1638 Decade-Long Trends in Surgery for Acute Type A Aortic Dissection

Background

Little is known about unwarranted variations in care and outcomes of patients who undergo surgical repair for type A acute aortic dissection(TAAD). We aim to investigate decade-long trends in TAAD surgical repair in England.

Method

Retrospective review of the National Institute for Cardiovascular Outcomes Research (NICOR) National Adult Cardiac Surgery Audit (NACSA) registry from January 2009 to December 2018 , which prospectively collects demographic and peri-operative clinical information for all adult cardiac surgery procedures in the UK.

Results

Over the 10-year period,3,686 TAAD patients underwent surgical repair in England. A steady doubling in the overall number of operations conducted in England was observed from 237 cases recorded in 2009 to 510 in 2018. Number of procedures per hospital per year also doubled, from 10 in 2009 to 21 in 2018. The risk profile of the operated patients remained unchanged. Overall, in-hospital mortality was 17.4% with a trend toward lower mortality in the most recent years (from 22.8% in 2009 to 14.7% in 2018). There was a significant variation in operative mortality across regions with a trend towards lower mortality in regions with a high-volume hospital.

Conclusions

Surgery is the only treatment for acute TAAD but is associated with high mortality. Prompt diagnosis and referral to a specialist center is paramount. The number of operations conducted in England has doubled in 10 years and the associated survival following surgery has improved. Regional variations exist in service provision with a trend towards better survival in high volume centers.

Report of a Delphi exercise to inform the design of a research programme on screening for thoracic aortic disease

Objectives

To inform the design of a clinical trial of a targeted screening programme for relatives of individuals affected by thoracic aortic disease, we performed a consensus exercise as to the acceptability of screening, the optimal sequence and choice of tests, long-term patient management, and choice of trial design.

Methods

Working with the Aortic Dissection Awareness UK & Ireland patient association, we performed a Delphi exercise with clinical experts, patients, and carers, consisting of three rounds of consultation followed by a final multi-stakeholder face-to-face workshop.

Results

Thirty-five experts and 84 members of the public took part in the surveys, with 164 patients and clinicians attending the final workshop. There was substantial agreement on the need for a targeted screening pathway that would employ a combined approach (imaging + genetic testing). The target population would include the first- and second-degree adult (> 15 years) relatives, with no upper age limit of affected patients. Disagreement persisted about the screening process, sequence, personnel, the imaging method to adopt, computed tomography (CT) scan vs magnetic resonance imaging (MRI), and the specifics of a potential trial, including willingness to undergo randomisation, and measures of effectiveness and acceptability.

Conclusion

A Delphi process, initiated by patients, identified areas of uncertainty with respect to behaviour, process, and the design of a targeted screening programme for thoracic aortic disease that requires further research prior to any future trial.

Endovascular treatment of ruptured abdominal aortic aneurysms: aorto-uni-iliac or bifurcated endograft?

PURPOSE

This study evaluated the safety and technical and clinical success rates of positioning endovascular endografts (EG) in ruptured abdominal aneurysms.

MATERIALS AND METHODS

Patients with a ruptured abdominal aortic aneurysm confirmed by contrast-enhanced computed tomography angiography (CTA) were eligible for the analysis. Of 67 patients, 42 (62.7%) were treated with EG. Thirteen patients (30.9%) received an aorto-uni-iliac EG (group A) and 29 a bifurcated EG (group B). Patients were divided for comparative analysis according to the configuration of the EG implanted.

RESULTS

The primary technical success rate was 100%; the primary clinical success rate was 95% (40/42). There were two intraoperative deaths (4.7%) related to intractable shock. No patient required conversion to open repair. Overall, 12 patients (28.5%) died within 30 days. The in-hospital death rate was 30.9% (13/42). Hospital mortality rate was statistically higher in group A; the type of EG and intensive care unit admission were the only independent predictors of hospital mortality.

CONCLUSIONS

In our experience, a higher mortality rate was observed for the aorto-uni-iliac configuration; shock at admission was confirmed as the most important factor for postoperative survival.

Visceral artery aneurysms: management of 48 cases

AIM

The purpose of this study was to review the outcomes of endovascular treatment and open repair of visceral artery aneurysms, and to compare their results.

METHODS

Between January 1995 and January 2009, 42 patients (22 males) underwent surgical or endovascular treatment for visceral artery aneurysms. Mean age was 60 ± 13 (range, 35-85). Overall, 12 patients (25%) were asymptomatic, twenty-six patients (54.2%) were symptomatic, and 10 aneurysms (20.8%) were ruptured. The first 12 cases (28.6%) were treated with open repair; thereafter, endovascular techniques were used to treat 30 VAAs (71.4%).

RESULTS

Ten patients were treated in emergency setting [8 in the endovascular group (26.6%) and 2 in the open repair group (16.7%), P=0.491]. In the endovascular group, primary technical success was achieved in 29 of 30 VAAs (96.6%). Overall in-hospital mortality was 2.4%. Major complications occurred in 8 patients (3 endovascular vs 5 open repair, P=0.01). Overall, mean hospitalization was 9.7 vs. 13 days (P<0.0001). Mean follow-up was 64 months (range, 3 months-14 years). In the endovascular group, reperfusion was higher in larger (>5 cm) aneurysms (P<0.0001).

CONCLUSION

Endovascular techniques could be the first treatment option for all visceral artery aneurysms.

Unruptured ventricular septal wall dissection. A case report

Dissection of the interventricular septum (IVS) is a rare condition, which can uncommonly complicate an acute myocardial infarction (AMI). We describe a case of unruptured IVS dissection observed 16 days after 2 close episodes of AMI. The diagnosis was made by transthoracic echocardiography. An echo-free space within the thickness of IVS, extended from the apex to the mid-portion, for a total length of about 30 mm was evident. The careful examination of the left ventricle did not reveal any discontinuity of the myocardial wall. The stable clinical condition, the absence of flow within the dissection, the demonstration of its favourable evolution during the hospitalisation and the characteristics of the underlying coronary disease (left anterior descending artery occlusion without myocardial viability) led to the decision of avoiding surgery. The predischarge contrast echocardiographic examination (Levovist) showed clearly the border of the infarcted zone and demonstrated an area reduction and echogenicity increase of the neocavitation, with partially organised thrombi. The patient recovered uneventfully and was discharged on medical therapy with a clinical and echocardiographic follow-up program. We believe that for IVS hemorrhagic dissection a nonsurgical option can be proposed; surgery should only be considered for myocardial revascularization when indicated. A close echocardiographic follow-up is mandatory.

Effects of adenosine and defibrotide adjunct to a standard crystalloid cardioplegic solution

AIM

Adenosine has many actions potentially useful as adjunct to a cardioplegia. Defibrotide was recently shown to have protective effects during cardiac arrest. The aim of this study was to compare these 2 substances to delineate their profile of action in the setting of cardioplegic arrest.

METHODS

A Langendorff model for isolated rat hearts was employed: 3 groups of 8 hearts each were used, respectively with plain St. Thomas cardioplegia as control (group C), and the same solution added with adenosine (group A) or defibrotide (group D). The hearts had a baseline perfusion for 30 minutes with Krebs-Henseleit solution at 37 degrees C, cardioplegia administration for 3 minutes, then 30 minutes of ischemia without any perfusion and finally 30 minutes of reperfusion with Krebs-Henseleit solution at 37 degrees C.

RESULTS

The time to attain heart arrest was 20% shorter in group A, but this difference did not reach statistical significance (A: 13.6+/-1.5; D: 16.8+/-2.7; C: 17.3+/-2.2 s). The heart rate during reperfusion in group A was almost identical to baseline, while in both group C and D it was significantly lower (A: 101%, D: 93.4%, C: 82.4%, p<0.01).A and D decreased significantly the release of creatine phospokinase compared to group C (p=0.006). Lactate dehydrogenase release was lower in both treatment groups, although statistical significance was not reached. Peak positive dP/dT decreased more in controls during reperfusion (A: -23+/-6%, D: -17+/-5%, C: -31+/-5%, p=ns). Negative dP/dT was significantly worse in controls compared to both treatments (A: -19+/-6%, D: -12+/-5%, C: -34+/-7%, p=0.035).

CONCLUSIONS

Both adenosine and defibrotide have protective effects in an isolated model of cardioplegic arrest. Adenosine is significantly more active on heart rate while defibrotide is more active on contractily. Further studies are justified in order to test the combination of these 2 drugs.

[Endometriosis of the large intestine. A report of 2 clinical cases]

Intestinal involvement of endometriosis requiring treatment is 5%, but only 0.7% needs intestinal resection. The authors report two cases of colic endometriosis and illustrate problems in diagnosis and management of this disease. Usually intestinal endometriosis takes the form of asymptomatic superficial serosal implants, encountered incidentally at laparotomy for other diseases, but it can also result in obstruction and occasionally bleeding. Any premenopausal woman with episodic bowel symptoms associated with gynecologic complaints should be suspected of endometriosis of the colon. Diagnosis can be suspected by double-contrast enema examination and colonoscopy with biopsy, although neither is likely to establish the diagnosis with certainty. In fact there are no radiologic or diagnostic imaging findings that are specific for endometriosis and unequivocal diagnosis requires microscopic examination. Differential diagnosis includes primary carcinoma of the colon and other benign diseases (pelvic inflammatory disease, diverticulitis, inflammatory bowel disease, pelvic abscess, polyps, etc.). The treatment of patients with uncomplicated, but symptomatic gastrointestinal endometriosis depends on the age of the patient and her childbearing attitude. Resection of the affected bowel should be done in patient with pain, bleeding, changes in bowel habits and intestinal obstruction and it is necessary to avoid neglecting a malignant tumor. Total abdominal hysterectomy and bilateral oophorectomy is the treatment of choice in the perimenopausal and menopausal women. In symptomatic women desiring children the only resection of involved colon may be appropriate treatment. In these subjects hormonal therapy can be useful.

[Urolithiasis in pregnancy]

Urolithiasis is a cause of abdominal pain occurring during pregnancy requiring hospitalization. Of 3793 deliveries in a 5-year period 11 were complicated by urinary calculi during pregnancy. The incidence was 0.29% and in 45% the calculi passed spontaneously. Conservative therapy was resolute in 100% of cases and didn't have any consequence on pregnancy and neonatal outcome. Pathogenesis, diagnostic and therapeutic approach are considered.