Modification of Penn Classification and Its Validation for Acute Type A Aortic Dissection

Abstract

We read the recent report entitled Utility of the Penn Classification in Predicting Outcomes of Surgery for Acute Type A Aortic Dissection that was published in The American Journal of Cardiology, 1 Kimura N. Ohnuma T. Itoh S. Sasabuchi Y. Asaka K. Shiotsuka J. Adachi K. Yuri K. Matsumoto H. Yamaguchi A. Sanui M. Adachi H. Utility of the Penn classification in predicting outcomes of surgery for acute type A aortic dissection. Am J Cardiol. 2014; 113: 724-730 PubMed Scopus (43) Google Scholar in which Kimura et al investigated whether Penn classes predict outcomes after surgery for acute type A aortic dissection (AAAD) by comparing the hospital outcomes of 351 patients divided into 4 groups based on Penn classification. The investigators proposed that morbidity and mortality were high in patients with generalized ischemia (Penn Ac and Penn Abc groups). In addition, they recommended that changing the surgical strategies based on the Penn classification is important. A more aggressive surgical approach, such as total arch replacement, should be performed in Penn class Aa cases, especially if patients are young. In contrast, we agree with the comment by Kimura et al that prolonged operation time might increase the already high operative risk through infection (e.g., mesenteric ischemia) or multiorgan failure (e.g., Penn Ac and Penn Abc groups) 1 Kimura N. Ohnuma T. Itoh S. Sasabuchi Y. Asaka K. Shiotsuka J. Adachi K. Yuri K. Matsumoto H. Yamaguchi A. Sanui M. Adachi H. Utility of the Penn classification in predicting outcomes of surgery for acute type A aortic dissection. Am J Cardiol. 2014; 113: 724-730 PubMed Scopus (43) Google Scholar as our recent reports pointed out. 2 Chen Y.F. Chien T.M. Yu C.P. Ho K.J. Wen H. Li W.Y. Chen C.W. Huang J.W. Hsieh C.C. Chen H.M. Chiu C.C. Lee C.S. Lin C.C. Acute aortic dissection type A with acute coronary involvement: a novel classification. Int J Cardiol. 2013; 168: 4063-4069 Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar , 3 Chien T.M. Li W.Y. Wen H. Huang J.W. Hsieh C.C. Chen H.M. Chiu C.C. Chen Y.F. Stable hemodynamics associated with no significant electrocardiogram abnormalities is a good prognostic factor of survival for acute type A aortic dissection repair. Interact Cardiovasc Thorac Surg. 2013; 16: 158-165 Crossref PubMed Scopus (10) Google Scholar Therefore, the hospital outcomes of surgery in patients in Penn Ac and Penn Abc groups might be improved through less invasive hemiarch replacement based on patient's age and preoperative co-morbidity. 1 Kimura N. Ohnuma T. Itoh S. Sasabuchi Y. Asaka K. Shiotsuka J. Adachi K. Yuri K. Matsumoto H. Yamaguchi A. Sanui M. Adachi H. Utility of the Penn classification in predicting outcomes of surgery for acute type A aortic dissection. Am J Cardiol. 2014; 113: 724-730 PubMed Scopus (43) Google Scholar Kimura et al have also pointed out that the mortality rate of Penn Aa group was 2.7% in their study cohort; in addition, 3.1% in the Penn group 4 Augoustides J.G. Geirsson A. Szeto W.Y. Walsh E.K. Cornelius B. Pochettino A. Bavaria J.E. Observational study of mortality risk stratification by ischemic presentation in patients with acute type A aortic dissection: the Penn classification. Nat Clin Pract Cardiovasc Med. 2009; 6: 140-146 Crossref PubMed Scopus (121) Google Scholar and 13.7% in the Karolinska group. 5 Olsson C. Hillebrant C.G. Liska J. Lockowandt U. Eriksson P. Franco-Cereceda A. Mortality in acute type A aortic dissection: validation of the Penn classification. Ann Thorac Surg. 2011; 92: 1376-1383 Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar This is in line with the observation that we have (1.6%, 1 of 63) in patients who presented with stable hemodynamics associated with no significant electrocardiographic abnormalities. 3 Chien T.M. Li W.Y. Wen H. Huang J.W. Hsieh C.C. Chen H.M. Chiu C.C. Chen Y.F. Stable hemodynamics associated with no significant electrocardiogram abnormalities is a good prognostic factor of survival for acute type A aortic dissection repair. Interact Cardiovasc Thorac Surg. 2013; 16: 158-165 Crossref PubMed Scopus (10) Google Scholar Furthermore, the mortality rate of Penn Abc group (branch vessel malperfusion and circulatory collapse) was 21.6% in the study by Kimura et al, 40.0% in the Penn group, 4 Augoustides J.G. Geirsson A. Szeto W.Y. Walsh E.K. Cornelius B. Pochettino A. Bavaria J.E. Observational study of mortality risk stratification by ischemic presentation in patients with acute type A aortic dissection: the Penn classification. Nat Clin Pract Cardiovasc Med. 2009; 6: 140-146 Crossref PubMed Scopus (121) Google Scholar and 44.4% in the Karolinska group, 5 Olsson C. Hillebrant C.G. Liska J. Lockowandt U. Eriksson P. Franco-Cereceda A. Mortality in acute type A aortic dissection: validation of the Penn classification. Ann Thorac Surg. 2011; 92: 1376-1383 Abstract Full Text Full Text PDF PubMed Scopus (68) Google Scholar which was very similar to the mortality rate (41.2%) of our patient group 3 Chien T.M. Li W.Y. Wen H. Huang J.W. Hsieh C.C. Chen H.M. Chiu C.C. Chen Y.F. Stable hemodynamics associated with no significant electrocardiogram abnormalities is a good prognostic factor of survival for acute type A aortic dissection repair. Interact Cardiovasc Thorac Surg. 2013; 16: 158-165 Crossref PubMed Scopus (10) Google Scholar who had preoperative shock combined with myocardial ischemia on electrocardiogram. Thus, the validity of the Penn classification is further supported by our findings. However, this well-organized study could still benefit from further discussion on the patients with branch vessel malperfusion with ischemia, so-called Penn class Ab. First, Kimura et al showed excellent surgical outcomes for AAAD patients with mesenteric ischemia (in-hospital mortality: 6%, 1 of 17). AAAD complicated with mesenteric malperfusion is an uncommon but ominous complication carrying a high risk of in-hospital mortality. 6 Santini F. Montalbano G. Casali G. Messina A. Iafrancesco M. Luciani G.B. Rossi A. Mazzucco A. Clinical presentation is the main predictor of in-hospital death for patients with acute type A aortic dissection admitted for surgical treatment: a 25 years experience. Int J Cardiol. 2007; 115: 305-311 Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar , 7 Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection. J Thorac Cardiovasc Surg. 2009; 138: 1363-1369 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar , 8 Eusanio M.D. Trimarchi S. Patel H.J. Hutchison S. Suzuki T. Peterson M.D. Bar tolomeo R.D. Folesani G. Pyeritz R.E. Braverman A.C. Montgomery D.G. Isselbacher E.M. Nienaber C.A. Eagle K.A. Fattori R. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg. 2013; 145: 385-390 Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar The recent reports demonstrated that cases with mesenteric malperfusion were associated with dismal mortality rates (75% [6 of 8] from a German group 7 Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection. J Thorac Cardiovasc Surg. 2009; 138: 1363-1369 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar and 63.3% [43 of 68] from the International Registry of Acute Aortic Dissection, 8 Eusanio M.D. Trimarchi S. Patel H.J. Hutchison S. Suzuki T. Peterson M.D. Bar tolomeo R.D. Folesani G. Pyeritz R.E. Braverman A.C. Montgomery D.G. Isselbacher E.M. Nienaber C.A. Eagle K.A. Fattori R. Clinical presentation, management, and short-term outcome of patients with type A acute dissection complicated by mesenteric malperfusion: observations from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg. 2013; 145: 385-390 Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar respectively). We advocate Kimura et al that individualized and detailed surgical strategies should be carried out on AAAD patients with mesenteric malperfusion based on their excellent results in this special patient group. Second, regarding the brain malperfusion, it has been acknowledged that a wide spectrum of symptoms is associated with brain malperfusion. Conscious patients with a transient or even persistent neurological deficit preoperatively usually have a similar operative and longer term survival as patients without neurological deficit. 7 Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection. J Thorac Cardiovasc Surg. 2009; 138: 1363-1369 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar , 9 Bonser R.S. Ranasinghe A.M. Loubani M. Evans J.D. Thalji N.M.A. Bachet J.E. Carrel T.P. Czerny M. Bartolomeo R.D. Grabenwoger M. Lonn L. Mestres C.A. Schepens M.A.A.M. Weigang E. Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol. 2011; 58: 2455-2474 Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar In contrast, patients with dense deficits or coma have a poor postoperative prognosis, and resuscitative surgery in such patients might be considered futile. 7 Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection. J Thorac Cardiovasc Surg. 2009; 138: 1363-1369 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar , 9 Bonser R.S. Ranasinghe A.M. Loubani M. Evans J.D. Thalji N.M.A. Bachet J.E. Carrel T.P. Czerny M. Bartolomeo R.D. Grabenwoger M. Lonn L. Mestres C.A. Schepens M.A.A.M. Weigang E. Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol. 2011; 58: 2455-2474 Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar Nonetheless, neurological recovery has been reported in cases in which rapid reperfusion on comatous patients within 10 10 Estrera A.L. Garami Z. Miller C.C. Porat E.E. Achouh P.E. Dhareshwar J. Meada R. Azizzadeh A. Safi H.J. Acute type A aortic dissection complicated by stroke: can immediate repair be performed safely?. J Thorac Cardiovasc Surg. 2006; 132: 1404-1408 Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar or 12 11 Pocar M. Passolunghi D. Moneta A. Matioli R. Donatelli F. Coma might not preclude emergency operation in acute aortic dissection. Ann Thorac Surg. 2006; 81: 1348-1351 Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar hours of presentation is achieved. The most comprehensive study of patients with AAAD presenting with major brain injury was based on the International Registry of Acute Aortic Dissection database, 12 Eusanio M.D. Patel H.J. Nienaber C.A. Montgomery D.M. Korach A. Sundt T.M. De Vincentiis C.D. Voehringer M. Peterson M.D. Myrmel T. Folesani G. Larsen M. Desai N.D. Bavaria J.E. Appoo J.J. Kieser T.M. Fattori R. Eagle K. Bartolomeo R.D. Trmarchi S. Patients with type A acute aortic dissection presenting with major brain injury: should we operate on them?. J Thorac Cardiovasc Surg. 2013; 145: S213-S221 Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar which included 87 patients with cerebrovascular accident and 54 patients with coma. The overall hospital mortality was 22.7% without brain injury, 40.2% with cerebrovascular accident, and 63.0% with coma. Thus, brain injury at presentation significantly (p <0.001) affects hospital survival of patients with AAAD. 12 Eusanio M.D. Patel H.J. Nienaber C.A. Montgomery D.M. Korach A. Sundt T.M. De Vincentiis C.D. Voehringer M. Peterson M.D. Myrmel T. Folesani G. Larsen M. Desai N.D. Bavaria J.E. Appoo J.J. Kieser T.M. Fattori R. Eagle K. Bartolomeo R.D. Trmarchi S. Patients with type A acute aortic dissection presenting with major brain injury: should we operate on them?. J Thorac Cardiovasc Surg. 2013; 145: S213-S221 Abstract Full Text Full Text PDF PubMed Scopus (71) Google Scholar Third, coronary circulation is not an uncommon site of malperfusion reported in the literature with an approximate incidence of 6% to 19%. 2 Chen Y.F. Chien T.M. Yu C.P. Ho K.J. Wen H. Li W.Y. Chen C.W. Huang J.W. Hsieh C.C. Chen H.M. Chiu C.C. Lee C.S. Lin C.C. Acute aortic dissection type A with acute coronary involvement: a novel classification. Int J Cardiol. 2013; 168: 4063-4069 Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar , 7 Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection. J Thorac Cardiovasc Surg. 2009; 138: 1363-1369 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar , 13 Neri E. Toscano T. Papalia U. Frati G. Massetti M. Capannini G. Tucci E. Buklas E. Muzzi L. Oricchio L. Sassi C. Proximal aortic dissection with coronary malperfusion: presentation, management, and outcome. J Thorac Cardiovasc Surg. 2001; 121: 552-560 Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar , 14 Kawahito K. Adachi H. Murata S. Yamaguchi A. Ino T. Coronary malperfusion due to type A aortic dissection: mechanism and surgical management. Ann Thorac Surg. 2003; 76: 1471-1476 Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar Kimura et al shared a similar experience that we have in regard to the incidence of coronary malperfusion (6.3%, 22 of 351 vs 9.9%, 14 of 142, p = 0.17) and in-hospital mortality (27.3%, 6 of 22 vs 21.4%, 3 of 14, p = 0.69). 1 Kimura N. Ohnuma T. Itoh S. Sasabuchi Y. Asaka K. Shiotsuka J. Adachi K. Yuri K. Matsumoto H. Yamaguchi A. Sanui M. Adachi H. Utility of the Penn classification in predicting outcomes of surgery for acute type A aortic dissection. Am J Cardiol. 2014; 113: 724-730 PubMed Scopus (43) Google Scholar , 3 Chien T.M. Li W.Y. Wen H. Huang J.W. Hsieh C.C. Chen H.M. Chiu C.C. Chen Y.F. Stable hemodynamics associated with no significant electrocardiogram abnormalities is a good prognostic factor of survival for acute type A aortic dissection repair. Interact Cardiovasc Thorac Surg. 2013; 16: 158-165 Crossref PubMed Scopus (10) Google Scholar In the presence of coronary malperfusion, in-hospital mortality doubles, and some patients will die intraoperatively from low output syndrome. 9 Bonser R.S. Ranasinghe A.M. Loubani M. Evans J.D. Thalji N.M.A. Bachet J.E. Carrel T.P. Czerny M. Bartolomeo R.D. Grabenwoger M. Lonn L. Mestres C.A. Schepens M.A.A.M. Weigang E. Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol. 2011; 58: 2455-2474 Abstract Full Text Full Text PDF PubMed Scopus (165) Google Scholar In a series from the Leipzig group, 7 Girdauskas E. Kuntze T. Borger M.A. Falk V. Mohr F.W. Surgical risk of preoperative malperfusion in acute type A aortic dissection. J Thorac Cardiovasc Surg. 2009; 138: 1363-1369 Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar in-hospital mortality was significantly higher in patients with coronary malperfusion than in patients without it (39.4% vs 17.1%, p = 0.004). It is important to note that Kimura et al addressed that the in-hospital mortality was significantly higher in patients with coronary malperfusion. They emphasized that such organ-specific ischemia (i.e., coronary malperfusion) remains a surgical challenge and is associated with worse unfavorable outcomes. 1 Kimura N. Ohnuma T. Itoh S. Sasabuchi Y. Asaka K. Shiotsuka J. Adachi K. Yuri K. Matsumoto H. Yamaguchi A. Sanui M. Adachi H. Utility of the Penn classification in predicting outcomes of surgery for acute type A aortic dissection. Am J Cardiol. 2014; 113: 724-730 PubMed Scopus (43) Google Scholar Utility of the Penn Classification in Predicting Outcomes of Surgery for Acute Type A Aortic DissectionAmerican Journal of CardiologyVol. 113Issue 4PreviewThe Penn classification, a risk assessment system for acute type A aortic dissection (AAAD), is based on preoperative ischemic conditions. We investigated whether Penn classes predict outcomes after surgery for AAAD. Three hundred fifty-one patients with DeBakey type I AAAD treated surgically, January 1997 to January 2011, were divided into 4 groups per Penn class: Aa (no ischemia, n = 187), Ab (localized ischemia with branch malperfusion, n = 67), Ac (generalized ischemia with circulatory collapse, n = 46), and Abc (localized and generalized ischemia, n = 51). Full-Text PDF