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Clothier JS, Kobsa S. Management of Acute Type A Aortic Dissection. Cardiol Clin 2025; 43:261-277. [PMID: 40268355 DOI: 10.1016/j.ccl.2025.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2025]
Abstract
This article reviews the management of acute type A aortic dissection (ATAAD), from initial temporizing medical therapy to the technical aspects of urgent surgical repair, which is the definitive treatment for ATAAD. Surgical repair and the extent of aortic resection and replacement are dictated by the location and extent of intimal tears, as well as aneurysmal dilation of the aorta. Cardiopulmonary bypass, hypothermic circulatory arrest, and cerebral perfusion are major considerations in management of this acute process. Several techniques pertinent to each portion of the involved aorta and relevant intraoperative management points are also discussed.
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Affiliation(s)
- Jessica S Clothier
- USC Comprehensive Aortic Center, Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, 1520 San Pablo St, Suite 4300 Los Angeles, CA 90033, USA
| | - Serge Kobsa
- USC Comprehensive Aortic Center, Division of Cardiac Surgery, Department of Surgery, Keck School of Medicine of the University of Southern California, 1520 San Pablo St, Suite 4300 Los Angeles, CA 90033, USA.
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Zakko J, Ghincea C, Reece TB. Future Paradigms of Aortic Dissection. Cardiol Clin 2025; 43:329-336. [PMID: 40268361 DOI: 10.1016/j.ccl.2024.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2025]
Abstract
Acute type A dissection remains a challenging disease to manage, which is associated with high morbidity and mortality both at presentation and in the chronic setting. This article reviews contemporary debates in operative management, summarizes the currently accepted standard of care, and explores the optimal extent of aortic repair given the high rate of long term aortic degeneration.
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Affiliation(s)
- Jason Zakko
- Department of Surgery, University of Colorado, Aurora, USA
| | | | - T Brett Reece
- Department of Surgery, University of Colorado, Aurora, USA.
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Faltermeier CM, Burke CR. Cerebral Perfusion and Protection During Repair of Type A Dissection. Cardiol Clin 2025; 43:307-316. [PMID: 40268358 DOI: 10.1016/j.ccl.2024.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2025]
Abstract
Patients with the highest risk of neurologic injury after cardiac surgery are those undergoing repair of type A aortic dissections. Since the 1950s, extensive research has been conducted to improve the safety and neurologic outcomes of these patients. Surgeons now routinely use hypothermia with circulatory arrest, and adjunctive cerebral perfusion methods. This article highlights the historic development of modern cerebral perfusion and protection, and discusses technical details and clinical outcomes of cannulation strategies, temperature management, and antegrade cerebral perfusion and retrograde cerebral perfusion.
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Affiliation(s)
- Claire M Faltermeier
- Department of Surgery, Division of Cardiothoracic Surgery, University of Washington, Seattle
| | - Christopher R Burke
- Department of Surgery, Division of Cardiothoracic Surgery, University of Washington, Seattle.
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Brown JA, Yousef S, Serna-Gallegos D, Sá MP, Agrawal N, Thoma F, Wang Y, Phillippi J, Sultan I. Long-term outcomes of total arch replacement with bilateral antegrade cerebral perfusion using the "arch first" approach. Perfusion 2025; 40:850-857. [PMID: 38863259 DOI: 10.1177/02676591241259622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
ObjectiveTo report outcomes of total arch replacement (TAR) with hypothermic circulatory arrest and bilateral antegrade cerebral perfusion (bACP) using an "arch first" approach for acute Type A aortic dissection (ATAAD). The "arch first" approach involved revascularization of the aortic arch branch vessels with uninterrupted ACP, before lower body circulatory arrest, while the patient was cooling.MethodsThis was an observational study of aortic surgeries from 2010 to 2021. All patients who underwent TAR with bACP for ATAAD were included. Short-term and long-term outcomes were reported utilizing descriptive statistics and Kaplan-Meier survival estimation.ResultsA total of 215 patients were identified who underwent TAR + bACP for ATAAD. Age was 59.0 [49.0-67.0] years and 35.3% were female. 73 patients (34.0%) underwent a concomitant aortic root replacement, 188 (87.4%) had aortic cannulation, circulatory arrest time was 37.0 [26.0-52.0] minutes, and nadir temperature was 20.8 [19.4-22.5] degrees Celsius. 35 patients (16.3%) had operative mortality (STS definition), 17 (7.9%) had a new stroke, 79 (36.7%) had prolonged mechanical ventilation (>24 h), 35 (16.3%) had acute renal failure (by RIFLE criteria), and 128 (59.5%) had blood product transfusions. One-year survival was 77.1%, while 5-years survival was 67.1%. During follow-up, there were 23 (10.7%) reinterventions involving the descending thoracic aorta - either thoracic endovascular aortic repair or open thoracoabdominal aortic replacement.ConclusionsAmong patients with ATAAD, short-term postoperative outcomes after TAR + bACP using the "arch first" approach are acceptable. Moreover, this operative strategy may furnish long-term durability, with a reasonably low reintervention rate and satisfactory overall survival.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michel Pompeu Sá
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nishant Agrawal
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Yisi Wang
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Julie Phillippi
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Wang X, Ma J, Li C, Yang F, Wang L, Du Z, Li H, Zhu J, Zhang H, Hou X. Does Higher Temperature During Moderate Hypothermic Circulatory Arrest Increase the Risk of Paraplegia in Acute DeBakey I Aortic Dissection Patients? Can J Cardiol 2025; 41:749-760. [PMID: 38981559 DOI: 10.1016/j.cjca.2024.06.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 06/23/2024] [Accepted: 06/28/2024] [Indexed: 07/11/2024] Open
Abstract
BACKGROUND In this study, we sought to assess the safety of high-moderate (24.1-28.0°C) and low-moderate (20.1-24.0°C) systemic hypothermia during circulatory arrest (MHCA) in patients with acute DeBakey I aortic dissection (DeBakey I AAD), particularly concerning spinal cord protection. METHODS From 2009 to 2020, 1759 patients with DeBakey I AAD who underwent frozen elephant trunk and total arch replacement surgery at a tertiary centre were divided into preoperative malperfusion (viscera, spinal cord, or lower extremities) and nonmalperfusion subgroups. The baseline differences were balanced with the use of propensity score matching. Prognoses were compared between those who were subjected to high-MHCA (nasopharyngeal temperature 24.1-28.0°C) and low-MHCA (nasopharyngeal temperature 20.1-24.0°C). RESULTS In the nonmalperfusion subgroup (n = 1389), 469 pairs of matched patients showed lower in-hospital mortality and incidence of acute kidney injury in the high-MHCA group than in the low-MHCA group: in-hospital mortality 7.0% vs 10.2% (P = 0.01); acute kidney injury, 57.1% vs 64.6% (P < 0.01). The duration of mechanical ventilation was shorter in the high-MHCA group than that in the low-MHCA group (P = 0.03). No significant difference in the incidence of paraplegia was observed between the 2 groups. In the malperfusion subgroup (n = 370), 112 pairs of matched patients showed a higher incidence of paraplegia in the high-MHCA group than in the low-MHCA group (15.9% vs 6.5%; P = 0.04). CONCLUSIONS The safety of high-MHCA, a commonly used temperature management strategy during aortic arch surgery, was recognised in most patients with DeBakey I AAD. However, among patients with preoperative distal organ malperfusion, low-MHCA may be more appropriate owing to an increased risk of postoperative paraplegia associated with high-MHCA.
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Affiliation(s)
- Xiaomeng Wang
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jiawang Ma
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chenglong Li
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Feng Yang
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Liangshan Wang
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhongtao Du
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Haiyang Li
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongjia Zhang
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Xiaotong Hou
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Shen FM, Lin YM, Huang MC, Liu JP, Huang LC, Chen LW, Dai XF. Effectiveness of an integrated cerebral protection protocol in type A aortic dissection surgery: an inverse probability treatment weighting analysis. BMC Surg 2025; 25:62. [PMID: 39934744 PMCID: PMC11818039 DOI: 10.1186/s12893-025-02783-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 01/17/2025] [Indexed: 02/13/2025] Open
Abstract
BACKGROUND Cerebral protection strategies in type A aortic dissection (TAAD) surgery are critical yet inconclusive. We propose an integrated cerebral protection protocol. This study aimed to evaluate the effectiveness of this protocol. METHODS From January 2020 to December 2022, 85 patients were treated with an integrated protocol incorporating bilateral antegrade cerebral perfusion (ACP) and moderate hypothermia, with measures to prevent the shedding of thrombus or endothelial debris (BACP group), while traditional protocols were applied to 273 additional patients (UACP group). Inverse probability treatment weighting (IPTW) was performed to balance baseline characteristics. Three logistic regression models were used to evaluate the relationship between the two cerebral protection strategies and neurologic complications. Stepwise logistic regression was further employed to identify risk factors for cerebral complications. RESULTS Baseline characteristics were balanced after IPTW adjustment. The BACP group had a significantly shorter operative time (364.79 vs. 397.61 min, P = 0.022), significantly fewer neurologic complications (5.6% vs. 15.9%, P = 0.032), and transient neurologic injury (3.0% vs. 12.5%, P = 0.035). Binary multivariable logistic regression analysis showed that the cerebral complication risk was 3.14 times greater with the traditional protocol compared to the integrated protocol (odds ratio[OR]:3.14, 95%confidence interval[CI]:1.19-8.27, P = 0.020). Stepwise logistic regression confirmed that cerebral complications were dramatically increased with unilateral ACP (OR:2.99, 95%CI:1.14-7.82, P = 0.025), while bilateral ACP had a significant impact on decreasing cerebral complications. CONCLUSIONS Our integrated protocol effectively minimizes postoperative cerebral complications. Moderate hypothermia combined with BACP and measures to prevent brain debris could be adopted as an effective strategy for cerebral protection in TAAD surgery.
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Affiliation(s)
- Fei-Min Shen
- Department of Cardiac-thoracic Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
- Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, China
| | - Yi-Min Lin
- Department of Cardiac-thoracic Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Ming-Cheng Huang
- Department of Cardiac-thoracic Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Jin-Ping Liu
- Department of Cardiac-thoracic Surgery, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Ling-Chen Huang
- Department of Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liang-Wan Chen
- Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, China
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China
| | - Xiao-Fu Dai
- Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, China.
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, China.
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Zhou S, Liu Y, Zhang B, Wang L, Zhao R, Xie M, Chen X, Dun Y, Sun X. A comprehensive organ protection strategy in total arch replacement: a propensity-weighted analysis. Eur J Cardiothorac Surg 2025; 67:ezae385. [PMID: 39447042 PMCID: PMC11842131 DOI: 10.1093/ejcts/ezae385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 08/28/2024] [Accepted: 10/23/2024] [Indexed: 10/26/2024] Open
Abstract
OBJECTIVES The goal was to report the outcomes and determine the effectiveness of a comprehensive organ protection strategy in total arch replacement. METHODS A total of 350 patients who underwent total arch replacement were enrolled. Fifty-four patients underwent the comprehensive organ protection strategy with bilateral antegrade cerebral perfusion and the aortic balloon occlusion technique (comprehensive strategy group); 296 patients underwent the standard strategy with unilateral antegrade cerebral perfusion (standard strategy group). Inverse probability of treatment weighting was used to balance the baseline characteristics. RESULTS After inverse probability of treatment weighting, the comprehensive strategy group had lower incidences of 30-day mortality (0.9% vs 4.9%, P = 0.002), continuous renal replacement therapy (0.6% vs 10.3%, P < 0.001), renal failure (4.6% vs 13.7%, P < 0.001), hepatic dysfunction (11.6% vs 21.1%, P = 0.001) and shorter duration of mechanical ventilation [16 (13, 31) vs 20 (14, 48) h, P = 0.011]. Multivariable logistic analysis showed that the comprehensive strategy was an independent protective factor of 30-day mortality [odds ratio (OR): 0.242, 95% confidence interval (CI): 0.068-0.867, P = 0.029], continuous renal replacement therapy (OR: 0.045, 95% CI: 0.008-0.264, P = 0.001), renal failure (OR: 0.351, 95% CI: 0.156-0.788, P = 0.011) and mechanical ventilation >20 h (OR: 0.531, 95% CI: 0.319-0.883, P = 0.015). Kaplan-Meier analysis showed that mid-term survival was comparable. CONCLUSIONS The comprehensive organ protection strategy might improve early survival, reduce the use of continuous renal replacement therapy, have protective effects on the kidney and shorten mechanical ventilation time in total arch replacement. This strategy might be considered a viable alternative in total arch replacement.
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Affiliation(s)
- Sangyu Zhou
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yanxiang Liu
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bowen Zhang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Luchen Wang
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ruojin Zhao
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Mingxin Xie
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xuyang Chen
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yaojun Dun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaogang Sun
- Department of Cardiovascular Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Grasty MA, Lawrence K. Advances and Innovation in Acute Type a Aortic Dissection. J Clin Med 2024; 13:7794. [PMID: 39768716 PMCID: PMC11728286 DOI: 10.3390/jcm13247794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2024] [Revised: 11/20/2024] [Accepted: 12/05/2024] [Indexed: 01/16/2025] Open
Abstract
The prompt and appropriate management of acute type A aortic dissections is imperative for patient survival. Advances in medical technology have broadened the adjuncts available to treat the spectrum of pathology within this population. The role of medical management prior to surgical intervention and the components of operative management, including cannulation strategies, neuroprotection, and the extent of aortic intervention, have been explored in-depth within the literature. More recent work has identified novel open and endovascular techniques available to treat acute type A dissections. This review aims to summarize the literature, with a particular focus on innovation in cardiac surgery and its role in the care of this high-risk population.
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Affiliation(s)
| | - Kendall Lawrence
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA
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Jiang F, Wang X, Carmichael M, Chen Y, Huang R, Xiao Y, Zhou J, Su C. Contemporary comparative surgical outcomes of type A aortic dissection in US and China: an analysis of the national inpatient sample database and a Chinese multi-institutional registry. J Cardiothorac Surg 2024; 19:632. [PMID: 39543647 PMCID: PMC11566593 DOI: 10.1186/s13019-024-03023-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 08/30/2024] [Indexed: 11/17/2024] Open
Abstract
BACKGROUND To investigate the contemporary comparative inpatient prognosis among US and Chinese patients with type A aortic dissection (TAAD). METHODS Data from Chinese multi-institutional TAAD registry and the US National Inpatient Sample databases were analyzed. We used multivariable logistic regression models to compare in-hospital mortality and perioperative complication rates between the US and China. Length of stay and overall costs were fitted with quantile regression models. Independent prognostic factors associated with post-operative survival were assessed via Cox proportional hazards models. RESULTS Among 3,121 eligible TAAD patients, 1,073 were from China (25.0% female; mean ± SD age, 53.9 ± 12.4) and 2,048 were from the US (31.2% female; mean ± SE age, 59.8 ± 0.3). During the study period, the in-hospital mortality rates in China and the US were 15.5% and 13.3%, yet the difference was insignificant after adjustment (aOR, 1.16; 95% CI, 0.69-1.97). While there was no significant difference in overall perioperative complications (aOR, 1.07; 95% CI, 0.52-2.18), the patterns of complications differed between two cohorts. While Chinese TAAD patients experienced significantly longer duration of hospitalization (median difference, + 10.4 days; 95% CI, 9.2-11.5), the US TAAD cohort had significantly greater overall hospitalization costs (49.9; 95% CI, 55.4-44.5, in 1000 USD). CONCLUSIONS Notwithstanding significant differences in demographic and clinical characteristics, TAAD patients from China and the US demonstrated comparable in-hospital mortality and overall perioperative complication rates. Future initiatives should focus on expanding surgical eligibility to the elderly Chinese TAAD patients and optimizing the duration of hospitalization without undermining meaningful clinical outcomes. TRIAL REGISTRATION KY20220425-05, April 5th 25 2022.
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Affiliation(s)
- Feng Jiang
- School of International Business, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Xiaodi Wang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Michael Carmichael
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yanfei Chen
- School of International Business, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Ruijian Huang
- School of International Business, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Yue Xiao
- School of International Business, China Pharmaceutical University, Nanjing, Jiangsu, China
| | - Jifang Zhou
- School of International Business, China Pharmaceutical University, Nanjing, Jiangsu, China.
| | - Cunhua Su
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu, China.
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Wakisaka H, Miwa S, Matsubayashi Y, Mori Y, Lee J, Kamiya K, Takashima N, Suzuki T. Moderate hypothermia circulatory arrest as a brain-protective strategy for type A aortic dissection. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 39:ivae166. [PMID: 39361276 PMCID: PMC11474003 DOI: 10.1093/icvts/ivae166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2024] [Revised: 07/17/2024] [Accepted: 10/01/2024] [Indexed: 10/16/2024]
Abstract
OBJECTIVES Brain-protective strategies for acute type A aortic dissection (TAAD) remain controversial. Moderate hypothermia circulatory arrest (MHCA) without cerebral perfusion is not commonly used. However, we aimed to assess its safety and efficacy in 358 patients who underwent hemiarch replacement with MHCA for acute type A aortic dissection at our institution from August 2012 to August 2022. METHODS Clinical outcomes were compared according to circulatory arrest time [≤15 min (S group, n = 52) vs ≥16 min (L group, n = 306)]. The primary outcome was postoperative stroke. RESULTS The S group had more older patients (72.5 vs 68.8 years; P = 0.04), a greater incidence of carotid artery malperfusion (21% vs 11%; P = 0.043) and a lower body mass index (21.7 vs 23.6 kg/m2; P < 0.01) and hemodynamic instability (3.8% vs 16%; P = 0.02) than the L group. The incidence of postoperative stroke (7.7% vs 12%; P = 0.33) and the rate of 30-day mortality (5.8% vs 6.5%; P = 0.83) did not significantly differ between groups. After adjusting for all potential confounding factors pre- and intraoperatively, there was no significant difference in postoperative outcomes between groups. CONCLUSIONS MHCA alone for TAAD had comparable postoperative outcomes with circulatory arrest times under and over 15 min. However, longer arrest times were associated with a higher risk of stroke.
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Affiliation(s)
- Hodaka Wakisaka
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Shunta Miwa
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Yuji Matsubayashi
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Yotaro Mori
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Junghun Lee
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Kenichi Kamiya
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Noriyuki Takashima
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
| | - Tomoaki Suzuki
- Department of Cardiovascular Surgery, Shiga University of Medical Science, Shiga, Japan
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Ram E, Lau C, Dimagli A, Chu NQ, Soletti G, Gaudino M, Girardi LN. Reoperative total arch replacement after previous cardiovascular surgery: Outcomes in 426 consecutive patients. J Thorac Cardiovasc Surg 2024; 168:963-972.e2. [PMID: 37657714 DOI: 10.1016/j.jtcvs.2023.08.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 07/30/2023] [Accepted: 08/15/2023] [Indexed: 09/03/2023]
Abstract
OBJECTIVE Total aortic arch replacement (TAR) after previous cardiovascular surgery is technically challenging and is becoming more frequent as outcomes for primary arch repair have improved. primary. We analyzed outcomes of reoperative compared with first-time TAR. METHODS The institutional aortic database was queried to identify consecutive patients undergoing TAR between 1997 and 2022. In total, 426 patients underwent TAR, of whom 150 (35%) had previous cardiovascular surgery (reop TAR) and 276 (65%) underwent their first cardiovascular operation. RESULTS The reop TAR group was younger (61 ± 13 vs 71 ± 11, P < .001) with more comorbidities such as ischemic heart disease (12% vs 4.3%, P = .006), previous stroke (36% vs 14.5%, P < .001), and renal impairment (24% vs 12.7%, P = .004). Reop TAR had longer cardiac ischemic times (119.3 ± 45.5 minutes vs 98 ± 31.9 minutes, P < .001), a greater operative mortality (3.3% vs 0.4%, P = .040), and incurred a 4-fold increased risk of major adverse event (95% confidence interval [CI], 1.41-11.49, P = .009). Ten-year survival was also lower in the reop TAR cohort (76% vs 82.2%; hazard ratio, 1.79; 95% CI, 1.12-2.86, P = .015) and there was greater need for late reinterventions, mainly on the downstream aorta (hazard ratio, 1.29; 95% CI, 1.03-1.62, P = .024). CONCLUSIONS Reop TAR is a technically challenging operation and is associated with increased operative mortality and adverse events. Gratifying results can be obtained with meticulous surgical planning and focused attention on end-organ protection. Late reinterventions occur in a significantly greater percentage of patients undergoing reop TAR, and future studies should focus attention on identifying those at-risk groups who may benefit from a more aggressive index procedure.
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Affiliation(s)
- Eilon Ram
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Ngoc-Quynh Chu
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Giovanni Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
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12
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Jiang Q, Huang K, Wang D, Xia J, Yu T, Hu S. A comparison of bilateral and unilateral cerebral perfusion for total arch replacement surgery for non-marfan, type A aortic dissection. Perfusion 2024; 39:1070-1079. [PMID: 36898141 PMCID: PMC11437689 DOI: 10.1177/02676591231161919] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2023]
Abstract
OBJECTIVES Acknowledging lacking of consensus exist in total aortic arch (TAA) surgery for acute type A aortic dissection (AAD), this study aimed to investigate the neurologic injury rate between bilateral and unilateral cerebrum perfusion on the specific population. METHODS A total of 595 AAD patients other than Marfan syndrome receiving TAA surgery since March 2013 to March 2022 were included. Among them, 276 received unilateral cerebral perfusion (via right axillary artery, RCP) and 319 for bilateral cerebral perfusion (BCP). The primary outcome was neurologic injury rate. Secondary outcomes were 30-day mortality, serum inflammation response (high sensitivity C reaction protein, hs-CRP; Interleukin-6, IL-6; cold-inducible RNA binding protein, CIRBP) and neuroprotection (RNA-binding motif 3, RBM3) indexes. RESULTS The BCP group reported a significantly lower permanent neurologic deficits [odds ratio: 0.481, Confidence interval (CI): 0.296-0.782, p = 0.003] and 30-day mortality (odds ratio: 0.353, CI: 0.194-0.640, p < 0.001) than those received RCP treatment. There were also lower inflammation cytokines (hr-CRP: 114 ± 17 vs. 101 ± 16 mg/L; IL-6: 130 [103,170] vs. 81 [69,99] pg/ml; CIRBP: 1076 [889, 1296] vs. 854 [774, 991] pg/ml, all p < 0.001), but a higher neuroprotective cytokine (RBM3: 4381 ± 1362 vs 2445 ± 1008 pg/mL, p < 0.001) at 24 h after procedure in BCP group. Meanwhile, BCP resulted in a significantly lower Acute Physiology, Age and Chronic Health Evaluation (APACHE) Ⅱscore (18 ± 6 vs 17 ± 6, p < 0.001) and short stay in intensive care unit (4 [3,5] vs. 3 [2,3] days, p < 0.001) and hospital (16 ± 4 vs 14 ± 3 days, p < 0.001). CONCLUSIONS This present study indicated that BCP compared with RCP was associated with lower permanent neurologic deficits and 30-day mortality in AAD patients other than Marfan syndrome receiving TAA surgery.
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Affiliation(s)
- Qin Jiang
- Department of Cardiac Surgery, Affiliated Hospital of University of Electronic Science and Technology, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Keli Huang
- Department of Cardiac Surgery, Affiliated Hospital of University of Electronic Science and Technology, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Deliang Wang
- Department of Cardiac Surgery, Affiliated Hospital of University of Electronic Science and Technology, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Jiaqi Xia
- Department of Cardiac Surgery, Affiliated Hospital of University of Electronic Science and Technology, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Tao Yu
- Department of Cardiac Surgery, Affiliated Hospital of University of Electronic Science and Technology, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Shengshou Hu
- Department of Cardiac Surgery, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
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13
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Werner P, Winter M, Mahr S, Stelzmueller ME, Zimpfer D, Ehrlich M. Cerebral Protection Strategies in Aortic Arch Surgery-Past Developments, Current Evidence, and Future Innovation. Bioengineering (Basel) 2024; 11:775. [PMID: 39199732 PMCID: PMC11351742 DOI: 10.3390/bioengineering11080775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/18/2024] [Accepted: 07/26/2024] [Indexed: 09/01/2024] Open
Abstract
Surgery of the aortic arch remains a complex procedure, with neurological events such as stroke remaining its most dreaded complications. Changes in surgical technique and the continuous innovation in neuroprotective strategies have led to a significant decrease in cerebral and spinal events. Different modes of cerebral perfusion, varying grades of hypothermia, and a number of pharmacological strategies all aim to reduce hypoxic and ischemic cerebral injury, yet there is no evidence indicating the clear superiority of one method over another. While surgical results continue to improve, novel hybrid and interventional techniques are just entering the stage and the question of optimal neuroprotection remains up to date. Within this perspective statement, we want to shed light on the current evidence and controversies of cerebral protection in aortic arch surgery, as well as what is on the horizon in this fast-evolving field. We further present our institutional approach as a large tertiary aortic reference center.
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Affiliation(s)
- Paul Werner
- Correspondence: (P.W.); (M.W.); Tel.: +431-40400-69890 (P.W.)
| | - Martin Winter
- Correspondence: (P.W.); (M.W.); Tel.: +431-40400-69890 (P.W.)
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14
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Biancari F, Dell'Aquila AM, Onorati F, Rossetti C, Demal T, Rukosujew A, Peterss S, Buech J, Fiore A, Folliguet T, Perrotti A, Hervé A, Nappi F, Conradi L, Pinto AG, Lega JR, Pol M, Kacer P, Wisniewski K, Mazzaro E, Gatti G, Vendramin I, Piani D, Ferrante L, Rinaldi M, Quintana E, Pruna-Guillen R, Gerelli S, Di Perna D, Acharya M, Mariscalco G, Field M, Kuduvalli M, Pettinari M, Rosato S, Mustonen C, Kiviniemi T, Roberts CS, Mäkikallio T, Juvonen T. Classification of the Urgency of the Procedure and Outcome of Acute Type A Aortic Dissection. Am J Cardiol 2024; 217:59-67. [PMID: 38401652 DOI: 10.1016/j.amjcard.2024.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 01/09/2024] [Accepted: 01/29/2024] [Indexed: 02/26/2024]
Abstract
Surgery for type A aortic dissection (TAAD) is associated with a high risk of early mortality. The prognostic impact of a new classification of the urgency of the procedure was evaluated in this multicenter cohort study. Data on consecutive patients who underwent surgery for acute TAAD were retrospectively collected in the multicenter, retrospective European Registry of TAAD (ERTAAD). The rates of in-hospital mortality of 3,902 consecutive patients increased along with the ERTAAD procedure urgency grades: urgent procedure 10.0%, emergency procedure grade 1 13.3%, emergency procedure grade 2 22.1%, salvage procedure grade 1 45.6%, and salvage procedure grade 2 57.1% (p <0.0001). Preoperative arterial lactate correlated with the urgency grades. Inclusion of the ERTAAD procedure urgency classification significantly improved the area under the receiver operating characteristics curves of the regression model and the integrated discrimination indexes and the net reclassification indexes. The risk of postoperative stroke/global brain ischemia, mesenteric ischemia, lower limb ischemia, dialysis, and acute heart failure increased along with the urgency grades. In conclusion, the urgency of surgical repair of acute TAAD, which seems to have a significant impact on the risk of in-hospital mortality, may be useful to improve the stratification of the operative risk of these critically ill patients. This study showed that salvage surgery for TAAD is justified because half of the patients may survive to discharge.
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Affiliation(s)
- Fausto Biancari
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland; Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
| | - Angelo M Dell'Aquila
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Cecilia Rossetti
- Division of Cardiac Surgery, University of Verona Medical School, Verona, Italy
| | - Till Demal
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Andreas Rukosujew
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Sven Peterss
- Department of Cardiac Surgery, LMU University Hospital, Ludwig Maximilian University, Munich, Germany
| | - Joscha Buech
- Department of Cardiac Surgery, LMU University Hospital, Ludwig Maximilian University, Munich, Germany; German Centre for Cardiovascular Research, Partner Site Munich Heart Alliance, Munich, Germany
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France
| | - Thierry Folliguet
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Creteil, France
| | - Andrea Perrotti
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Amélie Hervé
- Department of Thoracic and Cardiovascular Surgery, University of Franche-Comte, Besancon, France
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Angel G Pinto
- Cardiovascular Surgery Department, University Hospital Gregorio Marañón, Madrid, Spain
| | - Javier Rodriguez Lega
- Cardiovascular Surgery Department, University Hospital Gregorio Marañón, Madrid, Spain
| | - Marek Pol
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Petr Kacer
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Konrad Wisniewski
- Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany
| | - Enzo Mazzaro
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Cardio-Thoracic and Vascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Igor Vendramin
- Cardiothoracic Department, University Hospital, Udine, Italy
| | - Daniela Piani
- Cardiothoracic Department, University Hospital, Udine, Italy
| | - Luisa Ferrante
- Cardiac Surgery, Molinette Hospital, University of Turin, Turin, Italy
| | - Mauro Rinaldi
- Cardiac Surgery, Molinette Hospital, University of Turin, Turin, Italy
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clínic de Barcelona, University of Barcelona, Barcelona Spain
| | - Robert Pruna-Guillen
- Department of Cardiovascular Surgery, Hospital Clínic de Barcelona, University of Barcelona, Barcelona Spain
| | - Sebastien Gerelli
- Department of Cardiac Surgery, Centre Hospitalier Annecy Genevois, Epagny Metz-Tessy, France
| | - Dario Di Perna
- Department of Cardiac Surgery, Centre Hospitalier Annecy Genevois, Epagny Metz-Tessy, France
| | - Metesh Acharya
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, United Kingdom
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, Leicester, United Kingdom
| | - Mark Field
- Liverpool Centre for Cardiovascular Sciences, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Manoj Kuduvalli
- Liverpool Centre for Cardiovascular Sciences, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Matteo Pettinari
- Department of Cardiac Surgery, Ziekenhuis Oost Limburg, Genk, Belgium
| | - Stefano Rosato
- National Center for Global Health, Istituto Superiore di Sanitá, Rome, Italy
| | - Caius Mustonen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Tuomas Kiviniemi
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | | | - Timo Mäkikallio
- Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland
| | - Tatu Juvonen
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland; Research Unit of Surgery, Anesthesia and Critical Care, University of Oulu, Oulu, Finland
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15
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Nappi F, Alzamil A, Avtaar Singh SS, Spadaccio C, Bonnet N. Current Knowledge on the Interaction of Human Cytomegalovirus Infection, Encoded miRNAs, and Acute Aortic Syndrome. Viruses 2023; 15:2027. [PMID: 37896804 PMCID: PMC10611417 DOI: 10.3390/v15102027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/21/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023] Open
Abstract
Aortic dissection is a clinicopathological entity caused by rupture of the intima, leading to a high mortality if not treated. Over time, diagnostic and investigative methods, antihypertensive therapy, and early referrals have resulted in improved outcomes according to registry data. Some data have also emerged from recent studies suggesting a link between Human Cytomegalovirus (HCMV) infection and aortic dissection. Furthermore, the use of microRNAs has also become increasingly widespread in the literature. These have been noted to play a role in aortic dissections with elevated levels noted in studies as early as 2017. This review aims to provide a broad and holistic overview of the role of miRNAs, while studying the role of HCMV infection in the context of aortic dissections. The roles of long non-coding RNAs, circular RNAs, and microRNAs are explored to identify changes in expression during aortic dissections. The use of such biomarkers may one day be translated into clinical practice to allow early detection and prognostication of outcomes and drive preventative and therapeutic options in the future.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (N.B.)
| | - Almothana Alzamil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (N.B.)
| | | | - Cristiano Spadaccio
- Department of Cardiothoracic Surgery, Mayo Clinic, Rochester, Rochester, MN 55905, USA;
| | - Nicolas Bonnet
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (N.B.)
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16
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Nappi F, Alzamil A, Salsano A, Avtaar Singh SS, Gambardella I, Santini F, Fiore A, Perocchio G, Demondion P, Mesnildrey P, Schoell T, Bonnet N, Leprince P. Lactate-Based Difference as a Determinant of Outcomes following Surgery for Type A Acute Aortic Dissection: A Multi-Centre Study. J Clin Med 2023; 12:6177. [PMID: 37834821 PMCID: PMC10573384 DOI: 10.3390/jcm12196177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/18/2023] [Accepted: 09/18/2023] [Indexed: 10/15/2023] Open
Abstract
UNLABELLED Type A acute aortic dissection (TAAAD) is a serious condition within the acute aortic syndromes that demands immediate treatment. Despite advancements in diagnostic and referral pathways, the survival rate post-surgery currently sits at almost 20%. Our objective was to pinpoint clinical indicators for mortality and morbidity, particularly raised arterial lactate as a key factor for negative outcomes. METHODS All patients referred to the three cardiovascular centres between January 2005 and December 2022 were included in the study. The inclusion criteria required the presence of a lesion involving the ascending aorta, symptoms within 7 days of surgery, and referral for primary surgical repair of TAAAD based on recommendations, with consideration for other concomitant major cardiac surgical procedures needed during TAAAD and retrograde extension of TAAAD. We conducted an analysis of both continuous and categorical variables and utilised predictive mean matching to fill in missing numeric features. For missing binary variables, we used logistic regression to impute values. We specifically targeted early postoperative mortality and employed LASSO regression to minimise potential collinearity of over-fitting variables and variables measured from the same patient. RESULTS A total of 633 patients were recruited for the study, out of which 449 patients had complete preoperative arterial lactate data. The average age of the patients was 64 years, and 304 patients were male (67.6%). The crude early postoperative mortality rate was 24.5% (110 out of 449 patients). The mortality rate did not show any significant difference when comparing conservative and extensive surgeries. However, malperfusion had a significant impact on mortality [48/131 (36.6%) vs. 62/318 (19.5%), p < 0.001]. Preoperative arterial lactates were significantly elevated in patients with malperfusion. The optimal prognostic threshold of arterial lactate for predicting early postoperative mortality in our cohort was ≥2.6 mmol/L. CONCLUSION The arterial lactate concentration in patients referred for TAAAD is an independent factor for both operative mortality and postoperative complications. In addition to mortality, patients with an upper arterial lactate cut-off of ≥2.6 mmol/L face significant risks of VA ECMO and the need for dialysis within the first 48 h after surgery. To improve recognition and facilitate rapid transfer and surgical treatment protocol, more diligent efforts are required in the management of malperfusion in TAAAD.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Almothana Alzamil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Italy DISC Department, University of Genoa, 16145 Genoa, Italy; (A.S.); (F.S.); (G.P.)
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiothoracic Surgery, Weill Cornell Medicine–New York, Presbyterian Medical Center, 505 E 70th St., New York, NY 10065, USA;
| | | | - Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Italy DISC Department, University of Genoa, 16145 Genoa, Italy; (A.S.); (F.S.); (G.P.)
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Créteil, France;
| | - Giacomo Perocchio
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, Italy DISC Department, University of Genoa, 16145 Genoa, Italy; (A.S.); (F.S.); (G.P.)
| | - Pierre Demondion
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47–83, 75013 Paris, France; (P.D.); (P.L.)
| | - Patrick Mesnildrey
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Thibaut Schoell
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Nicolas Bonnet
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (P.M.); (T.S.); (N.B.)
| | - Pascal Leprince
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47–83, 75013 Paris, France; (P.D.); (P.L.)
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17
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Ede J, Teurneau-Hermansson K, Ramgren B, Moseby-Knappe M, Larsson M, Sjögren J, Wierup P, Nozohoor S, Zindovic I. Radiological properties of neurological injury following acute type A aortic dissection repair. JTCVS OPEN 2023; 15:38-60. [PMID: 37808039 PMCID: PMC10556816 DOI: 10.1016/j.xjon.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 10/10/2023]
Abstract
Objective The study objective was to assess the radiological properties of acute type A aortic dissection-related neurological injuries and identify predictors of neurological injury. Methods Our single-center, retrospective, observational study included all patients who underwent acute type A aortic dissection repair between January 1998 and December 2021. Multivariable analyses and Cox regression were performed to identify predictors of embolic lesions, watershed lesions, neurological injury, 30-day mortality, and late mortality. Results A total of 538 patients were included. Of these, 120 patients (22.3%) experienced postoperative neurological injury; 74 patients (13.8%) had postoperative stroke, and 36 patients (6.8%) had postoperative coma. The 30-day mortality was 22.7% in the neurological injury group versus 5.8% in the no neurological injury group (P < .001). We identified several independent predictors of neurological injury. Cerebral malperfusion (odds ratio, 2.77; 95% confidence interval, 1.53-5.00), systemic hypotensive shock (odds ratio, 1.97; 95% confidence interval, 1.13-3.43), and aortic arch replacement (odds ratio, 3.08; 95% confidence interval, 1.17-8.08) predicted embolic lesions. Diabetes mellitus (odds ratio, 5.35; 95% confidence interval, 1.85-15.42), previous cardiac surgery (odds ratio, 8.62; 95% confidence interval, 1.47-50.43), duration of hypothermic circulatory arrest (odds ratio, 1.05; 95% confidence interval, 1.01-1.08), cardiopulmonary bypass time (odds ratio, 1.01; 95% confidence interval, 1.00-1.01), ascending aortic/arch cannulation (odds ratio, 5.68; 95% confidence interval, 1.88-17.12), and left ventricular cannulation (odds ratio, 17.81; 95% confidence interval, 1.69-188.01) predicted watershed lesions. Retrograde cerebral perfusion (odds ratio, 0.28; 95% confidence interval, 0.01-0.84) had a protective effect against watershed lesions. Conclusions In this study, we demonstrated that the radiological features of neurological injury may be as important as clinical characteristics in understanding the pathophysiology and causality behind neurological injury related to acute type A aortic dissection repair.
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Affiliation(s)
- Jacob Ede
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
| | - Karl Teurneau-Hermansson
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
| | - Birgitta Ramgren
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Radiology, Skåne University Hospital, Lund, Sweden
| | - Marion Moseby-Knappe
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Neurology, Skåne University Hospital, Lund, Sweden
| | - Mårten Larsson
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
| | - Johan Sjögren
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
| | - Per Wierup
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
| | - Shahab Nozohoor
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
| | - Igor Zindovic
- Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Department of Cardiothoracic Surgery, Skåne University Hospital, Lund, Sweden
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18
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Nappi F, Avtaar Singh SS, Gambardella I, Alzamil A, Salsano A, Santini F, Biancari F, Schoell T, Bonnet N, Folliguet T, Fiore A. Surgical Strategy for the Repair of Acute Type A Aortic Dissection: A Multicenter Study. J Cardiovasc Dev Dis 2023; 10:253. [PMID: 37367418 PMCID: PMC10299256 DOI: 10.3390/jcdd10060253] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/24/2023] [Accepted: 06/06/2023] [Indexed: 06/28/2023] Open
Abstract
Type A acute aortic dissection is associated with significant morbidity and mortality, with prompt referral imaging and management to tertiary referral centers needed urgently. Surgery is usually needed emergently, but the choice of surgery often varies depending on the patient and the presentation. Staff and center expertise also play a major role in determining the surgical strategy employed. The aim of this study was to compare the early- and medium-term outcomes of patients undergoing a conservative approach extended only to the ascending aorta and the hemiarch to those of patients subjected to extensive surgery (total arch reconstruction and root replacement) across three European referral centers. A retrospective study was conducted across three sites between January 2008 and December 2021. In total, 601 patients were included within the study, of which 30% were female, and the median age was 64.4 years. The most common operation was ascending aorta replacement (n = 246, 40.9%). The aortic repair was extended proximally (i.e., root n = 105; 17.5%) and distally (i.e., arch n = 250; 41.6%). A more extensive approach, extending from the root to the arch, was employed in 24 patients (4.0%). Operative mortality occurred in 146 patients (24.3%), and the most common morbidity was stroke (75, 12.6%). An increased length of ICU admission was noted in the extensive surgery group, which comprised younger and more frequently male patients. No significant differences were noted in surgical mortality between patients managed with extensive surgery and those managed conservatively. However, age, arterial lactate levels, "intubated/sedated" status on arrival, and "emergency or salvage" status at presentation were independent predictors of mortality both within the index hospitalization and during the follow-up. The overall survival was similar between the groups.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (T.S.); (N.B.)
| | | | - Ivancarmine Gambardella
- Department of Cardiothoracic Surgery, Weill Cornell Medicine—New York, Presbyterian Medical Center, New York, NY 10065, USA;
| | - Almothana Alzamil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (T.S.); (N.B.)
| | - Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, DISC Department, University of Genoa, 16126 Genoa, Italy; (A.S.); (F.S.)
| | - Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, DISC Department, University of Genoa, 16126 Genoa, Italy; (A.S.); (F.S.)
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00231 Helsinki, Finland;
| | - Thibaut Schoell
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (T.S.); (N.B.)
| | - Nicolas Bonnet
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France; (A.A.); (T.S.); (N.B.)
| | - Thierry Folliguet
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France; (T.F.); (A.F.)
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France; (T.F.); (A.F.)
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19
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Nappi F, Petiot S, Salsano A, Avtaar Singh SS, Berger J, Kostantinou M, Bonnet S, Gambardella I, Biancari F, Almazil A, Santini F, Chaara R, Fiore A. Sex-Based Difference in Aortic Dissection Outcomes: A Multicenter Study. J Cardiovasc Dev Dis 2023; 10:147. [PMID: 37103025 PMCID: PMC10143202 DOI: 10.3390/jcdd10040147] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Type A Acute Aortic Dissection (TAAAD) repair is a surgical emergency associated with high morbidity and mortality. Registry data have noted several sex-specific differences in presentation with TAAAD which may account for the differences in men and women undergoing surgery for this condition. METHODS A retrospective review of data from three departments of cardiac surgery (Centre Cardiologique du Nord, Henri-Mondor University Hospital, San Martino University Hospital, Genoa) between January 2005 and 31 December 2021 was conducted. Confounders were adjusted using doubly robust regression models, a combination of regression models with inverse probability treatment weighting by propensity score. RESULTS 633 patients were included in the study, of which 192 (30.3%) were women. Women were significantly older with reduced haemoglobin levels and pre-operative estimated glomerular filtration rate compared to men. Male patients were more likely to undergo aortic root replacement and partial or total arch repair. Operative mortality (OR 0.745, 95% CI: 0.491-1.130) and early postoperative neurological complication results were comparable between the groups. The adjusted survival curves using IPTW by propensity score confirmed the absence of a significant impact of gender on long-term survival (HR 0.883, 95% CI 0.561-1.198). In a subgroup analysis of women, preoperative levels of arterial lactate (OR 1.468, 95% CI: 1.133-1.901) and mesenteric ischemia after surgery (OR 32.742, 95% CI: 3.361-319.017) were significantly associated with increased operative mortality. CONCLUSIONS The advancing age of female patients alongside raised preoperative level of arterial lactate may account for the increasing preponderance among surgeons to perform more conservative surgery compared to their younger male counterparts although postoperative survival was similar between the groups.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint Denis, France
| | - Sandra Petiot
- Department of Anesthesia, Centre Cardiologique du Nord, 93200 Saint Denis, France
| | - Antonio Salsano
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, DISC Department, University of Genoa, 16126 Genoa, Italy
| | | | - Joelle Berger
- Department of Anesthesia, Centre Cardiologique du Nord, 93200 Saint Denis, France
| | - Marisa Kostantinou
- Department of Anesthesia, Centre Cardiologique du Nord, 93200 Saint Denis, France
| | - Severine Bonnet
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint Denis, France
| | - Ivancarmine Gambardella
- Department of Cardiothoracic Surgery, Presbyterian Medical Center, 505 E 70th St., New York, NY 10065, USA
| | - Fausto Biancari
- Heart and Lung Center, Helsinki University Hospital, University of Helsinki, 00231 Helsinki, Finland
| | - Almothana Almazil
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint Denis, France
| | - Francesco Santini
- Division of Cardiac Surgery, Ospedale Policlinico San Martino, DISC Department, University of Genoa, 16126 Genoa, Italy
| | - Rim Chaara
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France
| | - Antonio Fiore
- Department of Cardiac Surgery, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 94000 Creteil, France
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20
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Cerebral Protection Strategies and Stroke in Surgery for Acute Type A Aortic Dissection. J Clin Med 2023; 12:jcm12062271. [PMID: 36983272 PMCID: PMC10056182 DOI: 10.3390/jcm12062271] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 03/08/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Background: Perioperative stroke remains a devastating complication in the operative treatment of acute type A aortic dissection. To reduce the risk of perioperative stroke, different perfusion techniques can be applied. A consensus on the preferred cerebral protection strategy does not exist. Methods: To provide an overview about the different cerebral protection strategies, literature research on Medline/PubMed was performed. All available original articles reporting on cerebral protection in surgery for acute type A aortic dissection and neurologic outcomes since 2010 were included. Results: Antegrade and retrograde cerebral perfusion may provide similar neurological outcomes while outperforming deep hypothermic circulatory arrest. The choice of arterial cannulation site and chosen level of hypothermia are influencing factors for perioperative stroke. Conclusions: Deep hypothermic circulatory arrest is not recommended as the sole cerebral protection technique. Antegrade and retrograde cerebral perfusion are today’s standard to provide cerebral protection during aortic surgery. Bilateral antegrade cerebral perfusion potentially leads to superior outcomes during prolonged circulatory arrest times between 30 and 50 min. Arterial cannulation sites with antegrade perfusion (axillary, central or carotid artery) in combination with moderate hypothermia seem to be advantageous. Every concept should be complemented by adequate intraoperative neuromonitoring.
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21
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Unilateral versus bilateral antegrade cerebral perfusion during surgical repair for patients with acute type A aortic dissection. JTCVS OPEN 2022; 11:37-48. [PMID: 36172412 PMCID: PMC9510789 DOI: 10.1016/j.xjon.2022.05.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 04/01/2022] [Accepted: 05/05/2022] [Indexed: 11/30/2022]
Abstract
Objectives To compare unilateral versus bilateral antegrade cerebral perfusion (ACP) techniques on cerebral protection during acute type A aortic dissection repair. Methods Using an institutional database, we retrospectively reviewed patients who underwent acute type A aortic dissection repair with selective ACP techniques from October 2008 to December 2019. Primary end point was the detection of neurologic dysfunctions. The secondary end point was mortality. For baseline adjustment, the propensity score matching method was used. Multivariable logistic regression analysis was performed to determine the predictor of neurologic events. Results Among 522 patients (aged 62.0 ± 14.9 years; 45.7% women), unilateral and bilateral ACP techniques were used in 357 (64.7%) and 165 (35.3%) patients, respectively. Transient (19.6% vs 21.2%; P = .65) and permanent (7.0% vs 10.3%; P = .70) neurologic dysfunction rates were not significantly different in patients with unilateral versus bilateral ACP, respectively. Observed mortality rate was higher in the patients with bilateral ACP (hazard ratio, 2.05; 95% CI, 1.33-3.14; P = .001). Propensity-score matching yielded 94 pairs of patients. In matched analysis, bilateral ACP did not significantly lower the risks for transient (odds ratio, 0.87; 95% CI, 0.42-1.81; P = .71) and permanent (odds ratio, 1.42; 95% CI, 0.55-3.85; P = .47) neurologic dysfunction or death (hazard ratio, 1.65; 95% CI, 0.87-3.15; P = .13). In the multivariable analysis, the ACP technique was not significantly associated with perioperative neurologic deficit. Conclusions Despite additional supply, the patients undergoing bilateral ACP during acute type A aortic dissection repair did not have superior outcomes in neurologic and death events compared with the patients undergoing unilateral ACP.
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22
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Arnaoutakis GJ, Ogami T, Bobba CM, Serna-Gallegos D, Brown JA, Jeng EI, Martin TD, Beaver TM, Yousef S, Navid F, Sultan I. Cerebral protection using deep hypothermic circulatory arrest versus retrograde cerebral perfusion for aortic hemiarch reconstruction. J Card Surg 2022; 37:3279-3286. [PMID: 35894828 DOI: 10.1111/jocs.16809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 06/25/2022] [Accepted: 07/02/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND With evolutions in technique, recent data encourage the use of cerebral perfusion during aortic arch repair. However, a randomized data have demonstrated higher rates of neurologic injury according to MRI lesions using antegrade cerebral perfusion during hemiarch reconstruction. METHODS This was a retrospective review of two institutional aortic center databases to identify adult patients who underwent aortic hemiarch reconstruction for elective aortic aneurysm or acute type A aortic dissection. Patients were stratified according to cerebral protection method: (1) deep hypothermic circulatory arrest (DHCA) group versus (2) DHCA/retrograde cerebral perfusion (RCP) group. RESULTS A total of 320 patients and 245 patients underwent hemiarch reconstruction for aortic aneurysm electively and aortic dissection, respectively. In aneurysmal pathology, the DHCA group included 133 patients and the DHCA/RCP group included 187 patients. Operative mortality was 0.8% in the DHCA group and 2.7% in the DHCA/RCP group (p = 0.41). Kaplan-Meier survival estimates revealed comparable 2-year survival (p = 0.14). In dissection, 43 patients and 202 patients were included in the DHCA group and the DHCA/RCP group, respectively. Operative mortality was equivalent between the two groups (11.6% in the DHCA group and 9.4% in the DHCA/RCP group, p = 0.58). Long-term survival was similar at 2 years between the groups (p = 0.06). Multivariable analysis showed cerebral perfusion strategy was not associated with the composite outcome of operative mortality and stroke. CONCLUSIONS In treating both elective and acute ascending aortic pathologies with hemiarch reconstruction, both DHCA alone or in combination with RCP yield comparable results.
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Affiliation(s)
- George J Arnaoutakis
- Division of Thoracic and Caridovascular Surgery, University of Florida Health, Gainesville, Florida, USA
| | - Takuya Ogami
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Christopher M Bobba
- Division of Thoracic and Caridovascular Surgery, University of Florida Health, Gainesville, Florida, USA
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Cardiothoracic Surgery, Division of Cardiac Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - James A Brown
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Eric I Jeng
- Division of Thoracic and Caridovascular Surgery, University of Florida Health, Gainesville, Florida, USA
| | - Tomas D Martin
- Division of Thoracic and Caridovascular Surgery, University of Florida Health, Gainesville, Florida, USA
| | - Thomas M Beaver
- Division of Thoracic and Caridovascular Surgery, University of Florida Health, Gainesville, Florida, USA
| | - Sarah Yousef
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Forozan Navid
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Cardiothoracic Surgery, Division of Cardiac Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Cardiothoracic Surgery, Division of Cardiac Surgery, Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Samanidis G, Kanakis M, Kolovou K, Perreas K. Does deep hypothermic circulatory arrest with versus without retrograde cerebral perfusion affect the outcomes after proximal aortic arch aneurysm and acute type A aortic dissection repair? Different pathologies and cerebral protection techniques with similar results. J Card Surg 2022; 37:3287-3289. [PMID: 35894832 DOI: 10.1111/jocs.16808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 11/28/2022]
Abstract
Hypothermic circulatory arrest is used for proximal and total aortic arch correction in patients with aortic arch aneurysm and acute or chronic type A aortic dissection. Different cerebral perfusion techniques have been proposed for reducing morbidity and mortality rate. The study of Arnaoutakis et al. showed that deep hypothermic circulatory arrest with or without retrograde cerebral perfusion for proximal aortic aneurysm and acute type A aortic dissection correction had similar results with regard to morbidity and mortality rate. In addition, the short circulatory arrest time contributes for favorable outcomes of these patients. Although antegrade cerebral perfusion with hypothermic circulatory is widely used by many cardiac surgeons, deep hypothermic circulatory arrest with or without retrograde cerebral perfusion remains an alternative and safe method for brain protection in patients undergoing proximal aortic arch aneurysm or acute type A aortic dissection repair.
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Affiliation(s)
- George Samanidis
- First Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Meletios Kanakis
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Kyriaki Kolovou
- Department of Nephrology and Renal Transplantation, Medical School, National and Kapodistrian University of Athens, General Hospital Laiko, Athens, Greece
| | - Konstantinos Perreas
- First Department of Adult Cardiac Surgery, Onassis Cardiac Surgery Center, Athens, Greece
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24
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Montagner M, Kofler M, Pitts L, Heck R, Buz S, Kurz S, Falk V, Kempfert J. Matched comparison of 3 cerebral perfusion strategies in open zone-0 anastomosis for acute type A aortic dissection. Eur J Cardiothorac Surg 2022; 62:6565841. [PMID: 35396839 DOI: 10.1093/ejcts/ezac214] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 02/24/2022] [Accepted: 03/23/2022] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The present study aims to investigate outcomes after the surgical treatment of acute type A aortic dissection in regard to three available selective cerebral perfusion strategies. METHODS From 2000 to 2019, patients were selected based on the employment of either retrograde cerebral perfusion (RCP), unilateral antegrade cerebral perfusion (uACP) or bilateral antegrade cerebral perfusion (bACP) during open zone-0 anastomosis. Propensity score TriMatch analysis considering several preoperative and intraoperative variables was used to identify well-balanced triplets. The primary end point of the study was a new cerebral operation-related neurologic deficit. RESULTS Operative times (operation time, cardiopulmonary bypass time, reperfusion time) were significantly longer in the RCP group, in which deeper hypothermia was applied (27.5 [24-28], 28 [26-28] and 16 [16-17]°C for uACP, bACP and RCP, respectively, P-value <0.001). The RCP group showed higher red blood cell concentrates and fresh frozen plasma transfusion rates. No significant difference of new cerebral operation-related neurologic deficit was observed between the 3 groups (12.9% vs 12.9% vs 11.3% for RCP, uACP and bACP, P-value = 0.86). In addition, 30-day mortality showed similar distribution independently of the cerebral perfusion strategy adopted (17.7% vs 14.5% vs 17.7% for RCP, uACP and bACP, P-value = 0.86). CONCLUSIONS However, based on a small sample size, the comparison showed no relevant differences in terms of neurologic outcome and 30-day mortality, confirming RCP, uACP and bACP as safe and reproducible selective cerebral perfusion strategies in surgery for acute type A aortic dissection.
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Affiliation(s)
- Matteo Montagner
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | - Markus Kofler
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
| | - Leonard Pitts
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | - Roland Heck
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany
| | - Semih Buz
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
| | - Stephan Kurz
- Department of Cardiovascular Surgery, Charité-Berlin Medical School, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany.,Department of Cardiovascular Surgery, Charité-Berlin Medical School, Berlin, Germany.,Translational Cardiovascular Technologies, Institute of Translational Medicine, Department of Health Sciences and Technology, Swiss Federal Institute of Technology (ETH) Zurich, Zurich, Switzerland
| | - Jörg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site, Berlin, Germany
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25
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Tong G, Sun Z, Wu J, Zhao S, Chen Z, Zhuang D, Liu Y, Yang Y, Liang Z, Fan R, Sun T. Aortic Balloon Occlusion Technique Does Not Improve Peri-Operative Outcomes for Acute Type A Acute Aortic Dissection Patients With Lower Body Malperfusion. Front Cardiovasc Med 2022; 9:835896. [PMID: 35360012 PMCID: PMC8962400 DOI: 10.3389/fcvm.2022.835896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/26/2022] [Indexed: 12/04/2022] Open
Abstract
Background The management of malperfusion is vital to improve the outcomes of surgery for acute type A acute aortic dissection (ATAAD). Open arch repair under hypothermic circulatory arrest with selective antegrade cerebral perfusion (HCA/sACP) is safe and efficient but associated with inevitable hypothermia and ischemia-reperfusion injury. The aortic balloon occlusion (ABO) technique is shown to be organ protective by allowing higher temperature and shorter circulatory arrest time. In this study, we aimed to evaluate the safety and efficacy of this new technique for ATAAD patients with lower body malperfusion. Methods Between January 2013 and November 2020, 355 ATAAD patients with lower body malperfusion who underwent arch repair in our institute were enrolled. The patients were divided into 2 groups: ABO group (n = 85) and HCA/sACP group (n = 271). Propensity score matching was performed to correct baseline differences. Results Using the propensity score matching, 85 pairs were generated. Circulatory arrest time was significantly lower in the ABO group compared with the HCA/sACP group (median, 8 vs. 22 min; p < 0.001). The incidence of in-hospital mortality (10.6 vs. 12.9%; p = 0.812), stroke (7.1 vs. 7.1%; p = 1.000), dialysis (25.9 vs. 32.9%; p = 0.183), hepatic dysfunction (52.9 vs. 57.6%; p = 0.537), tracheostomy (4.7 vs. 2.4%; p = 0.682), paraplegia (1.2 vs. 4.7%; p = 0.368) were comparable between ABO and HCA/sACP groups. Other outcomes and major adverse events were comparable. The multivariable logistic analysis did not recognize ABO technique protective against any major adverse outcomes. Conclusions For ATAAD patients with lower body malperfusion, the ABO technique allows the performance of arch repair with frozen elephant trunk (FET) under higher temperature and shorter circulatory arrest time. However, ABO technique did not improve perioperative outcomes. Future studies are warranted to evaluate the efficacy of this technique.
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Affiliation(s)
- Guang Tong
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiac Surgery, Ganzhou Municipal Hospital, Ganzhou, China
| | - Zhongchan Sun
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Ganzhou Municipal Hospital, Ganzhou, China
| | - Jinlin Wu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Shuang Zhao
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zerui Chen
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Donglin Zhuang
- Department of Cardiovascular Surgery, National Center for Cardiovascular Disease, China and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Department of Structural Heart Disease, National Center for Cardiovascular Disease, China and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
- Key Laboratory of Cardiovascular Apparatus Innovation, Beijing, China
| | - Yaorong Liu
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yongchao Yang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Zhichao Liang
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Ruixin Fan
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Tucheng Sun
- Department of Cardiac Surgery, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- *Correspondence: Tucheng Sun
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26
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Association between Duration of Deep Hypothermic Circulatory Arrest and Surgical Outcome in Patients with Acute Type A Aortic Dissection: A Large Retrospective Cohort Study. J Clin Med 2022; 11:jcm11030644. [PMID: 35160094 PMCID: PMC8836663 DOI: 10.3390/jcm11030644] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 01/17/2022] [Accepted: 01/26/2022] [Indexed: 02/01/2023] Open
Abstract
(1) Background: Deep hypothermic circulatory arrest (DHCA) with selective antegrade cerebral perfusion (ACP) is an established cerebral protection technique for the conduction of complex surgical procedures involving the aortic arch. It is controversial whether the duration of DHCA is associated with adverse outcome in patients with acute type A aortic dissection (AAAD). Our goal was to investigate whether DHCA time was associated with surgical outcome in patients undergoing a surgical treatment of AAAD. (2) Methods: A total of 410 patients were divided into two groups based on the DHCA time less than 60 min and equal to or longer than 60 min. (3) Results: Patients with longer DHCA times were significantly younger (p = 0.001). Intraoperatively, complex procedures with aortic arch surgery were more common in patients with longer DHCA times (p < 0.001). Accordingly, cardiopulmonary bypass (p < 0.001), cross-clamping (p < 0.001) and DHCA times (p < 0.001) were significantly longer in this group. Postoperatively, only the duration of mechanical ventilation (p < 0.001) and the rate of tracheotomy were significantly higher in these patients. Thirty-day mortality was satisfactory for both groups (p = 0.746). (4) Conclusions: Our results showed that improvements in perioperative management including ACP allow for the successful performance of surgical treatment of AAAD under DHCA with a duration of even longer than 60 min.
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Patel PM, Dong A, Chiou E, Wei J, Binongo J, Leshnower B, Chen EP. Aortic Arch Management During Acute and Subacute Type A Aortic Syndromes. Ann Thorac Surg 2022; 114:694-701. [DOI: 10.1016/j.athoracsur.2021.12.064] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 11/26/2021] [Accepted: 12/29/2021] [Indexed: 11/01/2022]
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28
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6550400. [DOI: 10.1093/ejcts/ezac146] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Revised: 02/02/2022] [Accepted: 03/10/2022] [Indexed: 11/13/2022] Open
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29
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Song J, Wu J, Sun X, Qian X, Wei B, Wang W, Wang D, Qiu J, Cao F, Gao W, Zhao R, Dai L, Fan S, Xie E, Qiu J, Luo X, Yu C. It Is Advisable to Control the Duration of Hypothermia Circulatory Arrest During Aortic Dissection Surgery: Single-Center Experience. Front Cardiovasc Med 2021; 8:773268. [PMID: 34957256 PMCID: PMC8702722 DOI: 10.3389/fcvm.2021.773268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 11/02/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: The duration of hypothermic circulatory arrest (HCA) is one of the important factors affecting the prognosis of arch surgery, which is still controversial. The purpose of this study was to investigate the effect of HCA duration on early prognosis in type A aortic dissection (TAAD) patients who underwent arch surgery in our center. Methods: All consecutive patients who underwent surgical treatment for TAAD in Fuwai Hospital from January 2013 to December 2018 were included in this study and divided into four quartile groups based on HCA time. Baseline characteristics, perioperative indicators, and early mortality were statistically analyzed by propensity score matching (PSM) and restricted cubic spline (RCS) method. Perioperative adverse events were confirmed according to the American STS database and Penn classification. Results: About 1,018 consecutive patients (mean age 49.11 ± 1.4 years, male 74.7%) with TAAD treated surgically were eventually included in this study. After PSM, with the prolongation of HCA time, the surgical mortality rates of group [2,15], (15,18], (18,22], and (22,73] were 4.1, 6.6, 7.8, and 10.9% with p = 0.041, respectively. As shown in RCS, the mortality rate increased sharply after the HCA time exceeded 22 min. And from the subgroup analysis, the HCA time of 22 min or less was associated with better clinical outcomes (OR 2.09, 95%CI 1.25-3.45, p = 0.004). Conclusions: The early mortality increases significantly with the duration of HCA time when arch surgery was performed. And multiple systems throughout the body can be adversely affected.
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Affiliation(s)
- Jian Song
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinlin Wu
- Department of Cardiac Surgery, Guangdong Provincial People's Hospital, Guangdong Cardiovascular Institute, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiaogang Sun
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiangyang Qian
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Bo Wei
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Wang
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - De Wang
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiawei Qiu
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Fangfang Cao
- Department of Intensive Care Unit, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wei Gao
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Zhao
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lu Dai
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuya Fan
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Enzehua Xie
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juntao Qiu
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xinjin Luo
- Department of Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Cuntao Yu
- Department of Vascular Surgery, National Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Seese L, Chen EP, Badhwar V, Thibault D, Habib RH, Jacobs JP, Thourani V, Bakaeen F, O'Brien S, Jawitz OK, Zwischenberger B, Gleason TG, Sultan I, Kilic A, Coselli JS, Svensson LG, Chikwe J, Chu D. Optimal circulatory arrest temperature for aortic hemiarch replacement with antegrade brain perfusion. J Thorac Cardiovasc Surg 2021; 165:1759-1770.e3. [PMID: 34887095 DOI: 10.1016/j.jtcvs.2021.09.068] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study sought to identify the optimal temperature for moderate hypothermic circulatory arrest in patients undergoing elective hemiarch replacement with antegrade brain perfusion. METHODS The Society of Thoracic Surgeons adult cardiac surgery database was queried for elective hemiarch replacements using antegrade brain perfusion for aneurysmal disease (2014-2019). Generalized estimating equations and restricted cubic splines were used to determine the risk-adjusted relationships between temperature as a continuous variable and outcomes. RESULTS Elective hemiarch replacement with antegrade brain perfusion occurred in 3898 patients at 374 centers with a median nadir temperature of 24.9 °C (first quartile, third quartile = 22.0 °C, 27.5 °C) and median circulatory arrest time of 19 minutes (first quartile, third quartile = 14.0 minutes, 27.0 minutes). After adjustment for comorbidities, circulatory arrest time, and individual surgeon, patients cooled between 25 and 28 °C had an early survival advantage compared with 24 °C, whereas those cooled between 21 and 23 °C had higher risks of mortality compared with 24 °C. A nadir temperature of 27 °C was associated with the lowest risk-adjusted odds of mortality (odds ratio, 0.62; 95% confidence interval, 0.42-0.91). A nadir temperature of 21 °C had the highest risk of mortality (odds ratio, 1.4; 95% confidence interval, 1.13-1.73). Risk of experiencing a major morbidity was elevated in patients cooled between 21 and 23 °C, with the highest risk occurring in patients cooled to 21 °C (odds ratio, 1.12; 95% confidence interval, 1.01-1.24). CONCLUSIONS For patients with aneurysmal disease undergoing elective hemiarch with antegrade brain perfusion, circulatory arrest with a nadir temperature of 27 °C confers the greatest early survival benefit and smallest risk of postoperative morbidity.
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Affiliation(s)
- Laura Seese
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | | | | | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Department of Surgery, Congenital Heart Center, University of Florida, Gainesville, Fla
| | | | - Faisal Bakaeen
- Cardiovascular Surgery Department, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Sean O'Brien
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown, WVa
| | | | | | - Thomas G Gleason
- Division of Cardiac Surgery, Department of Surgery, University of Maryland, Baltimore, Md
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa; University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pa
| | - Arman Kilic
- Division of Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex
| | | | - Joanna Chikwe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pa; University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, Pa.
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Benedetto U, Dimagli A, Kaura A, Sinha S, Mariscalco G, Krasopoulos G, Moorjani N, Field M, Uday T, Kendal S, Cooper G, Uppal R, Bilal H, Mascaro J, Goodwin A, Angelini G, Tsang G, Akowuah E. Determinants of outcomes following surgery for type A acute aortic dissection: the UK National Adult Cardiac Surgical Audit. Eur Heart J 2021; 43:44-52. [PMID: 34468733 PMCID: PMC8720141 DOI: 10.1093/eurheartj/ehab586] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/21/2021] [Accepted: 08/17/2021] [Indexed: 01/16/2023] Open
Abstract
Aims Operability of type A acute aortic dissections (TAAAD) is currently based on non-standardized decision-making process, and it lacks a disease-specific risk evaluation model that can predict mortality. We investigated patient, intraoperative data, surgeon, and centre-related variables for patients who underwent TAAAD in the UK. Methods and results We identified 4203 patients undergoing TAAAD surgery in the UK (2009–18), who were enrolled into the UK National Adult Cardiac Surgical Audit dataset. The primary outcome was operative mortality. A multivariable logistic regression analysis was performed with fast backward elimination of variables and the bootstrap-based optimism-correction was adopted to assess model performance. Variation related to hospital or surgeon effects were quantified by a generalized mixed linear model and risk-adjusted funnel plots by displaying the individual standardized mortality ratio against expected deaths. Final variables retained in the model were: age [odds ratio (OR) 1.02, 95% confidence interval (CI) 1.02–1.03; P < 0.001]; malperfusion (OR 1.79, 95% CI 1.51–2.12; P < 0.001); left ventricular ejection fraction (moderate: OR 1.40, 95% CI 1.14–1.71; P = 0.001; poor: OR 2.83, 95% CI 1.90–4.21; P < 0.001); previous cardiac surgery (OR 2.29, 95% CI 1.71–3.07; P < 0.001); preoperative mechanical ventilation (OR 2.76, 95% CI 2.00–3.80; P < 0.001); preoperative resuscitation (OR 3.36, 95% CI 1.14–9.87; P = 0.028); and concomitant coronary artery bypass grafting (OR 2.29, 95% CI 1.86–2.83; P < 0.001). We found a significant inverse relationship between surgeons but not centre annual volume with outcomes. Conclusions Patient characteristics, intraoperative factors, cardiac centre, and high-volume surgeons are strong determinants of outcomes following TAAAD surgery. These findings may help refining clinical decision-making, supporting patient counselling and be used by policy makers for quality assurance and service provision improvement.
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Affiliation(s)
- Umberto Benedetto
- Bristol Heart Institute, University of Bristol, Senate House, Tyndall Avenue, Bristol BS8 1TH, UK
| | - Arnaldo Dimagli
- Bristol Heart Institute, University of Bristol, Senate House, Tyndall Avenue, Bristol BS8 1TH, UK
| | - Amit Kaura
- National Institute for Health Research Imperial Biomedical Research Centre, Imperial College London and Imperial College Healthcare NHS Trust, The Bays, South Wharf Road, St Mary's Hospital, London W21NY, UK
| | - Shubhra Sinha
- Bristol Heart Institute, University of Bristol, Senate House, Tyndall Avenue, Bristol BS8 1TH, UK
| | - Giovanni Mariscalco
- Department of Cardiac Surgery, Glenfield Hospital, Groby Rd, Leicester LE3 9QP, UK
| | - George Krasopoulos
- Oxford University Hospitals NHS Foundation Trust, Headley Way, Headington, Oxford OX3 9DU, UK
| | - Narain Moorjani
- Department of Cardiothoracic Surgery, Royal Papworth Hospital, Papworth Rd, Trumpington, Cambridge CB2 0AY, UK
| | - Mark Field
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Thomas Dr, Liverpool L14 3PE, UK
| | - Trivedi Uday
- Sussex Cardiac Center, Brighton and Sussex University Hospitals NHS Trust, Barry Building, Eastern Rd, Brighton BN2 5BE, UK
| | - Simon Kendal
- South Tees Hospitals NHS Trust, Marton Road, Middlesbrough TS4 3BW, UK
| | - Graham Cooper
- Sheffield Teaching Hospitals Foundation Trust, Royal Hallamshire Hospital, Glossop Rd, Broomhall, Sheffield S10 2JF, UK
| | - Rakesh Uppal
- Barts Heart Centre, William Harvey Research Institute, W Smithfield, London EC1A 7BE, UK
| | - Haris Bilal
- Department of Cardiothoracic Surgery, Manchester Royal Infirmary, Oxford Rd, Manchester M13 9WL, UK
| | - Jorge Mascaro
- University Hospital Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2GW, UK
| | - Andrew Goodwin
- South Tees Hospitals NHS Trust, Marton Road, Middlesbrough TS4 3BW, UK
| | - Gianni Angelini
- Bristol Heart Institute, University of Bristol, Senate House, Tyndall Avenue, Bristol BS8 1TH, UK
| | - Geoffry Tsang
- Wessex Cardiothoracic Center, University Hospital Southampton NHS Trust, Tremona Road Southampton, Hampshire SO16 6YD, UK
| | - Enoch Akowuah
- South Tees Hospitals NHS Trust, Marton Road, Middlesbrough TS4 3BW, UK
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32
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Malaisrie SC, Szeto WY, Halas M, Girardi LN, Coselli JS, Sundt TM, Chen EP, Fischbein MP, Gleason TG, Okita Y, Ouzounian M, Patel HJ, Roselli EE, Shrestha ML, Svensson LG, Moon MR. 2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg 2021; 162:735-758.e2. [PMID: 34112502 DOI: 10.1016/j.jtcvs.2021.04.053] [Citation(s) in RCA: 185] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 01/16/2023]
Affiliation(s)
- S Christopher Malaisrie
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill.
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa
| | - Monika Halas
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC
| | | | - Thomas G Gleason
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Hospitals, Ann Arbor, Mich
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Malakh L Shrestha
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
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Calcaterra D. Treatment of type A dissection: Searching for the Holy Grail. J Card Surg 2021; 36:1840-1842. [PMID: 33709445 DOI: 10.1111/jocs.15458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 11/27/2022]
Abstract
Current principles of surgical treatment of type A dissections are for the most part based on best evidence practice for the lack of controlled randomized studies providing definitive scientific evidence. Despite its widespread use, axillary cannulation still remains a debated topic as the preferred method of cannulation and perfusion strategy in the treatment of this complex condition.
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Affiliation(s)
- Domenico Calcaterra
- Department of Surgery, Florida Atlantic University, Boca Raton, Florida, USA
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To Perfuse or Not to Perfuse: That Is the Question. Ann Thorac Surg 2020; 110:1467-1468. [DOI: 10.1016/j.athoracsur.2020.06.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/13/2020] [Indexed: 11/19/2022]
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