Surgery For Acute Aortic Dissection Research Articles

Should aortic arch replacement be performed during initial surgery for aortic root aneurysm in patients with Marfan syndrome?†

The aim of this study was to investigate whether total arch replacement (TAR) during initial surgery for root aneurysm should be routinely performed in patients with Marfan syndrome (MFS). Retrospective analysis of 94 consecutive MFS patients fulfilling Ghent criteria who underwent 148 aortic surgeries and were followed at this institution during the past 16 years. The mean follow-up interval was 8.8 ± 7 years. Initial presentation was acute aortic dissection (AAD) in 35% of patients (76% Type A and 24% Type B) and aneurysmal disease in 65%. TAR was performed in 8% of patients during initial surgery for AAD (otherwise a hemi-arch replacement was performed) and 1.6% in elective root repair. Secondary TAR had to be performed in only 3% of patients without, but in 33% following AAD (33% Type A and 33% Type B; P = 0.0001). Thirty-day, 6-month, 1-year and overall mortalities were 3.2, 5.3, 6.4 and 11.7%, respectively. Operative and 30-day mortalities in secondary aortic arch replacement were zero. Secondary TAR after AAD did not increase the need for the replacement of the entire thoracoabdominal aorta during follow-up compared with patients without secondary TAR (37 vs 40%, P = 1.0). MFS patients undergoing elective root repair have small risk of reinterventions on the aortic arch, and primary prophylactic replacement does not seem to be justified. In patients with AAD, the need for reinterventions is precipitated by the dissection itself and not by limiting the procedure to the hemi-arch replacement in the emergency setting. Limiting surgery to the aortic root, ascending aorta and proximal aortic arch is associated with low mortality in MFS patients presenting with AAD.

Profound Thrombocytopenia after Treatment with Tirofiban; On-Pump Surgery for Acute Aortic Dissection and Coronary Bypass Surgery

We describe the case of a 69-year-old man who developed glycoprotein IIb/IIIa receptor (GPIIb/IIIa) antagonist associated thrombocytopenia and the successful management during urgent aortic dissection and coronary artery bypass grafting. A flow cytometric assay was developed to confirm the diagnosis of GPIIb/IIIa-antagonist induced thrombocytopenia. This case was further complicated by the concomitant presence of heparine/PF4 platelet antibodies, but was proven not to be the causal factor of the thrombocytopenia.

Unusual MRI findings in a case of Marchiafava Bignami disease

Twenty-four hours after surgery for acute aortic dissection, a 51-year-old man with alcoholism developed agitation, decreased consciousness, mutism, and upbeat nystagmus on upward gaze. He also showed left-sided weakness with pyramidal signs and spastic limb ataxia. After 4 weeks treatment with

Challenging management of a complex distal aortic arch pseudoaneurysm following previous aortic dissection repair

The primary goals of surgery for acute aortic dissection are to resect or control the intimal flap, prevent distal malperfusion, protect the brain and have a viable patient. However, several technical measures are important to prevent early and late sequalae, including adequate aortic resection, creating a stable anastamotic suture line, appropriate graft measurement and tailoring and completely resecting inciting aortic aneurysms. Utilizing simultaneous sternotomy and thoracotomy incisions, we report the re-operative management of a patient with an expanding distal aortic arch pseudoaneurysm, extending into the left pleural space, superimposed upon severely kinked proximal ascending aortic grafts and an aneurysmal aortic root only 6 months after initial repair.

急性大動脈解離手術後に発症したと考えられるヘパリン起因性血小板減少症の1例

急性大動脈解離手術後に発症したと考えられるヘパリン起因性血小板減少症の1例

Possible Anaphylaxis Due to Recombinant Factor VIIa Administration During Thoracic Aortic Surgery

Possible Anaphylaxis Due to Recombinant Factor VIIa Administration During Thoracic Aortic Surgery

急性A型大動脈解離術後に発生したへパリン起因性血小板減少症(HIT)の1例

急性A型大動脈解離術後に発生したへパリン起因性血小板減少症(HIT)の1例

Invited commentary

It has been known for some time that intravascular coagulation with thrombin and platelet activation, coupled with fibrinolysis, is present in patients presenting with symptomatic aortic dissection. The differential diagnosis of myocardial infarction and aortic dissection has received a diagnostic boost from the development of point-of-care testing, which rapidly reports plasma Troponin T and D-dimer levels from a small blood sample. Thus, it is not surprising that the authors of this paper [1Paparella D. Rotunno C. Guida P. et al.Hemostasis alterations in patients with acute aortic dissection.Ann Thorac Surg. 2011; 91: 1364-1370Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar] have demonstrated the rather remarkable levels of D-dimer, plasmin-antiplasmin ratio, and platelet factor IV levels in their group of patients who underwent operation for acute aortic dissection. It is also not surprising that patients who present to the operating room with ongoing consumptive coagulopathy would be a bleeding risk with a large aortic resection and grafting procedure. Therefore, their data regarding this process sets the stage for potential studies to assess treatment or, at least, amelioration of this condition. It is well known now that contact of blood with tissue factor from the patient's wound causes thrombin formation and platelet activation, which causes the coagulopathy during cardiopulmonary bypass. The administration of drugs, such as Alpha-Amino Caproic acid, can diminish the fibrinolysis associated with this process, which accentuates bleeding. Unfortunately, the actual dosing schedule of this compound has not been completely worked out (especially in complicated, high risk operations), and comparing post-bypass D-dimer levels and using increasing doses of Alpha-Amino Caproic acid to treat ongoing fibrinolysis has not been systematically studied. The other commonly used anti-fibrinolytic agent, Tranexamic acid, has also had very few studies regarding effectiveness against ongoing fibrinolysis, and large doses have been shown to be associated with a high incidence of seizures. The most powerful antifibrinolytic agent, Aprotinin, is now off the market and out of the picture. There are other recombinant proteinase inhibitors being studied, but these will not be available for patients for some time. It appears to me that studies to evaluate the importance of diminishing the consumptive coagulopathy not only associated with aortic dissection, but also with other major operations involving the aortic arch, redo surgery, and left ventricular assist device implantation are urgently needed. I, personally, hope the authors of this paper will begin studies such as that and that this will be followed by similar studies across the length and breadth of cardiac surgery. Hemostasis Alterations in Patients With Acute Aortic DissectionThe Annals of Thoracic SurgeryVol. 91Issue 5PreviewSurgery for acute aortic dissection (AAD) is frequently complicated by excessive postoperative bleeding and blood product transfusion. Blood flow through the nonendothelialized false lumen is a potential trigger for the activation of the hemostatic system; however, the physiopathology of the aortic dissection induced coagulopathy has never been precisely studied. The aim of the present study is the evaluation of the coagulation and fibrinolytic systems and platelet activation in patients undergoing surgery for AAD. Full-Text PDF

Hemostasis Alterations in Patients With Acute Aortic Dissection

Surgery for acute aortic dissection (AAD) is frequently complicated by excessive postoperative bleeding and blood product transfusion. Blood flow through the nonendothelialized false lumen is a potential trigger for the activation of the hemostatic system; however, the physiopathology of the aortic dissection induced coagulopathy has never been precisely studied. The aim of the present study is the evaluation of the coagulation and fibrinolytic systems and platelet activation in patients undergoing surgery for AAD. Eighteen patients undergoing emergent surgery for Stanford type A AAD were enrolled in the study. The activation of the coagulation and fibrinolytic systems and platelet activation were evaluated at 6 different time points before, during, and after the operation, measuring prothrombin fragment 1.2 (F1.2), plasmin-antiplasmin complex, and platelet factor 4, respectively. All measured biomarkers were increased before, during, and after the operations indicating a systemic activation of coagulation, fibrinolysis, and platelets. These changes were pronounced even preoperatively (T0), and soon after the beginning of cardiopulmonary bypass (T1) when the influence of hypothermia and prolonged cardiopulmonary bypass time were not yet involved. Time from symptom onset to intervention inversely correlated with preoperative F1.2 (r=-0.75; p=0.002) and plasmin-antiplasmin levels (r=-0.57; p=0.034). Blood flow through the false lumen is a powerful activator of the hemostatic system even before the operation. This remarkable activation may influence postoperative outcome of AAD patients.

Analysis of the Risk Associated With Pregnancy in Women With Marfan Syndrome

regnancy in patients with Marfan syndrome (MFS) is associated with the potential for lethal cardiovascular events and transmission of mutant genes to the children.1 Although aortic dissection is the most serious complication in patients with MFS, pregnancy increases the risk of such complications2,3 because of the maternal cardiovascular changes such as increases in the blood volume, heart rate, and stroke volume.4 Previous studies demonstrated that the risk factors for aortic complications during the perinatal period were an enlarged aortic root at the beginning of pregnancy, rapid growth of the aortic root, a family history of premature aortic dissection, and the presence of significant aortic regur gitation. 5 Small aortic diameter, however, cannot preclude the occurrence of aortic dissection during the perinatal period. Article p 2545 Severity of Cardiovascular Complications During Pregnancy In the early 1990s, the maternal and fetal mortality rates in MFS patients who developed type A aortic dissection during pregnancy were 30% and 50%, respectively. 6 Although the mortality rate has improved since then, women with MFS are still at risk of aortic complications during the perinatal period. A recent review1 presented 39 women who had MFS and experienced perinatal cardiovascular complications: acute aortic dissection was reported in 29 patients, including 21 patients with type A dissection; 23 patients developed acute aortic dissection during pregnancy, and 6 patients did after delivery. In 19 patients, dilatation of the aorta was diagnosed prior to pregnancy and 4 patients had a history of aortic surgery. Surgical intervention was required in 32 patients, of whom 7 underwent emergency surgery during pregnancy, because of acute aortic dissection. Among the patients with emergency surgery, operative maternal death was reported for 2 mothers, of whom 1 had intrauterine fetal death. Six fetuses survived but 1 had brain atrophy. Among the 39 patients in the review, 5 fetal deaths were reported, including 3 intrauterine fetal deaths and 2 elective abortions. Maternal death occurred in 5 cases. There was 1 prepartum death from multiple organ failure 4 days after emergency aortic surgery for acute aortic dissection that occurred at 26 weeks of pregnancy. The baby also died in utero during the surgery. One patient died 14 days after delivery from a ruptured aortic dissection. Three patients died late after delivery, because of dissection, endocarditis, and subarachnoid hemorrhage, respectively. Incidence of Cardiovascular Complications During Pregnancy It is difficult to clarify the incidence of cardiovascular events during pregnancy in patients with MFS because the severity of the patients differs among reports. A higher incidence of cardiovascular complications may be associated with a higher proportion of high-risk patients. Therefore, there is a bias toward a higher incidence of aortic events in publications from referral cardiovascular centers. In this issue of the Journal, Katsuragi et al report a relatively high incidence of aortic events compared with previous studies;7 the reported prevalence of perinatal aortic dissection in patients with MFS was 3.9%.8–10

Impact of clonidine administration on delirium and related respiratory weaning after surgical correction of acute type-A aortic dissection: results of a pilot study

Delirium and transient neurologic dysfunctions (TND) often complicate the postoperative course after surgery for acute type-A aortic dissection (AAD). We evaluated the role of clonidine on neurological outcome and respiratory function in 30 consecutive patients undergoing surgery for AAD. Patients were prospectively randomized to receive either clonidine (0.5 microg/kg bolus, followed by continuous infusion at 1-2 microg/kg/h) or placebo (NaCl 0.9%) in on starting and throughout the weaning period from the mechanical ventilation. Incidence of delirium and TND, Delirium Detection Score (DDS), weaning parameters [respiratory rate to tidal volume ratio - f/VT; pressure-frequency product (PFP); partial pressure of arterial oxygen to fractional inspired oxygen concentration (PaO(2)/FiO(2)); partial pressure of carbon dioxide (PaCO(2))], weaning duration and intensive care unit (ICU) length of stay were recorded. The two groups were similar for preoperative and operative variables and also for the incidence of postoperative complications. DDS was lower in the clonidine group (P<0.001). Patients weaned with clonidine showed lower f/VT and PFP, higher PaO(2)/FiO(2) and PaCO(2), lower DDS, weaning period and the related ICU length of stay (P<0.001). This was further confirmed in patients developing delirium/TND. Intravenous clonidine after surgery for AAD reduces the severity of delirium, improves the respiratory function, shortens the weaning duration and the ICU length of stay.

Outcome of acute type A aortic dissection: single-center experience from 1998 to 2007.

Acute aortic dissection (AAD) is a serious disease of the aorta with high mortality and morbidity, which requires emergency surgical treatment in order to close the site of the dissection and direct blood flow into the true lumen. Improvements in surgical technique have led to better management of patients with reduced operative mortality, although it still remains high. The aim of this study is to evaluate early and late outcomes of the surgical treatment of acute type A aortic dissection at the hospital of Lecce between 1998 and 2007. We also aim to establish a correlation between these outcomes and pre-operative conditions, surgical procedures and location of the site of the tear. From 1998 to 2007, 100 patients (69 males and 31 females, average age 62.2 +/- 12.3 years, range 22-85 years) underwent surgery for acute AAD at the center. Surgical techniques included replacement of the ascending aorta (Asc Ao) with or without valve replacement (including five patients who underwent the Bentall/De Bono procedure) and replacement of the Asc Ao with or without arch or hemiarch replacement. In-hospital mortality was 22%, with different results between surgery for replacement of the aorta and for aorta with valve replacement (respectively, 16% and 23%). Different mortality rates were found between the distal surgical treatments, with rates of 20.8% and 18.2% respectively between replacements of the Asc Ao and of Asc Ao with arch/hemiarch, although they were not statistically significant. A different mortality rate that was subject to the patient's preoperative condition has also been found (33.3% of mortality in patients in unstable or high-risk condition vs 13.8% in patients in stable condition). The peak reached 43.5% mortality in patients taken to the operating room while in shock or cardiac tamponade. The location of the site of the tear is another factor that distinguishes mortality rates, which are 17.8% if localized at the proximal ascending aorta and 22.2% in the aortic arch. Assessment of the outcome (10 years after surgery), has shown that four patients died several years later but for reasons unrelated to the surgery. The surgery of dissection is still an intervention with a relatively high in-hospital mortality risk, and whose outcome, which has been steady in the last 20 years, can be predicted according to the preoperative condition of the patient. This underlines the need to reduce the time of diagnosis indicating immediate surgical treatment.

Acute type A aortic dissection: 18 years of experience in one center (Hospital 12 de Octubre)☆

Here, we review our experience in acute type A aortic dissection analyzing the role of antegrade brain protection. A total of 105 patients underwent surgery for acute type A aortic dissection between March 1990 and October 2008. An open technique with deep hypothermia was used in 81 patients. Deep hypothermia alone was induced in 32 patients; in combination with retrograde cerebral perfusion in 26 patients and in combination with antegrade cerebral perfusion (ACP) in the final 23 patients. The overall hospital mortality rate was 15%. Hospital mortality risk factors were age >or=70 years and preoperative shock (P<0.05). Hospital mortality was reduced to 9% in the last 23 consecutive patients in whom ACP was accomplished (P=0.05). Survival rate after 1, 5, 10 and 15 years of follow-up was 97.6+/-1.7%, 84.3+/-4.4%, 60.7+/-7.5% and 57.1+/-7.8%, respectively. The only late death risk predictor was the non-use of ACP (P<0.05). Surgery for acute aortic dissection provides excellent results. ACP via the axillary artery improves the prognosis for these patients and should be the brain protection method of choice.

Optimal proportions of gelatin–resorcin–formalin components in aortic surgery☆☆☆

Gelatin-resorcin-formalin (GRF) glue, a haemostatic agent often employed for aortic surgery, has beneficial effects on early results in surgery for acute aortic dissection but may have late adverse effects, probably due to excess use of the activators such as formaldehyde and glutaraldehyde. The purpose of this study was to determine the optimal proportions of GRF components that minimise toxicity to human aortic smooth muscle cells and elastin with acceptable adhesive strength. (1) The degree of polymerisation was examined at various proportions (activator/gelatin+resorcinol=0%, 2%, 4%, 6%, 8% and 10%) to estimate adhesive strength. (2) (i) The toxicity of the activator was confirmed 24h after its supplementation to human aortic smooth muscle cells in various proportions (activator/human aortic smooth muscle cell=0%, 0.5%, 1%, 1.5%, 2% and 2.5%). (ii) The toxicity of GRF glue to human aortic smooth muscle cells was evaluated 1h and 60 h after its supplementation (activator/gelatin+resorcinol=0%, 2%, 4%, 6%, 8% and 10%). Another set of experiments in the same study was also performed. The only difference was that GRF glues were washed after polymerisation to exclude non-polymerised constituents. (3) Effects of 8%-GRF glue on toxicity to elastin derived from human aortic wall cells were investigated using an immunoblotting method. (1) The polymerisation area increased dose dependently and that of the 10% activator/gelatin+resorcinol mixture was significantly wider than those of 6%, 4%, 2% and 0%, but had no significant difference from that of 8%. (2) (i) Human aortic smooth muscle cell death occurred in all dishes except activator-free dishes. (ii) Sixty hours after exposure to GRF glue, human aortic smooth muscle cell death occurred only in the 10% dish. In a washed GRF glue study, no human aortic smooth muscle cell death occurred in any dishes. (3) Toxicity to elastin was not significantly different between 8%-GRF glue and the control, whereas toxicity of elastase to elastin was significantly higher than for both the glue and the control. An 8%-GRF glue provides lower toxicity to human aortic smooth muscle cells and elastin with an acceptable degree of polymerisation, and thus seems to be an optimal proportion for GRF glue.

Surgery for Acute Aortic Dissection: An Easy and Cheap Method to Reinforce the Anastomosis

Bleeding from the anastomotic site is a frequent complication of surgery for acute aortic dissection. Many methods have been devised in order to avoid this problem. We report a simple, easy technique to reinforce the anastomotic sites. One small 4-mm-high ring is cut from the same prosthesis and placed circumferentially inside the aorta edge. Another ring of the same width is opened in a "C" shape, and placed outside the aorta. The conduit was eventually sutured to the aorta in a standard fashion using a running 3-0 polypropylene suture. The final result appeared good with no bleeding, and the rim lines appear clearer and the edges easier to suture because the Dacron is thinner than other used materials (that is, Teflon). In our opinion, this technique is a simple method to reinforce the anastomosis for both proximal and distal aorta.

Surgery for acute aortic dissection using gelatin-resorcin-formalin glue: perspective from 10 years of follow-up at a single center

Acute type A aortic dissection is a lethal aortic disease with an extremely poor prognosis unless surgical intervention is performed in a timely manner. Since the clinical introduction of gelatin-resorcin-formalin (GRF) glue in Japan, tear-oriented aortic repairs have been widely performed with the aid of this glue at many institutions over the past decade. A total of 138 patients underwent glue-aided emergency operations for acute type A aortic dissection at Nihon University Itabashi hospital. The hospital mortality rate was 6.7%. The actuarial survival rate was 81.5% after 5 years and 54.8% after 10 years. The rate of freedom from reoperation was 87.9% after 5 years and 72.3% after 10 years. Although application of GRF glue remains controversial because of concerns about the cytotoxicity of formaldehyde and tissue necrosis, cytotoxicity and tissue necrosis have not been found at reoperation. GRF glue demonstrated excellent tissue adhesion and hemostasis capabilities and contributed to improved surgical results. Although some disadvantages have been reported, complications can be avoided by proper use of the glue and proper selection of surgical procedure, based on the pathology of the patient.

Two-Step Aortic Cross-Clamping Technique for Acute Type-A Aortic Dissection in Octogenarians

In octogenarians, due to the high mortality and morbidity, acute type-A aortic dissection requires a less invasive surgical approach. We describe a method in which replacement of the ascending aorta and stenting of the dissected arch are performed with mild hypothermic extracorporeal circulation.

Predictors of Mortality and Reoperation in Acute Type-A Aortic Dissection Surgery: 18 Years of Experience

To describe our experience with acute type-A aortic dissection surgery, including an analysis of the effect of cerebral protection on outcome. Between March 1990 and October 2007, 98 consecutive patients underwent surgery for acute type-A aortic dissection. Of these, 85 had an ascending aorta replacement, while the entire arch was replaced in 13. The aortic valve was replaced in 34 patients but preserved in the rest. An intimal tear was observed in 83 patients. The in-hospital mortality rate was 15%. Risk factors for in-hospital mortality were age > or = 70 years and preoperative cardiogenic shock (P< .05). Antegrade cerebral perfusion was used in the last 16 consecutive patients, whose in-hospital mortality rate was 6%. The proportions of patients who survived and who did not require reoperation at 1, 5 and 10 years of follow-up were 98.6%+/-1.3%, 86.2%+/-4.6% and 68.2%+/-8.9%, and 97.2%+/-1.9%, 82.5%+/-4.8% and 55.9%+/-7.9% for the two outcomes, respectively. The risk factors for reoperation were found to be severe preoperative aortic regurgitation and preservation of the aortic valve (P< .05). The only risk factor for late mortality was not using antegrade cerebral perfusion (P< .05). Despite its seriousness, surgery for acute aortic dissection produces good early and long-term results. Antegrade cerebral perfusion improves the prognosis of these patients and should be the technique of choice for cerebral protection.

Direct true lumen cannulation in surgery for acute Typ-A aortic dissection – a promising approach

Aims: The optimal arterial cannulation in acute Typ-A aortic dissection is controversial. We retrospectively investigated direct true lumen cannulation as an alternative to standard cannulation procedures.

Recombinant activated factor VII for refractory bleeding after acute aortic dissection surgery: A propensity score analysis*

The aim of this study was to assess safety and effectiveness of recombinant activated factor VII (rFVIIa) in patients with refractory bleeding undergoing acute aortic dissection surgery with deep hypothermic circulatory arrest. Propensity score-matched analysis. University hospital. Twenty-three cardiac surgery patients receiving rFVIIa compared with 23 matched controls. An intravenous bolus of rFVIIa (70 microg/kg) was administered at the end of a complete transfusion protocol. Five patients received rFVIIa in the operating room, and 18 patients received rFVIIa in the intensive care unit. Four of the intensive care unit patients required a second dose. Blood loss and transfusion requirements were significantly reduced in the period after rFVIIa administration. A highly significant reduction in hourly blood loss was found at -1 hr vs. 0 hrs and 0 hrs vs. 1 hr (-194 and -77.5 mL, respectively; both adjusted p < .001). In addition, significant improvements of international normalized ratio (p < .001), partial thromboplastin time (p < .001), platelet count (p < .001), fibrinogen (p < .001), and antithrombin (p < .001) were detected after rFVIIa administration. The two groups did not differ regarding adverse events. rFVIIa was successfully used as an additional therapy both during and after acute aortic dissection surgery with deep hypothermic circulatory arrest, when bleeding was refractory to conventional methods. Randomized studies are necessary to confirm the safety and efficacy of rFVIIa in this setting.