Acute Type A Aortic Dissection Complicated by COVID-19 Infection

Acute type A aortic dissection patients undergoing surgical repair during the COVID-19 pandemic

BACKGROUND

Acute type A aortic dissection (ATAAD) is a deadly form of acute aortic syndrome which necessitates emergency surgical repair. Coronavirus disease-19 (COVID-19) pandemic has caused a significant impact on surgery globally. The influence of the COVID-19 pandemic on ATAAD patients undergoing surgical repair remains undetermined.

METHODS

We conducted a systematic review and meta-analysis of studies comparing ATAAD patients undergoing aortic surgery before versus during the COVID-19 pandemic and literature review of published cases reporting COVID-19 patients undergoing surgical repair for ATAAD. PubMed, China National Knowledge Infrastructure, VIP, WANFANG, and SinoMed databases were searched for relevant studies and case reports till January 21st, 2023, and the database search was updated on January 3rd, 2024. Meta-analysis was performed by utilizing RevMan. Pooled odds ratio (OR) and 95% confidence interval (CI) were estimated for dichotomous data, and weighted mean difference (WMD) and 95% CI for continuous data, respectively. All P-values were 2-sided and statistical significance was defined as P < .05.

RESULTS

Meta-analysis of 5 included studies comparing ATAAD patients undergoing aortic surgery before versus during the COVID-19 pandemic demonstrated that, the patients in Group During-Pandemic (DP) were older than those in Group Before-Pandemic (BP; P = .005), and the body mass index of the patients in Group DP was lower than that of the patients in Group BP (P = .002), more patients in Group DP were smokers (P = .02). Meta-analysis also showed that, either the composite incidence of mortality and morbidities or individual morbidity was comparable between 2 groups, except that more patients in Group DP developed pneumonia (P = .05). Literature reviews of 24 published cases reporting COVID-19 patients undergoing surgical repair for ATAAD demonstrated that, twenty (83.3%) patients recovered well after aortic surgery and were finally discharged from hospital. Unfortunately, 4 patients died postoperatively, 3 due to multiple organ failure and one due to respiratory failure (RF). Reported postoperative complications included hypoxia, endotracheal re-intubation, RF, renal failure, coagulopathy, fever, multi-organ failure and shock.

CONCLUSION

The hospitalized outcomes of ATAAD patients undergoing surgical repair before versus during the COVID-19 were mostly comparable. ATAAD patients with concomitant COVID-19 infection who underwent emergent surgical repair had a high risk of mortality and morbidities.

Aortic dissection and Covid-19; a comprehensive systematic review

Coronavirus disease 19 (Covid-19) has been declared as a pandemic disease since March 2020; causing wide array of signs and symptoms, many of which result in increased mortality rates worldwide. Although it was initially known as an acute respiratory disease, Covid-19 is accompanied with several extrapulmonary manifestations, of which the cardiovascular ones are of major importance. Among other cardiovascular complications of Covid-19, aortic dissection has been a significant yet underrated problem. The pathophysiology of aortic dissection consists of various inflammatory pathways, that could be influenced by Covid-19 infection. We herein have reviewed articles inclusive of aortic dissection concurrent with Covid-19 infection in a systematic manner, along with the probable similarities in pathophysiology of aortic dissection with Covid-19 infection.

A Systematic Review of Arterial Dissections in COVID-19 Patients

INTRODUCTION

COVID-19 is often seen presenting with a myriad of signs and symptoms of multiorgan dysfunction including arterial dissection.

METHODS

Various theories have been proposed such as endothelial dysfunction triggered by hyperinflammatory response that results in rupture of atherosclerotic plaque and subsequent dissection.

RESULTS

However, the exact incidence is unknown and only case reports and case series have been published till date.

CONCLUSION

Here we carried out a systematic analysis of published case reports/series related to dissection of the aorta, coronary, cerebral, vertebral, cervical, renal, and splanchnic arteries.

Acute aortic dissection in the Marfan syndrome during the COVID-19 epidemic

A 17-year-old boy with a recent diagnosis of COVID-19 infection was admitted with acute chest pain due to type A aortic dissection and was subsequently diagnosed with the Marfan syndrome. Literature shows an increased rate of aortic dissection during flu season. The hypothesis is that a cytokine storm triggers the dissection.

The Spectrum of Antibiotic Prescribing During COVID-19 Pandemic: A Systematic Literature Review

Objectives: Over the last decades, there has been a significant increase in antimicrobial prescribing and consumption associated with the development of patients' adverse events and antimicrobial resistance (AMR) to the point of becoming a global priority. This study aims at evaluating antibiotic prescribing during COVID-19 pandemic from November 2019 to December 2020. Materials and Methods: A systematic review was conducted primarily through the NCBI database, using PRISMA guidelines to identify relevant literature for the period between November 1, 2019 and December 19, 2020, using the keywords: COVID-19 OR SARS-Cov-2 AND antibiotics restricted to the English language excluding nonclinical articles. Five hundred twenty-seven titles were identified; all articles fulfilling the study criteria were included, 133 through the NCBI, and 8 through Google Scholar with a combined total of 141 studies. The patient's spectrum included all ages from neonates to elderly with all associated comorbidities, including immune suppression. Results: Of 28,093 patients included in the combined studies, 58.7% received antibiotics (16,490/28,093), ranging from 1.3% to 100% coverage. Antibiotics coverage was less in children (57%) than in adults with comorbidities (75%). Broad-spectrum antibiotics were prescribed presumptively without pathogen identifications, which might contribute to adverse outcomes. Conclusions: During the COVID-19 pandemic, there has been a significant and wide range of antibiotic prescribing in patients affected by the disease, particularly in adults with underlying comorbidities, despite the paucity of evidence of associated bacterial infections. The current practice might increase patients' immediate and long-term risks of adverse events, susceptibility to secondary infections as well as aggravating AMR.

COVID-19 and aortic disease: a practical systematic review of the literature on management and outcomes

Since the advent of the 2019 coronavirus (COVID-19) outbreak, vascular specialists have faced dramatic changes in clinical and surgical practice. Although COVID-19 pulmonary signs and symptoms were the most pertinent problems initially, in the long term cardiovascular complications became the most fearsome, with poor outcomes in terms of morbidity and mortality. Algorithms and decision-making procedures have been modified, not only to treat new clinical findings in COVID-19 positive patients, but also to avoid complications related to pulmonary and systemic infections. Additionally, COVID-19 negative patients experienced challenging management, due to hospital crowding, the risk of nosocomial COVID-19 transmission, and pandemic emergencies. In this context, aortic interventions were subject to several difficulties. First, in COVID-19 positive patients, there was the onset of new pathological scenarios including thrombotic manifestations and the subsequent complications. Second, in both COVID-19 negative and positive patients, there was a need to deliver optimal treatment with acceptable perioperative risks, forcing a rethinking of decisionmaking especially in terms of indications for treatments. The aim of this systematic review is to present evidence published on COVID-19 and aortic-related issues, highlighting some challenging aspects regarding management, treatment and outcomes.

Cardiovascular considerations for anesthesiologists during the COVID-19 pandemic

The coronavirus disease (COVID-19) pandemic has brought critical challenges to anesthesiologists and perioperative practice. Whereas anesthesiologists may be primarily concerned with airway and respiratory management, the COVID-19 data accumulated to date indicate that primary and/or secondary cardiovascular complications are common. Previous studies have demonstrated that the mortality rate is significantly higher in patients with cardiovascular disease (CVD) than in patients without CVD. Dysregulation of immune function in patients with CVD may be involved in the prognosis of COVID-19 patients. Anesthesia and surgical procedures can modulate the immune system, and some patients undergoing surgery, particularly those undergoing cardiovascular procedures, have CVD. In perioperative management for patients with suspected or diagnosed COVID-19 and those who have recovered from COVID-19, it is important for anesthesiologists to be concerned not only with airway and respiratory management, but also with cardiovascular complications and perioperative circulatory management to control the progression of the disease in patients with COVID-19.

Impact of COVID-19 on aortic operations

The coronavirus disease 2019 (COVID-19) outbreak has profoundly affected all aspects of medicine and surgery. Vascular surgery practice and interventions were also forced to change in order to deal with new COVID-19-related priorities and emergencies. In this setting, difficulties in aortic disease management were two-fold: new vascular complications related to COVID-19 infection and the need to guarantee prompt and correct treatment for the general "non-COVID-19" population. Furthermore, discomfort deriving from precautions to minimize the risk of virus transmission among patients and among health care professionals, the need to separate COVID-19-positive from COVID-19-negative patients, and the high incidence of postoperative complications in COVID-19 cases created a challenging scenario for cardiac operations. The aim of this review was to provide evidence derived from the published literature (case reports, case series, multicenter experience, and expert opinion) on the impact of the COVID-19 outbreak on aortic vascular surgery services and interventions, describing COVID-19-related findings, intraoperative and postoperative outcomes, as well as the impact of the COVID-19 outbreak on noninfectious aortic patients.

The assessment of patients undergoing cardiac surgery for Covid-19: Complications occurring during cardiopulmonary bypass

The outbreak of the novel coronavirus pandemic (COVID-19) has resulted in dramatic changes to the conduct of surgery both from a patient management perspective and in protecting healthcare providers. The current study reports on the status of COVID-19 infections in patients presenting for cardiac surgery with cardiopulmonary bypass (CPB) on circuit complications. A tracking process for monitoring the presence of COVID-19 in adult cardiac surgery patients was integrated into a case documentation system across United States hospitals where out-sourced perfusion services were provided. Assessment included infection status, testing technique employed, surgery status and CPB complications. Records from 5612 adult patients who underwent cardiac surgery between November 1, 2020 and January 18, 2021 from 176 hospitals were reviewed. A sub-cohort of coronary artery bypass graft patients (3283) was compared using a mixed effect binary logistic regression analysis. 4297 patients had negative test results (76.6%) while 49 (0.9%) tested positive for COVID-19, and unknown or no results were reported in 693 (12.4%) and 573 (10.2%) respectively. Coagulation complications were reported at 0.2% in the negative test results group versus 4.1% in the positive test result group (p < 0.001). Oxygenator gas exchange complications were 0.2% in the negative test results group versus 2.0% in the positive test results group (p = 0.088). Coronary artery bypass graft patients with a positive test had significantly higher risk for any CPB complication (p = 0.003) [OR 10.38, CI 2.18–49.53] then negative test patients [OR 0.01, CI 0.00–0.20]. The present study has shown that patients undergoing cardiac surgery with CPB who test positive for COVID-19 have higher CPB complication rate than those who test negative.

Type A aortic syndromes in COVID-19 positive patients: Case series from a UK multicentre study

OBJECTIVE

The coronavirus disease (COVID-19) increases the respiratory complications and carries a higher mortality in the immediate postoperative period. The aim of this study was to analyze the outcomes of patients with type A acute aortic syndromes (AAS) diagnosed with COVID-19 in the perioperative period.

METHODS

Retrospective analysis of prospectively collected data between March and August 2020 from 20 participating cardiac surgery centers in the United Kingdom.

RESULTS

Among 122 patients who underwent emergency surgical repair for type A AAS at the participating centers, 3 patients (2.5%) tested positive for COVID-19 in the preoperative screeing, and 4 cases turned to be positive in the postoperative period having been operated on an unknown COVID-19 status. Another patient was diagnosed of COVID-19 disease based on radiological features. These eight patients had increased postoperative complications, including respiratory failure, longer ventilation times, and Intensive Therapy Unit (ITU) stay and increased mortality when compared with COVID-19 negative patients.

CONCLUSION

COVID-19 disease in the perioperative period of type A AAS poses a challenge. Despite the increasing morbidity and mortality associated with the virus, the prognosis of the aortic disease is poorer and emergency surgery should not be contraindicated based on the COVID-19 diagnosis alone.

Dissecting the Management and Outcomes of Thoracic Aortovascular Disease During the COVID-19 Pandemic

Objective

The COVID-19 pandemic has forced the cancellation of planned surgery and led to significant surgical service reductions. Early intervention in aortovascular disease is often critical and cannot be deferred despite these reductions. There is urgent need to evaluate the provision and outcomes of thoracic aortovascular intervention during the peak of the pandemic.

Methods

Prospective data was collected for patients receiving open and endovascular thoracic aortovascular intervention over two-time points; January-May 2020 and January-May 2019 at three tertiary cardiovascular centres. Baseline demographics, cardiovascular risk and COVID-19 screening results were noted. Primary outcomes were median length of intensive care unit and hospital stay, intra-operative mortality, 30-day mortality, post-operative stroke, and spinal cord injury.

Results

Patients operated in 2020 (41) had significantly higher median EuroSCORE II than 2019 (53) (7.44 vs. 5.86, P = 0.032) and rates of previous cardiac (19.5% vs. 3.8%, P = 0.019), aortic (14.6% vs. 1.9%, P = 0.041), and endovascular (22.0% vs. 3.8%, P = 0.009) intervention. There was an increase in proportion of urgent cases in 2020 (31.7% vs. 18.9%). There were no intra-operative deaths in 2020 and 1 in 2019 (P = 1.00). There were no significant differences (P ≥ 0.05) in 30-day mortality (4.9% vs. 13.2%), median intensive care unit length of stay (72 vs. 70 hr), median hospital length of stay (8 vs. 9 days), post-operative stroke (3 vs. 6), or spinal cord injury (2 vs. 1) between 2020 and 2019 respectively.

Conclusions

Despite the increased mortality risk of patients and urgency of cases during COVID-19, complicated by the introduction of cohorting and screening regimens, thoracic aortovascular intervention remained safe with comparable in outcomes to pre-COVID-19.

Aortic Pathology During COVID - 19 Pandemics. Clinical Reports in Literature and Open Questions on the two Co-Occurring Conditions

Background

Cardiovascular involvement in SARS-CoV-2 infection has emerged as one of viral major clinical features during actual pandemic; limb arterial ischemic events, venous thrombosis, acute myocardial infection and stroke have occurred in patients.

Acute aortic conditions have also been described, followed by interesting observations on cases, hypothesis, raised since the emergence of the pandemics.

Methods

a review of cases in literature of aortic pathology in patients with clinically suspected/microbiologically confirmed COVID-19 infection has been carried out to analyze anagraphic data, clinical presentation, treatment options and outcome.

Results

Seventeen cases have been included. Mean age of patients was 58.6 ± 15.2 years, with a male to female ratio of 12:15 (70.5% vs. 29.5%). Comorbidities were reported in 11 cases (64.7%), but in 5 cases (29.4%) no previous pathology was signaled in history. Hypertension was the most frequently reported comorbidity, in 8 cases, (47%), followed by renal pathology (17.6%), coronary artery disease (17.6%), previous aortic surgery (11.7%) and arrhythmia (11.7%); but also cerebrovascular disease, diabetes, autoimmune conditions, previous neoplasia and arrhythmia were reported once each. Fever and thoracic pain were the most frequently reported findings at presentation (8 cases, 47% each), followed by respiratory symptoms (6, 35.2%), low lymphocyte count (17.6%), features related to aneurysm rupture, ischemic stroke, abdominal pain and acute renal insufficiency. Reported aortic pathology included: type A aortic dissection (11 cases; 64.7%); new pathology of previous aortic graft (2 cases, 11.7%); 2 aortitis, 1 associated with type A aortic dissection; 1 thoraco-abdominal aortic aneurysm, 1 ruptured aortic aneurysm and 1 aortic embolizing thrombosis. Open surgery was carried out in 10 cases (58.8%), endovascular treatment in 3 (17.6%). Three patients (17.6%) died before surgery. Exitus was reported in 4 cases, with a total mortality of 23.5%.

Conclusions

Acute aortic events have occurred during pandemic in patients with clinically suspected/microbiologically confirmed COVID-19 infection. Confounding clinical features at presentation, the importance of anamnestic details (as previous vascular graft implant), the observed surgical and postoperatory challenges may suggest the need to consider the implications of the possible link between acute aortic events and SARS-CoV-2 infection, in order to promptly correctly diagnose the patient and respond to specific needs.

Is driver education contributing towards road safety? a systematic review of systematic reviews

BACKGROUND

There is a vast amount of literature on the effects of driver education. However, the evidence has become somewhat fragmented, making it challenging to understand driver education's effectiveness for improving road safety. The current study aimed to provide the efficacy of pre-LDE and post-LDE interventions aimed at improving the safety of drivers (includes crashes, injuries, or secondary outcomes).

METHODS

The following online databases were searched up to the 21st of February 2020: Web of Science (WOS), Scopus, PubMed, Cochrane library, and other relevant databases. Systematic reviews (SR) and meta-analyses were selected to investigate the efficacy of driving education in reducing crashes, injuries, or secondary outcomes. Two investigators independently conducted the data extraction and used the assessment of multiple systematic reviews (AMSTAR) tool to conduct a quality assessment of each SR identified.

RESULTS

Out of the 229 potential articles, seven SRs were eligible for the current overview of systematic reviews and meta-analyses. This overview showed that pre-and post-license education by people of all ages led to improvements in secondary outcomes, such as performance, self-perceived driving abilities, behind-the-wheel driving performance, and even a small decrease in traffic offenses. However, education was not effective in reducing crashes or injuries, either at the individual or community level.

CONCLUSIONS

There was no evidence that driver education is an effective approach to reducing crashes or injuries. This negative result might be due to ineffective teaching methods. To improve road safety, it appears necessary to change the method or content of driving education since the current approaches to driving education do not reduce traffic crashes or injuries.

Type A Aortic Dissection During COVID-19 Pandemic: Report From Tertiary Aortic Centers in the United States and China

Coronavirus disease 2019 (COVID-19) has substantially disrupted many processes of care related to emergency cardiac conditions, while there has been no clinical guidance regarding the management of type A aortic dissection. A retrospective multicenter study involving 52 consecutive patients (mean age 52.3, 28.9% women) with type A aortic dissection during COVID-19 pandemic was conducted at tertiary aortic centers in Michigan, Wuhan and Changsha (China). Twenty-four (46.2%) were considered clinically suspicious for COVID-19 based on radiographic lung lesions (70.8%) followed by dyspnea (25.0%), cough (12.5%), and fever (12.5%). Overall, 47 (90.4%) underwent an operation and 5 (9.6%) managed nonoperatively. All suspected patients underwent a reverse-transcriptase–polymerase-chain-reaction at arrival, whereas 82.1% in the nonsuspected (P = 0.054). Among the 24 patients either nonoperatively managed or whose operation was delayed for >24 hours, only 1 (4.2%) died. A total of 3 (6.4%) operated patients had a positive reverse-transcriptase–polymerase-chain-reaction at various timings, including 1 nonsuspected patient preoperatively and 2 with very recent COVID-19 infection. The first patient died of respiratory failure despite uneventful surgical repair and maximal medical management. The postoperative course of both patients with recent COVID-19 was characterized by severe coagulopathy requiring massive transfusions and prolonged ICU stay. However, both survived to hospital discharge. In light of the possible dismal outcomes associated with dual diagnoses of type A aortic dissection/COVID-19 and the higher-than-expected number of asymptomatic carriers, all type A dissection patients should be immediately tested for COVID-19. Surgical interventions in patients recovered from recent COVID-19 may be safe.

Management of acute type A aortic dissection during COVID-19 outbreak: Experience from Anzhen

OBJECTIVES

We seek to report our management protocol and early outcomes of acute type A aortic dissection (ATAAD) repair during the early phase of coronavirus disease 2019 (COVID-19).

METHODS

From January 23 to April 30, 2020, we performed ATAAD repair for 33 patients, including three with pregnancy-related TAADs. Confirmation of COVID-19 depended on the results of two nucleic acid tests and pulmonary computed tomography scan. Based on testing results and hemodynamic stability, patients were triaged to an isolated intensive care unit or negative pressure operating room for emergency surgery.

RESULTS

Mean age 50.2 ± 13.3 years and 20 were male (60.1%) and 8 patients were febrile (>37.3°C; 24.2%) and 17 were lymphopenic (51.5%). No patient was excluded from COVID-19 infection preoperatively. Extensive aortic repair with total arch replacement (TAR) was performed in 24 (72.7%), and limited proximal repair in 9 patients (27.3%). Cardiopulmonary bypass and cross-clamp times averaged 177 ± 34 and 88 ± 20 min for TAR, and 150 ± 30 and 83 ± 18 min for hemiarch, respectively. The mean operation time was 410 ± 68.3 min. Operative mortality was 6.1% (2/33). Complications included reintubation in four (12.1%), acute kidney failure in two (6.1%), and cerebral infarction in one (3.0%). No paraplegia nor re-exploration for bleeding occurred. COVID-19 was excluded in 100% eventually. No nosocomial infection occurred. Nor did any patient/surgical staff develop fever or test positive during the study period.

CONCLUSIONS

The results of this study show that our management protocol based on testing results and hemodynamic stability in patients with ATAAD during the COVID-19 pandemic was effective and achieved favorable early surgical outcomes.

Endocarditis mitroaórtica aguda en paciente con reparación mitral previa e infección intercurrente por COVID-19: controversia en la adherencia a las guías clínicas actuales

El nuevo coronavirus SARS-CoV-2 es el responsable de la pandemia actual (COVID-19) y la consecuente emergencia sanitaria internacional. El espectro clínico de esta entidad es amplio, con recientes reportes de casos con afectación cardíaca, principalmente miocarditis, en pacientes COVID-19. Hasta la fecha hay escasos reportes de casos COVID-19 con necesidad de cirugía cardíaca. La posición de la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) ha sido la de asegurar la correcta atención de pacientes emergentes y urgentes, de acuerdo con las guías clínicas actuales, sin embargo, en algunos casos la distinción entre la afectación de etiología cardíaca o pulmonar puede dificultar la toma de decisiones. Presentamos el caso de un varón con endocarditis infecciosa e infección intercurrente por COVID-19, en el que fue fundamental el consenso multidisciplinar para sentar la indicación quirúrgica, debido a que su sintomatología generaba controversia con las guías clínicas actuales de la Sociedad Europea de Cardiología (ESC) sobre endocarditis infecciosa. Consideramos que la adaptación de las guías durante la emergencia sanitaria actual y la toma multidisciplinar de decisiones pueden facilitar la actuación terapéutica en casos complejos de patologías cardíacas con indicación quirúrgica y coinfección por COVID-19.

When to Consider Deferral of Surgery in Acute Type A Aortic Dissection: A Review

Background

Acute type A aortic dissection (ATAAD) is a surgical emergency with an operative mortality of up to 30%, a rate which has not changed meaningfully in over two decades. A growing body of research has highlighted several comorbidities and presenting factors in which delay or permanent deferral of surgery may be considered; however, modern comprehensive summative reviews are lacking. The urgency and timing of this review are underscored by significant challenges in resource utilization posed by the COVID-19 pandemic. This review provides an update on the current understanding of risk assessment, surgical candidacy, and operative timing in patients with ATAAD.

Methods

A literature search was conducted through PubMed and Embase databases to identify relevant studies relating to risk assessment in ATAAD. Articles were selected via group consensus based on quality and relevance.

Results

Several patient factors have been identified which increase risk in ATAAD repair. In particular, frailty, advanced age, prior cardiac surgery, and use of novel anticoagulant medications have been studied. The understanding of malperfusion syndromes has also expanded significantly, including recommendations for surgical delay. Finally, approaches to triage have been significantly influenced by resource limitations related to the ongoing COVID-19 pandemic. While medical management remains a reasonable option in carefully selected patients at prohibitive risk for open surgery, endovascular therapies for treatment of ATAAD are rapidly evolving.

Conclusions

Early surgical repair remains the preferred treatment for most patients with ATAAD, however, improvements in risk stratification should guide appropriate delay or permanent deferral of surgery in select individuals.