Insights From the International Registry of Acute Aortic Dissection: A 20-Year Experience of Collaborative Clinical Research

Demographics and outcomes of acute type A aortic dissection in young adults in southeastern China: impact of syndromic heritable thoracic aortic disease

BACKGROUND

This study aimed to investigate the demographics and to evaluate long-term outcomes of acute type A aortic dissection (ATAAD) in surgically treated patients ≤40 years in China.

METHODS

This study included patients aged ≤40 with ATAAD who underwent surgical treatment at our institution between 2015 and 2019. The patients were categorized into groups according to heritable thoracic aortic disease (HTAD) presence or absence. The primary outcomes were in-hospital and late mortality, and aortic-related re-intervention.

RESULTS

Our cohort included 141 patients aged ≤ 40, representing 14.6% of all patients with ATAAD treated during the same period. 35.5% (50 of 141) of these cases were associated with HTAD. Among them, only 16.0% were aware of their condition prior to the occurrence of ATAAD. Most patients underwent extensive arch procedures and in-hospital mortality rate of patients was 14.2%, which was higher in the HTAD group than in the non-HTAD group (20.0% vs. 11.0%, p = .142). The overall 7-year survival was 80.0%. Twenty patients required late aortic reoperations, with emergency surgeries accounting for 45% of the cases. The incidence of reoperation was significantly higher in the HTAD group than that in the non-HTAD group (p = .03). In addition, the late aortic reoperation remained a risk factor for long-term survival after adjusting for clinical factors.

CONCLUSIONS

The prevalence of HTAD is high in the cohort of younger patients with ATAAD. HTAD is associated with high rates of in-hospital mortality and late reoperation. Extensive primary aortic repair is safe and has long-term benefits in young patients with ATAAD. Regular imaging assessment of the thoracoabdominal aorta after surgery is imperative for improving the long-term prognosis.

Association of thrombocytopenia and D-dimer elevation with in-hospital mortality in acute aortic dissection

BACKGROUND

Data on the association between the degree of platelet and coagulative-fibrinolytic variables abnormalities and the risk of in-hospital mortality in acute aortic dissection (AAD) are limited.

MATERIALS AND METHODS

This multicentre retrospective cohort study included patients diagnosed with AAD by aortic computed tomographic angiography between 2010 and 2021 in five tertiary hospitals in China. The primary outcome was defined as all-cause mortality during hospitalization. Associations between platelet counts, coagulation-fibrinolytic parameters and all-cause in-hospital mortality were assessed using Cox proportional hazards regression models.

RESULTS

Among the 2567 participants, the median age was 54 years (interquartile range, IQR: 47-63); 531 (20.7%) were female, and the in-hospital mortality rate was 589 (23.0%). The Cox proportional hazards regression model indicated that lower platelet count, prothrombin activity (PTA), and fibrinogen levels and longer prothrombin time (PT) and thrombin time (TT) were linearly positively associated with an increased risk of in-hospital mortality (p < 0.05). A non-linear and positive association was confirmed between D-dimer levels and in-hospital mortality risk (p < 0.05). Additionally, a significant interaction between platelet counts and D-dimer levels was observed (p = 0.029). According to the subgroup analysis, compared to those in the reference group, those with thrombocytopenia (<140 × 109/L) and high D-dimer levels (>14.6 µg/mL) had a 3.59-fold increased risk of in-hospital mortality (HR, 3.59; 95% CI, 2.00-6.42).

CONCLUSIONS

Our analysis revealed associations between changes in platelet count, PT, PTA, TT, fibrinogen and D-dimer levels and outcomes in patients with AAD. Furthermore, the combined effect of thrombocytopenia and high D-dimer levels significantly increased the risk of in-hospital mortality.

Lipopolysaccharide amplifies the endocytosis of circulating exosomes derived from aortic dissection patients by the endothelial cells via a JMJD6 dependent manner

AIM

The underlying mechanism of endothelial dysfunction during the aortic dissection (AD) remains unclear. The present study is aimed to uncover the intrinsic mechanism regulating the endocytosis of circulating exosomes by endothelial cells after AD takes place.

MATERIAL AND METHODS

Circulating exosomes extracted from both AD-patients and healthy donors (HD) were characterized and applied to human umbilical vein endothelial cells (HUVECs) in vitro with or without the co-exposure of lipopolysaccharide (LPS). The endocytosis of exosomes and inflammatory severity were evaluated. Besides, the JMJD6 expression pattern was explored, and si-RNA to knock down the JMJD6 expression was performed to test its role in exosome endocytosis.

KEY FINDINGS

Here, it was firstly shown that circulating exosomes of the AD patients were statistically higher than the HD. In vitro, the endocytosis of both AD- and HD-exosomes was both enhanced under the co-existence of the LPS, and the uptake of AD-exosomes instead of the control exosomes further worsened the LPS-induced cell injury and gene transcriptions of serial pro-inflammatory cytokines through the p65 signaling. Notably, LPS challenged ECs exhibited increased JMJD6 expression, and silencing JMJD6 effectively decreased the LPS enhanced exosome endocytosis, and attenuated the LPS + AD-exosomes induced cell pro-inflammatory injury.

SIGNIFICANCE

The findings above indicate that LPS co-exposure enhances the AD-exosomes endocytosis by the ECs and further aggravates the inflammatory injury; Targeting on the cellular JMJD6 shall mitigate AD-exosomes endocytosis, which might serve as a potential therapeutic approach for the endothelial dysfunction.

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.

Exploring disease perception and experiences of postoperative patients with Stanford type A aortic dissection: a qualitative study

BACKGROUND

Stanford type A aortic dissection (TAAD) is a critical cardiovascular emergency characterized by acute onset, rapid progression, severe clinical manifestations, high mortality rates, and frequent complications. Patient's postoperative experiences are closely linked to their physical and mental health. Therefore, understanding their illness experience is essential to facilitate recovery.

OBJECTIVE

This study aimed to explore disease perception and postoperative experience of TAAD patients through semi-structured interviews, providing a formulation for developing standardized postoperative management protocols.

METHODS

A phenomenological qualitative study was conducted in the cardiac and vascular surgery department of a tertiary hospital in Ningxia Hui Autonomous Region between January and May 2023. Purposive sampling was used to recruit postoperative TAAD patients. Semi-structured interviews were conducted to explore disease perception and experiences. Interview data were analyzed using Colaizzi's seven-step analysis.

RESULTS

A total of 16 patients were interviewed. Based on the interview data, 296 codes were extracted and pooled into 17 subthemes, which were finally integrated into 4 themes related to disease perception and experiences: significant symptom burden, complex and varied psychological experiences, different coping styles, and diverse needs for health services.

CONCLUSION

Postoperative TAAD patients face numerous health challenges. Healthcare providers should closely monitor physical symptoms, systematically address psychological fluctuations, develop targeted interventions based on identified coping patterns, and design patient-centered care models to address unmet needs. These strategies may alleviate adverse experiences and enhance rehabilitation outcomes.

Outcomes of a Standardized Protocol on the Management of Acute Type A Aortic Dissection: A Retrospective Cohort Study

Acute Type A aortic dissection (AAAD) is a life-threatening condition, with surgery being the recommended treatment. However, there is ongoing debate regarding the optimal surgical procedure. This study aimed to evaluate the impact of implementing a standardized protocol, introduced in our institution in 2016, on AAAD management.A retrospective cohort study was conducted involving patients treated surgically for AAAD between 2010 and 2021 in our department. Patients were divided into two groups: those who underwent surgery before 2016 using operator-dependent techniques, and those who underwent surgery starting in 2016 using a standardized protocol.A total of 104 patients were included in this study. The mean age was 66.5 ± 11.4 years and 55.8% were male. Demographics and preoperative data were similar in both groups. Arterial and venous cannulation site of both groups were different (p < 0.001): femoral artery and vein cannulation for group 1 versus subclavian artery and central venous canulation for group 2. Alone ascending aorta replacement versus ascending aorta plus hemiarch replacement were the preferred techniques in groups 1 and 2, respectively (p < 0.001). Hypothermic circulatory arrest and cerebral perfusion were largely performed in group 2 compared with group 1 (p < 0.001). The total time of surgery, the cardiopulmonary bypass, and aortic cross-clamping times were longer in group 2 (p < 0.05). Both groups had similar rates of postoperative complications, except for late reoperation and aortic dilatation rates, which were less frequent in group 2 (p < 0.05).The implementation of a standardized institutional protocol can transform AAAD surgery from a "surgeon-tailored" to a " patient-tailored" approach. The use of a standardized protocol in our institution resulted in a significant reduction of aortic reoperation and aortic dilation rates, suggesting that the introduction of standardized protocols in low-volume centers may improve AAAD management.

Oral Acid-Activated Hydrogen-Producing Nanoparticles Reduce Aortic Dissection Progression via RhoA/ROCK Inhibition in Mice

Aortic dissection (AD) is a life-threatening condition with a high mortality rate. Oxidative stress and endothelial and vascular smooth muscle cell migration contribute to AD pathogenesis. Herein, we investigated the therapeutic potential of hydrogen (H2), delivered via magnesium diboride nanosheets (MBNs), in a murine model of β-aminopropionitrile-induced AD. This treatment significantly improved survival rate and reduced AD progression, as evidenced by improved aortic wall structure and reduced false lumen formation. Transcriptomic analysis indicated modulation of the RhoA/ROCK pathway, confirmed using Western blotting, immunohistochemistry, and immunofluorescence, which showed significant downregulation of RhoA and ROCK2 after 28 days of treatment (P < 0.05). These findings suggest that hydrogen released from MBNs attenuates AD progression through reactive oxygen species scavenging and RhoA/ROCK pathway inhibition.

Delayed Diagnosis and Outcomes in Acute Aortic Dissection: A 10-Year Single-Center Retrospective Study

Introduction

Acute aortic dissection is a rare and life-threatening condition with highly variable clinical presentations, often resulting in atypical symptoms and initial misdiagnosis. This study aimed to investigate clinical presentations and explore the associations between clinical characteristics, delayed diagnosis, and in-hospital mortality among patients with acute aortic dissection.

Methods

A retrospective chart review was performed on patients presenting with acute aortic dissection at an urban academic emergency department in Thailand between January 1, 2011, and December 31, 2020. Baseline characteristics, clinical presentations, imaging findings, delayed diagnosis (>4 h from first emergency department contact), and in-hospital mortality rates were analyzed.

Results

The study included 103 patient charts, predominately men (71 patients), with a median age of 71 years (interquartile range of 58-78 years). Abdominal pain (36.9%) and thoracic pain (24.3%) were the most common presenting symptoms. Dyspnea (11.7%), altered consciousness (4.9%), and syncope (4.9%) were the three main painless presenting atypical symptoms. Atypical presentations were not significantly associated with delayed diagnosis, which occurred in 27.2% of cases. Normotension, a history of coronary artery disease, and pleural effusion were associated with delayed diagnosis. Abnormal chest films were major risk factors for in-hospital mortality, observed in 22.3% of patients with acute aortic dissection, whereas delayed diagnosis was not directly related to such mortality.

Conclusion

The incidence of acute aortic dissection in the urban Thai population was 32.4 per 100,000 patient-years, with a range of clinical presentations. A high index of suspicion for AAD is crucial for timely diagnosis, even in patients with atypical symptoms and seemingly normal vital signs. Careful interpretation of chest radiographs is essential as abnormal chest X-ray findings are associated with a poorer prognosis.

Sex differences in hospital outcomes of medically-managed type B aortic dissection

Background

Medical management is recommended for uncomplicated type B aortic dissection (TBAD). However, data focused on sex differences in outcomes in TBAD patients managed medically are limited.

Methods

Hospitalizations of adults with TBAD were identified using the 2016-2019 Nationwide Readmissions Database. TBAD diagnosis was deduced by inclusion of thoracic or thoracoabdominal aorta dissection and exclusion of presumed type A aortic dissection. Hospitalizations associated with intervention were excluded. Multivariable logistic regression modeling was used to investigate the association of sex with in-hospital mortality. A Cox proportional hazards model was used to assess the association between sex and readmission rates.

Results

There were 52,269 TBAD hospitalizations (58% male). Compared to men, women were older (72 vs. 65 years), had higher in-hospital mortality (11.5% vs. 8.5%), shorter median length of stay (3.95 vs. 4.23 days), and lower rates of elective admissions (6.4% vs. 8.2%) (all p < 0.05). Despite similar rates of hypertension, lower rates of coronary artery disease and smoking, and decreased rates of hospital-related complications, women experienced increased adjusted in-hospital mortality (odds ratio: 1.16; 95% CI, 1.06-1.27). There were no sex differences in readmission risk at 30, 90, and 180 days.

Conclusions

Women with TBAD managed medically experienced higher in-hospital mortality than men despite lower rates of atherosclerotic disease and risk factors. However, there were no sex differences in readmission risk at 30, 90, and 180 days. Prior research has demonstrated sex differences in presenting TBAD characteristics, including older age, varied signs/symptoms, and diagnostic delay in women. Data are needed to delineate additional causes of adverse acute outcomes in women managed medically, including condition- and medication-specific factors.

Predictive factors of early mortality in patients with type A aortic dissection: association between pulmonary artery adventitial hematoma and type A aortic dissection

OBJECTIVES

Pulmonary artery adventitial hematoma (PAAH) is a potential complication of aortic dissection (AD) that has been shown to have a deleterious effect on prognosis. However, the specific relationship between PAAH secondary to the rupture of type A AD with early mortality has not been fully characterised. We aimed to evaluate the relationship betweeen PAAH and the short-term prognosis of patients with this condition, and to determine how PAAH impacts the prognosis of patients with type A AD compared with other complications of type A AD.

METHODS

We retrospectively studied 344 patients with type A AD who were hospitalised at a single institution (164 men and 180 women with a mean [SD] age of 71.0 [12.6] years). These patients were allocated to two groups, comprising those who died within 1 week of the onset of symptoms (early mortality group; n = 33) and those who survived (survival group; n = 311). PAAH was classified according to the CT findings as stage 1 (only in the mediastinum), stage 2 (extending into the lung field ± the interlobular septa), or stage 3 (extending into the alveoli).

RESULTS

The patient cohort was comprised of 90 (26.2%) patients with PAAH of 344 patients with type A AD. 16 (48.5%) of 33 patients had PAAH in the early mortality group, and 74 (23.8%) of 311 patients had PAAH in the survival group. The early mortality group had higher prevalences of PAAH (p = 0.002), stage 3 PAAH (p < 0.001), pericardial haemorrhage (p = 0.001), mediastinal haemorrhage (p < 0.001), haemothorax (p < 0.001), renal ischaemia (p = 0.002), limb ischaemia (p = 0.001) and myocardial ischaemia (p = 0.004) than the survival group. Furthermore, multivariate analysis showed that age (p = 0.002), stage 3 PAAH (p < 0.001), limb ischaemia (p = 0.010), and myocardial ischaemia (p = 0.001) were risk factors for early mortality.

CONCLUSIONS

PAAH is not a rare complication of type A AD, and stage 3 PAAH is a risk factor for early mortality.

KEY POINTS

Question PAAH due to ruptured type A AD can occur and has been reported to correlate with prognosis. Findings PAAH is not a rare complication of Stanford type A AD, and Stage 3 PAAH is a risk factor with the greatest prognostic value on early mortality. Clinical relevance Knowing that PAAH often occurs with type A AD can help us avoid misdiagnosing stage 3 PAAH as pneumonia or pulmonary oedema.

Transcriptome Insights into Protective Mechanisms of Ferroptosis Inhibition in Aortic Dissection

Aortic dissection (AD) is a life-threatening vascular condition with limited pharmacological options, and shared risk factors with cardiac disease include hypertension, atherosclerosis, smoking, and dyslipidemia. This study investigated Ferrostatin-1 (Fer-1), a ferroptosis inhibitor, in a BAPN/Ang-II-induced mouse model of AD, revealing significant therapeutic potential. Fer-1 significantly reduced AD incidence and mortality by preserving aortic wall integrity. RNA sequencing identified 922 differentially expressed genes, with 416 upregulated and 506 downregulated. Bioinformatics analysis revealed that Fer-1 modulates key regulators, such as MEF2C and KDM5A, impacting immune responses, oxidative stress, apoptosis, and lipid metabolism. Additionally, Fer-1 alters miRNA expression, with the upregulation of miR-361-5p and downregulation of miR-3151-5p, targeting pathways involved in inflammation, oxidative stress, and smooth muscle cell (SMC) phenotypic stability. Functional pathway analysis highlighted the inhibition of actin cytoskeleton, ILK, and IL-17 signaling, essential for SMC differentiation and extracellular matrix remodeling. Gene interaction network analysis identified 21 central molecules, including CXCR3, ACACA, and BPGM, associated with lipid metabolism, inflammation, and vascular remodeling. This research elucidates the mechanism of ferroptosis in AD pathogenesis and establishes Fer-1 as a promising therapeutic intervention. AD and cardiac diseases share molecular mechanisms, risk factors, and pathological processes, positioning AD within the broader scope of cardiovascular pathology. By attenuating lipid peroxidation, oxidative stress, and inflammation, Fer-1 may have cardioprotective effects beyond AD, providing a foundation for future translational research in cardiovascular medicine.

Acute thrombolysis in a patient with Type A aortic dissection and critical leg ischemia in an Arctic country

A man in his early 50s presented at a remote hospital in Arctic Greenland with sudden severe chest and back pain, followed by critical ischemia in the right leg. Bedside ultrasound showed cessation of Doppler flow in the femoral artery, while ECG was normal. Aortic dissection was suspected, but lacking CT-scanner, MRI-scanner, or transesophageal ultrasound, the diagnosis could not be confirmed. The patient was treated symptomatically with thrombolysis for suspected femoral artery thrombosis. Overnight, the right leg regained color and pulses. The next day, weather circumstances allowed transfer to a secondary hospital, and CT-angiography showed a Type A aortic dissection extending from the aortic valve to both femoral arteries. Thrombolysis was stopped, and the patient was transferred and underwent surgery abroad at a specialized hospital. Despite 55-hour delay, the patient had a favorable outcome, returning to work 8 weeks post-surgery. This case highlights the diagnostic challenges in remote settings.

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.

Critical Review of Guidelines for Type B Aortic Dissection

The management of type B aortic dissection is one of the most challenging and debated topics in contemporary cardiovascular surgery practice. Patients with acute or chronic dissection-related complications face high morbidity and mortality if not treated promptly. For most patients requiring intervention, thoracic endovascular aortic repair (TEVAR) is considered the gold standard. However, both early and late TEVAR-related complications make decision-making complex, even for experienced clinicians. In many cases, optimal medical management with longitudinal imaging surveillance may be preferred. In response to these challenges, several societal guidelines have recently been published to provide evidence-based or expert consensus "best practice" recommendations. Although these guidelines share many commonalities, they also highlight key unresolved clinical questions. For example, debates persist over the appropriate use of TEVAR for "uncomplicated" TBAD, defining "high-risk" criteria for uncomplicated presentations, and management of the false lumen, among other topics. Despite recent updates, a critical evaluation of the nuanced differences between these guidelines is lacking. Therefore, the purpose of this review is to compare current clinical practice guidelines, highlight their similarities and differences, and offer a comprehensive evaluation of the evidence surrounding management of TBAD. Moreover, this analysis will provide recommendations to address important knowledge gaps.

Future Paradigms of Aortic Dissection

Acute type A dissection remains a challenging disease to manage, which is associated with high morbidity and mortality both at presentation and in the chronic setting. This article reviews contemporary debates in operative management, summarizes the currently accepted standard of care, and explores the optimal extent of aortic repair given the high rate of long term aortic degeneration.

Aortic Dissection: Diagnosis

A timely diagnosis of aortic dissection can be lifesaving given its deadly nature. A high index of suspicion should be maintained because patient presentation can mimic other common emergency room complaints. The gold standard diagnostic test is a computed tomography angiogram from the thoracic inlet to the femoral arteries which identifies aortic dissection with excellent accuracy. Echocardiography should be used to assess aortic valve function and to evaluate for pericardial effusion. A finding of aortic dissection should prompt a thorough investigation for its sequelae including malperfusion and/or rupture which should guide further workup with appropriate laboratory and imaging studies.

Current Management of Uncomplicated Type B Aortic Dissection

Aortic dissection is the most common thoracic aortic emergency and is associated with significant morbidity and mortality. Initial complications are dependent on reduction of sheer stress against the aortic wall to protect against rupture and minimize progression of the aortic wall injury. In patients with dissection starting at or distal to the left subclavian artery (Stanford type B), initial management includes strict blood pressure and heart rate control with monitoring for any complications such as malperfusion, rupture, or hemodynamic instability. Following the acute dissection event, survivors are faced with the lifelong need for blood pressure control and surveillance imaging to monitor for potential aortic deterioration leading to rupture or aneurysm formation. This review will discuss the latest recommendations for current management of uncomplicated type B aortic dissection including the evolving role of endovascular therapies.

Recommendations for Design, Execution, and Reporting of Studies on Experimental Thoracic Aortopathy in Preclinical Models

There is a recent dramatic increase in research on thoracic aortic diseases that includes aneurysms, dissections, and rupture. Experimental studies predominantly use mice in which aortopathy is induced by chemical interventions, genetic manipulations, or both. Many parameters should be deliberated in experimental design in concert with multiple considerations when providing dimensional data and characterization of aortic tissues. The purpose of this review is to provide recommendations on guidance in (1) the selection of a mouse model and experimental conditions for the study, (2) parameters for standardizing detection and measurements of aortic diseases, (3) meaningful interpretation of characteristics of diseased aortic tissue, and (4) reporting standards that include rigor and transparency.

Cabrol Procedure in Complex Aortic Root Reconstruction: A Case Series of Three Young Patients With Acute Aortic Syndrome

Acute aortic dissection is a rare but life-threatening syndrome, being accompanied by a mortality rate of 1%-2% per hour after the onset of symptoms if they remain untreated. The definitive therapy for type A acute aortic dissection is considered to be emergency surgery. However, the optimal method for aortic root reconstruction has been a controversial issue. This study presents three cases of acute thoracic aortic dissection (TAD) accompanied by complicated aortic root anatomy. These critical conditions were managed successfully with the Cabrol procedure. In this procedure, the coronary ostia are anastomosed to a second graft in an end-to-end fashion, which is then connected side to side with the ascending aorta. A 2-year follow-up of patients showed they had no new signs or symptoms or reemergence of them during this period. Follow-up transthoracic echocardiography (TTE) and computed tomography angiography (CTA) of the aorta showed no evidence of obstruction or complications of Cabrol and aortocoronary anastomosis. Although the modified Bentall procedure using coronary ostial aortic "buttons" may produce superior results and currently represents the standard of care for aortic root reconstruction, the Cabrol procedure can be considered a clinically valuable rescue procedure in patients whose management becomes more complicated due to anatomic difficulties.

Association of hyperuricaemia and hyperglycaemia with risk of in-hospital mortality in acute aortic dissection: a multicentre cohort study in the Han Chinese population

OBJECTIVE

The objective is to investigate the association of hyperuricaemia and hyperglycaemia with an increased risk of mortality in acute aortic dissection (AAD).

DESIGN

Retrospective multicentre cohort study.

SETTING

De-identified information of patients was collected from electronic medical records between 2010 and 2021 across five hospitals in China.

PARTICIPANTS

A total of 2603 AAD patients from 5337 patients who underwent arterial aortic computed tomographic angiography were selected after three rounds of screening.

MAIN OUTCOME MEASURE

All-cause in-hospital mortality.

RESULTS

Of the 2603 patients, 20.3% were women, and the mean age was 54 years old. In-hospital mortality risk escalated linearly with increased levels of uric acid (P non-linearity=0.1699) and serum glucose (P non-linearity=0.2423). The per SD of increment in uric acid was associated with 40% (1.40, 1.22 to 1.60) in HR and 95% CI of AAD all-cause in-hospital mortality and 39% (1.39, 1.22 to 1.58) in serum glucose after full adjustment. Patients with a decrease in uric acid and/or serum glucose within the 7 days preceding admission showed significantly lower in-hospital mortality compared with those without a decrease. Notably, patients exhibiting both hyperuricaemia and serum glucose>180.2 mg/dL faced over double mortality risk (2.21, 1.58 to 3.10) compared with those with normal uric acid and normal serum glucose levels.

CONCLUSIONS

Hyperuricaemia and hyperglycaemia are significantly associated with an increased risk of mortality among AAD patients in the Han Chinese population. These findings suggest the importance of monitoring and managing uric acid and glucose levels in AAD patients to potentially improve outcomes.

Predictive value of inflammatory indexes in in-hospital mortality for patients with acute aortic dissection

BACKGROUND

The purpose of this study was to assess the relationship between admission inflammatory indexes neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), and systemic immune-inflammation index (SII), and the risk of in-hospital all-cause mortality in acute aortic dissection (AAD) patients.

METHODS

A retrospective analysis was conducted on 597 AAD patients (Stanford classification: Stanford type A 365 patients, Stanford type B 232 patients) at a single center. Outcomes were the incidence of in-hospital all-cause mortality. The risk of all-cause death was compared between the groups with low and high inflammatory indexes using the Kaplan-Meier curve. The association between admission inflammatory indexes and outcomes was evaluated using the Cox regression model and restricted cubic splines (RCS). Stratified analysis was performed based on AAD type, age (< 50 years or ≥ 50 years), and gender.

RESULTS

The Kaplan-Meier curves revealed statistically significant differences in outcomes among the low and high inflammatory indexes groups. Cox regression analysis revealed that the in-hospital mortality risk was significantly high in the high inflammatory index groups. MLR was the strongest associated with in-hospital mortality risk. The RCS curve revealed that NLR was non-linearly and J-shaped correlated with in-hospital mortality, and MLR and SII were linearly correlated with in-hospital mortality. Stratified analysis showed interactions between NLR, MLR, and SII and AAD type and age for the risk of in-hospital mortality.

CONCLUSION

Admission high inflammatory indexes were independently associated with an increased risk of in-hospital all-cause mortality in AAD patients. The inflammatory indexes NLR, MLR, and SII may be useful indicators for predicting in-hospital all-cause mortality in AAD patients.

Estrogen Inhibits the Phenotypic Switching of Vascular Smooth Muscle Cells through ER-α/CREB in Aortic Dissection

Objective: To examine the alterations in estrogen levels in patients with aortic dissection (AD) and its protective effect on AD patients through the inhibition of vascular smooth muscle cells (VSMCs) phenotypic switching via the ER-α/CREB pathway. Methods: Demographic data were collected to assess sex disparity in AD patients, and serum 17β-estradiol (E2) levels were measured using ELISA. Phenotypic switching markers were analyzed in aortic tissues from AD patients and controls. Bioinformatics analysis identified estrogen-related pathways, focusing on the ER-α/CREB axis, with expression levels confirmed via immunohistochemistry and Western blot. AD mouse models were developed in male and ovariectomized female mice, with the effects of E2 supplementation on AD progression and VSMCs phenotypic switching evaluated. An AD cellular model was also employed to verify these findings through targeted pathway inhibition. Results: AD prevalence was higher in males, with reduced serum E2 levels observed in both male and postmenopausal female patients. Ovariectomized female mice showed increased AD incidence, while E2 supplementation reduced AD progression by inhibiting the phenotypic switching of VSMCs. Downregulation of ER-α and p-CREB/CREB expression was observed in AD patients, and E2 enhanced ER-α expression and CREB phosphorylation, preventing VSMC phenotypic switching. E2 also promoted ER-α/CREB interaction, and silencing ER-α inhibited CREB phosphorylation, leading to increased VSMC phenotypic switching. Conclusions: Estrogen (E2) plays a crucial role in preventing AD by maintaining VSMCs synthetic phenotype through the ER-α/CREB signaling pathway, providing a protective effect against the development of AD.

S100A8/A9 high-expression macrophages mediate renal tubular epithelial cell damage in acute kidney injury following acute type A aortic dissection surgery

Background

Acute kidney injury (AKI) is a major complication after acute type A aortic dissection (ATAAD), with an incidence rate of 20-66.7%. Many patients with AKI after ATAAD surgery show no clear signs of ischemia-reperfusion injury. In our previous study, S100A8 and S100A9 were identified as predictive biomarkers of AKI after ATAAD surgery. These proteins are primarily expressed in neutrophils and macrophages, where they contribute to cell damage and immune cell activation. However, the roles of S100A8/A9 in ATAAD-associated AKI remain unclear.

Methods

In this study, transcriptomics sequence was applied to identify differentially expressed genes in renal tubular epithelial cells (TCMK-1), stimulated by culture supernatant of S100A8/A9 overexpressed and downregulated RAW264.7 cells. Single-cell sequencing data were used to identify cell clusters with high S100A8/A9 expression. Cross-analysis between RNA sequencing datasets was used to investigate common pathways enrichment in both in vitro and in vivo models. Molecular biology experiments were used to explore the downstream signaling pathways of S100A8/S100A9.

Results

We found that S100A8/S100A9 expression levels were increased and co-localized primarily with macrophages in the kidneys of AKI mice. Marker genes of M1-type macrophages, like Nos2 and Il1b, were upregulated in S100A8/A9 overexpressed M1-type macrophages, while the opposite was observed in the downregulated group. In transcription sequencing results, TCMK-1 cells stimulated by the supernatant from S100A8/A9 overexpressed and downregulated RAW264.7 cells can activate the TNF and PPAR pathway respectively. Cross-analysis revealed that the TNF signaling, IL-17 signaling, and other inflammatory pathways were enriched in both S100A8/A9-related renal tubular epithelial cell impairment and other AKI sequencing datasets. Finally, recombinant protein S100A8/A9 activated the TNF signaling pathway in renal tubular epithelial cells.

Conclusion

These findings suggested that S100A8/A9 were promising predictive biomarkers for AKI after surgery for ATAAD. S100A8/A9 were upregulated and primarily localized in renal macrophages, where they promoted the transformation of macrophages into the M1 phenotype. S100A8/A9 overexpressed macrophages activated the TNF signaling pathway through secretion and direct interaction with renal tubular epithelial cells, highlighting the critical role of TNF signaling in AKI after ATAAD surgery.

Causal relationship between mitochondrial proteins and risks of aortic aneurysms and aortic dissection: a Mendelian randomization study

BACKGROUND

Mitochondrial dysfunction may be linked to the development of aortic aneurysm (AA) and aortic dissection (AD). This study aimed to evaluate the potential associations between proteins related to mitochondrial function and the risks of AA/AD using Mendelian randomization (MR).

METHODS

Large-scale publicly available genome-wide association studies (GWAS) and FinnGen summary data were utilized for MR analysis. The causal relationship between mitochondrial proteins and AA/AD was assessed using inverse-variance weighted (IVW) as the primary method. Sensitivity analyses were conducted to detect heterogeneity and pleiotropy by Cochran's Q test, MR-Egger test, MR-PRESSO global test, and "leave-one-out" analysis.

RESULTS

There were potential causal relationships between several mitochondrial proteins and AA/AD. Specifically, the iron-sulfur cluster assembly enzyme ISCU (OR = 1.165, 95% CI: 1.051-1.291, P = 0.004) and NFU1 iron-sulfur cluster scaffold homolog (OR = 1.184, 95% CI: 1.056-1.329, P = 0.004) were identified as potential risk factors for AA; whereas the 39 S ribosomal protein L14 (OR = 0.868, 95% CI: 0.764-0.987, P = 0.031) was found to be a protective factor for AA. Furthermore, 39 S ribosomal protein L33 (OR = 1.134, 95% CI: 1.010-1.274, P = 0.033) and cytochrome C oxidase subunit 5B (OR = 1.330, 95% CI: 1.037-1.706, P = 0.025) were associated with increased risks of AD; whereas the 39 S ribosomal protein L52 (OR = 0.736, 95% CI: 0.550-0.984, P = 0.038) and mitochondrial ubiquitin ligase activator of NFKB 1 (OR = 0.806, 95% CI: 0.656-0.989, P = 0.039) were identified as potential protective factors for AD. Sensitivity analysis confirmed the stability of the results.

CONCLUSIONS

This study identified potential genetic associations between mitochondrial proteins and AA/AD. Targeting these mitochondrial proteins may help prevent the occurrence of AA/AD.

Cardiac Tamponade Complicating Type A Acute Aortic Dissection: Insights From 25 Years of Registry Research

BACKGROUND

Cardiac tamponade (TMP) is a catastrophic complication of type A acute aortic dissection (TAAAD), increasing the risk of morbidity and mortality.

OBJECTIVES

The present study aimed to assess the characteristics, management, and outcomes of TAAAD patients with preoperative TMP enrolled in the International Registry of Acute Aortic Dissection database from 1996 to 2022.

METHODS

Data from 63 aortic centers were analyzed and TAAAD patients with and without preoperative TMP were compared. Multivariable modeling to assess factors associated with the presence of preoperative cardiac TMP and survival curves were performed. Overall median follow-up was 35.8 months (Q1-Q3: 11.6-59.4 months).

RESULTS

Of the 6,014 patients with TAAAD in the International Registry of Acute Aortic Dissection during the 25-year study period, 865 individuals (14.4%) developed TMP. Patients with TMP were older (age 64.9 vs 60.8 years; P < 0.0001) and less often male (61.8% vs 66.8%; P = 0.005). No differences were seen in time to presentation or diagnosis. Prior cardiac surgery was less common in patients with TMP (7.6% vs 12.8%; P < 0.0001). Syncope (37.4% vs 13.4%; P < 0.0001) and coma or altered consciousness (28% vs 8%; P < 0.0001) on presentation were more frequent in the TMP group. The majority of the cohort were managed surgically, rates of which were similar between groups (87.5% vs 87.7%; P = 0.911). In-hospital mortality was higher in patients with TMP (38.4% vs 15.4%; P < 0.001) but 4-year survival was similar (log-rank P = 0.767).

CONCLUSIONS

TMP is an important prognosticator of in-hospital mortality. It is associated with increased mortality of TAAAD and prompt surgery is required. Those who survive the hospital course, go on to share the same postdischarge course as those who did not have TMP.

Low rates of aortic surveillance imaging and clinical follow-up in patients with acute aortic dissection

OBJECTIVE

Patients that survive acute aortic dissection (AD) remain at high risk of morbidity/mortality from structural changes of the aorta. Aortic surveillance is challenging, especially within a tertiary referral center. Our aim was to identify follow-up imaging and appointment rates, and factors associated with incomplete surveillance in patients with acute AD.

METHODS

This was a single-center, retrospective study of acute AD patients at a tertiary care center from July 2012 to December 2022 who lived at least 1 year after AD. We defined complete surveillance as having computed tomography scans or magnetic resonance imaging scans of the chest and abdomen at 1 month (±14 days), 6 months (±1.5 months), 1 year (±3 months), and yearly thereafter. Data were obtained from the electronic health record. Predictors of absent imaging at the 1 year (±3 months) timepoint were evaluated using multivariable logistic regression.

RESULTS

Of the 272 patients in the study, 63.2% were male and 39.3% were White. The average age was 60.7 ± 14.7 years. Acute type A AD comprised 47.1% of our cohort; 91.4% underwent open repair within 1 week of presentation. Of the acute type B AD patients (52.9% of the cohort), 41.7% underwent thoracic endovascular aortic repair at the index admission. At the 1-year follow-up interval (±3 months), 26.5% were confirmed to have undergone aortic surveillance imaging, and 27.6% had an appointment with a cardiovascular specialist. Only 9.6% of the cohort was fully concordant with the recommended surveillance imaging in the first year of follow-up. On multivariate regression, non-English speakers (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.05-3.99; P = .03) and residence outside of hospital region (OR, 1.66; 95% CI, 1.02-3.17; P = .04) were independently-associated with lack of follow-up imaging at the 1-year timepoint, whereas longer length of stay was independently-associated with completed imaging at the 1-year timepoint (OR, 0.78; 95% CI, 0.41-0.89; P = .04).

CONCLUSIONS

This study highlights a low rate of surveillance and clinical follow-up for patients with acute AD and a significant disparity for non-English speaking patients and those who reside outside of the hospital region. This information should inform future quality initiatives to improve aortic surveillance following AD.

Aortic Dissection Incidence and Risk Factor Analysis: Findings from the China Kadoorie Biobank

OBJECTIVE

Data on the incidence of aortic dissection (AD) from population based prospective studies are scarce and its risk factors are not well studied in China. The aim of this study was to investigate the relatively accurate incidence of AD in ten regions of China and to identify its potential risk factors using a population based prospective study.

METHODS

Data from a prospective cohort study involving ∼510 000 middle aged adults in ten regions of China from 2004 - 2008 (the China Kadoorie Biobank) were used. The incidence of AD was calculated and the association between potential risk factors (body mass index [BMI], hypertension, and diabetes) and the occurrence of AD was evaluated using competing risk analysis.

RESULTS

The study included 512 724 participants (59.0% female, median age 51.5 years). During a median follow up of 121 months, 119 participants developed AD. The incidence of AD was 2.35 (95% confidence interval [CI] 1.93 - 2.77), 3.97 (95% CI 3.10 - 4.83), and 1.25 (95% CI 0.86 - 1.65) per 100 000 person years for the whole cohort, male participants, and female participants, respectively. Competing risk analysis identified female sex (hazard ratio [HR] 0.35, 95% CI 0.24 - 0.52; p < .001) and hypertension (HR 6.21, 95% CI 3.94 - 9.80; p < .001) as independent predictors of AD. BMI, diabetes, and random blood glucose were not associated with AD.

CONCLUSION

In contrast to previous data and clinical observations, there was no significant correlation between diabetes (or random blood glucose) or BMI and the occurrence of AD. Male sex and hypertension were independently associated with the occurrence of AD.

Distal anastomosis new entry tear in acute type A aortic dissection: A risk factor for distal aortic reoperation

Objective

To identify predictive factors for the occurrence of a distal anastomosis new entry tear (DANE) in patients who underwent hemiarch replacement after acute type A aortic dissection (ATAAD) and examine the association of DANE with distal aortic reoperation.

Methods

Between 1996 and March 2021, 434 patients underwent hemiarch replacement for DeBakey I ATAAD, of whom 327 patients had adequate postoperative imaging. Based on the presence of DANE on postoperative computed tomography angiography, patients were divided into the DANE group (n = 81) and the no-DANE group (n = 246). Primary outcomes were the cumulative incidence of distal aortic reoperation and the risk factors for DANE.

Results

Most perioperative characteristics and outcomes, including age, sex, malperfusion syndromes, aortic diameters, and operative mortality were similar in the 2 groups. Using death as a competing factor, the 10-year cumulative incidence of distal aortic reoperation was higher in the DANE group compared to the no-DANE group (30% vs 12%; P = .0001). The hazard ratio for DANE in distal reoperations was 2.28 (P = .005). A multivariable regression model showed that having an aortic surgeon was protective against DANE compared to having a nonaortic surgeon (odds ratio [OR], 0.29; P = .05) and identified branch dissection (OR, 2.42; P = .002) as a risk factor for the occurrence of DANE. Connective tissue disease and large-bore suture (4-0 vs 5-0) were not associated with DANE.

Conclusions

Optimizing surgical techniques to prevent DANE in ATAAD repair may prevent the need for reoperation on the distal aorta in DeBakey type I ATAAD.

Does Higher Temperature During Moderate Hypothermic Circulatory Arrest Increase the Risk of Paraplegia in Acute DeBakey I Aortic Dissection Patients?

BACKGROUND

In this study, we sought to assess the safety of high-moderate (24.1-28.0°C) and low-moderate (20.1-24.0°C) systemic hypothermia during circulatory arrest (MHCA) in patients with acute DeBakey I aortic dissection (DeBakey I AAD), particularly concerning spinal cord protection.

METHODS

From 2009 to 2020, 1759 patients with DeBakey I AAD who underwent frozen elephant trunk and total arch replacement surgery at a tertiary centre were divided into preoperative malperfusion (viscera, spinal cord, or lower extremities) and nonmalperfusion subgroups. The baseline differences were balanced with the use of propensity score matching. Prognoses were compared between those who were subjected to high-MHCA (nasopharyngeal temperature 24.1-28.0°C) and low-MHCA (nasopharyngeal temperature 20.1-24.0°C).

RESULTS

In the nonmalperfusion subgroup (n = 1389), 469 pairs of matched patients showed lower in-hospital mortality and incidence of acute kidney injury in the high-MHCA group than in the low-MHCA group: in-hospital mortality 7.0% vs 10.2% (P = 0.01); acute kidney injury, 57.1% vs 64.6% (P < 0.01). The duration of mechanical ventilation was shorter in the high-MHCA group than that in the low-MHCA group (P = 0.03). No significant difference in the incidence of paraplegia was observed between the 2 groups. In the malperfusion subgroup (n = 370), 112 pairs of matched patients showed a higher incidence of paraplegia in the high-MHCA group than in the low-MHCA group (15.9% vs 6.5%; P = 0.04).

CONCLUSIONS

The safety of high-MHCA, a commonly used temperature management strategy during aortic arch surgery, was recognised in most patients with DeBakey I AAD. However, among patients with preoperative distal organ malperfusion, low-MHCA may be more appropriate owing to an increased risk of postoperative paraplegia associated with high-MHCA.

Extracorporeal life support after surgical repair for acute type a aortic dissection: A systematic review and meta-analysis

BackgroundThe use of extracorporeal life support (ECLS) in patients after surgical repair for acute type A aortic dissection (ATAAD) has not been well documented.MethodsWe 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).ResultsTwelve 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.ConclusionECLS 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.

Development and Validation of a Novel Nomogram Risk Prediction Model for In-Hospital Death Following Extended Aortic Arch Repair for Acute Type A Aortic Dissection

Background

Extended aortic arch repair (EAR) is increasingly adopted for treating acute type A aortic dissection (ATAAD). However, existing prediction models may not be suitable for assessing the in-hospital death risk in ATAAD patients undergoing EAR. This study aims to develop a comprehensive risk prediction model for in-hospital death following EAR based on patient's preoperative status and surgical data, which may contribute to identification of high-risk individuals and improve outcomes following EAR.

Methods

We reviewed clinical records of consecutive adult ATAAD patients undergoing EAR at our institute between January 2015 and December 2022. Utilizing data from 925 ATAAD patients undergoing EAR, we employed multivariable logistic regression and machine learning techniques, respectively, to develop nomograms for in-hospital mortality. Employed machine learning techniques included simple decision tree, random forest (RF), eXtreme Gradient Boosting (XGBoost), and support vector machine (SVM).

Results

The nomogram based on SVM outperformed others, achieving a mean area under the receiver operating characteristic (ROC) curve (AUC) of 0.842 on training dataset and a mean AUC of 0.782 on testing dataset, accompanied by a Brier score of 0.058. Key risk factors included cerebral malperfusion, mesenteric malperfusion, preoperative critical station, Marfan syndrome, platelet count, D-dimer, coronary artery bypass grafting, and cardiopulmonary bypass time. A web-based application was developed for clinical use.

Conclusions

We develop a novel nomogram risk prediction model based on SVM algorithm for in-hospital death following extended aortic arch repair for ATAAD with good discrimination and accuracy.

Clinical Trial Registration

Registration number ChiCTR2200066414, https://www.chictr.org.cn/showproj.html?proj=187074.

GSDMD Deficiency Attenuates the Development of Ascending Aortic Dissections in a Novel Mouse Model

BACKGROUND

Mechanisms driving the development of type A aortic dissection (TAD) are currently poorly understood, and animal models of spontaneous TAD are limited. In the present study, we developed a novel mouse TAD model and evaluated the role of GSDMD (gasdermin D) in TAD development.

METHODS

TADs were created by treating the ascending aorta of adult C57BL/6J mice with Act E (active elastase) and β-aminopropionitrile. The temporal progress of the TAD pathology was rigorously characterized by histological evaluation and scanning electron microscopy, while potential mechanisms were explored using bulk RNA sequencing of specimens collected at multiple time points. With this novel TAD model, we conducted additional experiments to investigate the impact of GSDMD deficiency on TAD formation.

RESULTS

Ascending aortas challenged with Act E and β-aminopropionitrile developed pathology featuring the early onset of intimomedial tears (complete penetration) and intramural hematomas, followed by progressive medial loss and aortic dilation. Ingenuity pathway analysis and functional annotation of differentially expressed genes suggested that a unique inflammatory microenvironment, rather than general inflammation, promotes the onset of TADs by specifically recruiting neutrophils to the aortic wall. At later stages, T cell-mediated immune injury emerged as the primary driver of pathology. Gsdmd deficiency attenuated medial loss, adventitial fibrosis, and dilation of TADs. This protective effect correlated with a reduced cell death and decreased T-cell infiltration in TADs. Notably, cleaved GSDMD was detected in human TADs but was absent in healthy aortas.

CONCLUSIONS

A novel mouse TAD model was developed, specifically targeting the ascending aorta. This model generates a unique microenvironment that activates specific immune cell subsets, driving the onset and subsequent remodeling of TADs. Consistently, Gsdmd deficiency mitigates TAD development, likely by modulating cell death and T-cell responses. This model provides a valuable tool for studying immune injury mechanisms in TAD pathogenesis.

Enhanced machine learning models for predicting one-year mortality in individuals suffering from type A aortic dissection

OBJECTIVE

The study objective was to develop and validate an interpretable machine learning model to predict 1-year mortality in patients with type A aortic dissection, improving risk classification and aiding clinical decision-making.

METHODS

We enrolled 289 patients with type A aortic dissection, dividing them into a training cohort (202 patients) and a validation cohort (87 patients). The Least Absolute Shrinkage and Selection Operator method with 10-fold cross-validation identified 8 key factors related to 1-year mortality. The Treebag model's performance was assessed using accuracy, F1-Score, Brier score, area under the curve, and area under the precision-recall curve with calibration and clinical utility evaluated through decision curves. Shapley Additive Explanations analysis determined the most influential predictors.

RESULTS

The Treebag model outperformed others, achieving a Brier score of 0.128 and an area under the curve of 0.91. Key risk factors included older age and elevated white blood cell count, whereas higher systolic blood pressure, lymphocyte, carbon dioxide combining power, eosinophil, β-receptor blocker use, and surgical intervention were protective. A web-based application, TAAD One-Year Prognostic Risk Assessment Web, was developed for clinical use (available at https://taad-1year-mortality-predictor.streamlit.app/). This platform allows for the prediction of 1-year mortality in patients with type A aortic dissection based on the identified predictive factors, facilitating clinical decision-making and patient management.

CONCLUSIONS

The Treebag machine learning model effectively predicts 1-year mortality in patients with type A aortic dissection, stratifying risk profiles. Key factors for enhancing survival include surgical intervention, β-blocker administration, and management of systolic blood pressure, lymphocyte, carbon dioxide combining power, eosinophil, and white blood cell levels, offering a valuable tool for improving patient outcomes.

An acute aortic dissection prognostic score for predicting early in-hospital mortality in acute thoracic aortic dissection

Study objective

Acute thoracic aortic dissection (ATAD) has a high mortality rate. Factors that contribute to its onset include the environment, genetic factors, and infectious diseases. Recently, the presence of monocytes/macrophages has been suggested to attract inflammatory and immune cells to lesions. This, together with levels of D-dimer, brain natriuretic peptide (BNP), aspartate aminotransferase (AST), and lactate dehydrogenase (LD), may be useful in predicting a prognosis for ATAD. This study examined the relationship between a combination of such laboratory data and prognosis in ATAD.

Design

A single-center retrospective study. The association between early mortality from ATAD and laboratory data was statistically investigated.

Setting

Treatment strategies were at the discretion of each attending physician.

Participants

A total of 118 patients with ATAD (59 early deaths and 59 survivors).

Main outcome measures

The value of D-dimer, BNP, AST, and LD levels, and the peripheral blood monocyte ratio as scores for the early prediction of a prognosis without requiring advanced testing equipment.

Results

The AST/LD, D-dimer, and BNP levels were significantly elevated in those who died prematurely. In contrast, the monocyte ratio in the peripheral blood leukocyte fraction was significantly decreased. The AST/LD, which was associated with cardiac troponin I, was the most significant variable. An average positive value from each test was defined as an acute aortic dissection prognostic score (AAD-PS). The area under the curve on the receiver operating characteristic was 0.895.

Conclusion

In ATAD patients, the AAD-PS may be a potentially new and useful test item for predicting prognosis.

Gender Differences in Acute Type A Aortic Dissection: A Comprehensive Review and Meta-Analysis

We aimed to undertake a meta-analysis of cohort studies to evaluate gender-based differences for patients with acute type A aortic dissection. A systematic search was performed across PubMed, Embase, and Cochrane Library (2000 to 2023) for studies reporting gender-related discrepancies in clinical presentation, in-hospital management, and/or outcomes. Study effects were assessed using mean difference or risk ratio (RR) as aggregated estimates. Besides, individual patient-level data on survival were reestablished to form gender-related Kaplan-Meier curves to evaluate long-term survival outcome. The study protocol was registered in PROSPERO (ID: CRD42024524125). The 21 studies were analyzed, comprising 6,728 women and 12,839 men. Women had lower risks of postoperative acute kidney injury (RR 0.85; 95% confidence interval [CI] 0.72 to 1.00, p = 0.049) and reoperation (RR 0.89; 95% CI 0.81 to 0.99, p = 0.024) but a higher perioperative mortality (RR 1.11; 95% CI 1.03 to 1.18, p = 0.005) than men. In addition, the overall survival was poorer in women (p <0.001), with 10-year survival rates of 66.5% for men and 60.0% for women. In conclusion, acute type A aortic dissection presents gender differences, with women facing higher perioperative and long-term mortality despite lower acute kidney injury and reoperation risks, suggesting a need for tailored management and prevention strategies.

Presentation, management, and clinical outcomes of acute type A dissection: Does sex matter?

Background

Male-female differences in clinical presentation, management, and outcomes of acute type A aortic dissection (AD-A) have been reported; however, robust data are scarce. This study examined those differences.

Methods

Consecutive adults diagnosed with AD-A between 2007 and 2017 in 4 referral centers were included retrospectively. Baseline data, operative characteristics, and mortality and morbidity during follow-up were collected using patient files, questionnaires, and referral information.

Results

The study included 889 patients (37.5% female). Females were significantly older at presentation (median, 67.0 [interquartile range [IQR], 59.0-75.0] years vs 61.0 [IQR, 53.0-69.0] years; P < .001) and more often had cardiovascular comorbidities. Severe hypotension, tamponade, and nausea were more frequently observed in females. Short-term mortality was 18.5% in females and 21.2% in males (P = .362). No significant differences in treatment between males and females were observed. After surgery, the median follow-up was 6.2 years (IQR, 3.5-9.2 years). Overall 10-year survival was 50.1% (95% confidence interval [CI], 43.6%-57.6%) in females and 62.8% (95% CI, 58.1%-67.9%) in males (P = .009), although this difference was not significant after multivariable correction. Compared to the matched general population, survival was lower than expected in females and comparable to expected in males. The long-term reintervention rate in surgically treated survivors was comparable between males and females (2.1%/patient-year). Male- and female-specific risk factors for long term mortality were identified.

Conclusions

These findings highlight a distinct clinical profile at presentation with AD-A between males and females, while treatment approach and short-term mortality were comparable. The relatively poor long-term survival in females and male-/female-specific risk stratification warrant further investigation.

Ketorolac in the perioperative management of acute type A aortic dissection: a randomized double-blind placebo-controlled trial

BACKGROUND

Acute Type A Aortic Dissection (aTAAD) is a severe and life-threatening condition. While animal studies have suggested that ketorolac could slow the progression of aortic aneurysms and dissections, clinical data on its efficacy in aTAAD patients remain limited. This study seeks to evaluate the safety and effectiveness of ketorolac in this patient group.

METHODS

Patients were randomly assigned to receive either ketorolac or a placebo (0.9% saline). Treatment began at least 2 h prior to surgery (60 mg ketorolac or 2 ml saline administered once intramuscularly) and continued for 48 h post-surgery (30 mg ketorolac or 1 ml saline administered intramuscularly twice daily). The primary endpoints included assessing the safety and efficacy of ketorolac in improving the prognosis of aTAAD, focusing on mortality and organ malperfusion syndrome. Secondary endpoints included drug-related adverse events, blood test results, and other postoperative outcomes.

RESULTS

Of 179 patients who underwent aTAAD repair, 110 met the inclusion criteria and were randomized into two groups of 55. One patient discontinued the intervention due to erythroderma on the first postoperative day, leaving 54 patients in the ketorolac group and 55 in the placebo group for analysis. No significant differences were found in the primary endpoints. However, the ketorolac group showed lower intraoperative bleeding (median: 1.8 L vs. 2.0 L, P = 0.03), shorter intensive care unit (ICU) stays (median: 6.5 days vs. 8 days, P = 0.04), and lower total hospital costs (median: ¥170,430 vs. ¥187,730, P = 0.03).

CONCLUSIONS

Short-term ketorolac therapy did not alter the primary outcome but was associated with reduced intraoperative bleeding, shorter ICU stays, and potentially lower hospitalization costs. It demonstrates safety and a certain degree of effectiveness during the perioperative period. These findings suggest that ketorolac could be a viable option for perioperative management in patients with aTAAD.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Register ( www.chictr.org.cn , No: ChiCTR2300074394).

Reconstruction of the isolated left vertebral artery in total aortic arch replacement for type A aortic dissection via a single upper right hemisternotomy approach

OBJECTIVES

The isolated left vertebral artery (ILVA) is a rare congenital abnormality of the branches of the aortic arch. Its presence can influence both the surgical procedure and the prognosis of total aortic arch replacement. The goal of this study was to assess the early postoperative outcomes of ILVA reconstruction performed during total aortic arch replacement via a single upper right hemisternotomy approach.

METHODS

From October 2018 to March 2024, patients diagnosed with type A aortic dissection who underwent total aortic arch replacement via a single upper right hemisternotomy at the General Hospital of the Northern Theater Command were included. Based on the presence of ILVA, the patients were divided into the ILVA group and the control group. Patients in the ILVA group underwent intraoperative ILVA reconstruction, and relevant perioperative clinical data were collected and analysed. Inverse probability of treatment weighting was applied to balance the preoperative baseline data.

RESULTS

A total of 516 patients were included in the study. Of these, 34 patients were in the ILVA group, which included 27 males (79.4%) with a mean age of 48.9 ± 12.9 years; the remaining 482 patients were assigned to the control group, which included 360 males (74.7%) with a mean age of 50.5 ± 10.9 years. Following adjustment using the inverse probability of treatment weighting, the incidence of paraplegia was significantly lower in the ILVA group than in the control group (0% vs 2.14%, P = 0.003). Furthermore, the incidence of stroke (3.38% vs 6.55%, P = 0.354) and of in-hospital death (3.23% vs 5.58%, P = 0.454) was similar in both groups.

CONCLUSIONS

The research indicates that ILVA reconstruction during total aortic arch replacement via a single upper right hemisternotomy effectively preserved ILVA patency and resulted in excellent early outcomes. Statistically, the incidence of postoperative paraplegia was significantly lower compared to the that in the control group, and no significant differences were observed in deaths or other complications between the 2 groups.

CLINICAL REGISTRATION NUMBER

The study was approved by the Ethics Committee of the General Hospital of the Northern Theater Command, Shenyang City, China [Y(2024)188].

Case Report: Maintaining a balance between vascular access patency and stable dissection status in a hemodialysis patient with unrepaired type A aortic dissection

Introduction

Type A aortic dissection (AD) is a lethal situation with high mortality within short time after onset. We present here a rare hemodialysis patient whose condition was comorbid with unrepaired type A AD. The challenge we face is whether low-molecular-weight heparin (LMWH) should be used during dialysis.

Case presentation

A 72-year-old man with a history of hemodialysis for 2 years and 7 months sought medical attention due to thrombosis of the dialysis catheter. He had been diagnosed with an unrepaired type A aortic dissection (involving the aortic root, the ascending aorta, the aortic arch, the descending aorta, the abdominal aorta, the left common iliac artery, and the femoral artery) for more than 5 years. LMWH was not given during the previous dialysis process because of concerns about the rupture of the dissection. The lesion was salvaged via urokinase thrombolysis. However, the anticoagulant-free dialysis pattern occasionally caused dialyzer clotting and further increased the risk of catheter dysfunction. The patient repeatedly experienced dysfunction of the catheter in the following 8 months, with 2 episodes resolved via thrombolysis and 2 episodes replaced with new catheters. Finally, LMWH was used for each dialysis session to prevent thrombosis, with the dosage gradually increasing from 1,000 units to 2,000 units. The dosage of 2,000 units could support sufficient 4-hour dialysis for each session. Twenty-five months have passed since then, the patient has not experienced any further occlusion of the catheter, and the aortic dissection has not shown obvious changes (neither obvious expansion nor rupture).

Conclusion

Reducing the dosage of LMWH during hemodialysis is a feasible solution to maintain a balance between hemodialysis access patency and stable dissection status in this particular patient.

Computational fluid dynamics modelling of hemodynamics in aortic aneurysm and dissection: a review

Hemodynamic analysis based on computational fluid dynamics (CFD) modelling is expected to improve risk stratification for patients with aortic aneurysms and dissections. However, the parameter settings in CFD simulations involve considerable variability and uncertainty. Additionally, the exact relationship between hemodynamic features and disease progression remains unclear. These challenges limit the clinical application of aortic hemodynamic models. This review presents a detailed overview of the workflow for CFD-based aortic hemodynamic analysis, with a focus on recent advancements in the field. We also conducted a systematic review of 27 studies with large sample sizes (n > 5) that examine the hemodynamic characteristics of aortic aneurysms and dissections. Some studies identified consistent relationships between hemodynamic features and disease progression, reinforcing the potential for clinical application of aortic hemodynamic models. However, limitations such as small sample sizes and oversimplified patient-specific models remain. These findings emphasize the need for larger, more detailed studies to refine CFD modelling strategies, strengthen the connection between hemodynamics and diseases, and ultimately facilitate the clinical use of aortic hemodynamic models in disease management.

Prognostic Value of Biomarkers in Acute Aortic Dissection: Analysis of Clinical Outcomes and Mortality

Introduction: Acute aortic dissection (AAD) is a severe condition requiring immediate diagnosis and treatment to reduce high mortality rates. This study investigates laboratory markers that may support the diagnostic process and predict surgical outcomes and mortality in AAD patients. Materials and Methods: This retrospective study analyzed data from 85 patients diagnosed with AAD in an emergency setting. Patients over 18 years of age with a diagnosis of acute dissection were included. Key laboratory and clinical parameters were examined to determine their association with mortality and the likelihood of surgical intervention. Results: The study found that younger patients were more likely to undergo surgery, while parameters such as white blood cells (WBCs), neutrophil, and lymphocyte counts were elevated in those undergoing surgery. Mortality predictors included elevated mean platelet volume (MPV), low pH, bicarbonate (HCO3), and base deficit levels. Each unit increase in MPV was associated with a threefold increase in mortality risk, and DeBakey Type 1 patients exhibited the highest MPV levels. Discussion: WBC and MPV values were linked with surgical and mortality outcomes, respectively. Blood gas analysis parameters, particularly HCO3 and base deficit levels, were significant mortality predictors, underscoring the importance of metabolic markers in AAD assessment. The findings suggest that incorporating these laboratory parameters into diagnostic and treatment decisions could improve AAD management.

A deep-learning system integrating electrocardiograms and laboratory indicators for diagnosing acute aortic dissection and acute myocardial infarction

BACKGROUND

Acute Stanford Type A aortic dissection (AAD-type A) and acute myocardial infarction (AMI) present with similar symptoms but require distinct treatments. Efficient differentiation is critical due to limited access to radiological equipment in many primary healthcare. This study develops a multimodal deep learning model integrating electrocardiogram (ECG) signals and laboratory indicators to enhance diagnostic accuracy for AAD-type A and AMI.

METHODS

We gathered ECG and laboratory data from 136 AAD-type A and 141 AMI patients at Zigong Fourth People's Hospital (January 2019 to December 2023) for training and validation. Utilizing ResNet-34 (residual network), we extracted ECG features and combined them with laboratory and demographic data. We assessed logistic regression, RandomForest, XGBoost, and LightGBM models, employing shapley additive explanations (SHAP) for feature importance analysis. Data from 30 AMI and 32 AAD-type A patients (January to September 2024) were used as a prospective test set.

RESULTS

Incorporating ECG features significantly improved model's AUC value, with the RandomForest achieving the best performance (AUC 0.98 on validation, 0.969 on test). SHAP analysis revealed that troponin and D-dimer, along with the embedding features of ECG extracted by the deep neural network, are key characteristics for differentiating AAD-type A and AMI.

CONCLUSION

ECG features are valuable for distinguishing AAD-type A and AMI, offering a novel tool for rapid cardiovascular disease diagnosis through multimodal data fusion and deep learning.

Outcomes of Surgical Versus Conservative Management in Stanford Type a Aortic Dissection: A Single-Center Retrospective Study

Acute aortic dissection (AAD) is a critical cardiovascular emergency marked by the rupture of the aortic intima, resulting in blood infiltration into the media and the formation of a false lumen. AAD incidence varies by area, emphasizing the need for better diagnostics and epidemiological investigations. Bucharest University Emergency Hospital's Emergency Department conducted this retrospective cohort analysis from May 2021 to May 2023. We examined 26 Stanford Type A aortic dissection patients to establish in-hospital mortality and one-year survival rates. The primary objective was to analyze demographic, clinical, and paraclinical factors and their impact on patient outcomes. A total of 57.7% of the study group was male and had a mean age of 58.2 years, and 69.2% of patients had hypertension, indicating its importance as a risk factor. Acute chest discomfort was reported by 53.8%, neurological problems by 30.8%, and syncope or hypotension by 42.3%. CT angiography and transthoracic echocardiogram (TTE) confirmed the diagnosis and assessed dissection severity. Pericardial effusion (19.2%) and moderate to severe aortic regurgitation (26.9%) were notable. Management varied by dissection intensity and location. Emergency surgery was performed in 61.5% of patients within 24 h of diagnosis, resulting in a 12.5% in-hospital death rate. Conservatively managed patients had a 60.0% in-hospital death rate. Timely intervention is crucial, since the surgical cohort had an 87.5% one-year survival rate compared to 30% for the conservatively managed cohort. Acute renal damage (25%), protracted mechanical ventilation (31.3%), and advanced supportive care infections were postoperative sequelae. Conservative care exacerbated visceral ischemia (20%) and heart failure (10%). Advanced age and hypotension upon admission were independent mortality predictors, emphasizing the need for early risk assessment and personalized treatment. Multimodal imaging, timely surgical referral, and excellent postoperative care improve AAD outcomes, according to this study.

Understanding Thoracic Aortic Disease in Women

Multifaceted disparities exist between men and women with thoracic aortic aneurysm and dissection. Despite a higher prevalence of thoracic aortic aneurysm and dissection among men, women experience disproportionately accelerated aneurysmal expansion, greater risks of rupture or dissection, and acute aortic syndromes that occur at relatively smaller diameters. In the context of acute type A aortic dissection, they also experience more complications, increased out-of-hospital mortality, delays in presentation and diagnosis, and worse postoperative survival. These gaps are largely driven by sex differences in vascular aging and remodeling, which include arterial stiffening associated with the hormonal changes that occur during menopause. Furthermore, the increased risk of acute type A aortic dissection during pregnancy in women with thoracic aortic disease necessitates a multidisciplinary approach to peripartum counseling and surveillance. Despite significant recent improvements in early postoperative outcomes, other disparities persist, emphasizing the need for sex-specific research, patient counseling, routine monitoring, and surgical thresholds to bridge the gap in outcomes of thoracic aortic care between sexes. Elucidating the underlying mechanisms of aortic aging and its difference between men and women, as well as moving toward personalized management protocols, will give rise to improved outcomes in the treatment of thoracic aortopathy.

Validation of the German registry of acute aortic dissection type A score for predicting 30-day mortality after acute type A aortic dissection surgery in a single Japanese aortic centre

OBJECTIVES

This study evaluated the applicability of the German Registry of Acute Aortic Dissection Type A (GERAADA) score in predicting 30-day mortality in Japanese patients undergoing surgery for acute type A aortic dissection (ATAAD) and compared its predictive performance with that of the European System for Cardiac Operative Risk Evaluation II (EuroSCORE II).

METHODS

This single-centre retrospective study involved 154 patients who underwent emergency surgery for ATAAD between January 2019 and April 2024. The GERAADA and EuroSCORE II were calculated for each patient. Predictive accuracy for 30-day mortality was assessed using the area under the receiver operating characteristic curve (AUC). A multivariate logistic regression identified independent predictors of mortality, and long-term outcomes were evaluated using Kaplan-Meier analysis.

RESULTS

The 30-day mortality rate was 11.0%. The GERAADA score showed an AUC of 0.80, indicating good discriminatory ability, while the EuroSCORE II demonstrated moderate performance with an AUC of 0.67 (P = 0.07). The GERAADA score significantly overestimated mortality in this cohort, whereas the EuroSCORE II underestimated it. Independent predictors of mortality included the use of catecholamines at referral. Kaplan-Meier analysis revealed a 1-year survival rate of 79.4% with an AUC of 0.72, demonstrating the GERAADA score's utility as a predictor of long-term survival.

CONCLUSIONS

The GERAADA score provides accurate predictions of 30-day mortality in Japanese patients undergoing ATAAD surgery, comparable to the EuroSCORE II. This score demonstrates robust predictive ability for short- and long-term outcomes and may serve as a practical tool for risk stratification in ATAAD surgery.

Protective Effect on Spinal Cord Injury of Prophylactic Cerebrospinal Fluid Drainage in Extensive Aortic Arch Repair for Type A Aortic Dissection: A Retrospective Cohort Study

BACKGROUND

Cerebrospinal fluid drainage (CSFD) is commonly used to manage spinal cord injury (SCI) after aortic surgery. However, there is still limited evidence regarding its effectiveness in patients with type A aortic dissection undergoing total arch replacement plus frozen elephant trunk procedure.

METHODS

A total of 1931 patients were retrospectively enrolled between 2010 and 2023. Patients with high-risk postoperative SCI (N=445) were divided into 2 groups: with or without prophylactic CSFD to evaluate the protective effect of prophylactic CSFD. Patients with postoperative SCI (N=119) were divided into 3 groups, without CSFD, therapeutic CSFD, and prophylactic CSFD, and analyzed to compare the treatment effect of different CSFD strategies.

RESULTS

Prophylactic CSFD significantly reduced the incidence of postoperative SCI in high-risk patients (26.9% versus 17.7%, P=0.029), further supported by matching weights analysis of propensity score and conditional logistic regression. Analyses of the SCI population revealed less severe SCI symptoms in patients with prophylactic CSFD, as assessed by the American Spinal Injury Association Impairment Scale (adjusted P<0.05). Multivariable ordinal logistic regression showed that compared with those without CSFD, prophylactic CSFD (P=0.003) but not therapeutic CSFD (P=0.981) was beneficial to the in-hospital recovery of postoperative SCI. Long-term SCI outcomes did not differ among groups.

CONCLUSIONS

A prominent protective effect on SCI occurrence and recovery after the total arch replacement plus the frozen elephant trunk procedure was observed with prophylactic CSFD use in patients with type A aortic dissection. However, the effectiveness of therapeutic CSFD fell short of significance.

Extent of surgical repair and outcomes after surgery for type A aortic dissection

BACKGROUND

Acute Stanford type A aortic dissection is a severe emergency condition that, if left untreated, is associated with a high mortality rate. The extent of surgical repair may impact the outcomes of these patients.

METHOD

Patients operated for acute type A aortic dissection from a multicentre European registry were included. Patients were categorized based on the following types of surgical intervention: isolated ascending aortic replacement, ascending aortic replacement with concomitant aortic valve replacement, aortic root replacement, partial or total arch replacement, and partial or total arch replacement with concomitant aortic root replacement. The primary outcome was mortality rate, both in-hospital and at 10 years. Secondary outcomes were acute kidney injury requiring dialysis, neurological complications, a composite endpoint including in-hospital death, neurological complications and/or dialysis, and proximal endovascular or surgical aortic re-operations at 10 years.

RESULTS

3702 patients were included. The adjusted risk of in-hospital mortality was higher in all subsets of patients compared to those who underwent isolated ascending aortic replacement. The adjusted rates of in-hospital mortality ranged from 16.4% (95% c.i. 15.3 to 17.4) among patients who underwent isolated ascending aortic replacement to 27.7% (95% c.i. 23.3 to 31.2) among those who underwent aortic arch and concomitant aortic root replacement. The adjusted risks of neurological complications, renal replacement therapy and of the composite endpoint were significantly higher in patients who underwent partial/total aortic arch replacement. The adjusted risk estimates of 10-year mortality rate were markedly higher in patients who underwent partial/total aortic arch replacement with or without concomitant aortic root replacement. Extensive aortic repair did not significantly reduce the risk of distal or proximal aortic reoperations.

CONCLUSION

These findings suggest that, when feasible, limiting the extent of aortic replacement for acute type A aortic dissection may be beneficial in reducing mortality rate and major complications both in the short and long term.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04831073.