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Preoperative Predictors of Adverse Clinical Outcome in Emergent Repair of Acute Type A Aortic Dissection in 15 Year Follow Up. J Clin Med 2021; 10:jcm10225370. [PMID: 34830651 PMCID: PMC8625674 DOI: 10.3390/jcm10225370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Revised: 11/12/2021] [Accepted: 11/16/2021] [Indexed: 01/02/2023] Open
Abstract
Background: Acute type A aortic dissection (AAAD) has high mortality. Improvements in surgical technique have lowered mortality but postoperative functional status and decreased quality of life due to debilitating deficits remain of concern. Our study aims to identify preoperative conditions predictive of undesirable outcome to help guide perioperative management. Methods: We performed retrospective analysis of 394 cases of AAAD who underwent repair in our institution between 2001 and 2018. A combined endpoint of parameters was defined as (1) 30-day versus hospital mortality, (2) new neurological deficit, (3) new acute renal insufficiency requiring postoperative renal replacement, and (4) prolonged mechanical ventilation with need for tracheostomy. Results: Total survival/ follow-up time averaged 3.2 years with follow-up completeness of 94%. Endpoint was reached by 52.8%. Those had higher EuroSCORE II (7.5 versus 5.5), higher incidence of coronary artery disease (CAD) (9.2% versus 3.2%), neurological deficit (ND) upon presentation (26.4% versus 11.8%), cardiopulmonary resuscitation (CPR) (14.4% versus 1.6%) and intubation (RF) before surgery (16.9% versus 4.8%). 7-day mortality was 21.6% versus 0%. Hospital mortality 30.8% versus 0%. Conclusions: This 15-year follow up shows, that unfavorable postoperative clinical outcome is related to ND, CAD, CPR and RF on arrival.
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Zhang Y, Chen T, Chen Q, Min H, Nan J, Guo Z. Development and evaluation of an early death risk prediction model after acute type A aortic dissection. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1442. [PMID: 34733994 PMCID: PMC8506734 DOI: 10.21037/atm-21-4063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/02/2021] [Indexed: 11/29/2022]
Abstract
Background The purpose of the study was to assess the relationship between preoperative laboratory examination, clinical imaging data, and postoperative death of patients with acute type A aortic dissection (ATAAD) and to establish a prediction model of hospital death risk after the operation. Methods A total of 224 cases of acute Standford A aortic dissection were treated by total arch replacement using a tetrafurcate graft with stented elephant trunk implantation in Tianjin Chest Hospital. Based on preoperative laboratory examination and clinical imaging data of patients with ATAAD, the independent risk factors of postoperative hospital death were obtained using logistic analysis, and a risk prediction model of postoperative hospital death was developed. Results Independent risk factors of postoperative death in patients with ATAAD were: body mass index (BMI), preoperative neutrophil to lymphocyte ratio (NLR), mean platelet volume (MPV), creatinine (Cr), D-dimer, high-sensitive cardiac troponin T (hs-CTnT), apolipoprotein A1, left subclavian artery involvement, and iliac artery involvement. The regression equation of postoperative death risk was: logitP1 = −9.584 + 1.060 × NLR + 1.586 × MPV + 1.009 × Cr + 1.067 × D-dimer + 2.023 × hs-CTnT; the regression equation of postoperative death risk was: logitP2 = −3.296 + 3.242 × left subclavian artery involved + 4.564 × iliac artery involved; the regression equation of postoperative death risk was: logitP3 = −12.864 + 1.149 × BMI + 4.731 × left subclavian artery involved + 4.150 × iliac artery involved + 1.064 × NLR + 1.011 × Cr + 1.084 × D-dimer + 2.242 × hs-CTnT + 3.233 × apolipoprotein A1. Conclusions BMI, NLR, MPV, Cr, D-dimer, hs-CTnT, apolipoprotein A1, left subclavian artery involvement and iliac artery involvement can affect the hospital mortality rate of aortic dissection undergoing Sun’s operation to varying degrees, which may be helpful to guide the design of the perioperative treatment strategy.
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Affiliation(s)
- Yuhui Zhang
- Clinial College of Chest, Tianjin Medical University, Tianjin, China.,Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Tongyun Chen
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Qingliang Chen
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Hou Min
- Clinical Laboratory, Tianjin Chest Hospital, Tianjin, China
| | - Jiang Nan
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
| | - Zhigang Guo
- Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, China
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The effects of DeBakey type acute aortic dissection and preoperative peripheral and cardiac malperfusion on the outcomes after surgical repair. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 18:1-7. [PMID: 34552637 PMCID: PMC8442082 DOI: 10.5114/kitp.2021.105187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/16/2021] [Indexed: 12/23/2022]
Abstract
Introduction Emergent surgical repair of DeBakey type I and II acute aortic dissection represents the standard of care to prevent lethal complications. Aim Evaluation of the effect of extension of aortic dissection (AAD) according to DeBakey classification, type I and II AAD, and the relationship with preoperative peripheral and myocardial malperfusion on early outcome and the mid-term follow-up period. Material and methods A total of 135 patients who underwent AAD surgery between January 2015 and October 2019 were analysed. Results In total 103 patients were affected by DeBakey type I AAD and 32 by DeBakey type II; 56 patients preoperatively showed peripheral, cardiac malperfusion, or both. Intra-operative mortality was 11%. Postoperative peripheral, cardiac malperfusion, and intraoperative and postoperative mortality were lower for type II AAD. The protective factor for intra- and postoperative 60-day mortality was type II AAD (RR = 0.03, p = 0.001); independent predictors were hypertension, and preoperative cardiac and renal-visceral malperfusion. At 5 years the overall survival was 74 ±6.9%. Independent predictors of reduced survival were major extension of type I AAD (RR = 5.37, p < 0.05) and preoperative cardiac malperfusion (RR = 5.78, p < 0.05). Five-year freedom from cardiac death, redo surgical operation, and new vascular procedures on the thoracic and abdominal aorta was 92 ±5.7%, 99 ±1.2%, and 81 ±7.2%, respectively. Extension of DeBakey type I AAD into the thoracic-abdominal aorta segment was also a predictor of the need for new vascular procedures (RR = 1.66, p = 0.05). Conclusions A more favourable anatomy of DeBakey type II AAD is associated with better early and late outcomes after aortic repair. This is due to a lower incidence of peripheral and cardiac malperfusion.
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Salem M, Salib M, Friedrich C, Salem M, Puehler T, Schoettler J, Schoeneich F, Cremer J, Haneya A. Influence of Age on Postoperative Neurological Outcomes after Surgery of Acute Type A Aortic Dissection. J Clin Med 2021; 10:jcm10081643. [PMID: 33921536 PMCID: PMC8068896 DOI: 10.3390/jcm10081643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Acute type A aortic dissection (AAAD) is considered a fatal disease which requires an emergent surgical intervention. This study focuses onthe neurological outcome after surgical repair in cases of AAAD in comparison between elderly and young patients. METHODS a retrospective analysis of 368 consecutive patients who underwent emergency surgery of ascending aorta in moderate hypothermic circulatory arrest (MHCA) (20-24 °C) and antegrade cerebral perfusion after AAAD between 2001 and 2016. Patients were divided into two groups: those aged 75 years and older (68 (18.5%)) and those younger than 75 years (300 (81.5%)). RESULTS Comparing both groups, average age was 79.0 ± 3.2 vs. 59.2 ± 10.7 years (p < 0.001); female gender represents 58.8% of elderly patients vs. 28.7% in younger patients (p < 0.001). Intraoperatively, cardiopulmonary bypass time (155 min (131; 187) vs. 171 min (137; 220); p = 0.012), cross-clamping time (79 min (60; 105) vs. 93 min (71; 134); p = 0.001] and circulatory arrest time (29 min (22; 40) vs. 33 min (26; 49); p = 0.011) were significantly shorter in elderly than younger group. Postoperatively, there was no significant difference in delirium (11.8% vs. 20.5%; p = 0.0968) or stroke (11.8% vs. 16.1%; p = 0.369). The 30-day mortality was satisfactory for both groups but significantly higher in the elderly group (27.9% vs. 14.3%; p = 0.007). CONCLUSION The current study concluded that surgical treatment of AAAD in elderly patients can be applied safely without increasing risk of neurological complication. However, minimizing operation time may help limit the occurrence of postoperative neurological complication.
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Affiliation(s)
- Mohamed Salem
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
- Correspondence: ; Tel.: +49-431500-67089
| | - Michael Salib
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
| | - Christine Friedrich
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
| | - Mostafa Salem
- Department of Cardiology and Angiology, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany;
| | - Thomas Puehler
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
| | - Jan Schoettler
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
| | - Felix Schoeneich
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
| | - Jochen Cremer
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
| | - Assad Haneya
- Department of Cardiovascular Surgery, School of Medicine, Christian-Albrechts-University of Kiel, Arnold-Heller-Str. 3, D-24105 Kiel, Germany; (M.S.); (C.F.); (T.P.); (J.S.); (F.S.); (J.C.); (A.H.)
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Salem M, Friedrich C, Thiem A, Huenges K, Puehler T, Cremer J, Haneya A. Risk Factors for Mortality in Acute Aortic Dissection Type A: A Centre Experience Over 15 Years. Thorac Cardiovasc Surg 2020; 69:322-328. [PMID: 32559807 DOI: 10.1055/s-0040-1710002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Acute aortic dissection Type A (AADA) is still associated with a high mortality rate and frequent postoperative complications. This study was designed to evaluate the risk factors for mortality in AADA patients. PATIENTS AND METHODS This retrospective analysis included 344 consecutive patients who underwent surgery for AADA in moderate hypothermic circulatory arrest (20-24°C nasopharyngeal) between 2001 and 2016. RESULTS The 30-day mortality rate was 18%. Nonsurvivors were significantly older (65.7 ± 12.0 years vs. 62.0 ± 12.5 years; p = 0.034) with significantly higher Euro-score II [15.4% (6.6; 23.0) vs. 4.63% (2.78; 9.88); p < 0.001)]. Intraoperatively, survivors had statistically shorter cardiopulmonary bypass times [163 (134; 206) vs. 198 min (150; 245); p = 0.001]. However, the hypothermic circulatory arrest time was similar between both groups. Postoperatively, the incidence of acute kidney injury (AKI) (55.9 vs. 15.2%; p < 0.001), stroke (27.9 vs. 12.1%; p = 0.002) and sepsis (18.0 vs. 2.1%; p < 0.001) were significantly higher among nonsurvivors. The multi-variable logistic regression confirmed that older age, previous cardiac surgery, preoperative cardiopulmonary resuscitation (CPR), blood transfusion and postoperative acute kidney injury (AKI) were independent risk factors for mortality. CONCLUSION Our analysis suggested that the reason for mortality was multifactorial, especially age, previous cardiac surgery, CPR, transfusion, as well as postoperative AKI were considered risk factors for mortality.
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Affiliation(s)
- Mohamed Salem
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Christine Friedrich
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Alexander Thiem
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Katharina Huenges
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Thomas Puehler
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
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Reser D, Morjan M, Savic V, Pozzoli A, Maisano F, Mestres CA. Outcomes of patients operated for acute type A aortic dissection requiring preoperative cardiopulmonary resuscitation. J Card Surg 2020; 35:1425-1430. [PMID: 32340068 DOI: 10.1111/jocs.14586] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM Acute type A aortic dissection (AAAD) is a life-threatening condition. The emergency operation usually results in 20% perioperative mortality. If preoperative cardiopulmonary resuscitation (CPR) is necessary, there is an increase in the rate of mortality. The aim of the present study was to report the outcomes of AAAD surgery in patients requiring preoperative CPR in a high-volume center. METHODS A retrospective analysis of preoperative, intraoperative, postoperative, and follow-up data in patients requiring preoperative CPR in the setting of AAAD surgery was performed. RESULTS Between January 2006 and December 2018, 637 patients underwent emergency surgery for AAAD. In total, 26 (4%) patients received CPR; the mean age was 63 ± 13 years; and 18 were male (69%). The reason for CPR was acute tamponade (N = 14, 54%), pulseless electrical activity (N = 5, 19%), asystole or ventricular fibrillation (N = 7, 27%), and four (15%) patients were not operated due to prolonged CPR and severe initial neurological impairment. There was no intraoperative mortality. The in-hospital mortality rate was 50% (N = 11), due to severe cerebral damage confirmed by computed tomography, and six patients (55%) were older than 70 years. The median follow-up was 35 months (7-149), which was 100% complete; two patients had permanent hemiplegia, one had anterior spinal syndrome, and other two died during the follow-up. The overall survival rate was 41% (n = 9). CONCLUSION Surgery outcomes were still reasonable in AAAD patients requiring preoperative CPR in a high-volume center.
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Affiliation(s)
- Diana Reser
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Mohammed Morjan
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Vedran Savic
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Alberto Pozzoli
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Francesco Maisano
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Carlos A Mestres
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
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Mauduit M, Anselmi A, Tomasi J, Belhaj Soulami R, Roisné A, Flecher E, Rouze S, Verhoye JP. Early and late outcomes of aortic surgery under hypothermic circulatory arrest in the elderly: a single center study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2019; 60:733-741. [PMID: 31599143 DOI: 10.23736/s0021-9509.19.10874-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND With the progressive aging of the population, aortic surgeons are caring for an increasing number of elderly patients. The objective of this study was to analyze early and late outcomes of aortic surgery with hypothermic circulatory arrest in patients aged 70 and above at our institution. METHODS We performed a retrospective cohort study including every patient aged 70 years or older who underwent aortic surgery with hypothermic circulatory arrest between January 1995 and June 2016 at our institution. Operative results were compared with the contemporary younger counterparts aged <70 years. In-hospital mortality and postoperative stroke were primary outcomes of interest. The main secondary outcomes included acute renal failure, reoperation for bleeding, and spinal cord injury. RESULTS In the study population, the in-hospital mortality was 16.8% (21/125). Ten (8.0%) patients presented postoperative stroke, and 6 had temporary neurologic disturbance (4.8%). Spinal cord injury occurred in 1 (0.8%) patient. For elective interventions and type A aortic dissections, the in-hospital mortality and stroke rates were 4.6% (3/65) and 7.7% (5/65), 26.8% (11/41) and 12.2% (5/41), respectively. The proportion of non-elective interventions, including type A aortic dissection, and the type of neuroprotective strategy were similar in septuagenarians and younger patients. Patients aged ≥70 had significant shorter cardiopulmonary bypass, myocardial ischemia, and circulatory arrest durations, compared to their younger counterparts. The in-hospital mortality of septuagenarians and younger patients were similar for elective surgery (4.6% vs. 4.7%, P=0.900) and aortic dissections (26.8% vs. 15.1%, P=0.107). There was no statistically significant difference between the two age groups regarding postoperative stroke, spinal cord injury, renal failure requiring dialysis or reintervention for bleeding. Estimated 1-, 3-, and 5-year survival was 78.0%, 70.6%, and 65.7%, respectively. The 5-year survival for elective surgery was 74.9% and 56.0% for non-elective procedures. CONCLUSIONS Aortic surgery with circulatory arrest in the elderly demonstrated favorable early and late results when compared with younger individuals, with an acceptable operative risk even under emergency conditions, and should not be denied only because of the chronological age of the patients.
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Affiliation(s)
- Marion Mauduit
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France -
| | - Amedeo Anselmi
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Jacques Tomasi
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Reda Belhaj Soulami
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Antoine Roisné
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Erwan Flecher
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Simon Rouze
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardio-Vascular Surgery, Rennes University Hospital Center, Rennes, France
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Kondoh H, Satoh H, Daimon T, Tauchi Y, Yamamoto J, Abe K, Matsuda H. Outcomes of limited proximal aortic replacement for type A aortic dissection in octogenarians. J Thorac Cardiovasc Surg 2016; 152:439-46. [DOI: 10.1016/j.jtcvs.2016.03.093] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 02/23/2016] [Accepted: 03/12/2016] [Indexed: 01/16/2023]
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Conzelmann LO, Weigang E, Mehlhorn U, Abugameh A, Hoffmann I, Blettner M, Etz CD, Czerny M, Vahl CF. Mortality in patients with acute aortic dissection type A: analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac Surg 2015; 49:e44-52. [PMID: 26510701 DOI: 10.1093/ejcts/ezv356] [Citation(s) in RCA: 231] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 09/03/2015] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Acute aortic dissection type A (AADA) is an emergency with excessive mortality if surgery is delayed. Knowledge about independent predictors of mortality on surgically treated AADA patients is scarce. Therefore, this study was conducted to identify pre- and intraoperative risk factors for death. METHODS Between July 2006 and June 2010, 2137 surgically treated patients with AADA were enrolled in a multicentre, prospective German Registry for Acute Aortic Dissection type A (GERAADA), presenting perioperative status, operative strategies, postoperative outcomes and AADA-related risk factors for death. Multiple logistic regression analysis was performed to identify the influence of different parameters on 30-day mortality. RESULTS Overall 30-day mortality (16.9%) increased with age [adjusted odds ratio (OR) = 1.121] and among patients who were comatose (adjusted OR = 3.501) or those who underwent cardiopulmonary resuscitation (adjusted OR = 3.751; all P < 0.0001). The higher the number of organs that were malperfused, the risk for death was (adjusted OR for one organ = 1.651, two organs = 2.440, three organs or more = 3.393, P < 0.0001). Mortality increased with longer operating times (total, cardiopulmonary bypass, cardiac ischaemia and circulatory arrest; all P < 0.02). Arterial cannulation site for extracorporeal circulation, operative techniques and arch interventions had no significant impact on 30-day mortality (all P > 0.1). No significant risk factors, but relevant increases in mortality, were determined in patients suffering from hemiparesis pre- and postoperatively (each P < 0.01), and in patients experiencing paraparesis after surgery (P < 0.02). CONCLUSIONS GERAADA could detect significant disease- and surgery-related risk factors for death in AADA, influencing the outcome of surgically treated AADA patients. Comatose and resuscitated patients have the poorest outcome. Cannulation sites and operative techniques did not seem to affect mortality. Short operative times are associated with better outcomes.
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Affiliation(s)
- Lars Oliver Conzelmann
- HELIOS Clinic for Cardiac Surgery, Karlsruhe, Germany Task Force for Aortic Surgery and Interventional Vascular Surgery of the German Society for Cardiothoracic and Vascular Surgery
| | - Ernst Weigang
- Task Force for Aortic Surgery and Interventional Vascular Surgery of the German Society for Cardiothoracic and Vascular Surgery Department of Vascular Surgery and Endovascular Therapy, Evangelical Hospital Hubertus, Berlin, Germany
| | - Uwe Mehlhorn
- HELIOS Clinic for Cardiac Surgery, Karlsruhe, Germany
| | - Ahmad Abugameh
- Department of Cardiothoracic and Vascular Surgery, Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Isabell Hoffmann
- Institute for Medical Biometric, Epidemiology und Informatics, Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Maria Blettner
- Institute for Medical Biometric, Epidemiology und Informatics, Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Christian D Etz
- Task Force for Aortic Surgery and Interventional Vascular Surgery of the German Society for Cardiothoracic and Vascular Surgery Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
| | - Martin Czerny
- Task Force for Aortic Surgery and Interventional Vascular Surgery of the German Society for Cardiothoracic and Vascular Surgery Department of Cardiac and Vascular Surgery, University Hospital Freiburg, Freiburg, Germany
| | - Christian F Vahl
- Department of Cardiothoracic and Vascular Surgery, Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
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Malvindi PG, Modi A, Miskolczi S, Kaarne M, Barlow C, Ohri SK, Livesey S, Tsang G, Velissaris T. Acute type A aortic dissection repair in elderly patients. Eur J Cardiothorac Surg 2015; 48:664-70; discussion 671. [DOI: 10.1093/ejcts/ezu543] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 11/26/2014] [Indexed: 11/12/2022] Open
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Zheng J, Lu S, Sun X, Hong T, Yang S, Lai H, Wang C. Surgical management for acute type A aortic dissection in patients over 70 years-old. J Cardiothorac Surg 2013; 8:78. [PMID: 23577777 PMCID: PMC3639068 DOI: 10.1186/1749-8090-8-78] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 04/09/2013] [Indexed: 01/23/2023] Open
Abstract
Background This study aimed to retrospectively investigate our experience of surgical treatment for acute type A aortic dissection in patients older than 70 years. Methods From September 2005 to January 2012, eleven patients who were older than 70 years underwent surgical treatment for type A aortic dissection at our center and were included in this study. Total arch replacement was performed in three patients, seven patients underwent subtotal arch replacement and one with single-branched stent graft implantation. One patient underwent a valve-sparing (David) procedure while another underwent a concomitant aortic valve replacement (Wheat procedure). One patient required coronary artery bypass grafting. All operations were performed under deep hypothermic circulatory arrest and selective antegrade cerebral perfusion. Results There was one in-hospital death (9.1%) and no operative mortality within 30 days. Cardiopulmonary bypass time, myocardial ischemic time and antegrade cerebral perfusion time accounted for 151.4±33.5 minutes, 68.5±41.4 minutes and 30.3±12.9 minutes, respectively. Overall in-hospital duration, intensive care unit (ICU) time and mean ventilation time were 40.9±40.3 days, 16.5±22.5 days and 90.5±139.4 hours, respectively. New postoperative permanent neurological dysfunction and temporary neurological dysfunction were observed in one patient (9.1%) and in three patients (27.3%), respectively. Mean follow-up was 49.0±19.9 months and nine patients are still alive, one patient died of cancer after 24 months postoperation. Conclusions Surgical management for acute type A dissection in patients older than 70 years is a safe alternative with acceptable risk of death and the early and late results are satisfactory.
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Affiliation(s)
- Jiayu Zheng
- Shanghai Institute of Cardiovascular Disease, Zhongshan Hospital, Fudan University, Shanghai, China
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Kilic A, Tang R, Whitson BA, Sirak JH, Sai-Sudhakar CB, Crestanello J, Higgins RSD. Outcomes in the current surgical era following operative repair of acute Type A aortic dissection in the elderly: a single-institutional experience. Interact Cardiovasc Thorac Surg 2013; 17:104-9. [PMID: 23563053 DOI: 10.1093/icvts/ivt155] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES We reviewed our single-centre experience with emergent operative repair of Stanford Type A aortic dissections, with particular attention to outcomes in the elderly. METHODS Consecutive adult patients undergoing emergent operative repair of acute Type A aortic dissections between February 2004 and December 2011 at a single institution were identified. Patients were stratified into elderly (≥ 70 years) and control cohorts (<70 years). Kaplan-Meier analysis was used to evaluate survival. RESULTS A total of 117 patients undergoing emergent repair of Type A aortic dissection were identified during the study period, including 31 (26.5%) elderly and 86 (73.5%) control patients. The mean age in the elderly cohort was 78.0 ± 4.7 years, with 41.9% (13 of 31) being 80 years or older. The elderly and control groups were well matched with regard to preoperative comorbidities (each P>0.05) and the presence of malperfusion at presentation (elderly: 19.4 vs controls: 27.9%, P = 0.35). The most common site of tear involved the proximal ascending aorta (elderly: 83.9 vs controls: 84.9%), with fewer cases affecting the aortic arch (12.9 vs 14.0%; P = 0.75). Operative data, including cardiopulmonary bypass and aortic cross-clamp time, concomitant aortic valve procedures and arch replacement were also similar between cohorts. Fewer elderly patients underwent hypothermic circulatory arrest (67.7 vs 90.7%, P = 0.002). Overall survival to discharge was 87.2% (n = 102), with no difference in the elderly (83.9%; n = 26) vs controls (88.4%; n = 76; P = 0.52). The 30-day (elderly: 82.8 vs controls: 86.2%), 90-day (elderly: 79.0 vs controls: 84.8%) and 1-year (elderly: 75.4 vs controls: 84.8%) survivals were also comparable. CONCLUSIONS Excellent operative outcomes can be achieved in elderly patients undergoing emergent repair of Type A aortic dissections. Advanced patient age should therefore not serve as an absolute contraindication to operative repair in this high-risk cohort.
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Affiliation(s)
- Ahmet Kilic
- Division of Cardiac Surgery, Department of Surgery, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA.
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Surgery for acute type A aortic dissection in octogenarians is justified. J Thorac Cardiovasc Surg 2013; 145:S186-90. [DOI: 10.1016/j.jtcvs.2012.11.060] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Revised: 08/06/2012] [Accepted: 11/28/2012] [Indexed: 11/22/2022]
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Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol 2012; 58:2455-74. [PMID: 22133845 DOI: 10.1016/j.jacc.2011.06.067] [Citation(s) in RCA: 165] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Accepted: 06/07/2011] [Indexed: 01/11/2023]
Abstract
Acute type A aortic dissection is a lethal condition requiring emergency surgery. It has diverse presentations, and the diagnosis can be missed or delayed. Once diagnosed, decisions with regard to initial management, transfer, appropriateness of surgery, timing of operation, and intervention for malperfusion complications are necessary. The goals of surgery are to save life by prevention of pericardial tamponade or intra-pericardial aortic rupture, to resect the primary entry tear, to correct or prevent any malperfusion and aortic valve regurgitation, and if possible to prevent late dissection-related complications in the proximal and downstream aorta. No randomized trials of treatment or techniques have ever been performed, and novel therapies-particularly with regard to extent of surgery-are being devised and implemented, but their role needs to be defined. Overall, except in highly specialized centers, surgical outcomes might be static, and there is abundant room for improvement. By highlighting difficulties and controversies in diagnosis, patient selection, and surgical therapy, our over-arching goal should be to enfranchise more patients for treatment and improve surgical outcomes.
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Lyons O, Clough R, Patel A, Saha P, Carrell T, Taylor P. Endovascular Management of Stanford Type A Dissection or Intramural Hematoma With a Distal Primary Entry Tear. J Endovasc Ther 2011; 18:591-600. [DOI: 10.1583/11-3468.1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Estrera AL. Editorial comment To cut or not to cut, that is the question. Eur J Cardiothorac Surg 2011; 40:1064-5. [PMID: 21752663 DOI: 10.1016/j.ejcts.2011.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 06/03/2011] [Accepted: 06/07/2011] [Indexed: 11/19/2022] Open
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Biancari F, Vasques F, Benenati V, Juvonen T. Contemporary results after surgical repair of type A aortic dissection in patients aged 80 years and older: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2011; 40:1058-63. [PMID: 21561787 DOI: 10.1016/j.ejcts.2011.03.044] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2011] [Revised: 03/25/2011] [Accepted: 03/28/2011] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE The benefits of surgical treatment of type A aortic dissection (AAD) in patients aged 80 years and older are questioned by the perceived high operative risk of these patients. This issue has been investigated in the present meta-analysis of observational studies. METHODS Studies on surgical repair of AAD in patients aged 80 years and older were identified up to January 2011. The results were expressed as pooled proportions with 95% confidence interval (95% CI). RESULTS Pooled analysis showed that patients aged 80 years and older included in six studies had a significantly higher risk of immediate postoperative mortality compared with younger patients (risk ratio 2.32, 95% CI 1.47-3.66, p<0.0001, pooled estimates 45.7% vs 19.5%). Analysis of data retrieved from nine studies reporting on the results of surgical treatment of AAD in a total of 308 patients aged 80 years and older showed a pooled mortality rate of 36.7% (95% CI 23.8-51.8%, 111/308 patients). The pooled stroke rate was 11.9% (95% CI 7.3-18.7%, 37/347 patients). Pooled analysis of data from two studies evaluating patients surgically or medically treated showed a non-significant reduced risk of immediate postoperative death after surgery (risk ratio 0.42, 95% CI 0.14-1.29, pooled estimates: 25.2% vs 59.0%). CONCLUSIONS Immediate postoperative survival rates after surgery for AAD in patients aged 80 years and older are satisfactory. These findings suggest a confident approach toward emergency repair of AAD in this fragile patient population. More data on the intermediate survival and quality of life of these patients are, however, needed to better establish the role of emergency surgery for AAD in octogenarians and nonagenarians.
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Affiliation(s)
- Fausto Biancari
- Division of Cardio-thoracic and Vascular Surgery, Department of Surgery, Oulu University Hospital, Oulu, Finland.
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Campbell-Lloyd AJ, Mundy J, Pinto N, Wood A, Beller E, Strahan S, Shah P. Contemporary Results Following Surgical Repair of Acute Type A Aortic Dissection (AAAD): A Single Centre Experience. Heart Lung Circ 2010; 19:665-72. [DOI: 10.1016/j.hlc.2010.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2009] [Revised: 04/04/2010] [Accepted: 05/03/2010] [Indexed: 11/28/2022]
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Trimarchi S, Eagle KA, Nienaber CA, Rampoldi V, Jonker FH, De Vincentiis C, Frigiola A, Menicanti L, Tsai T, Froehlich J, Evangelista A, Montgomery D, Bossone E, Cooper JV, Li J, Deeb MG, Meinhardt G, Sundt TM, Isselbacher EM. Role of age in acute type A aortic dissection outcome: Report from the International Registry of Acute Aortic Dissection (IRAD). J Thorac Cardiovasc Surg 2010; 140:784-9. [DOI: 10.1016/j.jtcvs.2009.11.014] [Citation(s) in RCA: 168] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2009] [Revised: 10/01/2009] [Accepted: 11/06/2009] [Indexed: 10/19/2022]
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Stamou SC, Hagberg RC, Khabbaz KR, Stiegel MR, Reames MK, Skipper E, Nussbaum M, Lobdell KW. Is advanced age a contraindication for emergent repair of acute type A aortic dissection? Interact Cardiovasc Thorac Surg 2010; 10:539-44. [PMID: 20093267 DOI: 10.1510/icvts.2009.222984] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
With the general increase in human lifespan, cardiac surgeons are faced with treating an increasing number of elderly patients. The aim of our study was to investigate whether advanced age poses an increased risk for major morbidity and mortality with repair of acute type A aortic dissection. Between 2000 and 2008, 119 patients underwent emergency operation for acute type A aortic dissection at two institutions; 90 were younger than 70 years of age and 29 patients were 70 years or older. Major morbidity, operative and 5-year actuarial survival were compared between groups. The operative mortality rates were comparable between the two groups (18.9% in patients <70 years vs. 24.1% for patients >or=70 years, P=0.6). There was no difference in the rates of reoperation for bleeding (<70 years 31.7% vs. 14.3% for >or=70 years, P=0.09), stroke (18.9% for those <70 years vs. 20.7% for those >or=70 years, P=0.79), acute renal failure (22.2% for those <70 years vs. 17.2% for those >or=70 years, P=0.79) or prolonged ventilation (34.4% for those <70 years vs. 24.1% for those >or=70 years, P=0.36) between the two groups. Actuarial 5-year survival rates were 77% for patients <70 years vs. 59% for patients >or=70 years (P=0.07). The mortality for patients who presented with hemodynamic instability was markedly higher (10 out of 14 patients, 71.4%) compared with the mortality of those who presented with stable hemodynamics (21 out of 88 patients, 23.9%, P<0.001), regardless of age group. No significant differences in operative mortality, major morbidity and actuarial 5-year survival were observed between patients >or=70 years and younger patients although there was a trend toward a lower actuarial 5-year survival in older patients. Surgery for type A acute aortic dissection in patients 70 years or older can be performed with acceptable outcomes. Hemodynamic instability portends a poor prognosis, regardless of age.
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Affiliation(s)
- Sotiris C Stamou
- Division of Cardiothoracic Surgery, Department of Surgery and The Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Stevens L, Madsen JC, Isselbacher EM, Khairy P, MacGillivray TE, Hilgenberg AD, Agnihotri AK. Surgical management and long-term outcomes for acute ascending aortic dissection. J Thorac Cardiovasc Surg 2009; 138:1349-57.e1. [DOI: 10.1016/j.jtcvs.2009.01.030] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Revised: 11/06/2008] [Accepted: 01/04/2009] [Indexed: 11/16/2022]
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Surgical risk of preoperative malperfusion in acute type A aortic dissection. J Thorac Cardiovasc Surg 2009; 138:1363-9. [PMID: 19733865 DOI: 10.1016/j.jtcvs.2009.04.059] [Citation(s) in RCA: 146] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2008] [Revised: 02/20/2009] [Accepted: 04/12/2009] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Patients who have type A dissection with preoperative malperfusion syndromes are believed to be at extremely high surgical risk. Our aim was to evaluate perioperative and long-term results of patients with preoperative malperfusion. METHODS A total of 276 patients (174 men; mean age 59.5 +/- 13.4 years) underwent surgery for acute type A dissection between October 1994 and January 2008. Preoperative malperfusion syndromes were diagnosed in 93 (33.7%) patients (group I) and involved coronary circulation in 41 (15%) patients, central nervous system in 39 (14%) patients, limb ischemia in 32 (11.6%) patients, and mesenteric circulation in 8 (3%) patients. Postoperative results were compared between patients with preoperative malperfusion and those without this complication (group II, n = 183). RESULTS In-hospital mortality was 29.0% in group I versus 13.6% in group II (P = .002). The postoperative intensive care unit stay was longer (11.4 +/- 9.7 vs 7.7 +/- 6.9 days; P = .04) in the malperfusion group. A total of 6 (75%) patients with mesenteric malperfusion died. Long-term follow-up (range, 1-122 months postoperatively) was available in 100% of survivors. One-year and 5-year overall survivals were 49.8% +/- 11.8% and 41.8% +/- 12.6% in group I versus 70.4% +/- 7.6% and 56% +/- 10.4% in group II (P = .005). Cox regression analysis identified preoperative malperfusion as a significant risk factor for long-term mortality after surgery for type A dissection (hazard ratio, 1.7; 95% confidence intervals, 1.2-3.1). CONCLUSIONS Preoperative malperfusion is a significant risk factor influencing perioperative and long-term survival after surgery for acute type A dissection. Percutaneous interventional procedures and delayed surgery should be considered in patients with clinically apparent mesenteric malperfusion because of the dismal prognosis of immediate surgical therapy.
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Piccardo A, Regesta T, Zannis K, Gariboldi V, Pansini S, Tapia M, Concistré G, Collart F, Kreitmann P, Kirsch ME, Martinelli L, Passerone G, Caus T. Outcomes After Surgical Treatment for Type A Acute Aortic Dissection in Octogenarians: A Multicenter Study. Ann Thorac Surg 2009; 88:491-7. [DOI: 10.1016/j.athoracsur.2009.04.096] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Revised: 04/21/2009] [Accepted: 04/24/2009] [Indexed: 11/26/2022]
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Reevaluation of Direct True Lumen Cannulation in Surgery for Acute Type A Aortic Dissection. Ann Thorac Surg 2009; 87:1182-6. [DOI: 10.1016/j.athoracsur.2009.01.027] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2008] [Revised: 01/12/2009] [Accepted: 01/13/2009] [Indexed: 11/20/2022]
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Chen YC, Hsu RB. Aortic surgery requiring hypothermic circulatory arrest in octogenarians. J Formos Med Assoc 2008; 107:412-8. [PMID: 18492626 DOI: 10.1016/s0929-6646(08)60107-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Recent improvements in the outcomes of cardiovascular operation in octogenarians have resulted in an increase in the number of referrals of elderly patients for aortic surgery requiring hypothermic circulatory arrest. METHODS This was a retrospective chart review. RESULTS Between 2000 and 2007, 12 octogenarians with aortic aneurysms underwent surgery requiring hypothermic circulatory arrest. There were seven men with a median age of 83 years (range, 80-87 years). Diagnoses of aortic disease included acute type A aortic dissection in seven patients and degenerative thoracic aneurysm in five. Operation was performed through median sternotomy in eight patients and posterolateral thoracotomy in four. The median duration of hypothermic circulatory arrest was 50 minutes (range, 15-84 minutes). Method of brain protection during hypothermia was selective antegrade cerebral perfusion in five patients, retrograde cerebral perfusion in two, and arrest alone in five. The hospital mortality rate was 8%. Major postoperative complications occurred in six (50%) patients, with transient neurologic dysfunction in two patients and no stroke. CONCLUSION Although postoperative complications were common, the clinical outcome of aortic surgery requiring hypothermic circulatory arrest was acceptable.
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Affiliation(s)
- Ying-Cheng Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
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Shrestha M, Khaladj N, Haverich A, Hagl C. Is Treatment of Acute Type A Aortic Dissection in Septuagenarians Justifiable? Asian Cardiovasc Thorac Ann 2008; 16:33-6. [DOI: 10.1177/021849230801600109] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study was undertaken to analyze the risk of mortality and neurological complications after treatment of acute type A aortic dissection in septuagenarians. From 1996 through 2002, 24 patients > 70 years underwent surgery for acute type A aortic dissection. Their median age was 75 years (range, 71–82 years), and 15 were male. Eleven (46%) had previous neurological events, 22% presented with hemodynamic instability and aortic rupture was found in 7%. Ten had hypothermic circulatory arrest alone, 3 had it in combination with retrograde cerebral perfusion and 11 had selective antegrade cerebral perfusion as an adjunct. The overall survival rate was 71% (17/24). Temporary neurological dysfunction was found in 3 (12.5%), and permanent neurological dysfunction in 9 (37.5%), leading to death in 3. Comparison of mortality rates and neurological outcome showed a marked tendency towards better outcome in patients who had hypothermic circulatory arrest and selective antegrade cerebral perfusion. Surgery for aortic dissections in the elderly can be performed with acceptable mortality, but there is a high rate of neurological complications. Despite the small number of patients, selective antegrade cerebral perfusion seemed to reduce the incidence of neurological events.
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Affiliation(s)
- Malakh Shrestha
- Division of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Nawid Khaladj
- Division of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Division of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Christian Hagl
- Division of Cardiac, Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Halstead JC, Meier M, Etz C, Spielvogel D, Bodian C, Wurm M, Shahani R, Griepp RB. The fate of the distal aorta after repair of acute type A aortic dissection. J Thorac Cardiovasc Surg 2007; 133:127-35. [PMID: 17198797 DOI: 10.1016/j.jtcvs.2006.07.043] [Citation(s) in RCA: 237] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2005] [Revised: 06/15/2006] [Accepted: 06/17/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The residual aorta's behavior after repair of acute type A dissection is incompletely understood. We analyzed segmental growth rates, distal reoperation, and factors influencing long-term survival. METHODS One hundred seventy-nine consecutive patients (70% male; mean age, 60 years) with acute type A dissection underwent aggressive resection of the intimal tear and open distal anastomosis (1986-2003). Hospital mortality was 13.4%. Survivors had serial computed tomographic scans: digitization yielded distal segmental dimensions. Segment-specific average rates of enlargement and factors influencing faster growth were analyzed. Distal reoperations and patient survival were examined. RESULTS Eighty-nine (57%) patients had imaging data sufficient for growth rate calculations. The median diameters after repair were as follows: aortic arch, 3.6 cm; descending aorta, 3.7 cm; and abdominal aorta, 3.2 cm. Subsequent growth rates were 0.8, 1.0, and 0.8 mm/y, respectively. Initial size of greater than 4 cm (P = .005) and initial diameter of less than 4 cm with a patent false lumen (P = .004) predicted greater growth in the descending aorta, and male sex (P = .05) significantly affected growth in the abdominal aorta. No significant factors were found for the aortic arch. There were 25 distal aortic reoperations (16 patients), and risk of reoperation was 16% at 10 years. Risk factors reducing long-term survival after repair of acute type A dissection included age (P < .0001), new neurological deficit at presentation (P = .04), absence of preoperative thrombus in the false lumen of the ascending aorta (P = .03), and a patent distal false lumen postoperatively (P = .06) but not distal reoperation. CONCLUSIONS Growth of the distal aorta after repair of acute type A dissection is typically slow and linear. Distal reoperation is uncommon, and late risk of death is approximately twice that of a healthy population.
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Affiliation(s)
- James C Halstead
- Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
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