A Novel Inflammation-Based Risk Score Predicts Mortality in Acute Type A Aortic Dissection Surgery: The Additive Anti-inflammatory Action for Aortopathy and Arteriopathy Score

OBJECTIVE

To develop an inflammation-based risk stratification tool for operative mortality in patients with acute type A aortic dissection.

METHODS

Between January 1, 2016 and December 31, 2021, 3124 patients from Beijing Anzhen Hospital were included for derivation, 571 patients from the same hospital were included for internal validation, and 1319 patients from other 12 hospitals were included for external validation. The primary outcome was operative mortality according to the Society of Thoracic Surgeons criteria. Least absolute shrinkage and selection operator regression were used to identify clinical risk factors. A model was developed using different machine learning algorithms. The performance of the model was determined using the area under the receiver operating characteristic curve (AUC) for discrimination, calibration curves, and Brier score for calibration. The final model (5A score) was tested with respect to the existing clinical scores.

RESULTS

Extreme gradient boosting was selected for model training (5A score) using 12 variables for prediction-the ratio of platelet to leukocyte count, creatinine level, age, hemoglobin level, prior cardiac surgery, extent of dissection extension, cerebral perfusion, aortic regurgitation, sex, pericardial effusion, shock, and coronary perfusion-which yields the highest AUC (0.873 [95% confidence interval (CI) 0.845-0.901]). The AUC of 5A score was 0.875 (95% CI 0.814-0.936), 0.845 (95% CI 0.811-0.878), and 0.852 (95% CI 0.821-0.883) in the internal, external, and total cohort, respectively, which outperformed the best existing risk score (German Registry for Acute Type A Aortic Dissection score AUC 0.709 [95% CI 0.669-0.749]).

CONCLUSION

The 5A score is a novel, internally and externally validated inflammation-based tool for risk stratification of patients before surgical repair, potentially advancing individualized treatment.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT04918108.

Current Surgical Management of Acute Type A Aortic Dissection in China: A Multicenter Registry Study

Background

Many countries and regions have established multicenter registration studies to improve the outcomes of acute type A aortic dissection (ATAAD).

Objectives

The aims of this study were to report actual preoperative management, surgery type, and early outcomes of surgical treatment for ATAAD in China.

Methods

This cohort study uses data from the China Registry of Type A Aortic Dissection, a national clinical registry to investigate management of patients with Stanford type A aortic dissection. The data, including surgical management and outcomes of patients with ATAAD, were analyzed from January 2018 to December 2021.

Results

A total of 1,058 patients with ATAAD were enrolled in this study between January 2018 and December 2021. The mean age of all patients was 51.6 ±11.7 years. The median interval from onset to hospital was 10.65 hours (IQR: 6-24 hours), and the median interval from entering the emergency room to starting operation was 13 hours (IQR: 4.08-28.7 hours). Total arch repair was performed in 938 patients (88.7%), and frozen elephant trunk repair was performed in 800 patients (75.6%). The incidence of early mortality was 7.6%.

Conclusions

The population of patients with ATAAD in China experienced a longer interval from onset to arrival at the hospital, received more extensive aortic arch repair, and showed a relatively lower early mortality. These findings suggest that there may be a huge survivor bias in patients with ATAAD in China, more efforts should be made to promote prehospital emergency care and preoperative management of Chinese ATAAD patients. (A multicenter registration study of aortic dissection in China; ChiCTR1800015338).

Prognostic Impact of Systemic Coagulation-Inflammation Index in Acute Type A Aortic Dissection Surgery

BACKGROUND

A novel hematologic parameter, systemic coagulation-inflammation (SCI) index reflecting inflammation and coagulation pathways could be easily obtained from clinically routine laboratory findings. We hypothesize that the SCI index has prognostic implication in predicting operative mortality for patients with acute type A aortic dissection (ATAAD).

OBJECTIVES

This study aims to investigate the prognostic value of the SCI index and to establish an SCI-adding nomogram for mortality prediction in ATAAD patients.

METHODS

A total of 1,967 ATAAD patients surgically repaired were collected from 12 Chinese cardiovascular centers by the 5A (Additive Anti-inflammatory Action for Aortopathy & Arteriopathy [Multicenter Retrospective Study]) study III (2016-2020). SCI index was calculated as platelet count × fibrinogen/white blood cell count on admission. By adding SCI index, a nomogram was developed and evaluated for 90-day mortality prediction with conventional predictors via the Cox model with 10-fold cross-validation.

RESULTS

Patients were stratified with low SCI (<40), middle SCI (40-100), or high SCI (>100). The 90-day survival rates increased with SCI index (low 86.9%; [95% CI: 84.9%-89.0%], middle 92.7% [95% CI: 90.9%-94.9%], and high 96.4% [95% CI: 94.2%-98.6%]; log-rank P < 0.001). SCI index is independently associated with 90-day mortality (adjusted hazard ratio: 0.549; 95% CI: 0.424-0.710; P < 0.001). The addition of SCI index provided significantly incremental prognostic value to base model including age, serum creatinine, DeBakey class, and location of intimal entry (area under the curve: 0.677; 95% CI: 0.641-0.716 vs 0.724; 95% CI: 0.685-0.760; P = 0.002), which was confirmed by net reclassification improvement index (0.158; 95% CI: 0.065-0.235; P < 0.001) and integrated discrimination improvement index (0.070; 95% CI: 0.007-0.036; P < 0.001).

CONCLUSIONS

SCI index is easily obtainable, performs moderately well as a predictor of short-term mortality in ATAAD patients, and may be useful for risk stratification in emergency settings. (Additive Anti-inflammatory Action for Aortopathy & Arteriopathy [Multicenter Retrospective Study] III NCT04918108).

Aortic remodeling, reintervention, and survival after zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection: Midterm results

Objectives

To investigate the midterm results after zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection.

Methods

Between October 2014 and April 2021, 196 patients underwent zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection. The true lumen area, aortic lumen area, and false lumen status were assessed at four aortic levels, the proximal and distal descending thoracic aorta (level A and level B, respectively), celiac artery branching (level C), and terminal aorta (level D). Aortic remodeling (postoperative area as a percentage of the preoperative area) was classified into 3 groups, positive (true lumen area ≥120% with aortic lumen <120% or true lumen area ≥80% with aortic lumen <80%), minimal (80% ≤ true lumen area and aortic lumen area <120%), and negative remodeling (all other changes).

Results

In-hospital mortality was 13 (6.6%) patients. The overall survival rate was 85.1% at 5 years. The freedom from distal aortic reintervention was 89.9% at 5 years. The prevalence of completely thrombosed or obliterated false lumen at 2 years was 96.8% at level A, 88.4% at level B, 47.2% at level C, and 27.6% at level D. The prevalence of positive aortic remodeling at 2 years was 84.7% at level A, 75.0% at level B, 29.2% at level C, and 16.7% at level D.

Conclusions

Zone 0 arch repair with frozen elephant trunks for acute type A aortic dissection can avoid invasive aortic arch resection and facilitate aortic remodeling of the descending thoracic aorta. The FET effect on aortic remodeling is limited at the aortic level below the FET stent end.

Autologous blood transfusion in acute type A aortic dissection decreased blood product consumption and improved postoperative outcomes

Objective

To evaluate the effect of autologous blood use on blood product consumption and outcomes after acute type A aortic dissection repair.

Methods

From 2010 to October 2020, 497 patients underwent open acute type A aortic dissection repair, including those with autologous blood harvesting before cardiopulmonary bypass and transfusion after cardiopulmonary bypass (autologous blood transfusion [ABT], n = 397) and without autologous blood harvesting and transfusion (No-ABT, n = 100). The median ABT volume was 900 mL. Using propensity score matching, 89 matched pairs were identified based on age, sex, body mass index, preoperative hemoglobin, acute preoperative stroke, previous cardiac surgery, and cardiogenic shock.

Results

After propensity score matching, both groups were similar in demographic characteristics and aortic procedures. The ABT group required significantly less intraoperative transfusion of blood products (6 vs 11 units; P < .0001), including packed red blood cells (2 vs 4), fresh frozen plasma (2 vs 4), platelets (2 vs 2), and cryoprecipitate (0 vs 1); and combined intraoperative and postoperative transfusion (9 vs 13; P < .001). ABT was protective against intra- and postoperative blood product transfusion (odds ratio, 0.28; P = .01). The ABT group had significantly less sepsis, acute renal failure requiring dialysis, reintubation, and shorter intubation times and postoperative lengths of stay. Operative mortality was 6.7% in the ABT group versus 13% in the No-ABT group (P = .14). The midterm survival was similar between the 2 groups (5 year: 76% vs 74%). ABT had a hazard ratio of 0.81 for midterm mortality (P = .41).

Conclusions

Autologous blood transfusion was associated with better short-term outcomes and could be used routinely for acute type A aortic dissection repair. External multicenter prospective validation would be warranted.

In-Hospital Mortality of Patients With Acute Type A Aortic Dissection Hospitalized on Weekends Versus Weekdays

BACKGROUND

In acute aortic dissection, weekend admissions are reported to be associated with increased mortality compared with weekday admissions.

OBJECTIVE

This study aimed to determine whether patients with acute type A aortic dissection (ATAAD) admitted on weekends had higher in-hospital mortality than those admitted on weekdays in the Tokyo metropolitan area, where we developed a patient-transfer system for aortic dissection.

METHODS

Data were collected during the first year after our transfer system began (cohort I) and in the subsequent years from 2013 to 2015 (cohort II).

RESULTS

We studied 2,339 patients (500 in cohort I; 1,839 in cohort II) with ATAAD. Patients with weekend admissions had higher in-hospital mortality than those with weekday admissions in cohort I. In association with increased interfacility transfer during weekends and reduced mortality at non-high-volume centers, the in-hospital mortality in the weekend group improved from 37.2% in cohort I to 22.2% in cohort II (P < 0.001). After inverse probability weighting adjustment, weekend admission was associated with higher in-hospital mortality in cohort I (odds ratio: 2.28; 95% confidence interval: 1.48 to 3.52; P < 0.001), but not in cohort II (odds ratio: 0.96; 95% confidence interval: 0.75 to 1.22; P = 0.731). On multivariable analyses, weekend admission was associated with higher in-hospital mortality in combined cohort I+II; the associations between weekend admission and mortality were not significant in cohort II.

CONCLUSIONS

We found a significant reduction in in-hospital mortality in patients with weekend admissions for ATAAD. No mortality difference between weekend and weekday admissions was observed in the later years of the study.

Outcomes of acute type A aortic dissection repair: Daytime versus nighttime

Objective

We sought to report our experience of repairing acute type A aortic dissection (ATAAD) over 21 years during in-hours versus out-of-hours before and after the establishment of specialized aortic service and rota.

Methods

A retrospective analysis of all patients who had ATAAD repair between November 1998 and December 2019 in our center. In-hours were defined as 08:00 to 19:59 hours and out of hours were defined as 20:00 to 07:59 hours.

Results

A total of 286 patients underwent repair of ATAAD. Eighty operations took place during the prerota period (43 operations in hours, 37 out of hours) and 206 operations during the specialized rota period (110 in hours, 96 out of hours). There was no difference in 30-day mortality between the in-hours and out-of-hours groups in either the prerota (23.3% vs 32.4%; P = .36) or specialized rota periods (11.6% vs 11.5%; P = .94). Mean number of cases per year increased by 83% between the prerota and specialized rota periods. Thirty-day mortality reduced in both the in-hours (23.3% vs 11.6%) and out-of-hours (32.4% vs 11.5%) groups since introduction of the specialized aortic rota.

Conclusions

Outcomes in repair of ATAAD during in-hours and out-of-hours periods are similar when operated on in a specialized unit with a dedicated aortic team. This emphasizes the current global trend of service centralization without particular attention to time of day to operate on such critical cohort patients.