Octogenarians with uncomplicated acute type a aortic dissection benefit from emergency operation

Outcomes of surgery for acute type A dissection in octogenarians versus non-octogenarians: a systematic review and meta analysis

INTRODUCTION

Acute Type A Aortic Dissection (ATAAD) is a cardiothoracic emergency that requires urgent intervention. Elderly status, particularly age over 80, is an independent risk factor for mortality and morbidity. The mid-term outcomes of this age group are also unknown. This systematic review and meta-analysis of observational studies was therefore performed to analyse short- and mid-term mortality and morbidity in octogenarians following surgery for ATAAD.

METHODS

A systematic review was conducted for studies published since January 2000. The primary endpoint was short-term mortality, either reported as 30-day mortality or in-hospital mortality and medium-term (five year) survival. Secondary endpoints were rates of postoperative complications, namely stroke, acute renal failure (ARF), re-exploration and intensive care unit (ICU) length of stay (LOS).

RESULTS

A total of 16 retrospective studies, with a total of 16, 641 patients were included in the systematic review and meta-analysis. Pooled analysis demonstrated that octogenarian cohorts are at significantly higher risk of short-term mortality than non-octogenarians (OR 1.93; 95% CI 1.33-2.81; P < 0.001). Actuarial survival was significantly lower in the octogenarian cohort, with a five-year survival in the octogenarian cohort of 54% compared to 76% in the non-octogenarian cohort (P < 0.001). There were no significant differences between the cohorts in terms of secondary outcomes: stroke, ARF, re-exploration or ICU LOS.

CONCLUSION

Octogenarians are twice as likely to die in the short-term following surgery for ATAAD and demonstrate a significantly lower five-year actuarial survival. Patients and family members should be well informed of the risks of surgery and suitable octogenarians selected for surgery.

Age, sex, and contemporary outcomes in surgical repair of type A aortic dissection: Insights from the National Inpatient Sample

Objective

Acute type A aortic dissection (ATAAD) is a surgical emergency with significant morbidity and mortality, as well as significant center-level variation in outcomes. Our study aims to leverage a nationally representative database to assess contemporary in-hospital outcomes in surgical repair of ATAAD, as well as the association of age and sex with outcomes.

Methods

The National Inpatient Sample was queried to identify hospital discharge records of patients aged ≥18 years who underwent urgent surgical repair of ATAAD between 2017 and 2018. Patients with a diagnosis of thoracic aortic dissection, who underwent surgical intervention of the ascending aorta, were identified. Patient demographics were assessed, and predictors of in-hospital mortality were identified.

Results

We identified 7805 weighted cases of surgically repaired ATAAD nationally, with an overall mortality of 15.3%. Mean age was 60.0 ± 13.6 years. There was a male predominance, although female subjects made up a larger proportion of older age groups—female subjects up 18.4% of patients younger than 40 years with ATAAD but 53.6% of patients older than 80 years. In multivariable analysis controlling for sex, race, comorbidities, and malperfusion, age was a significant predictor of mortality. Patients aged 71 to 80 years had a 5.3-fold increased risk of mortality compared with patients ≤40 years old (P < .001), and patients aged >80 years had a 6.8-fold increased risk of mortality (P < .001). Sex was not significantly associated with mortality.

Conclusions

Surgical repair of ATAAD continues to carry high risk of morbidity and mortality, with outcomes impacted significantly by patient age, regardless of patient comorbidity burden.

Impact of comorbidities on older patients undergoing open heart surgery

BACKGROUND

The number of elderly patients undergoing cardiac surgery is increasing. Age greater than 80 years has been identified as a strong independent risk factor for shortand long-term survival. The current study is aimed to identify the impact of preoperative comorbidities on early and late outcomes in older patients undergoing cardiac surgery.

METHODS

Baseline characteristics, procedurals and postoperative complications of all patients undergoing cardiac surgery at our institution are collected. The current analysis is focused on patients aged at least 80 years at the time of intervention and treated from January 2010 to December 2019.

RESULTS

In-hospital mortality resulted as 6.3%. Redo intervention [odds ratio (OR) 2.49, 95% confidence interval (CI) 1.13-5.48], chronic obstructive pulmonary disease (COPD) (OR 2.99, 95% CI 1.75-5.12) and peripheral arterial disease (PAD) (OR 2.23, 95% CI 1.30-3.81) were independent baseline predictors of outcome in the multivariate analysis. Prolonged extracorporeal circulation time, need for transfusion and prolonged intubation time strongly and independently predicted in-hospital mortality. During a mean follow-up of 3.6 years 34.3% of patients died and unplanned admission (HR 1.33, 95% CI 1.05-1.67), NYHA class III-IV (HR 1.35, 95% CI 1.12-1.64), diabetes (HR 1.27, 95% CI 1.01-1.59), COPD (HR 1.60, 95% CI 1.25-2.04) and PAD (HR 1.32, 95% CI 1.03-1.71) resulted as independent predictors of all-cause death.

CONCLUSION

Cardiac surgery is feasible in octogenarians, with an acceptable risk of mortality. Chronological age itself should not be the main determinant of choice while referring patients for cardiac surgical intervention. Comorbidities such as COPD, PAD and diabetes need to be taken into account for risk stratification.

Outcome of emergency surgery for acute type A aortic dissection in octogenarians

BACKGROUND

Emergency surgery for acute type A aortic dissection (AAAD) was usually avoided or denied in octogenarians because of high surgical mortality. Refined surgical techniques and improved postoperative care have led to an improved in-hospital outcome. However, a significant number of operative survivors suffered from postoperative complications and had compromised quality of life. We sought to assess the clinical outcome of emergency surgery using a standard conservative approach in octogenarians with AAAD.

METHODS

From 2004 to 2021, 123 patients underwent emergency surgery for AAAD by one surgeon using a standard conservative approach with right subclavian artery cannulation, no aortic cross-clamp, selective antegrade cerebral perfusion, moderate systemic hypothermia, reinforced sandwich technique, and a strategy of limited aortic resection. Hospital and late outcomes were assessed in patients with age >80 years.

RESULTS

Eighteen patients (15%) were octogenarians with seven males (39%) and median age of 82 years (range, 80-89). Hypertension was present in six patients (33%). None had diabetes mellitus, Marfan, or bicuspid aortic valve. Dissection was intramural hematoma in six (33%) and DeBakey type I in 15 patients (83%). Cardiac tamponade with shock was present in seven patients (39%). Ascending aortic grafting was performed in 17 patients, and additional hemiarch replacement in one patient. The hospital mortality rate was 17% (3/18). Fourteen patients (82%) were alive and well at discharge.

CONCLUSIONS

Emergency surgery for AAAD using a standard conservative approach showed an improved outcome in octogenarians. The majority of patients could return home with an acceptable living.

Outcomes of urgent aortic wrapping for acute type A aortic dissection

OBJECTIVE

Standard surgical repair of acute type A aortic dissection is associated with high mortality rates, especially in high-risk patients. In an attempt to improve survival in frail patients, we evaluated the outcomes after ascending aorta wrapping in a high-risk patient cohort.

METHODS

This single-center retrospective cohort study included all consecutive patients treated using ascending aorta wrapping for an acute type A aortic dissection from 2008 to 2019. The primary end points included 30-day mortality, survival during follow-up, and dissection-related mortality. Secondary end points included assessment of aortic remodeling after ascending aorta wrapping. Patients with an aortic anatomy suitable for adjunctive endografting of the ascending aorta were also identified.

RESULTS

Thirty-five consecutive patients who underwent ascending aorta wrapping were included. Their median age was 77 years (range, 46-96 years). The 30-day all-cause mortality rate was 9%. Major complications occurred in 7 patients (21%), including early reinterventions in 11 (31%). Median follow-up was 36 months (range, 2.4-106.6; interquartile range, 72). The actuarial survival at 36 months was 82%. The dissection-related mortality was 11.4%. The median aortic growth of the nonwrapped descending thoracic aorta was 3.4 mm. Computed tomography scan analysis depicted that 88% of survivors were theoretical candidates for an additional endovascular procedure to exclude the primary entry tear.

CONCLUSIONS

Aortic wrapping is associated with favorable early outcomes and a low rate of aortic events during follow-up. This therapeutic option should be considered for patients considered too fragile for standard surgical repair.

Outcomes of Acute Aortic Dissection Surgery in Octogenarians

Background Octogenarians (≥80 years old) are high-risk patients for acute aortic dissection (AAD) surgery. However, no population-based study has investigated the late outcomes of AAD surgery in octogenarians. This study aimed to investigate the late outcomes of AAD surgery in octogenarians. Methods and Results A total of 3998 patients who received AAD surgery from 2005 to 2013 were identified from the Taiwan National Health Insurance Research Database. In-hospital complications and late outcomes including all-cause mortality, major adverse cardiac and cerebrovascular event, respiratory failure, and redo aortic surgery were evaluated. The risks of late outcomes between octogenarians and nonoctogenarians were compared using the multivariable Cox proportional hazard model or Fine and Gray competing model. The numbers of the octogenarians who underwent type A and B AAD surgeries were 206 (6%; 206/3423) and 79 (13.7%; 79/575), respectively. Compared with the nonoctogenarians, the type A octogenarians had higher risks of in-hospital mortality and several in-hospital complications, whereas the type B octogenarians did not. Furthermore, compared with the nonoctogenarians, the type A octogenarians had a higher risk of all-cause mortality (61.7% vs 32.5%; hazard ratio [HR], 2.35; 95% CI, 1.95-2.84) and a higher cumulative incidence of major adverse cardiac and cerebrovascular event and respiratory failure, and the type B octogenarians demonstrated a higher risk of all-cause mortality (44.3% vs 30.4%; HR, 1.74; 95% CI, 1.18-2.55). The octogenarians receiving AAD surgeries had higher mortality rates than the normal octogenarian population. Conclusions Octogenarians receiving AAD surgeries exhibit worse late outcomes than nonoctogenarian counterparts.

Surgical outcomes analysis in patients with uncomplicated acute type A aortic dissection: a 13-year institutional experience

This retrospective study aimed to clarify the short-term and mid-term outcomes of and prognostic factors for patients who underwent surgical repair for uncomplicated acute type A aortic dissection (ATAAD). Between January 2007 and June 2019, 603 consecutive patients underwent ATAAD repair at our institution. According to patients’ preoperative presentations and imaging studies, uncomplicated ATAAD was found in 276 (45.8%) patients by excluding preoperative complicated factors. Patients with uncomplicated ATAAD were classified into the survivor (n = 243) and non-survivor (n = 33) groups. Clinical features, surgical information, and postoperative complications were compared. Three-year survival and freedom from reoperation rates for survivors were analyzed using the Kaplan–Meier actuarial method. The in-hospital surgical mortality rate of uncomplicated ATAAD patients was 11.9%. The non-survivor group had a higher rate of postoperative malperfusion-related complications, and a multivariate analysis revealed that repeat surgery, retrograde cerebral perfusion, and intraoperative extracorporeal membrane oxygenation support were predictors of in-hospital mortality. In the survivor group, 3-year cumulative survival and freedom from aortic reoperation rates were 89.6% (95% confidence interval [CI] 84.8–92.9%) and 83.1% (95% CI 76.8–87.7%), respectively. In conclusion, uncomplicated and complicated ATAAD rates were similar; the short-term and mid-term surgical outcomes in patients with uncomplicated ATAAD were generally acceptable.

Surgical results in acute type A aortic dissection with preoperative cardiopulmonary resuscitation: Survival and neurological outcome

BACKGROUND

Acute type A aortic dissection (ATAAD) is a life-threatening disease that requires emergent surgical intervention. This retrospective study aimed to clarify the individual characteristics, short-term and mid-term outcomes, and prognostic factors of patients who underwent surgical repair of ATAAD with preoperative cardiopulmonary resuscitation (CPR).

METHODS

Between January 2007 and January 2020, 656 consecutive patients underwent ATAAD repair at our institution; 22 (3.4%) of these patients underwent CPR prior to surgery. Patients who underwent preoperative CPR were classified as the survivor group (n = 9) and non-survivor group (n = 13), according to whether they survived to hospital discharge. Clinical features, surgical information, and postoperative complications were analyzed and compared. Three-year cumulative survival rates and cerebral performance categories (CPC) scores are presented.

RESULTS

In patients undergoing CPR prior to ATAAD surgery, the in-hospital mortality rate was 59.1%. A total of 72.7% of patients underwent concomitant surgical resuscitation procedures during CPR such as emergent subxiphoid pericardiotomy and/or emergent cardiopulmonary bypass. The survivor group had a higher rate of return of spontaneous heartbeat (ROSB) compared to the non-survivor group (100% versus 53.8%; P = 0.017). The 3-year cumulative survival rates were 35.1% (95% confidence interval [CI], 27.6%-42.6%) and 85.7% (95% CI, 81.9%-88.8%) for overall patients and for survivors, respectively. As for the neurological outcome, 77.8% (7/9) of patients had full cerebral performance (CPC-1) at the 3-month follow-up examination after discharge.

CONCLUSIONS

Patients with ATAAD undergoing preoperative CPR, especially those without ROSB after CPR, are at high risk for in-hospital mortality. However, the short-term and mid-term outcomes, including the cerebral performance after discharge and 3-year survival rate, are promising for patients who survived to discharge.

Clinical outcome of acute thoracic aortic syndrome in nonagenarians

BACKGROUND

Decision-making regarding the operability of thoracic aortic disease in nonagenarian patients remains controversial because outcomes of open surgical repair of the thoracic aorta are unclear. We investigated the surgical and nonsurgical outcomes of acute thoracic aortic syndrome treatment in nonagenarians.

METHODS

After evaluating data in our institute from April 2016 to March 2020, we included 10 nonagenarians who needed surgical intervention on the thoracic aorta via a median sternotomy for acute thoracic aortic syndrome. The mean age of the cohort was 91.9 ± 2.1 years. Five patients underwent open surgical repair of the thoracic aorta (surgical group), and 5 refused surgery (nonsurgical group). All patients in the surgical group performed activities of daily living independently, with a mean clinical frailty scale of 3.2 ± 0.4. The surgical group included 4 patients with type A aortic dissection and one with a ruptured thoracic aortic aneurysm. Hemiarch replacement was performed in 3 patients and total arch replacement in 2. The mean follow-up period was 17.8 ± 5.1 months.

RESULTS

Hospital mortality rates were 0% in the surgical and 80% in the nonsurgical group. The mean length of hospitalization was 28.4 ± 6.7 days in the surgical group. The 1-year survival rates were 100% in the surgical group and 20% in the nonsurgical group.

CONCLUSION

Open surgical repair for acute thoracic aortic syndrome via median sternotomy is a reasonable treatment option even in nonagenarians. Involvement of family members is important for decision-making to devise the optimal treatment strategy (surgical vs. medical).

Risk Factors for Mortality in Acute Aortic Dissection Type A: A Centre Experience Over 15 Years

INTRODUCTION

Acute aortic dissection Type A (AADA) is still associated with a high mortality rate and frequent postoperative complications. This study was designed to evaluate the risk factors for mortality in AADA patients.

PATIENTS AND METHODS

This retrospective analysis included 344 consecutive patients who underwent surgery for AADA in moderate hypothermic circulatory arrest (20-24°C nasopharyngeal) between 2001 and 2016.

RESULTS

The 30-day mortality rate was 18%. Nonsurvivors were significantly older (65.7 ± 12.0 years vs. 62.0 ± 12.5 years; p = 0.034) with significantly higher Euro-score II [15.4% (6.6; 23.0) vs. 4.63% (2.78; 9.88); p < 0.001)]. Intraoperatively, survivors had statistically shorter cardiopulmonary bypass times [163 (134; 206) vs. 198 min (150; 245); p = 0.001]. However, the hypothermic circulatory arrest time was similar between both groups. Postoperatively, the incidence of acute kidney injury (AKI) (55.9 vs. 15.2%; p < 0.001), stroke (27.9 vs. 12.1%; p = 0.002) and sepsis (18.0 vs. 2.1%; p < 0.001) were significantly higher among nonsurvivors. The multi-variable logistic regression confirmed that older age, previous cardiac surgery, preoperative cardiopulmonary resuscitation (CPR), blood transfusion and postoperative acute kidney injury (AKI) were independent risk factors for mortality.

CONCLUSION

Our analysis suggested that the reason for mortality was multifactorial, especially age, previous cardiac surgery, CPR, transfusion, as well as postoperative AKI were considered risk factors for mortality.

Midterm outcomes of emergency surgery for acute type A aortic dissection in octogenarians

OBJECTIVE

The incidence of elderly patients with acute type A aortic dissection is increasing. A recent analysis of the International Registry of Acute Aortic Dissection failed to show a mortality benefit with surgery compared with medical management in octogenarians. Therefore, we compared our institutional outcomes of emergency surgery for acute type A aortic dissection in octogenarians versus septuagenarians to understand the outcomes of surgical intervention in elderly patients.

METHODS

From 2002 to 2017, 70 octogenarians (aged ≥80 years) and 165 septuagenarians (70-79 years) underwent surgery for acute type A aortic dissection (N = 235, total). Quality of life was assessed by the RAND Short Form-36 quality of life survey. Midterm clinical and functional data were obtained retrospectively.

RESULTS

At baseline, septuagenarians had a higher prevalence of diabetes (20.6% vs 5.7%, P = .01). The prevalence of cardiopulmonary resuscitation was 4.8% versus 10.0% (P = .24) in septuagenarians and octogenarians. The prevalence of cardiogenic shock was 18.2% versus 27.1% (P = .17). Thirty-day/in-hospital mortality was 21.2% versus 28.6% (P = .29). Multivariable logistic regression identified cardiogenic shock as an independent risk factor for in-hospital mortality (odds ratio, 10.07; 95% confidence interval, 2.30-44.03) in octogenarians. Survival at 5 years was 49.7% (42.1%-58.6%) versus 34.2% (23.9%-48.8%) in septuagenarians and octogenarians, respectively. Responses to the quality of life survey were no different between septuagenarians and octogenarians across all 8 quality of life categories.

CONCLUSIONS

Clinical outcomes after surgery for acute type A aortic dissection are similar in octogenarians and septuagenarians. For discharged survivors, quality of life remains favorable and does not differ between the 2 groups.

The impact of age on patients undergoing aortic arch surgery: Evidence from a multicenter national registry

OBJECTIVE

Elderly patients are typically offered aortic surgery at similar diameter thresholds as younger patients, despite limited data quantifying their operative risk. We aim to report the incremental risk experienced by elderly patients undergoing aortic arch surgery.

METHODS

In total, 2520 patients underwent aortic arch surgery between 2002 and 2018 in 10 centers. Patients were divided into 3 groups: <65 years (n = 1325), 65 to 74 years (n = 737), and ≥75 years (n = 458). Outcomes of interest were in-hospital mortality, stroke, and the modified Society of Thoracic Surgeons composite for mortality or major morbidity (STS-COMP). Multivariable modeling was performed to determine the association of age with these outcomes.

RESULTS

As age increased, there was an increasing rate of comorbidities, including diabetes (P < .001), renal failure (P < .001), and previous stroke (P = .01). Rates of acute aortic syndrome (P = .50) and total arch repair were similar (P = .59) between groups. Older patients had greater mortality (<65: 6.1% vs 65-74: 9.0% vs ≥75: 14%, P < .001), stroke (6.3% vs 7.7% vs 11%, P = .01) and STS-COMP (25% vs 32% vs 38%, P < .001). After multivariable risk-adjustment, a step-wise increase in complications was observed in the older age groups relative to the youngest in terms of in-hospital mortality (65-74: odds ratio [OR] 1.57, P = .04; ≥75: OR, 2.94, P = .001) and STS-COMP (65-74: OR, 1.57, P < .001; ≥75: OR, 1.96, P < .001).

CONCLUSIONS

Older patients experienced elevated rates of mortality and morbidity following aortic arch surgery. These results support a more measured approach when evaluating elderly patients. Further research is needed on age-dependent natural history of thoracic aneurysms and size thresholds for intervention.

The future of stenting in patients with type A aortic dissection: a systematic review

Acute type A aortic dissection (ATAAD) carries high morbidity and mortality rates and is a clinical emergency. The reported mortality rate is 50% to 65% within the first 48 hours without surgical intervention. Open surgery therefore remains the gold standard management for ATAAD. However, in patients who are deemed unfit for surgery and where possible, endovascular repair offers a useful alternative to medical treatment alone or high-risk open surgical repair. Several case reports, case series, and retrospective studies have reported good outcomes following endovascular treatment. The endovascular option also has comparable early and late outcomes, favourable aortic remodelling, and satisfactory overall survival despite having a higher-risk patient cohort. However, stenting in patients with ATAAD undoubtedly still has several limitations and technical challenges.

Replacing the ascending aorta in the elderly: do or do not

Advanced age is a proven independent factor for perioperative morbidity and mortality in all forms of aortic surgery and forms an important variable in most available risk scores. Improvements in selection and perioperative management of high-risk elderly cohorts have reduced the incidence of adverse outcomes. Concerns remain however in the surgical and anesthesiology community that exposing elderly frail patients to ascending aortic surgery is associated with significant risk. As with many clinical scenarios, individualization of care for each patient is of paramount importance. With advances in our understanding of perioperative and intraoperative care, age should no longer be considered in isolation as a contraindication to ascending aortic surgery.

Emergent aortic surgery in octogenarians: is the advanced age a contraindication?

Surgery of both the ascending and descending aortic segments in the context of an acute aortic syndrome is one of the greatest challenges for the cardiac surgeon. In the case of surgery of the descending aorta, surgical risk increases due to the technical complexity, the required aggressive approach and because surgical indication is usually established as a result of complications and therefore involves, almost always, critically ill patients. The aging of the population is causing such surgery to be considered in an increasing number of octogenarians. The present review analyzes the available scientific evidence on the surgical indications and outcomes of these complex procedures in this population, particularly in the emergent scenario. Ascending and descending thoracic aortic diseases are reviewed separately, and the role of both the current risk scores and frailty assessments are comprehensively discussed.

Surgical repair of Stanford type A aortic dissection in elderly patients: a contemporary systematic review and meta-analysis

BACKGROUND

The results of surgical treatment of type A aortic dissection (AAD) in the elderly are controversial and aggravated by a higher operative mortality rate. The studies published in this subset of patients are mainly retrospective analyses or small samples from international registries. We sought to investigate this topic by conducting a contemporary meta-analysis of the most recent observational studies.

METHODS

A systematic literature search was conducted for any study published in the last five years on aortic dissection treated surgically in patients 70 years and older. A pooled risk-ratio meta-analysis has been conducted three main post-operative outcomes: short-term mortality, stroke and acute kidney injury.

RESULTS

A total of 11 retrospective observational studies have been included in the quantitative meta-analysis. Pooled meta-analysis showed an increased risk of short term mortality for the elderly population [relative risk (RR) =2.25; 95% CI, 1.79-2.83; I (2)=0%; P<0.0001], and this has been confirmed in a sub-analysis of patients 80 years and older. The risk of having stroke (RR =1.15; 95% CI, 0.89-1.5; I (2)=0%; P=0.28) and acute kidney injury (RR =0.79; 95% CI, 0.5-1.25, I (2)=14%, P=0.31) after surgery were comparable to the younger cohort of patients.

CONCLUSIONS

Although affected by an increased risk of short-term mortality in the elderly, surgical repair remains the treatment of choice for AAD. The main post-operative outcomes are comparable to younger patients and the mid-term survival rates are acceptable.

Contemporary insights into the management of type A aortic dissection

INTRODUCTION

Acute Type A Dissection remains a surgical emergency with a relatively high operative mortality despite advances in cardiac surgical techniques and medical management over the past thirty years.

AREAS COVERED

In this presentation we will discuss the issues surrounding diagnosis, triage, surgical treatment and perioperative medical management as well as long term surveillance of patients suffering from Acute Type A Dissection and present the literature that supports our management strategies. Expert commentary: The ultimate goal of surgical intervention for patients with Type A Acute Aortic Dissection is an alive patient. A more complicated operation which addresses the root and arch and potentially reduces late complications should be approached with caution since it may increase the operative mortality of the procedure itself. With the recent evolution in endovascular techniques, there is hope that later complications can be reduced without increasing the risk of the primary operation. It remains to be seen whether the improved distal aortic remodeling afforded by a combined open/endovascular approach to Acute Type A Dissection will lead to decreased need for aortic reinterventions and overall long term complications of a residual descending thoracic chronic dissection.

Cardiothoracic surgical emergencies in the intensive care unit

Patients with cardiothoracic surgical emergencies are frequently admitted to the ICU, either prior to operative intervention or after surgery. Recognition and appropriate timing of operative intervention are key factors in improving outcomes. A collaborative team approach with the cardiothoracic service is imperative in managing this patient population.

Svensson class IV Ascending aortic dissection, often confused with penetrating ulcer

TWe present the case of a 64 years old male patient who had recently suffered an infective aortic valve endocarditis (Streptococcus agalactiae) complicated by embolic arthritis of the right hip. Initial echocardiography revealed moderate aortic insufficiency developed on a tricuspid aortic valve with a small vegetation (5 mm × 4 mm) on the left coronary cusp. Furthermore, an aneurysmal dilatation of the ascending aorta (maximal diameter, 54 mm) was noted. Other heart valves and left ventricular function were considered normal. The patient completed a 4 weeks course of antibiotherapy, and the right hip arthritis was treated by drainage and synovectomy. The patient was subsequently referred to surgery on an outpatient basis for the aneurysm of the ascending aorta. Preoperative computed tomography showed localized aortic dissection of the tubular ascending aorta characterized by an intimal tear without medial hematoma but excentric bulging of the aortic wall. This lesion was initially considered a penetrating ulcer of the aortic wall The operative specimen allowed to make differential diagnosis with a penetrating aortic ulcer by showing that the lesion did not develop within an atherosclerotic plaque. However, downstream extension of the dissection was probably limited by the presence of transmural calcifications on its distal side. The patient underwent successful complete aortic root replacement using a stentless Freestyle bioprosthesis with Dacron graft extension as reported previously.

Current Treatment Strategies for Acute Type B Aortic Dissection

Acute type B aortic dissection (ATBAD) is a medical emergency that is a common occurrence in patients with atherosclerotic disease. The presentation is usually severe, with tearing pain that radiates to the back, and various levels of end-organ ischemia and malperfusion, even rupture, may occur. Everyone agrees that prompt and aggressive blood pressure control with β-blockers and nitroprusside is imperative, but when to surgically intervene is still not well characterized. However, the advent of minimally invasive stent graft placement has reshaped our thoughts regarding therapeutic intervention for ATBAD. This review is an attempt to define the current surgical indications for treating ATBAD.

Successful acute type A aortic dissection repair in a nonagenarian

Surgical repair in older patients with acute type A aortic dissection (ATAAD) evokes a higher peri- and postoperative mortality, it therefore remains controversial in nonagenarians. The authors present a case of a surgically managed ATAAD in a nonagenerian, a 94-year-old man presented with an uncomplicated ATAAD, necessitating emergency surgical repair. The subsequent postoperative course was uneventful, and the patient was discharged after uncomplicated recovery. Aggressive surgical approach should be feasable in select nonagenarian patients with ATAAD, depending on the clinical presention and prior patient history.

Clinical dilemma in the surgical treatment of organ malperfusion caused by acute type A aortic dissection

The malperfusion syndrome associated with acute aortic dissection draws attention because the clinical picture is very dramatic, and patients with malperfusion have poorer clinical outcomes. To improve surgical outcomes, the ischemic damages associated with organ malperfusion should be minimized by restoring perfusion as early as possible, which occasionally can hardly coexist with central repair. This paper reviews the current evidence, problems, and dilemma related to the diagnosis and treatment of the malperfusion syndrome caused by acute type A aortic dissection.