Insights From the International Registry of Acute Aortic Dissection: A 20-Year Experience of Collaborative Clinical Research

Managing acute type A aortic dissections: Is a universal approach feasible?

The goal in the treatment of acute type A aortic dissection (ATAAD) is to resect the primary intimal tear while minimizing associated complications of the disease. This goal can be accomplished by different surgical techniques and operative strategies. The extent of proximal and distal aortic reconstruction and the use of cerebral perfusion adjuncts are highly variable between institutions and within institutions themselves. As operative outcomes for ATAAD have improved considerably over the past decade, the focus has shifted towards extensive aortic reconstruction to minimize aortic reinterventions. However, there remains a distinct difference in how patients with ATAAD are managed in North America when compared with those in East Asia.

Type A aortic dissection in the East and West: A comparative study between two hospitals from China and the US

BACKGROUND

In this study, we compare the clinical characteristics, intraoperative management, and postoperative outcomes of patients with acute type A aortic dissection (ATAAD) between two academic medical hospitals in the United States and China.

METHODS

From January 2011 to December 2017, 641 and 150 patients from Nanjing Drum Tower Hospital (NDTH) and Massachusetts General Hospital (MGH) were enrolled. Patient demographics, clinical features, surgical techniques, and postoperative outcomes were compared.

RESULTS

The annual number of patients presenting with ATAAD at MGH remained relatively stable, while the number at NDTH increased significantly over the study period. The average age was 51 years at NDTH and 61 years at MGH (P < .001). The percentage of patients with known hypertension at the two centers was similar. The time interval from onset of symptoms to diagnosis was significantly longer at NDTH than MGH (11 vs 3.5 hours; P < .001). Associated complications at presentation were more common at NDTH than MGH. More than 90% of patients (91% NDTH and 92% MGH) underwent surgery. The postoperative stroke rate was higher at MGH (12% vs 4%; P < .001); however, the 30-day mortality rate was lower (7% vs 16%; P = .006).

CONCLUSIONS

There was a significant increase in the number of ATAAD at NDTH during the study period while the number at MGH remained stable. Hypertension was a common major risk factor; however, the onset of ATAAD at NDTH was nearly one decade earlier than MGH. Chinese patients tended to have more complicated preoperative pathophysiology at presentation and underwent more extensive surgical repair.

Top 10 candidate aortic disease trials

Aortic pathologies such as aneurysm, dissection and trauma are relatively common and potentially fatal diseases. Over the past two decades, we have experienced unprecedented technical and medical developments in the field. Despite this, there is a great need, and great opportunities, to further explore the area. In this review, we have identified important areas that need to be further studied and selected priority aortic disease trials. There is a pressing need to update the AAA natural history and the role for endovascular AAA repair as well as to define biomarkers and genetic risk factors as well as influence of gender for development and progression of aortic disease. A key limitation of contemporary treatment strategies of AAA is the lack of therapy directed at small AAA, to prevent AAA expansion and need for surgical repair, as well as to reduce the risk for aortic rupture. Currently, the most promising potential drug candidate to slow AAA growth is metformin, and RCTs to verify or reject this hypothesis are warranted. In addition, the role of endovascular treatment for ascending pathologies and for uncomplicated type B aortic dissection needs to be clarified.

Sex-specific risk factors for early mortality and survival after surgery of acute aortic dissection type a: a retrospective observational study

Background

Although gender-related disparities in cardiovascular surgery have been investigated extensively in the past decades, knowledge about the impact of gender on outcomes after surgery for acute aortic dissection type A (AADA) is sparse. This study investigated the impact of gender on early morbidity and mortality and follow-up outcome in patients after surgery for AADA and to analyze gender-related risk factors for 30-day mortality.

Methods

This retrospective study included 368 consecutive patients (male 65.8% vs. female 34.2%) undergoing surgery for AADA between 2001 and 2016 at our department. Survival was estimated by Kaplan-Meier curves. Risk factors for 30-day mortality were assessed by multivariable logistic regression and interaction analysis.

Results

Women were older (70.7 years vs. 60.6 years; p <  0.001) and showed a higher logistic EuroSCORE I (31.0% vs. 19.7%, p <  0.001). In the male group, a higher portion of smokers (27.6% vs. 16.0%, p = 0.015) and intraoperatively, more complex procedures and longer cardiopulmonary bypass (CPB) (171 min vs. 149 min, p = 0.001) and cross-clamping times (94 min vs. 85 min, p = 0.018) occurred. 30-day mortality was 19.0% in the female and 16.5% in the male group (p = 0.545). Predictive for 30-day mortality in both genders was intraoperative blood transfusion, while in the female group chronic obstructive pulmonary disease (COPD), peripheral arterial disease and preoperative intubation were predictive. Preoperative cardiopulmonary resuscitation and duration of CPB time were predictors only in males. Averaged follow-up time was 5.2 years and survival did not differ between genders, even if it was stratified by age over 70 years.

Conclusions

This analysis demonstrated a similar and satisfactory survival in both genders after surgical treatment of AADA. Women and men differed significantly in age, unadjusted and adjusted risk factors and complexity of surgical treatment, but gender itself was no risk factor for mortality. These results suggest that the decision-making for surgical treatment should not depend on gender, but that accounting for sex-specific risk factors rather than common risk factors may help to improve the outcome in both genders.

Repair of Massive Stanford Type A Aortic Dissection in a Jehovah's Witness Using Bloodless Surgery

Refusal of blood product transfusion presents a unique challenge in patients requiring major cardiac surgery. We present a case of a 45-year-old African American female Jehovah's Witness with a history of aortic dissection who presented to the emergency department with worsening back pain. Imaging revealed aneurysmal dilatation of her known Stanford type A dissection measuring 10.9 cm. A staged carotid-subclavian bypass followed by aortic valve, ascending aorta, and aortic arch replacement with debranching was performed using a bloodless strategy.

Stepwise external wrapping procedure for Stanford type A aortic dissection in extremely high-risk patients: case reports

BACKGROUND

Acute aortic dissection (AAD) is a rare, but a life-threatening condition which can lead to coronary, brachiocephalic or branch vessel malperfusion, as well as aortic valve insufficiency, or aortic rupture. Mortality of surgical treatment in high-risk or elderly patients with Type A Acute aortic dissection (TAAAD) still remains high, and treatment for such patients remains controversial.

CASE PRESENTATION

A new surgical approach which entails "stepwise external wrapping (SEW)" using a zero-porosity artificial graft was developed in extremely high-risk patients with TAAAD. Herein, we described its surgical details and showed two representative cases which was successfully done.

CONCLUSIONS

Our SEW procedure is a feasible alternative to conventional graft replacement for TAAAD in extremely high-risk or aged patients, although the gold standard consists of surgical replacement of the dissected aorta. (129 words).

Impact of Endovascular False Lumen Embolization on Thoracic Aortic Remodeling in Chronic Dissection

BACKGROUND

Retrograde false lumen (FL) perfusion after thoracic endovascular aortic repair (TEVAR) for chronic dissection is a mode of treatment failure. Thrombosis of the FL is associated with favorable reverse remodeling. Objectives are to describe FL embolization (FLE) strategy and assess aortic remodeling and survival.

METHODS

From January 2009 to December 2017, 51 patients with chronic dissection underwent FLE, most after previous TEVAR. Devices included a combination of iliac plug (29 patients), coils (19 patients), or nitinol plug (3 patients). Computed tomography was performed before discharge, at 3 months, and annually (median follow-up 2 years [range, 1 month to 7 years]).

RESULTS

After FLE, mean maximum aortic diameter decreased (64.2 ± 12 mm to 61.0 ± 13 mm; P = .03), true lumen diameter increased (24.7 ± 10 mm to 33.7 ± 8 mm; P < .001), and FL diameter decreased (36.7 ± 12 mm to 25.6 ± 15 mm, P < .001). For reverse remodeling, FL thrombosis with ≥10% decrease in diameter and ≥10% increase in true lumen diameter was achieved in 20 (39.2%; 16 primarily, 4 secondarily). Nine patients progressed after the first FLE: persistent FL flow with increase in aortic diameter and underwent repeat FLE with complete thrombosis (n = 4) or open thoracoabdominal completion (n = 5). A total of 26 patients had indeterminate response (FL thrombosis without change in maximum diameter), and none have required reoperation. Six patients had complete obliteration of the entire FL. At last follow-up, 42 (82%) patients were alive. Three deaths were related to aortic pathology.

CONCLUSIONS

FLE is an important endovascular adjunct to TEVAR promoting reverse aortic remodeling in select patients with chronic aortic dissection and persistent retrograde FL perfusion.

Acute Aortic Syndromes: Diagnostic and Therapeutic Pathways

Acute aortic syndromes are life-threatening medical conditions that include classic acute aortic dissection (AAD), aortic intramural hematoma, penetrating aortic ulcer, and even aortic pseudoaneurysm and traumatic aortic injury. The European Society of Cardiology has designed a multiparametric diagnostic algorithm to provide stepwise diagnosis. All patients with AAD should receive aggressive medical therapy to control blood pressure and heart rate. Urgent surgical repair is recommended for type A AAD. Uncomplicated type B AAD requires aggressive medical therapy. In contrast thoracic endovascular repair is recommended for complicated type B. AAD should be considered a lifelong disease that affects the entire aorta.

Changes in the diagnosis and management of acute aortic syndrome and associated mortality in the last 20 years

INTRODUCTION AND OBJECTIVES

Mortality is high in acute aortic syndrome (AAS), which therefore requires early treatment. This study aimed to analyze changes in the diagnosis and treatment of AAS over 20 years at our center.

METHODS

From 1999 to 2018, 451 patients diagnosed with AAS (336 men; mean age, 60.9±12.4 years) were prospectively included (270 type A and 181 type B). Clinical variables, diagnosis, treatment, and in-hospital complications were analyzed.

RESULTS

The use of computed tomography (CT) as the first-line diagnostic technique increased from 62.8% to 94.2% (P <.001). Surgical treatment of type A AAS rose from 67.4% to 82.5% (P=.09). Mortality from type A AAS decreased significantly from 53.1% to 26.3% (P <.001) as a result of the fall in mortality from surgical treatment (from 45.4% to 17.0%; P <.001). The use of medical treatment alone for type B AAS decreased from 91.8% to 61.7% (P <.001) due to the greater use of endovascular treatment. Mortality from type B AAS showed no significant reduction (16.2% to 10.6%; P=.15).

CONCLUSIONS

The diagnosis and treatment of AAS has changed substantially in the last 2 decades. CT has become the first-line diagnostic technique for AAS. In type A AAS, mortality has fallen significantly due to improvements in the results of surgical treatment. In type B AAS, the use of medical treatment alone has decreased due to the expansion of endovascular treatment, although in-hospital mortality has not decreased significantly.

Impact of center volume on outcomes of surgical repair for type A acute aortic dissections

BACKGROUND

Acute type A aortic dissection is a cardiovascular emergency requiring operative intervention. Despite advancements in operative technique and increased specialization of cardiovascular care, operative mortality, and morbidity after repair of type A aortic dissection remain high. Our aim was to assess national trends in outcomes of type A aortic dissection repair and the impact of institutional thoracic aortic repair volume on clinical outcomes and resource use in the United States.

METHODS

Using the procedural and diagnostic codes of the International Classification of Diseases, Ninth Revision, we identified type A aortic dissection repairs from the 2005 to 2014 database of the National Inpatient Sample. Hospitals were classified into low-, medium- and high-volume tertiles based on annual incidence of thoracic aortic operations. Patient demographics and hospital characteristics, as well as outcomes including mortality, cost, and duration of stay, were evaluated using parametric tests for trends and the volume-outcome relationship. We used a multivariable-adjusted logistic regression model to identify factors associated with mortality.

RESULTS

An estimated 25,231 patients received type A aortic dissection repair with an increasing temporal trend in volume and concomitant decrease in mortality. When stratified by hospital volume, 10,115 (40.1%), 8,194 (32.4%), and 6,920 (27.4%) underwent type A aortic dissection at low-volume, medium-volume, and high-volume, respectively. The unadjusted mortality rate in high-volume was the least (21.5% vs 16.8% vs 11.6% for low-volume, medium-volume, and high-volume, respectively; P < .001). Multivariable analysis revealed older age, lesser household incomes and comorbidities, including congestive heart failure (adjusted odds ratio 1.44; P < .001) and coagulopathy (adjusted odds ratio 1.33; P = .01) as statistically significant predictors of mortality; however, the risk-adjusted duration of stay (adjusted odds ratio 0.88; P = .06) was not different between low-volume and high-volume hospitals. After adjusting for patient and hospital characteristics, type A aortic dissection repair at low-volume hospitals was associated with increased likelihood of mortality compared with high-volume hospitals (adjusted odds ratio 2.10; P < .001). Patients undergoing type A aortic dissection repair at low-volume hospitals had increased odds of all complications including stroke, and respiratory complications compared than those at high-volume hospitals (P = .02, P < .001, and P < .001, respectively).

CONCLUSION

The volume of open surgical repair for type A aortic dissection in the United States has increased over the past decade, while mortality has decreased. Hospital aortic operative volume is strongly associated with outcomes for type A aortic dissection repair. Protocols for expeditious transfer of patients to high volume aortic centers may serve to further decrease the acute mortality and complications of this procedure.

Economic Burden and Healthcare Resource Use for Thoracic Aortic Dissections and Thoracic Aortic Aneurysms-A Population-Based Cost-of-Illness Analysis

Background

Thoracic aortic dissections (TADs) and thoracic aortic aneurysms (TAAs) are resource intensive. We sought to determine economic burden and healthcare resource use to guide health policy.

Methods and Results

Using universal healthcare coverage data for Ontario, Canada, from 2003 to 2016, a cost‐of‐illness analysis was performed. From a single‐payer's perspective, direct costs (hospitalization, reinterventions, readmissions, rehabilitation, extended care, home care, prescription drugs, and imaging) were assessed in 2017 Canadian dollars. Controls without TADs or TAAs were matched 10:1 on age, sex, and socioeconomic status to cases with TADs or TAAs to compare posthospital service use to the general population. Linear and spline regression were used for cost trends. Total hospital costs increased from $9 M to $20.7 M for TADs (P<0.0001) and $13 M to $18 M for TAAs (P<0.001). Costs cumulated to $587 M for 17 113 cases. Median hospital costs for TADs were $11 525 ($6102 medical, $26 896 endograft, and $30 372 surgery) with an increase over time (P=0.04). For TAAs, median costs were $16 683 ($7247 medical, $11 679 endograft, and $22 949 surgery) with a decrease over time (P=0.03). Home care was the most used posthospital service (TADs 44%, TAAs 38%), but rehabilitation had the highest median cost (TADs $11.9 M, TAAs $11 M). Men had increased median costs for indexed hospitalizations relative to women, yet women used more posthospital services with higher service costs.

Conclusions

Total yearly costs have increased for TADs and TAAs. Median hospital costs have increased for TADs yet decreased for TAAs. Women use posthospital healthcare services more often than men.

Association between admission time and in-hospital mortality in acute aortic dissection patients: A retrospective cohort study

PURPOSE

This study aimed to evaluate the relationship between admission time and in-hospital mortality in acute aortic dissection (AAD) patients.

METHODS

The risk factors of in-hospital clinical outcomes were retrospectively evaluated in patients with AAD. All the patients were enrolled from January to December 2017 and were divided into two groups depending on the time of admission: daytime admissions were conducted from 8: 00 to 17: 30 hours whereas, nighttime admissions were from 17: 30 to 8: 00 hours. The primary endpoints were in-hospital mortality. Univariate and multivariable cox analyses were used to test the association between admission time and in-hospital mortality.

RESULTS

The average age of the 363 participants in the present study was 52.25 ± 11.77 years, of which 81.6% were male. A total of 183 (50.4%) of these patients were admitted during nighttime. In-hospital mortality rate was higher in the nighttime admission group than in the daytime admission group (HR=1.86; 95%CI, 1.13 to 3.06, P=0.015). After adjusting for age, sex, and other risk factors, nighttime admission suggested as an independent risk factor for in-hospital mortality (HR=2.67, 95%CI, 1.30 to 5.46; P=0.007). Further subgroup analysis showed that none of the variables had a significant effect on the association between nighttime admission and in-hospital mortality.

CONCLUSION

Nighttime admission for type A acute aortic dissection is associated with a higher risk of in-hospital mortality. Therefore, health care systems should focus on managing the increased risk of in-hospital mortality among patients admitted at night, regardless of the cause.

The Management of Penetrating Aortic Ulcer

Penetrating aortic ulceration (PAU) is part of the spectrum of acute aortic syndromes (AAS), and is defined as an ulcerated intimal disruption due to atherosclerotic disease. PAU may be simple, isolated and asymptomatic, or it may be symptomatic, aneurysmal and extensive; these may progress and lead to rupture. This review aims to evaluate the treatment options for PAU. Treatment options range from radiological surveillance, risk factor modification, best medical therapy and open or endovascular surgical repair. Patients with PAU are frequently older and comorbid with relatively damaged aortic tissue; this can make open surgical repair more challenging. Endovascular repairs for larger, symptomatic, aneurysmal PAU may be performed with acceptable outcomes. Complex endovascular repairs may be required depending on the pathology. Patients with small, asymptomatic, uncomplicated PAU may be safely followed up with surveillance. PAU with concomitant intramural haematoma (IMH) should be closely monitored to observe for resolution or progression following conservative and medical management strategies. PAU is a unique entity and its natural history should be studied independently to better understand appropriate management strategies. This research is currently lacking, and larger studies or registries may be helpful in optimising PAU management.

Cause-specific mortality of type B aortic dissection and assessment of competing risks of mortality

OBJECTIVE

Natural history studies of type B aortic dissection (TBAD) commonly report all-cause mortality. Our aim was to determine cause-specific mortality in TBAD and to evaluate the clinical characteristics associated with aorta-related and nonaorta-related mortality.

METHODS

Clinical and administrative records were reviewed for patients with acute TBAD between 1995 and 2017. Demographics, comorbidities, presentation, and initial imaging findings were abstracted. Cause of death was ascertained through a multimodality approach using electronic health records, obituaries, social media, Social Security Death Index, and state mortality records. Causes of death were classified as aorta related, nonaorta related, or unknown. A Fine-Gray multivariate competing risk regression model for subdistribution hazard ratio was employed to analyze the association of clinical characteristics with aorta-related and nonaorta-related mortality.

RESULTS

A total of 275 individuals met inclusion criteria (61.1 ± 13.7 years, 70.9% male, 68% white). Mean survival after discharge was 6.3 ± 4.7 years. Completeness of follow-up Clark C index was 0.87. All-cause mortality was 50.2% (n = 138; mean age, 70.1 ± 14.6 years) including an in-hospital mortality of 8.4%. Cause-specific mortality was aorta related, nonaorta related, and unknown in 51%, 43%, and 6%, respectively. Compared with patients with nonaorta-related mortality, patients with aorta-related mortality were younger at acute TBAD (69.5 ± 11.2 years vs 61.6 ± 15.5 years; P = .001), underwent more descending thoracic aortic repairs (19.4% vs 45.8%; P = .002), and had a shorter survival duration (5.7 ± 3.9 vs 3.4 ± 4.5 years; P = .002). There was clear variation in cause of death by each decade of life, with higher aorta-related mortality among those younger than 50 years and older than 70 years and a stepwise increase in nonaorta-related mortality with each increasing decade (P < .001). All-cause mortality at 1 year, 3 years, and 10 years was 15%, 24%, and 57%, respectively. After accounting for competing risks, the cumulative incidence of aorta-related mortality at 1 year, 3 years, and 10 years was 8.9%, 16.5%, and 27.2%, respectively, and that of nonaorta-related mortality was 2.7%, 7.2%, and 29%, respectively. A maximum descending thoracic aortic diameter >4 cm was associated with an increase in hazard of aorta-related mortality by 84% (subdistribution hazard ratio, 1.84; 95% confidence interval, 1.03-3.28) on multivariate competing risk regression analysis.

CONCLUSIONS

TBAD is associated with high 10-year mortality. Those at risk for aorta-related mortality have a clinical phenotype different from that of individuals at risk for nonaorta-related mortality. This information is important for building risk prediction models that account for competing mortality risks and to direct optimal and individualized surgical and medical management of TBAD.

Skeletal muscle quality affects patient outcomes in acute type A aortic dissection

OBJECTIVES

Although skeletal muscle quantity is linked to surgical outcomes, quality remains unexamined. In this study, we evaluated whether skeletal muscle quality and quantity could predict surgical outcomes in acute type A aortic dissection (ATAAD).

METHODS

Skeletal muscle quality and quantity were evaluated using computed tomography (CT) values and the psoas muscle mass index, respectively. From May 2004 to December 2017, 324 ATAAD patients underwent aortic replacement after CT scans and psoas muscle mass index measurements. Patients were grouped into intramuscular fat (IMF; n = 55) and non-IMF (n = 269) deposition groups.

RESULTS

The mean ages of the patients were 72.3 ± 9.7 and 66.8 ± 12.1 years (P = 0.002), and hospital mortality rates were 3.6% (2/55) and 7.4% (20/269; P = 0.393) for IMF and non-IMF deposition groups, respectively. IMF deposition was a risk factor for a deterioration in activities of daily living at discharge by multivariable analysis [odds ratio 0.33, 95% confidence interval (CI) 0.16-0.69; P = 0.003]. The mean follow-up was 43.9 ± 36.8 months. The 5-year survival was significantly worse for the IMF deposition group (IMF 73.8% vs non-IMF 88.2%; P = 0.010). The multivariable Cox proportional hazard analysis showed that IMF deposition significantly predicted poor survival (hazard ratio 3.26, 95% CI 1.47-7.24; P = 0.004), unlike psoas muscle mass index and age.

CONCLUSIONS

Skeletal muscle quality, defined by IMF deposition, was an independent predictor of overall survival and postoperative activities of daily living dependence risk in patients undergoing surgery for ATAAD. Thus, IMF deposition may be an additional risk factor for estimating late outcomes of ATAAD surgery.

Triglyceride/High-Density Lipoprotein Cholesterol Ratio Is Associated with In-Hospital Mortality in Acute Type B Aortic Dissection

Background

Triglyceride/high-density lipoprotein cholesterol (TG/HDL-c) ratio varies with vascular and other metabolic diseases. However, its role in acute type B aortic dissection is not well understood. In the current study, we evaluated the relationship between TG/HDL-c ratio and in-hospital mortality in type B aortic dissection.

Methods

We performed a retrospective analysis of consecutive patients between January 2015 and December 2018, by targeting dependent (TG/HDL-c ratio) and independent (in-hospital mortality) variables. TG/HDL-c ratio was determined as a division of TG levels by HDL-c levels.

Results

Of 523 patients in the study, we found a mean age of 55.00 ± 11.74 years, 15.68% of them being female. A fully-adjusted model revealed a positive relationship between TG/HDL-c ratio and in-hospital mortality in acute type B aortic dissection after adjusting confounders (OR = 2.08, 95% CI 1.32 to 3.27). This relationship was also nonlinear, with a point of 2.05. OR values (and confidence intervals) for the right (>2.05) and left (≤2.05) sides of the inflection point were 1.0 (0.580-1.26, P = 0.983) and 3.17 (1.54-6.57, P = 0.001), respectively.

Conclusions

The TG/HDL-c ratio and in-hospital mortality in type B AAD have a nonlinear relationship among Chinese population. This ratio increased in-hospital mortality when it is less than 2.05.

Current status in decision making to treat acute type A dissection: limited versus extended repair

Acute type A aortic dissection remains one of the most challenging conditions in aortic surgery. Despite the advancements in the field, the mortality rate still remains high. Though there is a general consensus that the ascending aorta should be replaced, the distal extension of the surgery still remains a controversy. Few surgeons argue for a conservative approach to reduce operative and postoperative morbidity while others considering the problems associated with "downstream problems" support an aggressive approach including a frozen elephant trunk. The cohort in the Indian subcontinent and APAC is far different from the western world. Many factors determine the decision for surgery apart from the pathology of the disease. Economy, availability of the suitable prosthesis, the experience of the surgeon, ease of access to the medical facility all contribute to the decision making to treat acute type A dissection.

Relationship of Platelet Counts and Inflammatory Markers to 30-Day Mortality Risk in Patients with Acute Type A Aortic Dissection

Markers of prothrombotic state and inflammation are associated with the prognosis of patients with acute type A aortic dissection (AAAD). However, it is unclear that the relationship between these biomarkers and their combined impact on risk stratification. The present study evaluated the prognostic value of platelet counts, lymphocyte to neutrophil ratio (LNR), and lymphocyte to monocyte ratio (LMR), alone and in combination. A retrospective analysis of clinical data of 744 AAAD patients was conducted to identify whether these biomarkers were related to the 30-day mortality risk. A Kaplan-Meier analysis and log-rank test were used to compare survival between groups. A Cox hazard regression multivariable analysis was performed for 30-day mortality. Individual biomarker (platelet count, LNR, or LMR) was unable to predict 30-day mortality. However, combinations of all three biomarkers provided additive predictive value over either marker alone, the receiver operating characteristic (ROC) model had a prediction probability of 0.739 when platelet counts, LNR, and LMR were included. Cox hazard regression multivariable analysis showed that combinations of all three biomarkers were the strongest predictor of 30-day mortality (p < 0.021). Combined with these three easily measurable biomarkers at admission, they could help identify AAAD patients with a high risk of 30-day mortality.

An analysis of patients with acute aortic dissection who were transported by physician-staffed helicopter

PURPOSE

The present study aimed to determine whether or not patients with acute aortic dissection (AAD) treated by the staff of a doctor helicopter (DH) service while being transported from the scene or for interhospital transportation obtained a favorable outcome.

METHODS

We retrospectively investigated all patients with AAD who were transported by DH between January 2015 and December 2019 using the registry data of the DH control room of our hospital.

RESULTS

One hundred five cases were enrolled in the present study. All patients were transported within 24 h from the onset. Male patients accounted for 55.2% of the study population, the average age was 71 years and the rate of Stanford A AAD was 51.4%. Regarding transportation, 61.6% of the patients underwent interhospital transportation, and 42.8% were transported to our hospital. All patients underwent drip infusion during transportation and 81.9% of the patients received drugs (e.g., depressors, pain killers and/or antiemetics). Two patients underwent tracheal intubation due to unconsciousness and profound shock with restless state, respectively. The systolic blood pressure after transportation to hospital was significantly higher in comparison to before transportation. No patients suffered cardiac arrest or showed a deterioration of vital signs. All patients were safely transported to the destination.

CONCLUSION

The present study suggests the safety of using a Dr. Heli to transport AAD patients from the scene and for interhospital transportation, even after the onset.

Marfan Syndrome Versus Bicuspid Aortic Valve Disease: Comparative Analysis of Obstetric Outcome and Pregnancy-Associated Immediate and Long-Term Aortic Complications

Pregnancy poses a threat to women with aortopathy. Conclusive data on the obstetric and aortic outcome in this risk collective, especially when it comes to aortic complications in the long term, are still missing. This study offers a comparative analysis of pregnancy-associated outcome in 113 consecutive women with Marfan syndrome or bicuspid aortic valve disease, including 46 ever-pregnant and 37 never-pregnant women with Marfan syndrome, and 23 ever-pregnant and 7 never-pregnant females with bicuspid aortic valve disease. The overall obstetric outcome was comparable between ever-pregnant women with Marfan syndrome and with bicuspid aortic valve disease (p = 0.112). Pregnancy-associated aortic dissection occurred in two women with Marfan syndrome (3%) during a total of 62 completed pregnancies, whereas no single case of aortic event occurred in women with bicuspid aortic valve disease during a total of 36 completed pregnancies (p = 0.530). In the long-term follow-up, aortic dissection occurred in 21% of ever-pregnant women with Marfan syndrome, but in none of the women with bicuspid aortic valve disease (p = 0.022). Proximal aortic surgery was performed with similar frequency in ever-pregnant women with Marfan syndrome and with bicuspid aortic valve disease in the long term (p = 0.252). However, ever-pregnant women with Marfan syndrome were younger when surgery was performed (44 ± 9 vs. 59 ± 7 years; p = 0.041). In Marfan syndrome, long-term growth of the aorta was comparable between ever-pregnant and never-pregnant women. Pregnancy thus exhibited an increased immediate aortic risk only in women with Marfan syndrome, but not in women with bicuspid aortic valve disease. Previous pregnancy did not relate to an increased long-term risk of adverse aortic events in women with Marfan syndrome or with bicuspid aortic valve disease.

A meta-analysis of combined proximal stent grafting with or without adjunctive distal bare stent for the management of aortic dissection

BACKGROUND

The efficacy and safety of placement of a proximal covered stent graft combined with a distal bare stent are controversial because of the lack of evidence. This systematic review and meta-analysis compared the outcomes of combined proximal covered stent grafting with distal bare stenting (BS group) and proximal covered stent grafting without distal bare stenting (non-BS group).

METHODS

The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases and key references were searched up to January 26, 2019. Predefined outcomes of interest were mortality, morbidity, and postoperative assessment of aortic remodeling. We pooled risk ratios (RRs) of the outcomes of interest using fixed effects model or random effects model.

RESULTS

Overall, eight observational studies involving 914 patients were included. There were no significant differences in overall aorta-related mortality (RR, 0.54; confidence interval [CI], 0.24-1.24; P = .15), complete thoracic false lumen (FL) thrombosis rate (RR, 1.23; CI, 0.83-1.81; P = .30), or complete abdominal FL thrombosis rate (RR, 1.96; CI, 0.68-5.69; P = .21) between the BS group and the non-BS group. The BS group had a lower rate of partial thoracic FL thrombosis (RR, 0.40; CI, 0.25-0.65; P = .0002), a lower stent graft-induced new entry rate (RR, 0.08; CI, 0.02-0.41; P = .003), and a lower reintervention rate (RR, 0.42; CI, 0.26-0.69; P = .0005).

CONCLUSIONS

Combined proximal covered stent grafting with distal adjunctive bare stenting had the potential to reduce the partial thoracic FL thrombosis rate and the rates of stent graft-induced new entry and reintervention but was not associated with lower aorta-related mortality or the complete FL thrombosis rate. Further research with a stricter methodology is needed.

Acute Type A Aortic Dissection Repair After Hours: Does It Influence Outcomes?

BACKGROUND

Time of day has been associated with adverse outcomes in certain surgical pathologies. Because acute type A aortic dissection typically mandates immediate repair, relatively little attention has been paid to the potential impact of the day-night timing of the operation itself. We sought to determine whether patients with acute dissection treated during typical working hours demonstrated a difference in outcomes compared with those who required surgery after hours.

METHODS

We undertook a comprehensive review of our prospectively collected database from July 2014 to October 2018. A total of 164 consecutive patients underwent primary repair of an acute type A dissection. Based on the procedure start time, patients were divided into 2 groups: working hours (7 am to 4 pm, Monday to Friday; n = 60), and after hours (all other times, including weekends and holidays; n = 104). We propensity-matched 58 pairs of patients and analyzed perioperative data and short-term clinical outcomes.

RESULTS

Thirty-day mortality for all 164 patients was 10.4% (17 deaths), which was not significantly different between the matched groups (working-hours: 8 deaths [13.8%] versus after hours: 4 deaths [6.9%]; P = .36). Perfusion, cross-clamp, and circulatory arrest times did not differ between groups, nor did the types of aortic repairs performed. Postoperative complications were also comparable, including stroke, reoperation for bleeding, and new-onset renal failure requiring dialysis.

CONCLUSIONS

Thirty-day mortality and major morbidity after acute type A dissection repair are independent of when the operation is performed. Expeditious surgical intervention is recommended for all primary acute type A dissection, irrespective of time of day.

Type A aortic dissection mimicking saddle pulmonary embolism on CT imaging

Type A aortic dissection is an uncommon cause of chest pain that carries a high morbidity and mortality rate. A previous history of hypertension and coronary artery bypass grating (CABG) are recognized risk factors for Type A aortic dissection. We present a case of an elderly man who presents with acute onset chest pain and was found to have an acute ruptured Type A aortic dissection that has a "saddle pulmonary embolism"-like appearance on computed tomography (CT) imaging. We also describe the clinical, laboratory, and radiological workup done leading up to the diagnosis of Type A aortic dissection in the emergency setting.

Systematic Review and Meta-analysis of Current Literature on Isolated Abdominal Aortic Dissection

OBJECTIVE

To present the pooled quantitative evidence of basic profiles, initial treatment strategies, and clinical outcomes in patients with isolated abdominal aortic dissection (IAAD).

METHODS

A comprehensive systematic review and meta-analysis was performed of all available studies reporting IAAD, retrieved from the MEDLINE, Embase, and Cochrane Databases. The logistic normal random effect model was fitted using the generalised linear mixed model with random intercepts to calculate the pooled proportion estimates.

RESULTS

Seventeen studies with 482 patients were included in this meta-analysis. Male smokers with hyperlipidaemia and hypertension were the most prominent basic profile. IAADs were predominantly spontaneous and infrarenal, and roughly half were acute and symptomatic. Approximately 67% [95% confidence interval (CI) 42-86%] of patients were managed initially conservatively. In the overall population, the 30 day all cause mortality was 3% (95% CI 1-5%) and the long term mortality during follow up was 8% (95% CI 5-14%). Re-intervention during follow up occurred in 8% (95% CI 5-15%) of patients. In the subgroup analysis, patients with conservative treatment had a 30 day mortality of 1% (95% CI 0-8%), a long term mortality of 5% (95% CI 1-29%), and a re-intervention rate of 18% (95% CI 10-29%). Patients with open surgery had a 30 day mortality of 9% (95% CI 0-82%), a long term mortality of 12% (95% CI 4-31%), and a re-intervention rate of 9% (95% CI 1-44%). Patients with endovascular repair had a 30 day mortality of 2% (95% CI 0-10%), a long term mortality of 5% (95% CI 2-13%), a re-intervention rate of 6% (95% CI 3-13%), and a persistent endoleak rate of 4% (95% CI 2-10%).

CONCLUSION

Appropriate initial treatment strategies can be used to obtain acceptable clinical outcomes in patients with IAAD. Invasive intervention is necessary if patients match certain indications for intervention. Regular imaging surveillance should be provided for all patients, especially those treated conservatively.

Effects of IL-22 on cardiovascular diseases

Interleukin-22 (IL-22), which belongs to the IL-10 family, is an alpha helix cytokine specifically produced by many lymphocytes, such as Th1, Th17, Th22, ILCs, CD4+ and CD8+ T cells. In recent years, more and more studies have demonstrated that IL-22 has an interesting relationship with various cardiovascular diseases, including myocarditis, myocardial infarction, atherosclerosis, and other cardiovascular diseases, and IL-22 signal may play a dual role in cardiovascular diseases. Here, we summarize the recent progress on the source, function, regulation of IL-22 and the effects of IL-22 signal in cardiovascular diseases. The study of IL-22 will suggest more specific strategies to maneuver these functions for the effective treatment of cardiovascular diseases and future clinical treatment.

Acute Aortic Dissection With ST Segment Myocardial Infarction Following Masturbation

BACKGROUND

Acute aortic dissection is the most common life-threatening disorder affecting the aorta, and can mimic other disease processes. We describe an unusual presentation of a critically ill patient with initial hematospermia diagnosed with a type A acute aortic dissection.

CASE REPORT

A 68 year old man presented to a community ED after masturbation and report of blood in his ejaculate, followed by rapid development of severe low back, chest and hip pain with shock. ECG showed evidence of ST segment elevation, but suspicion remained high for thoracic or abdominal aortic catastrophe. Bedside ultrasound demonstrated no pericardial effusion, a severely hypokinetic myocardium and a question of fluid in the left perinephric space. Attempts were made to resuscitate the patient, and an ED chest/abdomen/pelvis CT showed a type A acute thoracic aortic dissection. Unfortunately, the patient remained profoundly unstable, with multiple arrests. He was transferred to a tertiary care facility, but expired shortly after arrival. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: An emergency physician needs to be aware of the myriad of presentations of acute aortic dissection. Although hematospermia was felt ultimately to be an incidental symptom, sexual activity may bring about a significant transient increase in blood pressure, which could contribute to sheer force causing aortic injury. Awareness of this trigger and a careful sensitive history may aid the clinician in early diagnosis.

Atypical Hemolytic Uremic Syndrome following Acute Type A Aortic Dissection

Atypical hemolytic uremic syndrome (aHUS) is a thrombotic microangiopathy (TMA)-related disease that manifests as a triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury (AKI) and is caused by uncontrolled activation of the complement system. We report the case of a 61-year-old woman with acute type A aortic dissection that subsequently developed into aHUS. The hematologic disorders underlying aHUS improved after treatment with the complement inhibitor eculizumab. It is important to consider aHUS when a patient clinically develops a triad of microangiopathic hemolytic anemia, thrombocytopenia, and an increasing creatinine level following cardiovascular surgery.

A novel risk score on admission for predicting death or need for surgery in patients with acute type A intramural hematoma receiving medical therapy

There has been continuing discussion regarding the treatment strategy for acute type A intramural hematoma (IMH). Most patients are treated conservatively in Japan; hence, predicting fatal events and stratifying risks based on results normally obtained on hospital arrival are important. We aimed to examine the incidences and risk factors of death or need for surgery for acute type A IMH in patients receiving medical treatment and to identify high-risk patients using clinical findings on hospital arrival. From 2011 to 2016, 57 consecutive patients (mean age 72.5 years; male 36.8%) diagnosed with acute type A IMH who were receiving treatment at Shizuoka City Shizuoka Hospital were retrospectively included. Primary endpoint was a composite of cardiovascular death and operation within 1 year after onset. To evaluate sensitivity and specificity of the risk factors and risk score, we estimated the area under the receiver operating characteristic (ROC) curve. Mean follow-up duration was 621 days. Mean systolic blood pressure (SBP) was 129 mmHg. Computed tomography (CT) on arrival showed a mean ascending aorta diameter of 46 mm. Ulcer-like projection (ULP) in the ascending aorta and pericardial effusion (PE) were seen in 33% and 42% of cases, respectively. Twenty-eight patients (49.1%) reached the primary endpoint (cardiovascular death, 7 cases [12.3%]; operation, 21 cases [36.8%]). In univariate analysis of admission values, the primary endpoint group had significantly lower SBP (113.0 ± 28.5 vs 144.3 ± 33.5 mmHg), higher ascending aorta diameter (49.5 ± 8.1 vs 43.6 ± 5.9 mm), and higher frequency of ULP (53.8% vs 13.8%) and PE (58.6% vs 25.0%) than the event-free group. Multivariate analysis showed that ULP on admission CT was a significant predictor of the primary endpoint. The risk score was considered using these risk factors. On admission, the primary endpoint could be predicted with 89.7% sensitivity and 75% specificity (area under the ROC curve 0.823) if the patient had ULP and/or > 2 of the following factors: SBP < 120 mmHg, ascending aorta diameter > 45 mm, and PE. SBP and CT findings on arrival were significantly associated with cardiovascular death and the need for surgery in patients with acute type A IMH receiving initial medical therapy. The novel risk score was useful for predicting cardiovascular death and surgery.

Comparative Proteomic Investigation of Plasma Reveals Novel Potential Biomarker Groups for Acute Aortic Dissection

Acute aortic dissection (AAD) is a catastrophic cardiovascular disease with high disability and mortality due to multiple fatal complications. However, the molecular changes of the serum proteome after AAD are not very clear. Here, we performed isobaric tags for relative and absolute quantitation- (iTRAQ-) based comparative proteomic analysis to investigate the proteome profile changes after AAD by collecting plasma samples from 20 AAD patients and 20 controls. Out of the 345 identified proteins, 266 were considered as high-quality quantified proteins (95%confident peptides ≥ 2), of which 25 proteins were accumulated and 12 were reduced in AAD samples. Gene ontology enrichment analysis showed that the 25 AAD-accumulated proteins were enriched in high-density lipoprotein particles for the cellular component category and protein homodimerization acidity for the molecular function category. Protein-protein interaction network analysis showed that serum amyloid A proteins (SAAs), complement component proteins, and carboxypeptidase N catalytic chain proteins (CPNs) possessed the key nodes of the network. The expression levels of six selected AAD-accumulated proteins, B2-GP1, CPN1, F9, LBP, SAA1, and SAA2, were validated by ELISA. Moreover, ROC analysis showed that the AUCs of B2-GP1 and CPN1 were 0.808 and 0.702, respectively. Our data provide insights into molecular change profiles in proteome levels after AAD and indicate that B2-GP1 and CPN1 are potential biomarkers for AAD.

Rapid Response in Type A Aortic Dissection: Is There a Decisive Time Interval for Surgical Repair?

Background and Aim of the Study The objective was to evaluate whether there is a decisive time interval for patients to undergo surgery and to analyze if a rapid response in acute aortic dissection type A (AADA) affects patient selection.

Methods In 283 patients undergoing surgery for AADA, median time from onset of initial symptoms to skin incision was 6.9 hours (interquartile range [IQR], 5.0–11.7 hours). Patients were divided into three groups according to median time point of surgery (median ± 3 hours, i.e., 4–10; < 4; and >10 hours).

Results Almost 50% of patients presented in a critical preoperative state at hospital admission. Subanalysis identified patients being operated within 4 hours as an exclusive high-risk cohort (higher rates of preoperative neurologic dysfunction, tamponade, and cardiopulmonary resuscitation). Patients undergoing surgery between 4 and 10 hours showed a significantly better long-term survival (p = 0.021). Surgery within this time interval had a clear protective effect on 30-day mortality (odds ratio [OR]: 0.448. 95% confidence interval [CI]: 0.219–0.915). High age (OR: 1.037; 95% CI: 1.008–1.067), preoperative malperfusion syndrome (OR: 2.802; 95% CI: 1.351–5.811), and preoperative tamponade (OR: 2.621; 95% CI: 1.171–5.866) were factors predicting 30-day mortality.

Conclusion Rapid response in AADA interacts with the natural course of the disease resulting in an overrepresentation of critical patients. While the cohort below 4 hours represents the high-risk patients, time from symptom onset to initiation of surgery should not exceed 10 hours.

Master of the Masquerade: An Atypical Presentation of Acute Aortic Dissection

Acute aortic dissection (AAD) is associated with unacceptably high mortality rate. As such, early diagnosis and aggressive management are essential in order to avoid life-threatening complications. Herein, we report an atypical presentation of AAD and clinical sequelae.