Early reperfusion strategy improves the outcomes of surgery for type A acute aortic dissection with malperfusion

Uchida, Keiji; Karube, Norihisa; Kasama, Keiichiro; Minami, Tomokazu; Yasuda, Shota; Goda, Motohiko; Suzuki, Shinichi; Imoto, Kiyotaka; Masuda, Munetaka

doi:10.1016/j.jtcvs.2018.02.007

Cited by 81 publications

(70 citation statements)

References 20 publications

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“…Mortality in the central repair group was significantly higher if preoperative malperfusion was not addressed by early reperfusion (18%). On the other hand, early reperfusion reduced mortality to very low levels (3.4%), which was similar to the one in the no malperfusion group [12].…”

Section: Discussionsupporting

confidence: 61%

“…At the same time, their cohort included an unusually low number of patients in cardiogenic shock on admission, only 5.2%, and this undoubtedly afforded them the necessary time to treat those patients by interventional means. A more recent study by Uchida et al underscores that strategy [12]. They presented their series of early reperfusion in a mixed sample of acute (69%) and chronic (31%) aortic dissections, only 81% of which underwent surgical repair.…”

Section: Discussionmentioning

confidence: 99%

“…The presence of malperfusion can increase mortality to 29% [7], or even 43% if 3 or more systems are affected [8]. Some recent reports have argued for an “ischemia-first” approach, in which severe malperfusion is addressed prior to aortic repair [9,10,11,12]. On the other hand, the Stanford Group have recently published excellent results using the traditional “aorta-first” technique [13].…”

Section: Introductionmentioning

confidence: 99%

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How Much Malperfusion Is Too Much in Acute Type A Aortic Dissections?

Feier

Cozma

Sintean

et al. 2019

JCM

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(1) Background: Malperfusion is a central limiting factor in the setting of acute Type A aortic dissections (AAAD). We sought to find preoperative metabolic acidosis thresholds that might influence decision-making in this setting. (2) Methods: We retrospectively reviewed consecutive patients operated on with AAAD between January 2002 and December 2017. We analyzed preoperative variables that might influence early and long-term outcomes, with particular emphasis on malperfusion markers. (3) Results: Our sample consisted of 153 patients, most of them male (69.2%), with a mean age of 55.89 ± 12.8 years. Malperfusion was present in 20.9% of cases: peripheric 25, renal 7, cerebral 4, and mesenteric 3. Cardiogenic shock was present in 18.9% of patients. Logistic regression revealed entry site (odds ratio (OR) = 2.83, p = 0.03), cardiogenic shock (OR = 3.30, p = 0.03), prebypass pH (OR = 0.93, p = 0.02) as independent risk factors for early death (<30 days). Receiver operating characteristic (ROC) analysis identified a prebypass pH of 7.25 as a cutpoint for an unfavourable early outcome. Patients whose prebypass pH was ≤7.25 had a 2.98 higher relative risk (65.7% vs. 22%, p < 0.001). Prebypass pH 7.25 (hazard ratio (HR) = 4.00, p < 0.01) and entry site (HR = 2.10, p = 0.04) were independent predictors of early phase survival (<30 days), while long-term survival (>30 days) was determined by age >65 years (HR = 3.12, p = 0.02). (4) Conclusions: Patients with a prebypass pH ≤ 7.25 have an unacceptably high early mortality after AAAD repair. Those patients might benefit from a two-stage approach.

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Section: Discussionsupporting

confidence: 61%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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How Much Malperfusion Is Too Much in Acute Type A Aortic Dissections?

Feier

Cozma

Sintean

et al. 2019

JCM

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“…In contemporary reports, the overall early mortality from ATAAD (30-day or in-hospital) in operated patients ranges from 5% to 24% [56][57][58][59] and has uniformly been around 17% in current multi-centre studies (German Registry of Acute Aortic Dissection type A, (GERAADA), 17%; International Registry of Aortic Dissection (IRAD), 18%; NORCAAD, 16%) [11,48,49]. Patients who are clinically stable with normal perfusion syndrome generally do well after surgery, with low mortality (of around 3%) [59,60]. In contrast, in patients with unstable haemodynamics or preoperative malperfusion, the mortality is substantial (18-40%) [7,61].…”

Section: Surgical Treatmentmentioning

confidence: 99%

Acute type A aortic dissection – a review

Guðbjartsson

Ahlsson

Geirsson

et al. 2019

Scandinavian Cardiovascular Journal

105

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Acute type A aortic dissection (ATAAD) is still one of the most challenging diseases that cardiac surgeons encounter. This review is based on the current literature and includes the results from the Nordic Consortium for Acute Type-A Aortic Dissection (NORCAAD) database. It covers different aspects of ATAAD and concentrates on the outcome of surgical repair. The diagnosis is occasionally delayed, and ATAAD is usually lethal if prompt repair is not performed. The dynamic nature of the disease, the variation in presentation and clinical course, and the urgency of treatment require significant attentiveness. Many surgical techniques and perfusion strategies of varying complexity have been described, ranging from simple interposition graft to total arch replacement with frozen elephant trunk and valve-sparing root reconstruction. Although more complex techniques may provide long-term benefit in selected patients, they require significant surgical expertise and experience. Short-term survival is first priority so an expedited operation that fits in with the surgeon's level of expertise is in most cases appropriate. ARTICLE HISTORY Definitions and classification systemsDissection of the aorta occurs when the aortic media is separated, usually by pulsatile flow that penetrates the intimal layer of the aortic wall [14] (Figure 1(b)). This allows blood to flow between the layers of the aortic wall, forcing the layers apart, creating a false lumen parallel to the native (i.e. true) aortic lumen (Figure 1(b)). Consequently, the false lumen can propagate in both directions from the tear of intima and affect most of its distal branches, including the coronary, cerebral, and mesenteric arteries [15]. Another-but less common-CONTACT Tomas Gudbjartsson

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“…Many researchers advocate that prompt intervention should be performed for aortic branch obstruction after the diagnosis of malperfusion. 5,8)…”

Section: Discussionmentioning

confidence: 99%

Critical Malperfusion Caused by Central Aortic Repair for Acute Aortic Dissection: A Case Report

Mochida

Morinaga

Shimizu

et al. 2019

Annals of Vascular Diseases

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We encountered a case of hepatic malperfusion resulting from central repair for Stanford type A acute aortic dissection (AAD). A 78-year-old woman had AAD, for which ascending aortic repair was performed. Hepatic malperfusion developed 3 days postoperatively. The superior mesenteric and celiac arteries were occluded by a false lumen (FL). We believed that the surgery caused a change in the blood flow in FL. Percutaneous transluminal angioplasty and stenting of the superior mesenteric artery were performed, and the patient’s condition improved. Thus, intervention for the branched artery should be performed prior to central repair, depending on the type of malperfusion.

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Early reperfusion strategy improves the outcomes of surgery for type A acute aortic dissection with malperfusion

Abstract: Our strategy might improve the outcomes of surgery for type A acute aortic dissection with malperfusion. This strategy enables us to avoid unproductive central repair procedures in irreversibly damaged patients.

Cited by 81 publications

References 20 publications

How Much Malperfusion Is Too Much in Acute Type A Aortic Dissections?

How Much Malperfusion Is Too Much in Acute Type A Aortic Dissections?

Acute type A aortic dissection – a review

Critical Malperfusion Caused by Central Aortic Repair for Acute Aortic Dissection: A Case Report

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