Importance of blood pressure control after repair of acute type a aortic dissection: 25-year follow-up in 252 patients

Blood Pressure and Heart Rate Management in Patients After Repair of Type A Aortic Dissection

BACKGROUND

The long-term optimal targets for blood pressure and heart rate in patients after surgical repair of acute type A aortic dissection (TAAD) remain unclear. This study evaluated the long-term association of blood pressure and heart rate control on patients after TAAD surgical repair.

METHODS

We identified 839 patients who underwent TAAD surgical repair and survived to discharge between 2003 and 2018 from the Chang Gung Research Database. Primary outcomes included all-cause mortality, aortic progression, and aortic surgery events. Vital signs examined were systolic blood pressure (SBP), diastolic blood pressure, and heart rate (HR) at discharge and at 3 months of follow-up.

RESULTS

The patients were a mean age of 57.2 ± 13.6 years, and approximately two-thirds were men. The results showed that SBP >150 mm Hg at discharge was correlated with increased all-cause mortality (adjusted hazard ratio [aHR], 3.21; 95% CI, 1.61-6.37). Moreover, an HR between 81 and 100 beats/min was associated with a higher hazard of all-cause mortality (aHR, 2.59; 95% CI, 1.28-5.24) and an HR >100 beats/min was also associated with a higher hazard of aortic surgery events (aHR, 2.19; 95% CI 1.24-3.86) compared with an HR of ≤80 beats/min at discharge. During the 3-month follow-up, an HR >100 beats/min was associated with a higher hazard of all-cause mortality (aHR, 3.59; 95% CI, 1.19-10.78) relative to an HR ≤80.

CONCLUSIONS

The careful management of blood pressure and HR contributes to favorable long-term outcomes in patients after surgical repair of TAAD.

Aortic Remodeling in Patients with Arterial Hypertension: Pathophysiological Mechanisms, Therapeutic Interventions and Preventive Strategies-A Position Paper from the Heart and Hypertension Working Group of the Italian Society of Hypertension

In patient with arterial hypertension the whole aorta is exposed to increased wall stress due to pressure overload. Different blood pressure (BP) components have been reported as main determinant of aortic remodelling. In particular increased diastolic BP has been associated with aortic dilatation across all its segments with smaller increase in aortic root and ascending aorta related to increased systolic BP and pulse pressure. Optimal BP control is crucial to prevent development of aortic aneurysm and acute aortic disease. Many studies have evaluated the role of different antihypertensive drug classes for prevention of adverse aortic remodelling including beneficial effects of ACEIs, ARBs, dihydropyridinic calcium channel blockers and Beta-blockers. The present review discusses pathophysiological mechanisms, therapeutic interventions and preventive strategies for development of aortic remodeling in patients with arterial hypertension.

Aortic Root Replacement: Should We Wait Until 5 cm?

Surgical replacement of the ascending aorta and root was first undertaken in the 1950s although methodologies were rudimentary compared to the current era. Advances in brain protection and surgical technique have made complex root procedures relatively low risk in experienced hands. The standard critieria for elective replacement of the root and ascending aorta has been 5.5 cm when there is no connective tissue etiology for the aneurysm. Recent literature has suggested that a more liberal criteria would may be appropriate in healthy patient at low risk, patients with high-risk features including strong family history of adverse aortic events, and in centers whose outcomes are such that the risk of surgery at lower aortic size is far less than the risk of progression of disease or significant adverse event. This manuscript critically evaluates recent literature to suggest in which patients and at what type of centers a more aggressive prophylactic approach should be entertained.

Hypertension self-management trajectory patterns and associated factors among Chinese patients with aortic dissection after surgical repair: a longitudinal study

AIMS

In patients with aortic dissection (AD) after surgical repair, especially those with hypertension, better management of blood pressure is associated with better health outcomes. The aim of this study is to identify hypertension self-management trajectory patterns and associated factors among Chinese aortic dissection patients after surgical repair to assist in developing tailored behavioural interventions for this population.

METHODS AND RESULTS

178 patients with aortic dissection who underwent surgical repair were followed for 3 months. Data on hypertension self-management, hypertension knowledge, self-efficacy, and social support were collected before discharge and at 1 and 3 months after discharge. Sociodemographic and clinical data were also collected. A latent class growth model and generalized estimating equations were used to explore hypertension self-management trajectory patterns and factors associated with each pattern. The participants' average age was 57.95 (± 11.27) years. Two hypertension self-management trajectory patterns were identified: 'rapid ascent then suppressed growth' (93.4%) and 'continuously slow ascent' (6.6%). For the 'rapid ascent then suppressed growth' pattern, age, educational background, type of health insurance, family monthly income, self-efficacy, and social support were associated with this pattern (P < 0.05).

CONCLUSION

Healthcare providers may prioritize hypertension self-management for patients who are younger, have lower educational levels, have resident or employee medical insurance and have a family monthly income between 5001 and 10 000 yuan. Self-efficacy and social support might serve as targets for future intervention to improve hypertension self-management.

REGISTRATION

ChiCTR2100050542.

Knowledge, attitude and practice towards postoperative management among patients with type A aortic dissection or their relatives: a cross-sectional study in China

OBJECTIVES

To assess the knowledge, attitude and practice (KAP) of patients with type A aortic dissection (AD) or their relatives regarding postoperative management.

DESIGN

Cross-sectional study.

SETTING

The participants were recruited from three hospitals between October 2022 and February 2023.

PARTICIPANTS

Patients diagnosed with type A AD or their relatives.

INTERVENTIONS

No interventions were administered. A structured questionnaire was used to gather the demographic and KAP data from the participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome measures included the levels of KAP regarding postoperative management.

RESULTS

A total of 483 participants were included. They exhibited poor knowledge (15.52±7.67, possible score: 0-32), positive attitude (31.10±5.86, possible score: 9-45) and poor practice (21.96±4.83, possible score: 8-40) towards postoperative management. The multivariable logistic analysis showed that knowledge scores (OR=1.09, 95% CI 1.05 to 1.12, p<0.001), attitude scores (OR=1.22, 95% CI 1.16 to 1.29, p<0.001) and diagnosis for ≤5 years (OR=1.97, 95% CI 1.23 to 3.15, p=0.005) were independently associated with good practice. The structured equation modelling analysis showed that knowledge directly influenced attitudes (β=0.22, p<0.001) and practice (β=0.15, p<0.001), while attitude directly impacted practice (β=0.52, p<0.001) and mediated the relationship between knowledge and practice (β=0.11, p<0.001).

CONCLUSIONS

Patients with type A AD and their relatives have poor knowledge, positive attitudes and poor practice towards postoperative management. Knowledge might be the prerequisite for practice, and attitudes have a mediating effect.

Nursing Home Admission and Home Care Initiation After Acute Aortic Dissection: A Nationwide Registry-Based Cohort Study

Background

Little is known about long-term outcomes beyond survival following acute aortic dissection. The aim of this research was to evaluate rates of home care initiation and nursing home admission during the first year after discharge and to assess factors associated with these needs.

Methods

All patients in Denmark with a first-time diagnosis of acute aortic dissection type A or B between 2006 and 2015 were identified using national registries. Patients discharged alive without nursing home or home care use before aortic dissection were included, along with age-matched and sex-matched population controls without aortic dissection (at a ratio of 1:5). Cause-specific multivariable Cox regression was used to derive adjusted hazard ratios.

Results

The study population comprised 1093 patients and 5465 control individuals with a median (IQR) age of 64 (55-71) years; 70.6% were men. During their hospital stay, 2.7% of patients were registered with a first-time diagnosis of stroke, 7.1% with heart failure, and 2.2% with acute kidney failure; 5.9% of patients needed first-time dialysis. During the first year after discharge, 0.8% of patients who had had aortic dissection were admitted to a nursing home, 7.8% started home care, and 5.9% died. Among controls, these rates were 0.2%, 1.2%, and 1.2%, respectively. Patients who had had aortic dissection had significantly increased risk of initiating home care (hazard ratio, 7.47 [95% CI, 5.38-18.37]; P < .001) and of being admitted to a nursing home (hazard ratio, 4.28 [95% CI, 1.73-10.59]; P = .001). Initiation of home care and nursing home admission were related to advanced age, female sex, preexisting comorbidities, in-hospital complications, and conservative management of type A aortic dissection.

Conclusion

Only a small proportion of patients who survived an aortic dissection needed home care or nursing home admission after hospital discharge.

Use of Anti-Thrombotic Drugs and In-Hospital Mortality in Acute Aortic Dissection Patients

Acute aortic dissection occurs due to a primary tear in the aortic intima, with blood from the aortic lumen entering the adjacent diseased media. In the clinical setting, practitioners often hesitate before the use of anti-thrombotic drugs in the acute phase of aortic dissection. Therefore, we examined the clinical course in patients who had already received antithrombotic therapies at the onset of acute aortic dissection, and who were given anti-thrombotic drugs in the acute phase during hospitalization. We retrospectively enrolled 685 consecutive patients with acute aortic dissection (type A/B: 454/231), who were transferred to Kurume University Hospital from 2004 to 2020. In types A and B, there were no significant differences between in-hospital mortality with or without antithrombotic therapies at the onset (14.3% vs. 16.4%, p = 0.66 in type A, 2.6% vs. 7.3%, p = 0.29 in type B). Patients in type A who survived more than a day and were treated with anti-thrombotic drugs during hospitalization had significantly lower in-hospital mortality compared with those who received no anti-thrombotic drugs in the acute phase (2.2% vs. 16.1%, p < 0.001), while there was no significant difference between in-hospital mortality in the two type-B groups (2.4% vs. 4.9%, p = 0.48). Although there were variations in response among patients with acute aortic dissection, anti-thrombotic drugs did not worsen in-hospital mortality for patients with acute aortic dissection, indicating that medical staff should not hesitate to administer anti-thrombotic drugs if indicated.

Safety of exercise for adults with thoracic aortic aneurysms and dissections

Background

Current guidelines for patients with thoracic aortic aneurysms or dissections (TAD) restrict vigorous exertion with the intention to prevent acute aortic dissections. However, a safe threshold for exercise intensity has not been established for TAD patients. In this study, we measured exertional changes in systolic and diastolic blood pressure during isometric and dynamic exercises in a cohort of TAD patients to determine safety of moderate intensity exercise.

Methods

Thirty-one adults with TAD and 14 controls were recruited from UTHealth outpatient clinics. All participants completed an exercise protocol consisting of two circuits of five moderate intensity exercises: hand grips, leg raises, bicep curls, stationary cycling, and wall sits. Blood pressure values were recorded during exercise using Spacelabs OnTrak Ambulatory Blood Pressure monitors. Perceived exertion during each exercise was measured using the Borg CR-10 scale.

Results

No significant differences in the maximum exertional systolic pressure, diastolic pressure, or change from baseline was found between the TAD and control groups. Higher amounts of self-reported weekly moderate activity level (MAL) in TAD correlated with lower exertional SBP during exercise. Higher Borg scores were associated with a greater change in systolic pressure.

Conclusion

Moderate intensity exercise is safe and feasible for many TAD patients. Our data confirms that the Borg score may be a useful proxy for exercise intensity. In this study, we establish a reproducible exercise protocol that can be adapted to create individualized exercise regimens for TAD patients as part of a care plan to improve long-term cardiovascular health.

Relationship Between Heart Rate at Discharge and Long-Term Outcomes of Surgically Treated Patients With Type A Acute Aortic Dissections

BACKGROUND

Resting heart rate (HR) at discharge is an important predictor of mortality after acute myocardial infarction. However, in patients with Stanford type A acute aortic dissections (TA-AADs), the relationship between HR and long-term outcomes is unclear. Therefore, this relationship was investigated in the present study.

METHODS AND RESULTS

Surgically treated consecutive patients with TA-AAD (n=721) were retrospectively categorized according to HR quartiles, recorded within 24 h before discharge (<70, 70-77, 78-83, and ≥84 beats/min). The study endpoints included aortic aneurysm-related deaths, sudden deaths, aortic surgeries, and hospitalizations for recurrence of acute aortic dissections. The mean (±SD) patient age was 65.8±13.0 years. During a median observation period of 5.8 years (interquartile range 3.9-8.5 years), 17.2% of patients (n=124) experienced late aortic events. Late aortic surgery was performed in 14.0% of patients. After adjusting for potential confounders, including β-blocker use, HR at discharge remained an independent predictor of long-term aortic outcomes. Patients with discharge HR ≥84 beats/min had a higher risk (hazard ratio 1.86; 95% confidence interval 1.06-3.25; P=0.029) of long-term aortic events than those with HR <70 beats/min; the cumulative survival rates were similar among the groups (log-rank, P=0.905).

CONCLUSIONS

In surgically treated patients with TA-AAD, HR at discharge independently predicted long-term aortic outcomes. Consequently, HR in patients with TA-AAD should be optimized before discharge, particularly if the HR is ≥84 beats/min.

From Court to Couch: Exercise and Quality of Life after Acute Type A Aortic Dissection

Background  Acute Type A aortic dissection can be physically and mentally stressful with little known about survivors' postrepair activity levels, exercise habits, and quality of life (QOL). This study was aimed to describe pre- and postdissection changes regarding exercise, understand physician recommendations, quantify use of cardiac rehabilitation, and assess QOL in dissection survivors.

Methods  A total of 295 acute Type A aortic dissection survivors were surveyed about exercise, cardiac rehabilitation, QOL, sexual activity, and posttraumatic stress disorder (PTSD) with 137 (46%) respondents.

Results  Respondents were less likely to participate in competitive athletics after than before dissection (1/131 [0.76%] vs. 26/131 [20%], p [McNemar test] < 0.0001) or lift heavy objects (11/111 [9.9%] vs. 41/111 [37%], p  < 0.0001). Forty-eight of 132 respondents (36%) did not participate in cardiac rehabilitation. Compared with general population norms, respondents reported lower median QOL physical component scores (40 [26, 51; 15th, 85th percentile], p  < 0.0001); these were lower in respondents who did not exercise (Hodges–Lehmann [HL; 95% confidence interval (CI)]: –6.8 [–11, –2.4], p  = 0.002), limited sexual activity (–8.0 [–13, –4.3], p  = 0.0002), or screened positive for PTSD (–10 [–14, –5.3], p  = 0.0002). Median mental component scores were similar to general population norms (HL [95% CI]: 55 [34, 61], p  = 0.24) but were lower among respondents who did not exercise (–4.2 [–7.8, –1.0], p  = 0.01), limited sexual activity (–5.5 [–10, –1.8], p  = 0.003), or screened positive for PTSD (–16 [–22, –10], p  < 0.0001).

Conclusion  Physicians should prescribe cardiac rehabilitation, encourage appropriate exercise, promote resumption of sexual activity, and identify and treat PTSD after surgery for acute Type A aortic dissection.

Is Compliance With Guideline Recommended Follow-Up After Aortic Dissection Associated With Survival?

BACKGROUND

Patients with acute aortic dissection (AD) remain at risk for long-term complications and thus are recommended to adhere closely to American College of Cardiology and American Heart Association aorta guideline-based follow-up imaging and clinic visits. The long-term outcomes of compliance with such a model are not well understood.

METHODS

This was a retrospective cohort study of patients at a regional AD center who survived hospital discharge for AD and who were analyzed by compliance with initial follow-up at 3 months and long term after AD. The primary end point was death.

RESULTS

A total of 172 (66% type A; 33% type B) patients survived hospitalization and were followed up over 48 months (interquartile range [IQR], 21, 88 months). Of these patients, 122 (71%) attended the first follow-up appointment, and 90 (52%) attended more than two-thirds of recommended appointments. Patients who attended the first follow-up visit had improved long-term follow-up compliance (75% [IQR, 50%, 91%]) compared with patients who did not attend the first visit (18% [IQR, 0%, 57%]). Noncompliance with the scheduled long-term follow-up was associated with a 50% increase in the risk of death (hazard ratio, 1.6; 95% confidence interval, 1.2, 2.1; P < .001). Furthermore, in patients with low compliance (consistently attending less than one-third of follow-up appointments), the lifetime risk of death after AD was more than double that of patients with high compliance (consistently attending more than two-thirds of appointments) (hazard ratio, 2.2; 95% confidence interval, 1.5, 3.1; P < .001).

CONCLUSIONS

Nearly one-third of patients with AD do not attend the first recommended follow-up visit, and such failure was associated with later noncompliance with subsequent follow-up. Low-compliant patients have double the lifetime risk of death after AD than do high-compliant patients.

Impact of hypertension on short- and long-term survival of patients who underwent emergency surgery for type A acute aortic dissection

Background

To explore the clinical characteristics and prognosis of patients with hypertension underwent emergency surgery for type A acute aortic dissection (TA-AAD).

Methods

The present study enrolled 712 consecutive patients diagnosed with TA-AAD and received aortic repair surgery at our hospital between January 2014 to December 2018. Clinical characteristics of enrolled patients were retrospectively reviewed. Patients were grouped by preexisting hypertension history and matched with propensity scores matching method. Patients’ clinical characteristics were compared and analyzed before and after propensity scoring. To identify predictors for long-term mortality rate, Kaplan-Meier survival estimation and Cox proportional hazard analysis were performed.

Results

A total of 492 patients (69.1% of all patients in the cohort) were included in the hypertensive group and they had increased age and weight compared to patients in the non-hypertensive group. Between two groups, preoperative leukocyte count and serum creatinine level were found significant different (P<0.05). After propensity scoring, 128 pairs (256 patients) were successfully matched. Our analysis showed that there was no significant difference of ventilation duration, 30-day mortality rate, intensive care unit stay and hospitalization time between two groups. However, our data suggested that hypertensive patients presented with less intra-operative aortic valve involvement. There was a significant difference in long-term survival rate (P=0.037) between two groups. Cox regression analysis demonstrated that hypertension was an independent risk factor [hazard ratio (HR), 3.040; 95% confidence interval (CI), 1.124–8.227; P=0.029].

Conclusions

Our data suggested that TA-AAD patients complicated with hypertension had increased age and weight compared to non-hypertensive patients. Concomitant hypertension identified upon hospital administration was an independent risk factor for long-term survival in TA-AAD patients while did not influence the 30-day mortality rate.

Surgical Outcomes of Type A Aortic Dissection at a Small-Volume Medical Center: Analysis according to the Extent of Surgery

Background

Despite progress in treatment, Stanford type A aortic dissection is still a life-threatening disease. In this study, we analyzed surgical outcomes in patients with Stanford type A aortic dissection according to the extent of surgery at Daegu Catholic University Medical Center.

Methods

We retrospectively analyzed 98 patients with Stanford type A aortic dissection who underwent surgery at our institution between January 2008 and June 2018. Of these patients, 82 underwent limited replacement (hemi-arch or ascending aortic replacement), while 16 patients underwent total arch replacement (TAR). We analyzed in-hospital mortality, postoperative complications, the overall 5-year survival rate, and the 5-year aortic event-free survival rate.

Results

The median follow-up time was 48 months (range, 1–128 months), with a completion rate of 85.7% (n=84). The overall in-hospital mortality rate was 8.2%: 6.1% in the limited replacement group and 18.8% in the TAR group (p=0.120). The overall 5-year survival rate was 78.8% in the limited replacement group and 81.3% in the TAR group (p=0.78). The overall 5-year aortic event-free survival rate was 85.3% in the limited replacement group and 88.9% in the TAR group (p=0.46).

Conclusion

The extent of surgery was not related to the rates of in-hospital mortality, complications, aortic events, or survival. Although this study was conducted at a small-volume center, the in-hospital mortality and 5-year survival rates were satisfactory.

Faster Transition From Intravenous to Oral Antihypertensives Associated With Improved Outcomes After Aortic Dissection

Background: After stabilization with intravenous (IV) antihypertensives, the impact of speed-of-transition from IV to enteral (PO) medications in the intensive care unit (ICU) is unknown. Objective: To assess ICU length of stay (LOS) based on transition time from IV to PO antihypertensive therapy. Methods: Retrospective study of aortic dissection patients admitted from June 2013 to July 2017 at a tertiary teaching hospital. Patients were grouped based on achieving full transition to PO medications in either ≤72 hours or >72 hours from the first PO dose. Secondary end points included hospital LOS, IV infusion volume, medication cost, and time spent with arterial/central lines. Results: A total of 56 patients transitioned completely from IV to PO therapy in ≤72 hours, and 72 patients required more than 72 hours. Demographics, IV and PO medication choices, and timing of first PO medication administration were similar between groups. ICU LOS was shorter in the group transitioned in ≤72 hours compared with those who took longer to transition (3.6 vs 10.5 days; P < 0.001). Hospital LOS, IV infusion volume, and cost were also significantly lower in the ≤72-hour group (P < 0.001). The rapid transition group also spent less time with arterial lines (44 vs 156 hours, P < 0.001) and central lines (45 vs 242 hours, P < 0.001). Conclusion and Relevance: In this cohort, transitioning to PO antihypertensives in ≤72 hours was associated with shorter ICU LOS and improvement in other measured outcomes. These observational data are the first to describe a potentially critical juncture in postdissection care; a prospective study is warranted.

Optimal blood pressure control for patients after thoracic endovascular aortic repair of type B aortic dissection

BACKGROUND

Guidelines recommend tight systolic blood pressure (SBP) control for favorable outcomes of type B aortic dissection (BAD) but are still limited by the optimal cut-off value of SBP. The purpose of this study was to evaluate the optimal cut-off value of SBP in BAD patients after thoracic endovascular aortic repair (TEVAR).

METHODS

From January 2011 to April 2017, 269 consecutive patients with BAD after TEVAR were included in the study. All patients were followed up according to a strict follow-up protocol. Cox regression analysis was used to examine the association between SBP at discharge and 90-day aortic related adverse events (ARAE).

RESULTS

All 269 patients completed 90 days of follow-up, and the unadjusted ARAE-free rates at 90-day was 95.1 ± 1.3%. The cut-off value of SBP at discharge identified by receiver operator curve was 130 mmHg for 90-day ARAE. In multivariable models, binary SBP at discharge was significant associated with 90-day ARAE (HR 3.780; 95% CI 1.236-11.556; p = 0.020). Hybrid operation (OR 2.046; 95%CI 1.015-4.122; p = 0.045) and insertion of ≥2 stents (OR 2.950; 95%CI 1.172-7.426; p = 0.022) were demonstrated to be independently associated with poor SBP control (SBP > 130 mmHg) using Logistic analysis.

CONCLUSIONS

The optimal cut-off value of SBP at discharge was 130 mmHg which can be used to predict short-term ARAE. Blood pressure in patients with hybrid operation and ≥ 2 stents should be given more focus.

Impact of preoperative elevated serum creatinine on long-term outcome of patients undergoing aortic repair with Stanford A dissection: a retrospective matched pair analysis

BACKGROUND

The aim of the present study was to determine whether raised preoperative serum creatinine affected the long-term outcome in patients undergoing surgical aortic repair for Stanford A acute aortic dissection (AAD).

METHODS

A total of 240 patients diagnosed with Stanford A AAD underwent surgical repair from January 2006 to April 2015. A propensity score matching was applied, resulting in 73 pairs consisting of one group with normal and one group with preoperative elevated creatinine levels. The cohorts were well balanced for baseline and preoperative clinical characteristics. Both groups were compared regarding their early postoperative variables, as well as estimated survival with up to 9-year follow up. Also, the impact of acute postoperative kidney injury and its severity on long-term survival was analyzed.

RESULTS

The proportion of patients suffering Stanford A AAD with raised creatinine levels was 31.3% ( n = 75). After propensity matching, there were no statistically significant differences regarding demographics, comorbidities, preoperative baseline and clinical characteristics. Postoperatively matched patients with elevated creatinine had longer intensive care unit ( p < 0.001) and total hospital stay ( p = 0.002), prolonged intubation times ( p = 0.014), higher need for hemofiltration ( p < 0.001), higher incidence of temporary neurological disorders ( p = 0.16), infection ( p = 0.005), and trend toward higher incidence of sepsis ( p = 0.097). However, there were no significant differences regarding 30-day mortality (20.5% versus 20.5%, p = 1.000) and long-term overall survival. Further, neither the incidence nor the different stages of acute kidney injury according to the Acute Kidney Injury Network showed any statistically significant differences in terms of long-term survival for both groups [log rank p = 0.636, Breslow (generalized Wilcoxon) p = 0.470, Tarone-Ware p = 0.558].

CONCLUSIONS

Patients with elevated creatinine levels undergoing surgical repair for Stanford A AAD demonstrate higher rate of early postoperative complications. However, 30-day mortality and long-term survival in this patient cohort is not significantly impaired.

Association of Thyroid Function with Early/Mid-term Aorta-Related Adverse Events and Readmissions after Thoracic Endovascular Aortic Repair

The prognosis of patients after thoracic endovascular aortic repair (TEVAR) is affected by several clinical characteristics. This study aimed to evaluate whether thyroid hormones predicts early (30 days) and mid-term (12 months) aorta-related adverse events (ARAE) and readmissions (ARAR) in patients after TEVAR. A total of 338 continuous patients who underwent TEVAR were included and stratified based on quartile of free thyroxine (FT4) levels examined before surgery. The relationship of FT4 levels with early or mid-term ARAE and ARAR were assessed using univariate and multiple logistic regression analysis. The incidence of ARAE and ARAR were 2.7% and 4.1% within 30 days, and 8.9% and 13.5% within 12 months, respectively. After adjusting for confounders, the lowest FT4 quartile group were noted to be at significantly greater risk than the highest FT4 quartile group in early (OR 10.105, 95% CI 1.103 to 92.615, P = 0.041) and mid-term (OR 5.687, 95% CI 1.708 to 18.935, P = 0.005) ARAR, but not significantly different in early (OR 2.097, 95% CI 0.228 to 19.307, P = 0.513) and mid-term (OR 0.695, 95% CI 0.207 to 2.332, P = 0.556) ARAE. Thus, patients with low-normal FT4 levels after TEVAR are at greater risk of ARAR, but not ARAE, in both the early and the mid-term follow-up periods.

Intensive blood pressure control in patients with acute type B aortic dissection (RAID): study protocol for randomized controlled trial

BACKGROUND

Blood pressure control is an essential therapy for patients with acute type B aortic dissection (ABAD) and should be maintained throughout the entire treatment. Thus, vast majority current guidelines recommend control the blood pressure to lower than 140/90 mmHg. Theoretically, a much lower target may further decrease the risk of propagation of dissection. However, some argued that too lower blood pressure would compromise the organ perfusion. Thus, there is no unanimous optimal target for blood pressure in patients with ABAD so far. The present study aimed to investigate the optimal blood pressure target for patients with ABAD, in the hope that the result would optimize the treatment of aortic dissection (AD).

METHODS

The study is a multi-center randomized controlled clinical trial. Study population will include patients with new diagnosed ABAD and hypertension. Blocked randomization was performed where intensive blood pressure control (<120 mmHg) with conventional blood pressure control (<140 mmHg) were allocated at random in a ratio of 1:1 in blocks of sizes 4, 6, 8, and 10 to 360 subjects. Interim analysis will be performed. The primary outcome is a composite in-hospital adverse outcome, including death, permanent paraplegia or semi- paralysis during the hospitalization, and renal failure requiring hemodialysis at discharge. While the secondary outcomes include the aortic size, lower extremity or visceral ischemia, retrograde propagation into aortic arch or ascending aorta, mortality in 6 months and 1 year, intensive care unit (ICU) length of stay, total length of hospital stay, creatinine level, and surgical or endovascular intervention.

ETHICS AND DISSEMINATION

The study was approved by the institutional review board of Sir Run Run Shaw Hospital (approval number: 20160920-9). Informed consent will be obtained from participants or their next-of-kin. The results will be published in a peer-reviewed journal and shared with the worldwide medical community.

TRIAL REGISTRATION

NCT03001739 (https://register.clinicaltrials.gov/).

Exercise and Physical Activity for the Post-Aortic Dissection Patient: The Clinician's Conundrum

Despite the paucity of evidence, it is often presumed, and is physiologically plausible, that sudden, acute elevations in blood pressure may transiently increase the risk of recurrent aortic dissection (AD) or rupture in patients with a prior AD, because a post-dissection aorta is almost invariably dilated and may thus experience greater associated wall stress as compared with a nondilated aorta. Few data are available regarding the specific types and intensities of exercise that may be both safe and beneficial for this escalating patient population. The purpose of this editorial/commentary is to further explore this conundrum for clinicians caring for and counseling AD survivors. Moderate-intensity cardiovascular activity may be cardioprotective in this patient cohort. It is likely that severe physical activity restrictions may reduce functional capacity and quality of life in post-AD patients and thus be harmful, underscoring the importance of further exploring the role of physical activity and/or structured exercise in this at-risk patient population.

Long-Term Survival in Patients With Acute Kidney Injury After Acute Type A Aortic Dissection Repair

BACKGROUND

Although acute kidney injury (AKI) is known as a serious complication after operation for acute type A aortic dissection (AAAD), the long-term impact of AKI remains unclear. The aim of the present study is to investigate the long-term survival in patients with AKI after operation for AAAD.

METHODS

This study included 403 patients who underwent operation for AAAD from 1990 to 2011 at Jichi Medical University, Saitama Medical Center. Postoperative AKI was identified according to the Kidney Disease Improving Global Outcomes criteria. Kaplan-Meier survival analysis and Cox proportional hazards regression were modeled to analyze the association between the AKI stage and postoperative long-term survival.

RESULTS

Of 403 patients, 181 (44.9%) experienced postoperative AKI. Kaplan-Meier estimates for long-term survival were significantly different among patients without AKI and patients with stage 1, 2, and 3 AKI (p < 0.001). Hazard ratios of long-term survival for patients with stages 1, 2, and 3 AKI compared with patients without AKI were 1.38 (95% confidence interval [CI]: 0.84 to 2.26), 1.82 (95% CI: 0.95 to 3.51), and 3.79 (95% CI: 1.95 to 7.37), respectively. More patients with AKI died because of cardiovascular disease after discharge than patients without AKI (1.8% versus 6.0%, p = 0.03).

CONCLUSIONS

Stage 3 AKI is significantly associated with lower long-term survival after operation for AAAD. Patient follow-up after discharge that focuses on cardiovascular issues may benefit patients who survive AKI after AAAD operation.

Non-invasive cardiac output monitoring for cesarean delivery under epidural anesthesia in a patient with Marfan syndrome and cardiomyopathy

Maternal cardiac output and stroke volume increase significantly at the time of cesarean delivery. Parturients with baseline myocardial dysfunction are at increased risk of cardiovascular decompensation in the peripartum period and close hemodynamic monitoring is warranted. We report our use of intraoperative non-invasive cardiac output monitoring during cesarean delivery under epidural anesthesia in a 24-year-old woman with dilated cardiomyopathy secondary to Marfan syndrome, aortic arch, aortic valve and mitral valve replacements and a left ventricular ejection fraction of 37%. Three distinct hemodynamic trends were noted. After achieving adequate surgical anesthesia with 2% lidocaine 20mL, cardiac output and stroke volume rose for approximately 20min from baseline values of 6.3L/min and 69mL, respectively, to 9L/min and 107mL. Values subsequently trended down and remained depressed for nearly 20min following delivery. The lack of immediate post-delivery increases in both cardiac output and stroke volume were attributed to acute blood loss, intravascular volume depletion from fluid restriction, and slow infusion of oxytocin. By the end of surgery, cardiac output and stroke volume ultimately increased by 66% and 84% of baseline values, respectively. Systemic blood pressure, heart rate and cardiac output did not appear to correlate despite the use of phenylephrine to manage hypotension. The patient remained hemodynamically stable with no evidence of acute volume overload.

Epidemiology and Medication Utilization Pattern of Aortic Dissection in Taiwan: A Population-Based Study

Acute aortic dissection (AD) is a catastrophic condition associated with a high rate of mortality. However, current epidemiological information regarding AD remains sparse. The objective of the present study was to investigate the current epidemiological profile and medication utilization patterns associated with aortic dissection in Taiwan.In this population-based study, we identified cases of AD diagnosed during 2005 to 2012 in the complete Taiwan National Health Insurance (NHI) Research Database. Patients with AD were identified using the International Classification of Disease, Ninth Revision (ICD-9) code 441.0, and surgical interventions were defined using NHI procedure codes.A total of 9092 individuals with a mean age of 64.4 ± 15.1 years were identified. The cases were divided into 3 groups: Group A included 2340 patients (25.74%) treated surgically for type A AD; Group B included 1144 patients (12.58%) treated surgically for type B AD, and Group C included 5608 patients (61.68%) with any type of AD treated with medical therapy only. The average annual incidence of AD was 5.6 per 100,000 persons, and the average prevalence was 19.9 per 100,000 persons. Hypertension was the most common risk factor, followed by coronary artery disease and chronic obstructive pulmonary disease. Within 1 year of AD diagnosis, 92% of patients were taking antihypertensive medication. Calcium channel blockers were the most frequently prescribed antihypertensive medication for long-term observation in Taiwan.The annual trends revealed statistically significant increases in the numbers and percentages of prevalence, incidence, and mortality. Changes in patients' drug utilization in patterns were observed after AD diagnosis. Our study provides a local profile that supports further in-depth analyses in AD-affected populations.

Antihypertensive therapy with nicardipine for patients with aortic disease is associated with more esmolol usage than urapidil

BACKGROUND

Acute aortic disease is a common but challenging entity in clinical practice. Titration the blood pressure and heart rate to a target level is of paramount importance in the acute phase regardless of whether the patient will undergo a surgery or not eventually. In addition to the initially intravenous β-blockers, parenteral infusion of nicardipine and urapidil are the most common used antihypertensive therapy currently in mainland China. However, few empirical data was available with respect to the different effect on patients' outcome of the two antihypertensive strategies. Specifically given the deleterious reflex tachycardia of vasodilators which may increase force of ventricular contraction and potentially worsen aortic disease. Therefore, this study was aimed to evaluate the difference of the abovementioned two antihypertensive strategies on the outcome of patients with aortic disease.

METHODS

All patients with new diagnosed aortic diseases presented to our hospitals from January 1, 2013 to June 30, 2014 were retrospectively reviewed. The antihypertensive strategies and their association with patients' outcomes were evaluated with logistics regression.

RESULTS

A total of 120 patients with new diagnosed aortic disease were included in the study. Of them, 47 patients received urapidil while 73 patients received nicardipine antihypertensive therapy. Patients with nicardipine were more quickly to reach the target blood pressure level than those treated with urapidil (median, 18 vs. 35 min, P=0.024). After adjustment for patient demographics, co-morbidity, involved extend of aorta, interventional strategies, antihypertensive therapy with nicardipine (with urapidil as reference) for patients with aortic disease was significantly associated with high esmolol cost [odds ratio (OR): 6.2, 95% confidence interval (CI), 1.8-21.6, P=0.004] and longer ICU length of stay (LOS) (OR: 3.9, 95% CI, 1.5-10.3, P=0.006). However, there was no significant correlation between nicardipine use and ICU mortality (OR: 0.3; 95% CI, 0.1-1.4, P=0.123).

CONCLUSIONS

Although nicardipine achieved the target blood pressure level more quickly than urapidil for patients with aortic disease, it was associated with more esmolol use and longer ICU LOS.

Open repair of chronic complicated type B aortic dissection using the open distal technique

AIM

The present study aimed to analyze early and late outcomes after open repair of chronic type B aortic dissection.

METHODS

We retrospectively reviewed our cases of open descending thoracic aortic aneurysm (DTAA) with chronic dissection from 1991-2013. Long-term survival and aortic reinterventions were analyzed and patient comorbidities were evaluated in order to determine the risk of adverse outcomes. Furthermore, the technique for "distal first approach" is described.

RESULTS

Between 1991 and 2013, 240 (40%) descending thoracic aortic repairs with associated chronic dissection were performed. Mean age is 59 years and 178 (74%) are men. The majority of patients (218, 91%) underwent repair using the adjunct of distal aortic perfusion with cerebral spinal fluid drainage. Early mortality was 8.3% (20/240). Permanent neurologic deficit occurred in 1.3% (3/240). Stroke occurred in 2.9% (7/240), and dialysis on discharge in 6% (12/240). 5-, 10-, 15-, and 20-year survival was 72%, 60%, 45%, and 39%, respectively. Freedom from reoperation on the operated segment was 97%, 94%, 94% and 94% at 5, 10, 15 and 20 years.

CONCLUSIONS

Open repairs of chronic descending thoracic dissections can be performed with respectable morbidity and mortality. Risk of neurologic deficit remains low with use of adjuncts, and risk of reintervention on the involved aortic segment is also low. These results allow comparison with endovascular repair for chronic aortic dissection.

Lower heart rate in the early postoperative period does not correlate with long-term outcomes after repair of type A acute aortic dissection

Little evidence exists regarding the need for a reduction in postoperative heart rate after repair of type A acute aortic dissection. This single-center retrospective study was conducted to determine if lower heart rate during the early postoperative phase is associated with improved long-term outcomes after surgery for patients with type A acute aortic dissection. We reviewed 434 patients who underwent aortic repair between 1990 and 2011. Based on the average heart rate on postoperative days 1, 3, 5, and 7, 434 patients were divided into four groups, less than 70, 70–79, 80–89, and greater than 90 beats per minute. The mean age was 63.3 ± 12.1 years. During a median follow-up of 52 months (range 16–102), 10-year survival in all groups was 67 %, and the 10-year aortic event-free rate was 79 %. The probability of survival and being aortic event-free using Kaplan–Meier estimates reveal that there is no significant difference when stratified by heart rate. Cox proportional regression analysis for 10-year mortality shows that significant predictors of mortality are age [Hazard Ratio (HR) 1.04; 95 % confidence interval (CI) 1.07–1.06; p = 0.001] and perioperative stroke (HR 2.30; 95 % CI 1.18–4.50; p = 0.024). Neither stratified heart rate around the time of surgery nor beta-blocker use at the time of discharge was significant. There is no association between stratified heart rate in the perioperative period with long-term outcomes after repair of type A acute aortic dissection. These findings need clarification with further clinical trials.

Effects of Hemodynamic Instability on Early Outcomes and Late Survival Following Repair of Acute Type A Aortic Dissection

BACKGROUND

The goal of this study was to compare operative mortality and actuarial survival between patients presenting with and without hemodynamic instability who underwent repair of acute Type A aortic dissection. Previous studies have demonstrated that hemodynamic instability is related to differences in early and late outcomes following acute Type A dissection occurrence. However, it is unknown whether hemodynamic instability at the initial presentation affects early clinical outcomes and survival after repair of Type A aortic dissection.

METHODS

A total of 251 patients from four academic medical centers underwent repair of acute Type A aortic dissection between January 2000 and October 2010. Of those, 30 presented with hemodynamic instability while 221 patients did not. Median ages were 63 years (range 38-82) and 60 years (range 19-87) for patients presenting with hemodynamic instability compared to patients without hemodynamic instability, respectively (P = 0.595). Major morbidity, operative mortality, and 10-year actuarial survival were compared between groups.

RESULTS

Operative mortality was profoundly influenced by hemodynamic instability (patients with hemodynamic instability 47% versus 14% for patients without hemodynamic instability, P < 0.001). Actuarial 10-year survival rates for patients with hemodynamic instability were 44% versus 63% for patients without hemodynamic instability (P = 0.007).

CONCLUSIONS

Hemodynamic instability has a profoundly negative impact on early outcomes and operative mortality in patients with acute Type A aortic dissection. However, late survival is comparable between hemodynamically unstable and non-hemodynamically unstable patients.