. The patient was successfully liberated from the heart-lung machine and exhibited favorable cardiac function in the postoperative period. CONCLUSIONS We can conclude that initial peripheral cannulation with a half dose of heparin provides a relatively bloodless and secure re-entry sternotomy. Del-Nido cardioplegia is easy to implement, safe, and gives surgeons enough time without interruptions to perform complex procedures fluently.  .

Fate of the Patent False Lumen of the Descending Aorta After Surgical Treatment for Acute Type 1 Aortic Dissection

INTRODUCTION

This study aimed to investigate the factors affecting false lumen patency in the descending thoracic aorta among patients who underwent surgery for acute type 1 aortic dissection.

METHODS

A total of 112 patients with acute type 1 aortic dissection, with the flap below the diaphragm level, underwent surgery between January 2010 and September 2019. Of these, 60 patients who were followed up for ≥ 12 months and whose computed tomography scans were available were included in this study. The patients were divided into two groups: group I, consists of patent false lumen (n=36), and group II, consists of thrombosed false lumen (n=24). Demographic data, operative techniques, postoperative descending aortic diameters, reintervention, and late mortality were compared between the two groups.

RESULTS

The mean follow-up period of all patients was 37.6±26.1 months (range: 12-104). The diameter increase in the proximal and distal descending aorta was significantly higher in the patent false lumen group (5.3±3.7 mm vs. 3.25±2.34 mm; P=0.015; 3.1±2.52 mm vs. 1.9±1.55 mm; P=0.038, respectively). No significant difference in terms of hypertension was found between the two groups during the follow-up period (21 patients, 58.3% vs. 8 patients, 33.3%; P=0.058). A total of 29 patients (48.3%) were found to be hypertensive in the postoperative period.

CONCLUSION

After surgical treatment for acute type 1 aortic dissection, patients should be monitored closely, regardless of whether the false lumen is patent or thrombosed. Mortality and reintervention can be seen in patients with patent false lumen during follow-up.

Evaluation of the GERAADA score for prediction of 30-day mortality in patients with acute type A aortic dissection

OBJECTIVES

The German Registry of Acute Aortic Dissection Type A (GERAADA) score to predict 30-day mortality in patients suffering from acute aortic dissection type A (AADA) was recently introduced. The aim of this study was to evaluate if the GERAADA score's prediction corresponds with the authors' institutional results.

METHODS

All consecutive AADA patients between 2010 and 2020 were included. Retrospective data collection comprised 11 preoperative parameters: age, sex, previous cardiac surgery, inotropic support at referral, resuscitation before surgery, aortic regurgitation, preoperative hemiparesis, intubation/ventilation at referral, preoperative organ malperfusion, extension of aortic dissection and location of primary entry site. Calculations of the GERAADA score were individually performed by a cardiac surgeon blinded to the study for all patients via a web-based application (https://www.dgthg.de/de/GERAADA_Score).

RESULTS

A total of 371 AADA patients were operated at the authors' institution. The mean age was 62.7 ± 13.5 years and 233 (63%) were males. Prediction of 30-day mortality was accurate for the entire study cohort (actual vs predicted 30-day mortality: 15.1% vs 15.7%; P = 0.776) as well as for all 26 subgroups. In addition, preoperative resuscitation (P < 0.001), advanced age (P = 0.042) and other/unknown malperfusion (P = 0.032) were identified as independent risk factors.

CONCLUSIONS

The GERAADA score prediction of 30-day mortality after surgery is accurate, easily accessible due to its web-based platform and can be calculated with very basic preoperative clinical parameters. A prospective clinical trial is required to further evaluate the new GERAADA score as a useful tool to allow for improved decision-making in the emergency setting of AADA.