Abstract:Background
Acute type A aortic dissection (ATAAD) is a life-threatening disease that requires emergent surgical intervention. This retrospective study aimed to clarify the individual characteristics, short-term and mid-term outcomes, and prognostic factors of patients who underwent surgical repair of ATAAD with preoperative cardiopulmonary resuscitation (CPR).
Methods
Between January 2007 and January 2020, 656 consecutive patients underwent ATAAD repair at our instituti… Show more
“…If patients presented with hypertension or tachycardia before surgery, their hemodynamics were stabilized with intravenous beta-blockers to maintain systolic blood pressure (SBP) < 120 mmHg and a heart rate of 60–70 bpm, according to the established guidelines [ 8 ]. If patients presented with shock status, medical resuscitation and surgical rescue procedures were applied according to the standardized protocols previously reported by this institute [ 9 , 10 ]. Fig.…”
Background
The DeBakey classification divides Stanford acute type A aortic dissection (ATAAD) into DeBakey type I (D1) and type II (D2) according to the extent of acute aortic dissection (AAD). This retrospective study aimed to compare the early and late outcomes of D1-AAD and D2-AAD through a propensity score-matched analysis.
Methods
Between January 2009 and April 2020, 599 consecutive patients underwent ATAAD repair at our institution, and were dichotomized into D1 (n = 543; 90.7%) and D2 (n = 56; 9.3%) groups. Propensity scoring was performed with a 1:1 ratio, resulting in a matched cohort of 56 patients per group. The clinical features, postoperative complications, 5-year cumulative survival and freedom from reoperation rates were compared.
Results
In the overall cohort, the D1 group had a lower rate of preoperative shock and more aortic arch replacement with longer cardiopulmonary bypass time. The D1 group had a higher in-hospital mortality rate than the D2 group in overall (15.8% vs 5.4%; P = 0.036) and matched cohorts (19.6% vs 5.4%; P = 0.022). For patients that survived to discharge, the D1 and D2 groups demonstrated similar 5-year survival rates in overall (77.0% vs 85.2%; P = 0.378) and matched cohorts (79.1% vs 85.2%; P = 0.425). The 5-year freedom from reoperation rates for D1 and D2 groups were 80.0% and 97.1% in overall cohort (P = 0.011), and 93.6% and 97.1% in matched cohort (P = 0.474), respectively.
Conclusions
Patients with D1-AAD had a higher risk of in-hospital mortality than those with D2-AAD. However, for patients who survived to discharge, the 5-year survival rates were comparable between both groups.
“…If patients presented with hypertension or tachycardia before surgery, their hemodynamics were stabilized with intravenous beta-blockers to maintain systolic blood pressure (SBP) < 120 mmHg and a heart rate of 60–70 bpm, according to the established guidelines [ 8 ]. If patients presented with shock status, medical resuscitation and surgical rescue procedures were applied according to the standardized protocols previously reported by this institute [ 9 , 10 ]. Fig.…”
Background
The DeBakey classification divides Stanford acute type A aortic dissection (ATAAD) into DeBakey type I (D1) and type II (D2) according to the extent of acute aortic dissection (AAD). This retrospective study aimed to compare the early and late outcomes of D1-AAD and D2-AAD through a propensity score-matched analysis.
Methods
Between January 2009 and April 2020, 599 consecutive patients underwent ATAAD repair at our institution, and were dichotomized into D1 (n = 543; 90.7%) and D2 (n = 56; 9.3%) groups. Propensity scoring was performed with a 1:1 ratio, resulting in a matched cohort of 56 patients per group. The clinical features, postoperative complications, 5-year cumulative survival and freedom from reoperation rates were compared.
Results
In the overall cohort, the D1 group had a lower rate of preoperative shock and more aortic arch replacement with longer cardiopulmonary bypass time. The D1 group had a higher in-hospital mortality rate than the D2 group in overall (15.8% vs 5.4%; P = 0.036) and matched cohorts (19.6% vs 5.4%; P = 0.022). For patients that survived to discharge, the D1 and D2 groups demonstrated similar 5-year survival rates in overall (77.0% vs 85.2%; P = 0.378) and matched cohorts (79.1% vs 85.2%; P = 0.425). The 5-year freedom from reoperation rates for D1 and D2 groups were 80.0% and 97.1% in overall cohort (P = 0.011), and 93.6% and 97.1% in matched cohort (P = 0.474), respectively.
Conclusions
Patients with D1-AAD had a higher risk of in-hospital mortality than those with D2-AAD. However, for patients who survived to discharge, the 5-year survival rates were comparable between both groups.
“…A total of 51.9% of patients were diagnosed with preoperative hemopericardium according to imaging studies, 34.6% of whom presented with cardiac tamponade. In previous studies reported from this institute investigating the general ATAAD population, the incidence rates of preoperative hemopericardium and cardiac tamponade were only approximately 28–33% and 11–13%, respectively [ 12 , 15 , 28 , 29 ]. At our institute, an aggressive surgical rescue strategy was adopted for this high-risk subgroup.…”
Section: Discussionmentioning
confidence: 99%
“…This study identified several risk factors associated with in-hospital mortality, including preoperative CPR for hemodynamic collapse. The reported incidence of preoperative CPR ranges from 3.4% to 6.8% in previous studies [ 12 , 30 , 31 ]. As a recognized preoperative risk factor for ATAAD, the early surgical mortality rate ranges from 43% to 95% [ 12 , 30 , 32 ], which is approximately three to five times higher than that of the general ATAAD population [ 1 , 2 ].…”
Section: Discussionmentioning
confidence: 99%
“…The reported incidence of preoperative CPR ranges from 3.4% to 6.8% in previous studies [ 12 , 30 , 31 ]. As a recognized preoperative risk factor for ATAAD, the early surgical mortality rate ranges from 43% to 95% [ 12 , 30 , 32 ], which is approximately three to five times higher than that of the general ATAAD population [ 1 , 2 ]. In the present study, 14.2% (23/162) of patients underwent CPR before ATAAD repair, and 56.5% (13/23) did not survive to discharge.…”
Background
Acute type A aortic dissection (ATAAD) is a critical cardiovascular emergency that requires prompt surgical intervention for preserving life, particularly in patients with critical preoperative status. This retrospective study aimed to investigate the clinical features, early and late outcomes, and prognostic factors in patients undergoing aortic repair surgery for ATAAD complicated with preoperative shock.
Methods
Between April 2007 and July 2020, 694 consecutive patients underwent emergency ATAAD repair at our institution, including 162 (23.3%) presenting with preoperative shock (systolic blood pressure <90 mm Hg), who were classified into the survivor (n = 125) and non-survivor (n = 37) groups according to whether they survived to hospital discharge. The clinical demographics, surgical information, and postoperative complications were compared. Five-year survival and freedom from reoperation rates of survivors were analyzed using the Kaplan–Meier actuarial method. Multivariate logistic regression analysis was used to identify independent risk factors for in-hospital mortality.
Results
The in-hospital surgical mortality rate in patients with ATAAD and shock was 22.8%. The non-survivor group showed higher rates of preoperative cardiopulmonary resuscitation, acute myocardial infarction, and cerebral infarction, and was associated with longer cardiopulmonary bypass time, higher rates of total arch replacement and intraoperative extracorporeal membrane oxygenation implementation. The non-survivor group had higher blood transfusion volumes and rates of malperfusion-related complications. Multivariate analysis revealed that preoperative cardiopulmonary resuscitation, prolonged cardiopulmonary bypass time, and total arch replacement were risk factors for in-hospital mortality. For patients who survived to discharge, the 5-year cumulative survival and freedom from aortic reoperation rates were 75.6% (95% confidence interval, 67.6%–83.6%) and 82.6% (95% confidence interval, 74.2%–91.1%), respectively.
Conclusions
Preoperative shock in ATAAD is associated with a high risk of in-hospital mortality, particularly in patients who undergo cardiopulmonary resuscitation and complex aortic repair procedures with extended cardiopulmonary bypass. However, late outcomes are acceptable for patients who were stabilized through surgical treatment and survived to discharge.
“…The patients' preoperative hemodynamics were stabilized with intravenous beta-blockers to maintain a systolic blood pressure < 120 mmHg and heart rate of 60-70 bpm according to the established guidelines [9]. For patients who presented with shock status, medical and surgical resuscitation procedures were applied based on the standardized protocols in this institute [10,11].…”
Section: Patient Enrollment and Preoperative Managementmentioning
Background
Perioperative coagulopathy and intractable bleeding are severe complications in acute type A aortic dissection (ATAAD) repair surgery. Mediastinal packing with delayed sternal closure (DSC) is a commonly adapted technique to stabilize the hemorrhagic tendency. This retrospective study aims to investigate the early and late outcomes and risk factors in patients who underwent DSC procedure during ATAAD repair surgery.
Methods
This study investigated 704 consecutive patients who underwent ATAAD repair at this institution between January 2007 and September 2020. These patients were dichotomized into the DSC (n = 109; 15.5%) and primary sternal closure (PSC) groups (n = 595; 84.5%). The clinical features, surgical information, postoperative complications, 5-years cumulative survival, and freedom from reoperation rates were compared. A multivariate logistic regression analysis was used to identify the independent risk factors for patients who underwent DSC.
Results
The DSC group showed a higher rate of hemopericardium and preoperative malperfusion, and was associated with longer cardiopulmonary bypass and aortic clamping times and a higher rate of intraoperative extracorporeal membrane oxygenation (ECMO) support. The DSC group showed higher blood transfusion volumes and rate of reexploration for bleeding after surgery. However, the in-hospital mortality rates (17.4% vs. 13.3%; P = 0.249), 5-year survival rates (66.9% vs. 68.2%; P = 0.635), and freedom from reoperation rates (89.1% vs. 82.5%; P = 0.344) were comparable between the DSC and PSC groups. Multivariate analysis revealed that hemopericardium, preoperative malperfusion, and intraoperative ECMO support were risk factors for implementing DSC.
Conclusions
DSC is an efficient life-saving technique to stabilize patients with intractable bleeding after undergoing ATAAD repair surgery, which leads to acceptable short- and long-term outcomes. Patients who were at risk for intractable bleeding should have early decision-making for implementing DSC.
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