Acute Aortic Dissection Type A Patients Research Articles

Role of Helicopter Transfer and Cloud-Type Imaging for Acute Type A Aortic Dissection.

This study explored if long-distance transfer was safe for patients suffering from acute aortic dissection type A (AADA) and also analyzed the effectiveness of helicopter transfer and cloud-type imaging transfer systems for such patients in northern Hokkaido, Japan. The study included 112 consecutive patients who underwent emergency surgical treatment for AADA from April 2014 to September 2020. The patients were divided into two groups according to the location of referral source hospitals: the Asahikawa city group (group A, n = 49) and the out-of-the-city group (group O, n = 63). Use of helicopter transfer (n = 13) and cloud-type telemedicine (n = 20) in group O were reviewed as subanalyses.Transfer distance differed between groups (4.2 ± 3.5 km in group A vs 107.3 ± 69.2 km in group O; p = 0.0001), but 30-day mortality (10.2% in group A vs 7.9% in group O; p = 0.676) and hospital mortality (12.2% in group A vs 9.5% in group O; p = 0.687) did not differ. Operative outcomes did not differ with or without helicopter and cloud-type telemedicine, but diagnosis-to-operation time was shorter with helicopter (240.0 ± 70.8 vs 320.0 ± 78.5 minutes; p = 0.031) and telemedicine (242.0 ± 75.2 vs 319.0 ± 83.8 minutes; p = 0.007). We found that long-distance transfer did not impair surgical outcomes in AADA patients, and both helicopter transfer and cloud-type telemedicine system could contribute to the reduction of diagnosis-to-operation time in the large Hokkaido area. Further studies are mandatory to investigate if both the systems will improve clinical outcomes.

Treatment of acute type A aortic dissection with the Ascyrus Medical Dissection Stent in a consecutive series of 57 cases.

The Ascyrus Medical Dissection Stent (AMDS) has been recently introduced as an alternative for total arch replacement in acute aortic dissection type A (AADA). The aim of this study was to evaluate the postoperative outcomes after AMDS treatment in a large contemporary cohort of AADA patients. Data acquisition was performed retrospectively at 2 German aortic centres between 2020 and 2022 and comprised the perioperative parameters and postoperative results of all AADA patients. All patients treated with the AMDS for AADA were included in the study. The primary end point was in-hospital mortality. Secondary end points were defined as early postoperative and AMDS-related complications. Fifty-seven AADA patients treated by AMDS were included in the study group. The mean age was 64.6 ± 10.8 years and 59.7% (n = 34) were males. The actual in-hospital mortality was considerably lower than the predicted mortality risk by the German registry for acute aortic dissection type A score (16% vs 22%). The median ICU and in-hospital stay were 5 (interquartile range: 3-13) and 12 (interquartile range: 10-22) days, respectively. Postoperative complications comprised acute renal insufficiency (37%) with need for temporary (16%) or permanent dialysis (5%), delirium (26%), re-exploration for bleeding (14%), tracheostomy (14%) and new stroke (4%). A new AMDS-related complication (central stent collapse) was observed in 9% (n = 5) by postoperative computed tomography and chest X-ray. The incidence of complete central AMDS collapse did not impact 30-day mortality. The AMDS may be successfully used in AADA with acceptable 30-day mortality in accordance with the German registry for acute aortic dissection type A score. However, careful preoperative evaluation of the patient's individual aortic anatomy regarding potential contraindications and proper device implantation are strongly recommended to avoid complete central AMDS collapse.

Aortic root replacement in bicuspid versus tricuspid aortic valve patients.

BackgroundConcomitant replacement of the aortic root and aortic valve is a widely used treatment strategy in elective patients with aortic valve stenosis and root aneurysm. It is also a strategy frequently employed in patients with acute aortic dissection type A (AADA), involving the aortic root. Although more patients have undergone valve sparing procedures over the past decades, the classic ‘modified Bentall technique’ remains a valid option, particularly for patients with a bicuspid aortic valve (BAV). We aimed to compare the results of elective and emergency modified Bentall procedures in patients with bicuspid and tricuspid aortic valves (TAVs).MethodsWe retrospectively reviewed our database for patients undergoing either elective or emergency modified Bentall procedures between 2000 and 2018 and identified 827 elective cases (44% BAV) and 258 emergency cases (15% BAV). Analysis of intra- and postoperative outcomes and early mortality was performed. Due to inequality of the groups, a matching analysis was performed.ResultsWe found BAV patients to be significantly younger (elective: 58±18 vs. 65±14, P<0.001; emergency: 49±17 vs. 62±19, P<0.001) and healthier at time of surgery. In the AADA cohort, malperfusion rate was not different between bicuspid and tricuspid patients, however bicuspid AADA patients presented more often with an entry in the aortic root. After matching, procedure times and early outcomes did not differ between the groups, except for significantly higher rates of respiratory failure in elective TAV patients (10% vs. 5%, P=0.033). The 30-day mortality was 2% in elective cases and 22% in emergency AADA surgery. A subgroup analysis of elective patients with aortic diameter <55 mm also showed excellent outcomes.ConclusionsAfter adjustment for preoperative inequalities, no differences in early mortality and outcomes were found between bicuspid and tricuspid patients receiving elective or emergency modified Bentall surgery.

Effect of High-Flow Nasal Cannula for Hypoxemia Following Sun's Procedure in Acute Aortic Dissection Type a Patients.

Background: Patients with acute aortic dissection type A (AADA) often have hypoxemia (partial pressure of oxygen [PaO2]/fraction of inspired oxygen [FiO2] <300 mmHg) before weaning in the intensive care unit (ICU). This study compared the efficacy of high-flow nasal cannula (HFNC) with that of conventional oxygen therapy (COT) in patients with AADA following Sun's procedure.Methods: The medical records of 87 adult patients with AADA who underwent Sun's procedure and met the inclusion criteria (PaO2/FiO2 <300 mmHg before weaning) were retrospectively analyzed. After surgery, 41 patients were treated with HFNC and 46 were treated with COT. The oxygenation level, FiO2, partial pressure of carbon dioxide, heart rate, respiratory rate, subjective discomfort, and reintubation rate were recorded. The difference in lung volume loss between the HFNC and COT groups was assessed using the radiological atelectasis score (chest radiograph) or calculated from three-dimensional (3D) reconstructed computed tomography (CT) images.Results: From day 1 to day 5 after weaning, there was no significant difference in PaO2/FiO2 between the HFNC and COT groups, although the FiO2 was significantly lower in the HFNC group than in the COT group (P < 0.05). Further studies indicated that the percentage of lung volume loss (pleural effusion and/or pulmonary atelectasis) by 3D reconstruction of CT images at 4–8 days post-operation was significantly lower in the HFNC group (P < 0.05). The subjective experience of breathing discomfort, reintubation rate, and length of stay in the ICU were significantly reduced in the HFNC group (P < 0.05). There was no significant difference in readmission to the ICU and in-hospital mortality between the two groups.Conclusions: HFNC can be used as an effective oxygen therapy for AADA patients with hypoxemia after Sun's procedure.

Evaluation of the GERAADA score for prediction of 30-day mortality in patients with acute type A aortic dissection.

The German Registry of Acute Aortic Dissection Type A (GERAADA) score to predict 30-day mortality in patients suffering from acute aortic dissection type A (AADA) was recently introduced. The aim of this study was to evaluate if the GERAADA score's prediction corresponds with the authors' institutional results. All consecutive AADA patients between 2010 and 2020 were included. Retrospective data collection comprised 11 preoperative parameters: age, sex, previous cardiac surgery, inotropic support at referral, resuscitation before surgery, aortic regurgitation, preoperative hemiparesis, intubation/ventilation at referral, preoperative organ malperfusion, extension of aortic dissection and location of primary entry site. Calculations of the GERAADA score were individually performed by a cardiac surgeon blinded to the study for all patients via a web-based application (https://www.dgthg.de/de/GERAADA_Score). A total of 371 AADA patients were operated at the authors' institution. The mean age was 62.7 ± 13.5 years and 233 (63%) were males. Prediction of 30-day mortality was accurate for the entire study cohort (actual vs predicted 30-day mortality: 15.1% vs 15.7%; P = 0.776) as well as for all 26 subgroups. In addition, preoperative resuscitation (P < 0.001), advanced age (P = 0.042) and other/unknown malperfusion (P = 0.032) were identified as independent risk factors. The GERAADA score prediction of 30-day mortality after surgery is accurate, easily accessible due to its web-based platform and can be calculated with very basic preoperative clinical parameters. A prospective clinical trial is required to further evaluate the new GERAADA score as a useful tool to allow for improved decision-making in the emergency setting of AADA.

Risk Factors for Mortality in Acute Aortic Dissection Type A: A Centre Experience Over 15 Years.

Acute aortic dissection Type A (AADA) is still associated with a high mortality rate and frequent postoperative complications. This study was designed to evaluate the risk factors for mortality in AADA patients. This retrospective analysis included 344 consecutive patients who underwent surgery for AADA in moderate hypothermic circulatory arrest (20-24°C nasopharyngeal) between 2001 and 2016. The 30-day mortality rate was 18%. Nonsurvivors were significantly older (65.7 ± 12.0 years vs. 62.0 ± 12.5 years; p = 0.034) with significantly higher Euro-score II [15.4% (6.6; 23.0) vs. 4.63% (2.78; 9.88); p < 0.001)]. Intraoperatively, survivors had statistically shorter cardiopulmonary bypass times [163 (134; 206) vs. 198 min (150; 245); p = 0.001]. However, the hypothermic circulatory arrest time was similar between both groups. Postoperatively, the incidence of acute kidney injury (AKI) (55.9 vs. 15.2%; p < 0.001), stroke (27.9 vs. 12.1%; p = 0.002) and sepsis (18.0 vs. 2.1%; p < 0.001) were significantly higher among nonsurvivors. The multi-variable logistic regression confirmed that older age, previous cardiac surgery, preoperative cardiopulmonary resuscitation (CPR), blood transfusion and postoperative acute kidney injury (AKI) were independent risk factors for mortality. Our analysis suggested that the reason for mortality was multifactorial, especially age, previous cardiac surgery, CPR, transfusion, as well as postoperative AKI were considered risk factors for mortality.

Valve-Sparing Aortic Root Replacement as First-Choice Strategy in Acute Type a Aortic Dissection.

Background: Although, in theory, valve-sparing aortic root replacement (David procedure) is an ideal surgical option for acute aortic dissection type A (AADA) it is usually not regarded as the first-choice treatment due to the emergency setting and the relative complexity of the procedure. Here, we report the results of a consecutive, single-surgeon series of 45 AADA patients with the David procedure as first-choice treatment strategy.Methods and Results: Between September 2009 and July 2013 a total of 49 patients with AADA were consecutively operated by the same surgeon at our institution. The David procedure was the treatment of choice for the proximal aorta unless aortic valve pathology or critical preoperative patient status advocated against it. Median follow-up was 5.0 years (CI95%, 4.0–6.0). Out of the 45 patients included in this study the David procedure was performed in 28 patients (62.2%), while in 17 patients (37.8%) an alternative surgical strategy had to be pursued. Although X-clamping (168.5 ± 41.7 vs. 110.3 ± 51.1 min; p = 0.001), cardiopulmonary bypass (CPB) (245.0 ± 62.4 vs. 211.8 ± 123 min; p = 0.029) and total operation time (383.8 ± 88.5 vs. 312.8 ± 144.8; p = 0.047) were significantly longer in the David-group as compared to the non-David group, there was no difference in major complication rate as well as 30-day (17.9 vs. 23.5%; p = 0.645) and 5-year mortality (28.6 vs. 35.3%) between groups.Conclusions: This small series indicates that the David procedure may be safe and feasible as a primary surgical treatment strategy for AADA.

Outcome of Valve-sparing vs Bentall Procedure in Acute Type A Aortic Dissection

Objectives: Valve-sparing aortic surgery is increasingly used in contrast to the Bentall procedure in patients with an enlarged aortic root and normal aortic leaflets, despite the more complex operative technique in valve sparing root remodeling. To what extend complex valve sparing aortic surgery is feasible in acute aortic dissection type A (AADA) is not quite clear. In this study we analyze the long-term outcome after different valve sparing and Bentall procedures in AADA patients.

Validation and Adjustment of the Leipzig-Halifax Acute Aortic Dissection Type A Scorecard

The novel Leipzig-Halifax (LH) scorecard for acute aortic dissection type A (AADA) stratifies risk of in-hospital death based on age, malperfusion syndromes, critical preoperative state, and coronary disease. The study aim was to externally validate the LH scorecard performance and, if adequate, propose adjustments. All consecutive AADA patients operated on from 1996 to 2016 (n= 509) were included to generate an external validation cohort. Variables related to in-hospital death were analyzed using univariable and multivariable analysis. The LH scorecard was applied to the validation cohort, compared with the original study, and variable selection was adjusted using validation measures for discrimination and calibration. In-hospital mortality rate was 17.7% (LH cohort 18.7%). Critical preoperative state and Penn class non-Aa were independent predictors (odds ratio [OR] 2.42 and 2.45, respectively) of in-hospital death. The LH scorecard was adjusted to include Penn class non-Aa, critical preoperative state, and coronary disease. Assessing discrimination, area under receiver operator characteristic curve for the LH scorecard was 0.61 versus 0.66 for the new scorecard (p= 0.086). In-hospital mortality rates in low-, medium-, and high-risk groups were 14%, 15%, and 48%, respectively (LH scorecard) versus 11%, 23%, and 43%, respectively (new scorecard), and goodness-of-fit p value was 0.01 versus 0.86, indicating better calibration by the new scorecard. A lower Akaike information criterion value, 464 versus 448, favored the new scorecard. Through adjustment of the LH scorecard after external validation, prognostic performance improved. Further validated, the LH scorecard could be a valuable risk prediction tool.

Iatrogenic Catheter-Induced Acute Aortic Dissection Type A after Coronary Angiography-A Retrospective Consecutive Case Series.

Background Acute aortic dissection type A (AADA) is one of the most life-threatening situations and surgical demanding procedures even today. Usually AADA develops spontaneously, but it can be related also to interventional procedures. Methods We analyzed the data of 14 patients surgically treated in our institution with catheter-induced AADA (ciAADA) during coronary angiography between January 2004 and December 2014. Data were compared with overall AADA patients in this time period (n = 288). Results Nine of the 14 patients were female. Subjects were significantly older compared to the AADA patients (69 ± 11 vs. 62 ± 11; p = 0.021). At admission, ciAADA patients were more often hemodynamically instable and mechanically ventilated. Twelve patients underwent replacement of the ascending aorta and two patients received a modified Bentall operation. Cardiopulmonary bypass time (210 ± 92 vs. 172 ± 51 min) and cross-clamp time (122 ± 63 vs. 92 ± 40 min) were significantly longer due to additional coronary artery bypass grafts in 71.4 versus 3.1% due to myocardial ischemia. Operative mortality (7.1 vs. 2.1%, p = 0.29) and 30-day mortality (50.0 vs. 10.7%, p < 0.001) were higher in the ciAADA group. Conclusion Coronary angiography-induced AADA is a rare but severe complication. Due to additional myocardial ischemia and preoperative hemodynamic instability, patients with ciAADA have adverse outcome compared to overall AADA patients.

German Registry for Acute Aortic Dissection Type A: Structure, Results, and Future Perspectives.

The German Registry for Acute Aortic Dissection Type A (GERAADA) as an international registry for acute aortic dissection type A (AADA) offers a unique opportunity to answer questions regarding acute dissections that cannot be answered by single institution's database alone. GERAADA was started in 2006 by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS) and has collected more than 3,300 AADA patients' data from 56 centers in Germany, Austria, and Switzerland up to now. In the second generated validated dataset comprising the years from 2006 to 2010, 2,137 patients were surgically treated for AADA with an overall 30-day mortality of 16.9%, and a new postoperative neurologic dysfunction of 9.5%. Risk factors for neurologic dysfunction were malperfusion syndromes, dissections of the supra-aortic vessels, and longer operating time. Neuroprotective drugs had no influence on stroke rates. Hypothermic circulatory arrest and antegrade selective cerebral perfusion (ACP) led to similar results if arrest times were less than 30 minutes while ACP for longer arrest periods is advisable. Septuagenarians had an early mortality rate (15.8%) similar to the whole cohort's, but the mortality rate in octogenarians (34.9%) was much higher. GERAADA with its validated 2,137 patient files (2006-2010) is the largest database on AADA worldwide and continues to collect data. Structured follow-up of more than 5 years will be available in the future.

Mortality in patients with acute aortic dissection type A: analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA).

Acute aortic dissection type A (AADA) is an emergency with excessive mortality if surgery is delayed. Knowledge about independent predictors of mortality on surgically treated AADA patients is scarce. Therefore, this study was conducted to identify pre- and intraoperative risk factors for death. Between July 2006 and June 2010, 2137 surgically treated patients with AADA were enrolled in a multicentre, prospective German Registry for Acute Aortic Dissection type A (GERAADA), presenting perioperative status, operative strategies, postoperative outcomes and AADA-related risk factors for death. Multiple logistic regression analysis was performed to identify the influence of different parameters on 30-day mortality. Overall 30-day mortality (16.9%) increased with age [adjusted odds ratio (OR) = 1.121] and among patients who were comatose (adjusted OR = 3.501) or those who underwent cardiopulmonary resuscitation (adjusted OR = 3.751; all P < 0.0001). The higher the number of organs that were malperfused, the risk for death was (adjusted OR for one organ = 1.651, two organs = 2.440, three organs or more = 3.393, P < 0.0001). Mortality increased with longer operating times (total, cardiopulmonary bypass, cardiac ischaemia and circulatory arrest; all P < 0.02). Arterial cannulation site for extracorporeal circulation, operative techniques and arch interventions had no significant impact on 30-day mortality (all P > 0.1). No significant risk factors, but relevant increases in mortality, were determined in patients suffering from hemiparesis pre- and postoperatively (each P < 0.01), and in patients experiencing paraparesis after surgery (P < 0.02). GERAADA could detect significant disease- and surgery-related risk factors for death in AADA, influencing the outcome of surgically treated AADA patients. Comatose and resuscitated patients have the poorest outcome. Cannulation sites and operative techniques did not seem to affect mortality. Short operative times are associated with better outcomes.

Is Bentall Procedure Still the Gold Standard for Acute Aortic Dissection with Aortic Root Involvement?

The "ideal" treatment of acute aortic dissection type A (AADA) with dissected and dilated root is controversial. We compared the outcome of classical Bentall procedure (biological and mechanical) with valve-sparing David procedure. Between January 2002 and July 2011, 119 patients with AADA and aortic root involvement underwent surgery at our center. Thirty-one patients (group 1) received biological conduits, 41 (group 2) received mechanical conduits, and 47 (group 3) underwent David procedures. Cross-clamp, cardiopulmonary bypass, and circulatory arrest times were 151 ± 52, 232 ± 84, and 36 ± 30 minutes (group 1); 148 ± 44, 237 ± 91, and 45 ± 29 minutes (group 2); and 160 ± 46, 231 ± 63, and 35 ± 17 minutes (group 3), respectively. The 30-day mortality rates were 32.3% (group 1), 22% (group 2), and 12.8% (group 3). The 1-year rates for freedom from valve-related reoperation were 100% (group 1), 92.5% (group 2), and 95.2% (group 3) (p = 0.172). The 1-year survival rates were 61% (group 1), 61% (group 2), and 84.1% (group 3) (p = 0.008). Even in AADA patients with root involvement, David procedure has acceptable results. David procedure (if possible) or a Bio-Bentall (for pathological valves) seems to be the optimal technique.

Extra-anatomic revascularization for preoperative cerebral malperfusion due to distal carotid artery occlusion in acute type A aortic dissection.

Management of patients with acute aortic dissection type A (AADA) and cerebral malperfusion secondary to occlusion or stenosis of the left common carotid artery (LCCA) or right common carotid artery (RCCA) is a significant challenge. The aim of this study is to present our institutional strategy and postoperative results for this high-risk patient cohort. Between November 2005 and July 2013, 23 of 354 consecutively operated AADA patients [median age: 66.3; interquartile range (IQR): 55.2-69.9] suffered from cerebral malperfusion due to bilateral (n = 1) or unilateral occlusion of the LCCA/RCCA (n = 22). AADA repair comprised hemi- (n = 14) or total (n = 9) arch replacement in combination with aortic valve repair (n = 7) or replacement (n = 11), root replacement (n = 15) and coronary bypass (n = 3). Extra-anatomic aorto-carotid bypass was performed in all patients. Aorto-carotid bypass was performed at the beginning of the procedure to allow for unilateral selective cerebral perfusion (n = 17; 73.9%) or during the procedure if persisting malperfusion was suspected by near-infrared spectroscopy (n = 6; 26.1%). The median follow-up was 15.2 months (IQR: 4.8-34.1) and 100% complete. Median hospital stay and ICU stay were 16.0 (IQR: 12.5-26.0) and 13.7 (IQR: 2.0-16.5) days, respectively. Rethoracotomy for haemorrhage or cardiac tamponade was performed in 6 (26.1%) patients. Other postoperative complications comprised low cardiac output with extracorporeal membrane oxygenation (n = 2; 8.7%), sepsis (n = 4; 17.4%), respiratory insufficiency (n = 10; 43.5%), renal failure with temporary dialysis (n = 7; 30.4%) and visceral malperfusion (n = 2; 8.7%) requiring stent grafting (n = 1) or laparotomy with intestinal resection (n = 1). New stroke with or without permanent sensory or motor deficit was diagnosed in 8 (34.8%) patients. Temporary neurological deficits were seen in 9 (39.1%) individuals. Hospital and 1-year mortality rates were 13.0 and 30.4%, respectively. Overall survival after 36 months of the 23 patients (Group I = Extra-anatomic bypass) versus the remaining 331 AADA patients without distal RCCA/LCCA occlusion (Group II = no extra-anatomic bypass) was 69.6% (n = 16) in Group I vs 72.5% (n = 240) in Group II (P = 0.90). Extra-anatomic bypass for LCCA or RCCA occlusion allows for early selective cerebral perfusion during AADA repair, and may reduce the risk of neurological complications in patients with preoperative cerebral malperfusion.

126 * EXTRA-ANATOMIC REVASCULARISATION FOR DISTAL OCCLUSION OF THE LEFT OR RIGHT COMMON CAROTID ARTERY IN ACUTE TYPE A AORTIC DISSECTION WITH CEREBRAL MALPERFUSION

Objectives: Immediate restoration of cerebral perfusion in patients with acute aortic dissection type A (AADA) is crucial but may be aggravated if distal occlusion of the left (LCCA) or right common carotid artery (RCCA) is present. Methods: Between May 2007 and July 2013, 16 out of 313 conventionally operated AADA patients (median age 60.5; range 23–80) suffered from concomitant severe cerebral malperfusion with distal occlusion of the LCCA (n = 9) or RCCA (n = 8). AADA repair comprised hemi- (n = 9) or total (n = 7) arch replacement in combination with aortic valve repair (n = 6) or replacement (n = 5), root replacement (n = 9) and CABG (n = 1). Extra-anatomic carotid-to-aortic bypass was performed prior to circulatory arrest (n = 13) to allow for unilateral selective cerebral perfusion, or during the procedure if persisting malperfusion was suspected by near-infrared spectroscopy (NIRS) or Doppler (n = 3). Results: Mean ICU stay was 17.6 ± 21.1 days. Re-thoracotomy for haemorrhage (n = 1) or cardiac tamponade (n = 3) was performed in 4 patients. Postoperative complications comprised respiratory insufficiency with prolonged ventilation (n = 7), renal failure with temporary/permanent dialysis (n = 5) and persisting visceral malperfusion (n = 2) requiring stent grafting (n = 1) or intestinal resection (n = 1). Stroke with permanent sensory or motor deficits (PND) was diagnosed in 6 (37.5%) patients. Temporary neurological deficits were seen in 10 (62.5%) individuals, including 4 patients with PND. Hospital (n = 1) and 1-year (n = 3) mortality rates were 6.3% and 25.0%. Conclusion: Extra-anatomic bypass for distal LCCA or RCCA occlusion presents a valuable bail-out technique to restore cerebral perfusion during AADA repair, potentially reducing the increased incidence of neurological complications in patients with cerebral malperfusion.

Intraoperative neuroprotective drugs without beneficial effects? Results of the German Registry for Acute Aortic Dissection Type A (GERAADA)

Cerebral protection during acute aortic dissection Type A (AADA) surgery may be affected by perfusion strategies and ischaemic protective drugs. We analysed the impact of intraoperative barbiturate, steroid and mannitol use and adjunctive cerebral perfusion (CP), on 30-day mortality and new postoperative mortality-corrected permanent neurological dysfunction (PNDmc) in the German Registry for Acute Aortic Dissection Type A. Two thousand one hundred and thirty-seven AADA patients were registered over a 4-year period. The overall 30-day mortality was 16.9%, and the overall rate of PNDmc was 10.0%. A total of 48% of patients received no neuroprotective drugs (control group), steroid monotherapy was used in 11.2% of patients, barbiturates in 8.4%, mannitol in 7.3% and the remainder (25.1%) received a combination of these drugs. The PNDmc rate was 10.6% in the control group and lower (7.1%) in the steroid group (adjusted odds ratio [OR] 0.50; 95% confidence interval [95% CI] 0.24-0.96; P = 0.049). No PNDmc reduction was observed for mannitol or barbiturates. Thirty-day mortality was 18.7% in the control group and with 8.9% lower (P = 0.003) in the mannitol group (adjusted OR 0.58; 95% CI 0.19-1.49; P = 0.295). Hypothermic circulatory arrest that exceeded 30 min was associated with an increased 30-day mortality rate (31.4%) compared with patients who received adjunctive CP >30 min during aortic arch intervention (21.4%) (P = 0.04). We were unable to demonstrate a significant protective effect of any neuroprotective drug on 30-day mortality, or PNDmc rates during prolonged (≥30 min) cerebral ischaemia. Mannitol may be associated with decreased mortality in patients undergoing AADA surgery. Steroid administration may be associated with improved neurological outcomes, but more investigation is required.

Influence of operative strategy for the aortic arch in DeBakey type I aortic dissection - analysis of the German Registry for Acute Aortic Dissection type A (GERAADA).

Acute aortic dissection type A (AADA) remains a life threatening medical condition requiring emergent surgical therapy. Despite improvements in diagnostics, medical therapy and surgical technique, patient mortality and morbidity remains high (1). Standard treatment in the setting of AADA is the replacement of the ascending aorta with resection of the entry site, often in combination with an open distal anastomosis or hemiarch replacement, during a period of circulatory arrest with implementation of adjunct neuroprotective strategies such as cerebral perfusion and hypothermia (2). However, this treatment leaves the downstream aorta untouched and a residual dissection membrane remains in up to 70% of patients treated for AADA (3-7). The risk of progressive dilation with possible need for aortic re-intervention over the long-term remains (8-11). Due to this risk, a more aggressive approach with complete arch replacement and possible stenting of the proximal descending aorta via an antegrade approach has been adopted by a number of clinical institutions worldwide, to better obliterate the false lumen and thus reduce the incidence of late aortic complications (12-14). Other groups, however, have demonstrated an increased risk of mortality and morbidity when extensive surgery involving the aortic arch and the downstream aorta is implemented, thus recommending a more conservative approach to the treatment of AADA patients (15,16). The German Registry for Acute Aortic Dissection type A (GERAADA) is a web-based registry, initiated by the Working Group for Aortic Surgery and Interventional Vascular Surgery of the German Society for Thoracic and Cardiovascular Surgery. It is presently the largest registry worldwide documenting patients undergoing surgery for AADA (17-19). Analysis of GERAADA gave us the opportunity to compare the surgical outcomes of patients with DeBakey type I dissection treated by total arch replacement and those of hemiarch replacement with respect to early mortality, and onset of new neurological and malperfusion deficit.

Analysis of risk factors for neurological dysfunction in patients with acute aortic dissection type A: data from the German Registry for Acute Aortic Dissection Type A (GERAADA)

Acute aortic dissection type A (AADA) is associated with major adverse events, such as transient or persistent neurological dysfunction (ND), which may be patient-, disease- or surgery-related. There is a lack of consensus regarding risk factors for ND in AADA patients. The aim of this study was to analyse and identify risk factors for new postoperative ND after aortic repair for AADA. Between July 2006 and June 2010, 2137 AADA patients were enrolled in the multi-centre, prospective German Registry of AADA (GERAADA). Perioperative data were prospectively gathered from 50 institutes in Austria, Switzerland and Germany, and multivariate logistic regression analysis was performed to determine the independent predictors of new onset ND. ND occurred in 20.3% of all patients prior to surgery, 12.6% of which resolved postoperatively and 7.7% persisted. New ND after AADA surgery occurred in 9.5% of patients. Risk factors for an increased rate of postoperative new ND were malperfusion syndrome of three or more territories prior to surgery [odds ratio (OR) = 2.206, P = 0.0065], dissection of the supraaortic vessels (OR = 1.468, P = 0.0103) and longer operating time (OR = 1.002 per min, P = 0.0001). New postoperative ND was associated with an increased rate of mortality (22.5 vs. 16.1%, P = 0.0087). Arterial cannulation site had no statistically significant impact on neurological outcomes. Neurological complications are associated with increased mortality post-AADA repair. New onset ND is associated with extensive malperfusion syndrome, supraaortic vessel dissection and operative time and does not seem to be affected by choice of arterial cannulation site.

HEMS vs. EMS Transfer for Acute Aortic Dissection Type A

Background We thought to evaluate the impact of the mode of physician-based transportation (helicopter emergency medical service [HEMS] vs. ground-based emergency medical service [EMS]) on short- and long-term survival among patients suffering acute aortic dissection type A (AADA) as a primary end-point. Methods One-hundred-seventy-seven AADA patients (59 ± 13 years) were included who were admitted to a cardiothoracic surgery department with comprehensive transfer documentation. Cox proportional hazard models and log-rank tests were performed as well as Kaplan-Meier survival curves. Follow-up was 93% over 5 ± 2¾ years. Results Cox proportional hazard model found no mortality difference for HEMS versus EMS on primary transport ( P = .5), as well as log-rank (Mantel Cox) on interhospital transport ( P = 0.5). HEMS interhospital transfer was eightfold more expensive than EMS (HEMS, 3,871; EMS, 497; P = .01). Ninety-nine patients (56%) were alive at follow-up (mean survival, 1,153 days ± 1,124). Mortality after surgery was 2% (3/177) within the first hour, 5% (8/177) within 6 hours, 6% (10/177) within 12 hours, 11% (20/177) within 24 hours, 13% (23/177) within 48 hours, 14% (25/177) within 72 hours, and 26% (46/177) within 30 days after surgery. Conclusions We found no advantage of survival rates among patients suffering from AADA who were transferred by either HEMS or EMS in primary or secondary transport. Although HEMS traveled a distance more than twofold longer than ground-based EMS at the same mission time, HEMS was eightfold more expensive than ground-based EMS in AADA.