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Sá MP, Jacquemyn X, Hess N, Brown JA, Caldonazo T, Kirov H, Doenst T, Serna-Gallegos D, Kaczorowski D, Sultan I. Extracorporeal life support after surgical repair for acute type a aortic dissection: A systematic review and meta-analysis. Perfusion 2024:2676591241253464. [PMID: 38730556 DOI: 10.1177/02676591241253464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2024]
Abstract
BACKGROUND The use of extracorporeal life support (ECLS) in patients after surgical repair for acute type A aortic dissection (ATAAD) has not been well documented. METHODS We performed a systematic review and meta-analysis to assess the outcomes of ECLS after surgery for ATAAD with data published by October 2023 in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guidelines. The protocol was registered in PROSPERO (CRD42023479955). RESULTS Twelve observational studies met our eligibility criteria, including 280 patients. Mean age was 55.0 years and women represented 25.3% of the overall population. Although the mean preoperative left ventricle ejection fraction was 59.8%, 60.8% of patients developed left ventricle failure and 34.0% developed biventricular failure. Coronary involvement and malperfusion were found in 37.1% and 25.6%, respectively. Concomitant coronary bypass surgery was performed in 38.5% of patients. Regarding ECLS, retrograde flow (femoral) was present in 39.9% and central cannulation was present in 35.4%. In-hospital mortality was 62.8% and pooled estimate of successful weaning was 50.8%. Neurological complications, bleeding and renal failure were found in 25.9%, 38.7%, and 65.5%, respectively. CONCLUSION ECLS after surgical repair for ATAAD remains associated with high rates of in-hospital death and complications, but it still represents a chance of survival in critical situations. ECLS remains a salvage attempt and surgeons should not try to avoid ECLS at all costs after repairing an ATAAD case.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Nicholas Hess
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - James A Brown
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tulio Caldonazo
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Derek Serna-Gallegos
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - David Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Ramesh P, Al-Zubaidi FI, Abdelghaffar M, Babiker S, Aspinall A, Butt S, Sabry H, Zeinah M, Harky A. TEM Classification of Aortic Dissection-The Evolving Scoring System: A Literature Review. Heart Lung Circ 2024; 33:17-22. [PMID: 38143192 DOI: 10.1016/j.hlc.2023.10.013] [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: 08/03/2023] [Revised: 10/18/2023] [Accepted: 10/29/2023] [Indexed: 12/26/2023]
Abstract
Aortic dissection is an acute presentation that, if unnoticed, poses a significant risk to life. Anatomically, it is defined as a tear in the intimal layer of the aorta, but management differs significantly based on the location of this tear. Traditionally the Stanford and DeBakey classifications have been used to distinguish tear types and thus guide the most favourable management option, be it medical optimisation or surgery. Recently, a new Type-Entry-Malperfusion classification has been proposed to more accurately define and thus risk stratify patients with aortic dissection. This review summarises the Type-Entry-Malperfusion classification and highlights its potential advantages and limitations compared to other classifications. Clinical insights and potential barriers to adopting this classification are also described in this review.
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Affiliation(s)
- Pranav Ramesh
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | | | - Mariam Abdelghaffar
- School of Medicine, Royal College of Surgeons in Ireland, Busaiteen, Bahrain
| | | | - Alexandra Aspinall
- Faculty of Medicine, Health and Life Science, Swansea Medical School, Swansea, UK
| | - Sundas Butt
- Department of Plastic Surgery, Nottingham City Hospital, Nottingham, UK
| | - Haytham Sabry
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Mohamed Zeinah
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK; School of Medicine, Faculty of Health and Life Science, Ain Shams University, Cairo, Egypt
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK.
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3
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Ma M, Cao H, Li K, Pan J, Zhou Q, Tang X, Qin X, Zhu F, Wang D. Evaluation of Two Online Risk Prediction Models for the Mortality Rate of Acute Type A Aortic Dissection Surgery: The German Registry of Acute Aortic Dissection Type A Score and the European System for Cardiac Operative Risk Evaluation II. J Clin Med 2023; 12:4728. [PMID: 37510842 PMCID: PMC10381328 DOI: 10.3390/jcm12144728] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/26/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
EuroSCORE II is one of the most widely utilized cardiovascular surgery risk scoring systems. Recently, a new online score calculator, namely the German Registry of Acute Aortic Dissection Type A (GERAADA), was launched to predict 30-day surgical mortality for acute type A aortic dissection (ATAAD) patients. The aim of this study is to evaluate the predictive performance of these two scores. We calculated the two scores for 1346 ATAAD patients from January 2012 to December 2021. The overall performance was evaluated using Brier scores and Hosmer-Lemeshow statistics. Receiver Operating Characteristic (ROC) curves were employed to assess diagnostic ability, and the standardized mortality ratio (SMR) was utilized to evaluate calibration. The GERAADA score and EuroSCORE II predicted 30-day mortality rates of 14.7% and 3.1%, respectively, while the observed rate was 12.5%. The predictive ability of EuroSCORE II (AUC 0.708, 95% CI: 0.664-0.792) was superior to that of the GERAADA score (0.648, 95% CI: 0.605-0.692). The GERAADA score had higher sensitivity but lower specificity than EuroSCORE II. And the GERAADA score may overestimate mortality (0.76, 95% CI: 0.65-0.89), while EuroSCORE II may underestimate the mortality rate (3.17, 95% CI: 2.92-3.44). The EuroSCORE II was superior in predicting surgical mortality among ATAAD patients. But the observed 30-day mortality rate certified a good calibration for the GERAADA score.
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Affiliation(s)
- Ming Ma
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Hailong Cao
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Kai Li
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Jun Pan
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Qing Zhou
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Xinlong Tang
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Xichun Qin
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Feng Zhu
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
| | - Dongjin Wang
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing 210008, China
- Department of Thoracic and Cardiovascular Surgery, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing 210008, China
- Institute of Cardiothoracic Vascular Disease, Nanjing University, Nanjing 210008, China
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4
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Nežić DG, Živković IS, Miličić MD, Milačić PA, Košević DN, Boričić MI, Krasić SD, Mićović SV. On-line risk prediction models for acute type A aortic dissection surgery: validation of the German Registry of Acute Aortic Dissection Type A score and the European System for Cardiac Operative Risk Evaluation II. Eur J Cardiothorac Surg 2021; 61:1068-1075. [PMID: 34915555 DOI: 10.1093/ejcts/ezab517] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/21/2021] [Accepted: 10/03/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The German Registry of Acute Aortic Dissection Type A (GERAADA) on-line score calculator to predict 30-day mortality in patients undergoing surgery for acute type A aortic dissection (ATAAD) was recently launched. Using the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II), it is also possible to predict operative mortality for the same type of surgery. The goal of our study was to validate the prediction accuracy of these 2 on-line risk prediction models. METHODS Prospectively collected data for EuroSCORE II risk factors as well as all data for GERAADA scoring were extracted from an institutional database for 147 patients who underwent surgery for ATAAD between April 2018 and April 2021. The discriminative power was assessed using area under the receiver operating characteristic curve. The calibration of the models was tested by the Hosmer-Lemeshow statistics and by using the observed-to-expected (O/E) mortality ratio with the 95% confidence interval. RESULTS The observed operative mortality was 14.3%. The mean predicted mortality rates for the GERAADA score and the EuroSCORE II were 15.6% and 10.6%, respectively. The EuroSCORE II discriminative power (area under the curve = 0.799) significantly outperformed the discriminatory power of the GERAADA score (area under the curve = 0.550). The Hosmer-Lemeshow statistics confirmed good calibration for both models (P-values of 0.49 and 0.29 for the GERAADA score and the EuroSCORE II, respectively). The O/E mortality ratio certified good calibration for both scores [GERAADA score (O/E ratio of 0.93, 95% confidence interval: 0.53-1.33); EuroSCORE II (O/E ratio of 1.35, 95% confidence interval: 0.77-1.93)]. CONCLUSIONS The EuroSCORE II has better discriminative power for predicting operative mortality in ATAAD surgery than the GERAADA score. Both scores confirmed good calibration ability.
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Affiliation(s)
- Duško G Nežić
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
| | - Igor S Živković
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
| | - Miroslav D Miličić
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
| | - Petar A Milačić
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
| | - Dragana N Košević
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
| | - Mladen I Boričić
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
| | - Staša D Krasić
- Department of Pediatric Cardiology, Mother and Child Health Care Institute of Serbia, Belgrade, Serbia
| | - Slobodan V Mićović
- Department of Cardiac Surgery, "Dedinje" Cardiovascular Institute, Belgrade, Serbia
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5
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Wang M, Fan R, Gu T, Zou C, Zhang Z, Liu Z, Qiao C, Sun L, Gong M, Li H, Zhang H. Short-term outcomes of acute coronary involvement in type A aortic dissection without myocardial ischemia: a multiple center retrospective cohort study. J Cardiothorac Surg 2021; 16:107. [PMID: 33892753 PMCID: PMC8063355 DOI: 10.1186/s13019-021-01469-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 04/05/2021] [Indexed: 12/24/2022] Open
Abstract
Background To evaluate the early prognosis and management of acute coronary involvement (ACI) in type A aortic dissection (ATAAD) patients without myocardial ischemia (MI). Methods We conducted a retrospective cohort study on a multicenter database. A total of 931 ATAAD patients without MI underwent thoracic aortic surgery between 2018 and 2019 in the Acute Aortic Syndrome Cooperation Network (AASCN) and were enrolled in our study. Patients were divided into two groups: ACI group and non-ACI group. Results There were 139 ACI patients (14.9%) and 792 non-ACI patients (85.1%) in our cohort. ACI group had higher 30-day mortality after surgery than non-ACI group (log-rank test: P = 0.028,Cox regression: hazard ratio [HR], 2.3; 95% confidence interval [95% CI], 1.1–5.39; P = 0.047), especially in sub-group of advanced age (53–80 years; HR, 4.0; 95% CI, 1.3–12.8; P = 0.017), low diastolic blood pressure (29-69 mmHg, HR, 3.8; 95% CI, 1.3–11.2; P = 0.018), low systolic blood pressure (51–119 mmHg, HR, 3.6; 95% CI, 1.1–12.4; P = 0.040), high body mass index (BMI;27.25–47.52 kg/m2; HR, 3.7; 95% CI, 1.3–10.7; P = 0.015) and high hemoglobin (>145 g/L; HR, 4.3; 95% CI, 1.2–16.0; P = 0.030). Acute renal failure was significant more in ACI group than non-ACI group (24.5% vs. 15.9%; P = 0.014). Conclusions ACI increases the short-term postoperative mortality and acute renal failure in ATAAD patients without MI. ATAAD patients with ACI may need a narrower control range of blood pressure even if without myocardial ischemia. Trial registration ChiCTR1900022637. Retrospectively registered 19 April 2019.
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Affiliation(s)
- Maozhou Wang
- Department of Cardiac Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 South Road of Workers Stadium, Chaoyang District, Beijing, China.,Present address: Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ruixin Fan
- Guangdong General Hospital, Guangzhou, Guangdong, China
| | - Tianxiang Gu
- China Medical University First Hospital, China Medical University, Shenyang, Liaoning, China
| | - Chengwei Zou
- Shandong Provincial Hospital, Jinan, Shandong, China
| | - Zonggang Zhang
- People's Hospital of Xinjiang Uygur Autonomous Region, Urumqi, Xinjiang, Uygur Autonomous Region, China
| | - Zhonghong Liu
- First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, Heilongjiang, China
| | - Chenhui Qiao
- Zhengzhou University First Affiliated Hospital, Zhengzhou University, Zhengzhou, Henan, China
| | - Lizhong Sun
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, Chaoyang District, China
| | - Ming Gong
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, Chaoyang District, China.
| | - Haiyang Li
- Department of Cardiac Surgery, Beijing Chaoyang Hospital, Capital Medical University, 8 South Road of Workers Stadium, Chaoyang District, Beijing, China.
| | - Hongjia Zhang
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, 2 Anzhen Road, Beijing, Chaoyang District, China.
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6
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Lin CY, See LC, Tseng CN, Wu MY, Han Y, Lu CH, Tsai FC. Surgical outcomes analysis in patients with uncomplicated acute type A aortic dissection: a 13-year institutional experience. Sci Rep 2020; 10:14883. [PMID: 32913262 PMCID: PMC7484816 DOI: 10.1038/s41598-020-71961-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 08/12/2020] [Indexed: 11/13/2022] Open
Abstract
This retrospective study aimed to clarify the short-term and mid-term outcomes of and prognostic factors for patients who underwent surgical repair for uncomplicated acute type A aortic dissection (ATAAD). Between January 2007 and June 2019, 603 consecutive patients underwent ATAAD repair at our institution. According to patients’ preoperative presentations and imaging studies, uncomplicated ATAAD was found in 276 (45.8%) patients by excluding preoperative complicated factors. Patients with uncomplicated ATAAD were classified into the survivor (n = 243) and non-survivor (n = 33) groups. Clinical features, surgical information, and postoperative complications were compared. Three-year survival and freedom from reoperation rates for survivors were analyzed using the Kaplan–Meier actuarial method. The in-hospital surgical mortality rate of uncomplicated ATAAD patients was 11.9%. The non-survivor group had a higher rate of postoperative malperfusion-related complications, and a multivariate analysis revealed that repeat surgery, retrograde cerebral perfusion, and intraoperative extracorporeal membrane oxygenation support were predictors of in-hospital mortality. In the survivor group, 3-year cumulative survival and freedom from aortic reoperation rates were 89.6% (95% confidence interval [CI] 84.8–92.9%) and 83.1% (95% CI 76.8–87.7%), respectively. In conclusion, uncomplicated and complicated ATAAD rates were similar; the short-term and mid-term surgical outcomes in patients with uncomplicated ATAAD were generally acceptable.
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Affiliation(s)
- Chun-Yu Lin
- Department of Medicine, College of Medicine, Chang-Gung University, Taoyuan, Taiwan. .,Department of Cardiothoracic and Vascular Surgery, Chang-Gung Memorial Hospital, Linkou Medical Centre, 5 Fu-Shing Street, Kwei-Shan, Taoyuan, 333, Taiwan. .,Department of Cardiothoracic and Vascular Surgery, Chang-Gung Memorial Hospital, Tucheng Branch, New Taipei, Taiwan.
| | - Lai-Chu See
- Department of Public Health, College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Biostatistics Core Laboratory, Molecular Medicine Research Centre, Chang-Gung University, Taoyuan, Taiwan.,Division of Rheumatology, Allergy and Immunology, Linkou Medical Centre, Chang-Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chi-Nan Tseng
- Department of Medicine, College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Department of Cardiothoracic and Vascular Surgery, Chang-Gung Memorial Hospital, Linkou Medical Centre, 5 Fu-Shing Street, Kwei-Shan, Taoyuan, 333, Taiwan
| | - Meng-Yu Wu
- Department of Medicine, College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Department of Cardiothoracic and Vascular Surgery, Chang-Gung Memorial Hospital, Linkou Medical Centre, 5 Fu-Shing Street, Kwei-Shan, Taoyuan, 333, Taiwan
| | - Yi Han
- Department of Public Health, College of Medicine, Chang-Gung University, Taoyuan, Taiwan
| | - Cheng-Hui Lu
- Department of Medicine, College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Department of Cardiology, Chang-Gung Memorial Hospital, Linkou Medical Centre, Taoyuan, Taiwan
| | - Feng-Chun Tsai
- Department of Medicine, College of Medicine, Chang-Gung University, Taoyuan, Taiwan.,Department of Cardiothoracic and Vascular Surgery, Chang-Gung Memorial Hospital, Linkou Medical Centre, 5 Fu-Shing Street, Kwei-Shan, Taoyuan, 333, Taiwan
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7
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Ram H, Dwarakanath S, Green AE, Steyn J, Hessel EA. Iatrogenic Aortic Dissection Associated With Cardiac Surgery: A Narrative Review. J Cardiothorac Vasc Anesth 2020; 35:3050-3066. [PMID: 33008721 DOI: 10.1053/j.jvca.2020.07.084] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/23/2020] [Accepted: 07/30/2020] [Indexed: 01/16/2023]
Abstract
Iatrogenic aortic dissection (iAD) is a relatively rare but a life-threatening complication associated with cardiac surgery. All members of the team caring for cardiac surgical patients (surgeons, perfusionists, and anesthesiologists) must be familiar with this complication to minimize its incidence and improve outcome. The present narrative review focuses on iAD occurring intraoperatively and during the early postoperative period (within 1 month) of cardiac surgery. The review also addresses iAD that occurs late (beyond 1 month) after cardiac surgery and iAD associated with other procedures. iAD occurs in about 0.06% of cases when the ascending aorta is the site of arterial cannulation, in about 0.6% when the femoral or iliac arteries are used, and in about 0.5% when the axillary or subclavian arteries are used. Mortality is estimated to be 30% but is more than double if not recognized until the postoperative period. Site of origin of dissection is most commonly the arterial inflow cannula (∼33%). Other common sites are the aortic cross-clamp or partial occlusion clamp (∼29%) and the proximal saphenous vein anastomosis site (14%). Sixty percent of cases occur during coronary artery bypass graft (CABG) surgery and 17% during aortic valve surgery with or without CABG. iAD may be somewhat less common in off-pump versus on-pump CABG but is still not very rare. Risk factors, presentation, diagnosis, and management are reviewed in detail as is the key role of the use of echocardiography in the early diagnosis of iAD and for guiding its management.
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Affiliation(s)
- Harish Ram
- Department of Anesthesiology, University of Kentucky, Lexington, KY
| | | | - Ashley E Green
- Department of Anesthesiology, University of Kentucky, Lexington, KY
| | - Johannes Steyn
- Department of Anesthesiology, University of Kentucky, Lexington, KY
| | - Eugene A Hessel
- Department of Anesthesiology, University of Kentucky, Lexington, KY.
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8
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Surgical rescues for critical hemopericardium complicated by acute type A aortic dissection: Emergent subxiphoid pericardiotomy or cardiopulmonary bypass first? PLoS One 2020; 15:e0229648. [PMID: 32119707 PMCID: PMC7051057 DOI: 10.1371/journal.pone.0229648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 02/11/2020] [Indexed: 12/31/2022] Open
Abstract
Background Hemopericardium is a common and hazardous complication of acute type A aortic dissection (ATAAD). This retrospective study aimed to clarify the short-term and mid-term outcomes in patients who underwent surgical rescues for hemopericardium complicated by ATAAD. Methods Between January 2007 and March 2019, 586 consecutive patients underwent ATAAD repair at our institution. According to preoperative computed tomography, hemopericardium was found in 191 patients (32.6%), 150 were stabilized with medical treatment, and 41 underwent surgical rescues for critical hemodynamics. The 41 patients were classified into groups according to their rescue procedures: emergent subxiphoid pericardiotomy (E-SXP group, n = 26, 63.4%) or emergent cardiopulmonary bypass (E-CPB group, n = 15, 36.6%). Clinical features, surgical information, postoperative complications, and 3-year survival were analyzed and compared. Results Demographics, comorbidities and aortic repair procedures were generally homogenous between the two groups, except for sex. The average systolic blood pressure was 62.4 ± 13.3 mmHg and 67.1 ± 13.1 mmHg in the E-SXP and E-CPB groups, respectively. A total of 29.3% of patients underwent cardiopulmonary resuscitation (CPR) before surgical rescues. The in-hospital mortality was similar (30.8% versus 33.3%, P = 0.865) in the two groups. Multivariate analysis revealed that preoperative CPR was an in-hospital predictor of mortality. For patients who survived to discharge, 3-year cumulative survival rates were 87.8% ± 8.1% and 60.0% ± 19.7% in the E-SXP and E-CPB groups, respectively (P = 0.170). Conclusions Patients who underwent surgical rescues for ATAAD-complicated hemopericardium are at a high risk of in-hospital mortality. The two rescue procedures revealed similar short-term and mid-term outcomes.
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9
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Capoccia M, Maybauer MO. Extra-corporeal membrane oxygenation in aortic surgery and dissection: A systematic review. World J Crit Care Med 2019; 8:135-147. [PMID: 31942440 PMCID: PMC6957356 DOI: 10.5492/wjccm.v8.i8.135] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/29/2019] [Accepted: 11/30/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Very little is known about the role of extracorporeal membrane oxygenation (ECMO) for the management of patients undergoing major aortic surgery with particular reference to aortic dissection.
AIM To review the available literature to determine if there was any evidence.
METHODS A systematic literature search through PubMed and EMBASE was undertaken according to specific key words.
RESULTS The search resulted in 29 publications relevant to the subject: 1 brief communication, 1 surgical technique report, 1 invited commentary, 1 retrospective case review, 1 observational study, 4 retrospective reviews, 13 case reports and 7 conference abstracts. A total of 194 patients were included in these publications of whom 77 survived.
CONCLUSION Although there is no compelling evidence for or against the use of ECMO in major aortic surgery or dissection, it is enough to justify its use in this patient population despite current adverse attitude.
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Affiliation(s)
- Massimo Capoccia
- Department of Aortic and Cardiac Surgery, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London SW3 6NP, United Kingdom
| | - Marc O Maybauer
- Department of Anaesthesia, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester M13 9WL, United Kingdom
- Department of Anaesthesiology and Intensive Care Medicine, Phillips University, Marburg 35037, Germany
- Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Brisbane QLD 4032, Queensland, Australia
- Advanced Critical Care and Transplant Institute, Integris Baptist Medical Centre, Oklahoma City, OK 73112, United States
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Impact of reduced left ventricular function on repairing acute type A aortic dissection: Outcome and risk factors analysis from a single institutional experience: Erratum. Medicine (Baltimore) 2018; 97:e12571. [PMID: 30235779 PMCID: PMC6160235 DOI: 10.1097/md.0000000000012571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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