Long-term outcomes of total arch replacement versus proximal aortic replacement in acute type A aortic dissection: Meta-analysis of Kaplan-Meier-derived individual patient data

The German Registry of Acute Aortic Dissection Type A score for 30-day mortality prediction in Type A Acute Aortic Dissection surgery: a systematic review and meta-analysis

OBJECTIVES

The German Registry of Acute Aortic Dissection Type A (GERAADA) score is a risk score for predicting 30-day mortality after an operation for type A acute aortic dissection (TAAAD). This meta-analysis sought to assess the performance of the GERAADA model and compare it to the performance of the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II).

METHODS

A systematic search of 3 online databases was conducted to identify studies that externally validated the GERAADA score. A random-effect meta-analysis was conducted, pooling area under the curve (AUC) data, operative mortality observed/expected (O/E) ratios and observed-expected (O-E) differences-of the GERAADA model in all studies and of the EuroSCORE II when available.

RESULTS

Eleven studies were selected, including a total of 10 360 patients. The observed in-hospital mortality rate was 12.2%. Pooled expected mortality rates estimated by the GERAADA score and the EuroSCORE II were 18.4% and 5.8%, respectively. The pooled analyses for the GERAADA scores showed moderate discrimination [AUC 0.70, 95% confidence interval (CI) 0.66-0.73] and good calibration [observed-expected (O-E) differences -12.3, 95% CI -27.1 to 2.58; O/E ratio 0.81, 95% CI 0.57-1.05]. Results from 5 studies (2133 patients) investigating both scores simultaneously revealed similar AUC results (P = 0.50), significantly lower O-E differences (P = 0.03) and a trend towards O/E ratios closer to 1 (P = 0.08) with the GERAADA score compared to the EuroSCORE II.

CONCLUSIONS

The GERAADA score seemed to offer a better calibration for predicting 30-day postoperative death following TAAAD operations, even though further studies are needed to confirm these findings. The moderate discriminatory capacity of both scores highlights the challenges of predicting outcomes in complex cardiovascular conditions like TAAAD.

The optimal annual case volume for acute type A aortic dissection surgery in relation to long-term outcomes

OBJECTIVES

Previous analyses of the volume-outcome relationship have focused on short-term outcomes such as early mortality. The current study aims to update a novel statistical methodology, facilitating the evaluation of the relation between procedural volume and time-to-event outcomes such as long-term survival, using surgery for acute type A aortic dissection as an illustrative example.

METHODS

This study employed an existing dataset of type A dissection outcomes, retrieved from literature. Studies were included when reporting on annual case load and long-term survival, which served as the primary outcome of interest. Individual patient data were reconstructed from the included studies, and a hazard ratio was determined per study in relation to overall survival, after which the calculated hazard ratios were incorporated in a restricted cubic-spline model, facilitating the application of the elbow method.

RESULTS

Fifty-two studies were included (n = 14 878 patients), with a median follow-up of 5 years. One-, 3-, 5- and 10-year survival of the overall cohort were 82% [95% confidence interval (CI) 82-83%], 79% (95% CI 78-80%), 74% (95% CI 74-75%) and 60% (95% CI 59-62%), respectively. A significant non-linear volume-outcome relation for long-term survival was observed in both the unadjusted and adjusted analyses (P = 0.030 and P = 0.002), with an optimal annual case load of 32 cases/year (95% CI 31-33).

CONCLUSIONS

Based on the available data, these findings imply that the annual case volume to achieve optimal long-term survival is located near a procedural volume of 32 cases/year. After accrual of more annual procedures, long-term survival may no longer significantly improve any further.

Total Arch Replacement Versus Hemiarch Replacement in Hemodynamic Performance: A Simulation Study

Acute type A aortic dissection (ATAAD) is a life-threatening aortic emergency with high mortality. Currently, hemiarch replacement (HAR) and total arch replacement (TAR) are the primary surgeries for ATAAD, but their long-term outcomes remain debated, possibly due to the influence of clinical factors in multicenter studies. This study aims to evaluate the long-term outcomes of HAR and TAR by in silico analysis, mitigating the impact of clinical factors. A personalized model was reconstructed to simulate HAR and TAR by altering the material properties at the replacement regions, obtaining hemodynamic and wall response parameters through two-way fluid-structure interaction analysis. HAR exhibits a higher increase in von Mises stress at the anastomosis compared to pre-operation levels (HAR: 4.39 times normal, TAR: 2.42 times normal), increasing the risk of pseudoaneurysm formation. TAR induced more severe streamline absence in the arch branches, potentially resulting in intermittent blood flow to the upper limbs and brain. HAR poses a higher risk of pseudoaneurysm formation at the anastomosis, while TAR carries increased risks of upper limb and cerebral ischemia. Enhanced monitoring of the anastomosis in HAR patients and vigilance for upper limb fatigue and cerebral ischemic events in TAR patients are recommended. This study offers effective guidance for managing postoperative HAR and TAR patients, contributing to the prevention of complications and enhancing their postoperative quality of life.

Central versus peripheral cannulation for acute type A aortic dissection: A meta-analysis of over 14,000 patients

OBJECTIVE

The optimal cannulation strategy for patients with acute type A aortic dissections (ATAAD) is unclear.

METHODS

A systematic search was performed to identify all studies comparing aortic and non-aortic cannulation in patients undergoing ATAAD repair. The primary endpoint was overall survival. The secondary endpoints were operative mortality, postoperative stroke, renal failure, renal replacement therapy, paraplegia, and mesenteric ischemia. Pooled meta-analyses with aggregated and reconstructed time-to-event data were performed.

RESULTS

Twenty-three studies were included (aortic: 3904; non-aortic: 10,719). Ten-year overall survival was 61.1 ​% and 58.4 ​% for aortic and non-aortic cannulation, respectively (HR 1.07; 95 ​% CI 0.92-1.25; p ​= ​0.38). No statistically significant difference was observed for operative mortality (p ​= ​0.10), stroke (p ​= ​0.89), renal failure (p ​= ​0.83), or renal replacement therapy (p ​= ​0.77).

CONCLUSION

Patients undergoing surgery for ATAAD can undergo aortic cannulation with similar outcomes to those who undergo non-aortic cannulation.

Predictors of Late Adverse Events in Patients with Surgically Treated Type I Aortic Dissection

OBJECTIVE

Residual aortic dissection (AD) following DeBakey type I AD repair is associated with a high rate of adverse events that need additional intervention or surgery. This study aimed to identify clinical and early post-operative computed tomography angiography (CTA) imaging factors associated with adverse events in patients with type I AD after ascending aorta replacement.

METHODS

This single centre, retrospective cohort study included consecutive patients with type I AD who underwent ascending aorta replacement from January 2011 to December 2017 and post-operative CTA within three months. The primary outcome was AD related adverse events, defined as AD related death and re-operation due to aortic aneurysm or impending rupture. The location and size of the primary intimal tears, aortic diameter, and false lumen status were evaluated. Regression analyses were performed to identify factors associated with AD related adverse events. A decision tree model was used to classify patients as high or low risk.

RESULTS

Of 103 participants (55.43 ± 13.94 years; 49.5% male), 24 (23.3%) experienced AD related adverse events. In multivariable Cox regression analysis, connective tissue disease (hazard ratio [HR] 15.33; p < .001), maximum aortic diameter ≥ 40 mm (HR 4.90; p < .001), and multiple (three or more) intimal tears (HR 7.12; p < .001) were associated with AD related adverse events. The three year cumulative survival free from AD related events was lower in the high risk group with aortic diameter ≥ 40 mm and multiple intimal tears (41.7% vs. 90.9%; p < .001).

CONCLUSION

Early post-operative CTA findings indicating a maximum aortic diameter ≥ 40 mm and multiple intimal tears may predict a higher risk of adverse events. These findings suggest the need for careful monitoring and more vigilant management approaches in these cases.

Total Arch vs Hemiarch Repair in Acute Type A Aortic Dissection: Systematic Review and Meta-Analysis of Comparative Studies

Background

We aimed to compare the short- and long-term outcomes of total arch replacement (TAR) vs hemiarch replacement (HAR) in the management of acute type A aortic dissection.

Methods

We searched the literature for studies directly comparing TAR to HAR in acute type A aortic dissection. Hazard ratios (HRs) were extracted from digitized Kaplan-Meier curves.

Results

A total of 6526 patients were identified, of which 2060 (32%) had received a TAR. A total of 37% of patients were female, and the mean age (standard deviation) of the cohort was 59.8 ± 11.8 years. TAR patients had a higher prevalence of preoperative malperfusion (34% vs 26%). The TAR group had higher odds of 30-day mortality (4404 patients; odds ratio [OR] 1.79, 95% confidence interval [CI] 1.29-2.49), renal failure requiring dialysis (3475 patients; OR 1.34, 95% CI 1.02-1.76), and a trend toward higher rates of stroke (3292 patients; OR 1.49, 95% CI 0.93-2.39). No significant differences were observed in prevalence of permanent spinal cord injury, visceral ischemia, or reoperation for bleeding. The TAR group had a non-statistically significant increase in long-term mortality (4408 patients; HR 1.25, 95% CI 0.99-1.57), but showed a trend toward improved freedom from long-term aortic reoperation (1359 patients; HR 0.53; 95% CI 0.18-1.59). In a subgroup analysis, the hazard ratio of long-term mortality favoured TAR in only the subgroup of studies in which the difference in malperfusion was > 10% between groups.

Conclusions

TAR could be associated with improved freedom from long-term aortic reoperation but with potentially increased perioperative risks. We recommend a tailored surgical approach.

Six-Year Outcomes of Total Arch Replacement vs Debranching With TEVAR for Aortic Arch Pathologies: Meta-Analysis of Kaplan-Meier-Derived Data From Propensity Score-Matched Studies

BACKGROUND

Total arch replacement (TAR) and debranching plus thoracic endovascular aortic repair (TEVAR) serve as significant therapeutic options for aortic arch pathologies. It remains unclear whether one of these approaches should be considered preferable. Our study aimed to compare the long-term outcomes of these 2 approaches.

METHODS

We carried out a pooled meta-analysis of time-to-event data extracted from studies published by December 2023. Eligibility criteria included populations with any aortic arch pathology who underwent debranching plus TEVAR or TAR, propensity score-matched (PSM) studies (prospective/retrospective; single-center/multicentric), and the outcomes included follow-up for overall survival/mortality and/or reinterventions.

RESULTS

Eleven PSM studies met our eligibility criteria, including a total of 1142 patients (571 matched pairs). We did not observe any statistically significant difference in the risk of all-cause death between the groups (hazard ratio [HR]=1.20, 95% confidence interval [CI]=0.91-1.56, p=0.202), but patients who underwent TAR had a significantly lower risk of late aortic reinterventions compared with patients who underwent debranching plus TEVAR (HR=0.38, 95% CI=0.23-0.64, p<0.001). Our meta-regression analyses for all-cause mortality identified statistically significant coefficients for age (coefficient=-0.047; p=0.012) and type A aortic dissections (coefficient=0.012; p=0.010).

CONCLUSIONS

Debranching plus TEVAR and TAR demonstrate no statistically significant differences in terms of survival in patients with aortic arch pathologies, but TAR is associated with lower risk of late aortic reinterventions over time. Although older patients may benefit more from debranching plus TEVAR rather than from TAR, patients with dissections may benefit more from TAR.

CLINICAL IMPACT

Although the 2 strategies seem to be equally valuable in terms of survival, total aortic arch replacement (when compared with debranching plus TEVAR to treat patients with aortic arch pathologies) is associated with reduction of late aortic reinterventions over time in patients with and without aortic dissections. However, we should consider debranching plus TEVAR in older patients as it is associated with lower risk of death in this population. The novelty of our study lies in the fact that, instead of comparing study-level effect estimates, we analyzed the outcomes with reconstructed time-to-event data. This offered us the opportunity of performing our analyses with a mathematically appropriate model which consider events and time; however, these findings might be under the influence of treatment allocation bias.

Inconsistent False Lumen Enhancement Predicts Late Aortic Events After Hemiarch Replacement in Acute Type A Aortic Dissection

The impact of inconsistent enhancement within the patent false lumen on the occurrence of late aortic events remains uncertain. We enrolled 55patients who exhibited a patent false lumen after hemiarch replacement. The Hounsfield unit (HU) measurements in the patent false lumen were obtained at 2 specific locations: the aortic arch (a) and the descending aorta (b). The false lumen HU score was calculated as the absolute value of 1 - a/b, representing the discrepancy in HUs within the patent false lumen. We investigated the cut-off value of the false lumen HU score with the receiver operating characteristics curve to predict the incidence of late aortic events. We divided the patients based on the cut-off value and compared the cumulative incidence of the late aortic events. The analysis of the receiver operating characteristics curve showed that the cut-off value of the false lumen HU score was 0.345. Based on this cut-off value, we divided them into 2 groups: Group A (score <0.345, n = 26) and Group B (score ≥0.345, n = 29). The baseline characteristics were similar between the 2 groups. The cumulative incidence of the late aortic events was significantly lower in Group A (7.8% at 5 years) than in Group B (39.9% at 5 years) (p = 0.02). The false lumen HU score might be useful to predict the incidence of late aortic events after hemiarch replacement.

Frozen elephant trunk versus conventional proximal repair of acute aortic dissection type I

Objective

The extent of surgery and the role of the frozen elephant trunk (FET) for surgical repair of acute aortic dissection type I are still subjects of debate. The aim of the study is to evaluate the short- and long-term results of acute surgical repair of aortic dissection type I using the FET compared to standard proximal aortic repair.

Methods

Between October 2009 and December 2016, 172 patients underwent emergent surgery for acute type I aortic dissection at our center. Of these, n = 72 received a FET procedure, while the other 100 patients received a conventional proximal aortic repair. Results were compared between the two surgery groups. The primary endpoints included 30-day rates of mortality and neurologic deficit and follow-up rates of mortality and aortic-related reintervention.

Results

Demographic data were comparable between the groups, except for a higher proportion of men in the FET group (76.4% vs. 60.0%, p = 0.03). The median age was 62 years [IQR (20), p = 0.17], and the median log EuroSCORE was 38.6% [IQR (31.4), p = 0.21]. The mean follow-up time was 68.3 ± 33.8 months. Neither early (FET group 15.3% vs. proximal group 23.0%, p = 0.25) nor late (FET group 26.2% vs. proximal group 23.0%, p = 0.69) mortality showed significant differences between the groups. There were fewer strokes in the FET patients (FET group 2.8% vs. proximal group 11.0%, p = 0.04), and the rates of spinal cord injury were similar between the groups (FET group 4.2% vs. proximal group 2.0%, p = 0.41). Aortic-related reintervention rates did not differ between the groups (FET group 12.1% vs. proximal group 9.8%, p = 0.77).

Conclusion

Emergent FET repair for acute aortic dissection type I is safe and feasible when performed by experienced surgeons. The benefits of the FET procedure in the long term remain unclear. Prolonged follow-up data are needed.

Long-term sex-based outcomes after surgery for acute type A aortic dissection: Meta-analysis of reconstructed time-to-event data

BACKGROUND

The influence of sex on outcomes of surgery for acute type A aortic dissection remains incompletely characterized. We sought to evaluate post-procedural survival in the follow-up of females versus males.

METHODS

We carried out a systematic review with meta-analysis of Kaplan-Meier-derived time-to-event data from studies published by June 2023 in the following databases: PubMed/MEDLINE, EMBASE, Web of Science and CENTRAL/CCTR (Cochrane Controlled Trials Register).

RESULTS

Twelve studies met our eligibility criteria, including 11,696 patients (3753 females; 7943 males). The mean age ranged from 41.2 to 72.6 years with low prevalence of bicuspid aortic valve (ranging from 0.0% to 12.0%) and connective tissue disorders (ranging from 0.8% to 7.3%). We found a considerable prevalence of coronary artery disease (ranging from 12.1% to 21.1%) and malperfusion (ranging from 20.0% to 46.3%). At 10 years, females undergoing surgery had a significantly higher risk of all-cause mortality compared with males (HR 1.25, 95%CI 1.14-1.38, P ​< ​0.001).

CONCLUSION

In the follow-up of patients undergoing surgery for type A aortic dissection, females presented poorer overall survival in comparison with males.

Type A aortic dissection: optimal annual case volume for surgery

BACKGROUND AND AIMS

The current study proposes a novel volume-outcome (V-O) meta-analytical approach to determine the optimal annual hospital case volume threshold for cardiovascular interventions in need of centralization. This novel method is applied to surgery for acute type A aortic dissection (ATAAD) as an illustrative example.

METHODS

A systematic search was applied to three electronic databases (1 January 2012 to 29 March 2023). The primary outcome was early mortality in relation to annual hospital case volume. Data were presented by volume quartiles (Qs). Restricted cubic splines were used to demonstrate the V-O relation, and the elbow method was applied to determine the optimal case volume. For clinical interpretation, numbers needed to treat (NNTs) were calculated.

RESULTS

One hundred and forty studies were included, comprising 38 276 patients. A significant non-linear V-O effect was observed (P < .001), with a notable between-quartile difference in early mortality rate [10.3% (Q4) vs. 16.2% (Q1)]. The optimal annual case volume was determined at 38 cases/year [95% confidence interval (CI) 37-40 cases/year, NNT to save a life in a centre with the optimal volume vs. 10 cases/year = 21]. More pronounced between-quartile survival differences were observed for long-term survival [10-year survival (Q4) 69% vs. (Q1) 51%, P < .01, adjusted hazard ratio 0.83, 95% CI 0.75-0.91 per quartile, NNT to save a life in a high-volume (Q4) vs. low-volume centre (Q1) = 6].

CONCLUSIONS

Using this novel approach, the optimal hospital case volume threshold was statistically determined. Centralization of ATAAD care to high-volume centres may lead to improved outcomes. This method can be applied to various other cardiovascular procedures requiring centralization.

Current Outcome after Surgery for Type A Aortic Dissection

OBJECTIVE

The aim of this study was to evaluate the outcomes of different surgical strategies for acute Stanford type A aortic dissection (TAAD).

SUMMARY BACKGROUND DATA

The optimal extent of aortic resection during surgery for acute TAAD is controversial.

METHODS

This is a multicenter, retrospective cohort study of patients who underwent surgery for acute TAAD at 18 European hospitals.

RESULTS

Out of 3902 consecutive patients, 689 (17.7%) died during the index hospitalization. Among 2855 patients who survived 3 months after surgery, 10-year observed survival was 65.3%, while country-adjusted, age-adjusted, and sex-adjusted expected survival was 81.3%, yielding a relative survival of 80.4%. Among 558 propensity score-matched pairs, total aortic arch replacement increased the risk of in-hospital (21.0% vs. 14.9%, P =0.008) and 10-year mortality (47.1% vs. 40.1%, P =0.001), without decreasing the incidence of distal aortic reoperation (10-year: 8.9% vs. 7.4%, P =0.690) compared with ascending aortic replacement. Among 933 propensity score-matched pairs, in-hospital mortality (18.5% vs. 18.0%, P =0.765), late mortality (at 10-year: 44.6% vs. 41.9%, P =0.824), and cumulative incidence of proximal aortic reoperation (at 10-year: 4.4% vs. 5.9%, P =0.190) after aortic root replacement was comparable to supracoronary aortic replacement.

CONCLUSIONS

Replacement of the aortic root and aortic arch did not decrease the risk of aortic reoperation in patients with TAAD and should be performed only in the presence of local aortic injury or aneurysm. The relative survival of TAAD patients is poor and suggests that the causes underlying aortic dissection may also impact late mortality despite surgical repair of the dissected aorta.

Cardiac Surgery 2022 Reviewed

PubMed displayed almost 37,000 hits for the search term "cardiac surgery AND 2022." As before, we used the PRISMA approach and selected relevant publications for a results-oriented summary. We focused on coronary and conventional valve surgery, their overlap with interventional alternatives, and briefly assessed surgery for aorta or terminal heart failure. In the field of coronary artery disease (CAD), key manuscripts addressed prognostic implications of invasive treatment options, classically compared modern interventions (percutaneous coronary intervention [PCI]) with surgery (coronary artery bypass grafting [CABG]), and addressed technical aspects of CABG. The general direction in 2022 confirms the superiority of CABG over PCI in patients with anatomically complex chronic CAD and supports an infarct-preventative effect as underlying mechanism. In addition, the relevance of proper surgical technique to achieve durable graft patency and the need for optimal medical treatment in CABG patients was impressively illustrated. In structural heart disease, the comparisons of interventional and surgical techniques have been characterized by prognostic and mechanistic investigations underscoring the need for durable treatment effects and reductions of valve-related complications. Early surgery for most valve pathologies appears to provide significant survival advantages, and two publications on the Ross operation prototypically illustrate an inverse association between long-term survival and valve-related complications. For surgical treatment of heart failure, the first xenotransplantation was certainly dominant, and in the aortic surgery field, innovations in arch surgery prevailed. This article summarizes publications perceived as important by us. It cannot be complete nor free of individual interpretation, but provides up-to-date information for decision-making and patient information.