Acute Type A Aortic Dissection Research Articles

Role of initial medical treatment and effectiveness of thoracic endovascular aortic repair for acute type A aortic dissection with thrombosed false lumen.

The optimal treatment for acute type A aortic dissection (AAAD) with thrombosed false lumen (T-FL) of the ascending aorta remains controversial. The goal of this study was to evaluate clinical outcomes of initial medical treatment (IMT) and the effectiveness of thoracic endovascular aortic repair (TEVAR) for AAAD with T-FL. We retrospectively analysed 60 patients with AAAD with T-FL. Emergency aortic repair was performed in 33 patients, and IMT was selected in 27 uncomplicated patients with ascending aortic diameter < 50 mm and ascending T-FL thickness ≤ 10 mm. Among the 27 patients who received IMT, 14 had intramural haematomas at admission; however, new ulcer-like projections appeared in 7 (50%) during hospitalization. Before discharge, 12 (44%) were given medical treatment only, and 15 (56%) required delayed aortic repair including TEVAR in 8 and open repair in 7. The median interval from onset to delayed repair was 9 days, and significantly more patients received TEVAR compared to those receiving emergency repair (53% vs 21%; P = 0.043). Between the TEVAR (n = 15) and the open repair (n = 33) groups, 1 (7%) 30-day death occurred in the TEVAR group, whereas no in-hospital deaths occurred in the open repair group. During the median follow-up time of 24.8 months, no aorta-related death was observed, and there were no statistically significant differences in the rate of freedom from aortic events (TEVAR: 92.8%/3 years vs open repair: 88.4%/3 years; P = 0.871). Our management, using a combination of emergency aortic repair, IMT and delayed aortic repair for AAAD with T-FL, achieved favourable clinical outcomes. Among the selected Japanese patients, IMT with repeated multidetector computed tomography could detect a new intimal tear that could be closed by TEVAR in some cases. Using EVAR for this pathology resulted in acceptable early and midterm outcomes. Further investigations are required to validate the safety and efficacy of this management procedure.

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.

Use of the cardiopulmonary coupling index based on refined composite multiscale entropy for prognostication of acute type A aortic dissection.

The aim of this study is to assess the influence of cardiopulmonary coupling (CPC) based on RCMSE on the prediction of complications and death in patients with acute type A aortic dissection (ATAAD). The cardiopulmonary system may be nonlinearly regulated, and its coupling relationship with postoperative risk stratification in ATAAD patients has not been studied. This study was a single-center, prospective cohort study (ChiCTR1800018319). We enrolled 39 patients with ATAAD. The outcomes were in-hospital complications and all-cause readmission or death at 2 years. Of the 39 participants, 16 (41.0%) developed complications in the hospital, and 15 (38.5%) died or were readmitted to the hospital during the two-year follow-up. When CPC-RCMSE was used to predict in-hospital complications in ATAAD patients, the AUC was 0.853 (p < 0.001). When CPC-RCMSE was used to predict all-cause readmission or death at 2 years, the AUC was 0.731 (p < 0.05). After adjusting for age, sex, ventilator support (days), and special care time (days), CPC-RCMSE remained an independent predictor of in-hospital complications in patients with ATAAD [adjusted OR: 0.8 (95% CI, 0.68-0.94)]. CPC-RCMSE was an independent predictor of in-hospital complications and all-cause readmission or death in patients with ATAAD.

Prognostic significance of neutrophil count on in-hospital mortality in patients with acute type A aortic dissection.

The goal of this study was to assess the impact of neutrophil count, in patients with acute type A aortic dissection (ATAAD). This study retrospectively collected data from patients between September 2017 and June 2021. Youden's index was used to determine the optimal cut-off value for the neutrophil count and patients were divided into two subgroups. A restricted cubic spline (RCS) was used to model the relationship between variables and in-hospital mortality. The least absolute shrinkage and selection operator (LASSO) method and multivariate logistic regression analyses were used to investigate the independent prognostic factors for in-hospital mortality in patients with ATAAD. A total of 467 patients were enrolled in this study. In-hospital mortality was 7.28%. The group with elevated neutrophil counts had significantly higher mortality than the group with decreased neutrophil counts (10.8% vs. 3.2%, P = 0.02). This data shows that elevated neutrophil count was significantly associated with in-hospital mortality (OR 3.07, 95% CI 1.22-7.62, P = 0.02). Neutrophil count is an independent risk factor for in-hospital mortality in patients with ATAAD. It is an effective inflammatory index, which can be individualized for patients.

Continuous Myocardial Perfusion during Distal Anastomosis of Acute Type A Aortic Dissection.

The effect of continuous myocardial perfusion (CMP) on the surgical results of acute type A aortic dissection (ATAAD) remains unclear. From January 2017 to March 2022, 141 patients who underwent ATAAD (90.8%) or intramural hematoma (9.2%) surgery were reviewed. Fifty-one patients (36.2%) received proximal-first aortic reconstruction and CMP during distal anastomosis. Ninety patients (63.8%) underwent distal-first aortic reconstruction and were placed in traditional cold blood cardioplegic arrest (CA; 4°C, 4:1 blood-to-Plegisol) throughout the procedure. The preoperative presentations and intraoperative details were balanced using inverse probability of treatment weighting (IPTW). Their postoperative morbidity and mortality were analyzed. The median age was 60 years. The incidence of arch reconstruction in the unweighted data was higher in the CMP compared with the CA group (74.5 vs 52.2%, p = 0.017) but was balanced after IPTW (62.4 vs 58.9%, p = 0.932, standardized mean difference = 0.073). The median cardiac ischemic time was lower in the CMP group (60.0 vs 130.9 minutes, p < 0.001), but cerebral perfusion time and cardiopulmonary bypass time were similar. The CMP group did not demonstrate any benefit in the reduction of the postoperative maximum creatine kinase-MB ratio (4.4 vs 5.1% in CA, p = 0.437) or postoperative low cardiac output (36.6 vs 24.8%, p = 0.237). Surgical mortality was comparable between groups (15.5% in CMP vs 7.5% in the CA group, p = 0.265). Application of CMP during distal anastomosis in ATAAD surgery, irrespective of the extent of aortic reconstruction, reduced myocardial ischemic time but did not improve cardiac outcome or mortality.

Single-Cell RNA-Seq Analysis Reveals Macrophages Are Involved in the Pathogenesis of Human Sporadic Acute Type A Aortic Dissection.

Macrophages play an important role in the progression of sporadic acute type A aortic dissection (ATAAD). The aim of this study was to characterize the cellular heterogeneity of macrophages in ATAAD tissues by scRNA-seq. Ascending aortic wall tissue from six ATAAD patients and three heart transplant donors was assessed by scRNA-seq and then analyzed and validated by various bioinformatic algorithms and histopathology experiments. The results revealed that the proportion of macrophages in ATAAD tissues (24.51%) was significantly higher than that in normal tissues (13.69%). Among the six macrophage subclusters, pro-inflammatory macrophages accounted for 14.96% of macrophages in the AD group and 0.18% in the normal group. Chemokine- and inflammation-related genes (CCL2, CCL20, S100A8, and S100A9) were expressed more intensively in macrophages in ATAAD tissue than in those in normal tissue. Additionally, intercellular communication analysis and transcription factor analysis indicated the activation of inflammation and degradation of the extracellular matrix in ATAAD tissue. Finally, immunohistochemistry, immunofluorescence, and Western blot experiments confirmed the overexpression of macrophage marker genes (CD68 and CD163) and matrix metalloproteinases (MMP9 and MMP2) in ATAAD tissue. Collectively, our study provides a preliminary evaluation of the role of macrophages in ATAAD, and the results could aid in the development of therapeutic options in the future.

Impact of preoperative malperfusion on postoperative outcomes in type A aortic dissection - importance of serum lactate estimation in ongoing malperfusion.

Acute type A aortic dissection (ATAAD) is one of the most critical emergencies in cardiovascular surgery. Additional complications such as organ malperfusion can significantly decrease the chances of survival. Despite promptly performed surgical treatment, impaired organ perfusion may persist, thus close postoperative monitoring is recommended. But, is there a surgical consequence due to the existence of a preoperatively known malperfusion and is there a correlation between pre-, peri- and postoperative levels of serum lactate and proven malperfusion? Between 2011 and 2018, 200 patients (66% male; median age: 62.5years; interquartile range: +/-12.4years) that received surgical treatment at our institution for an acute dissection DeBakey type I were enrolled in this study. The cohort was divided into two groups according to the preoperative existence of malperfusion and non-malperfusion. At least one kind of malperfusion occurred in 74 patients (Group A: 37%), while 126 patients (Group B: 63%) showed no evidence of malperfusion. Furthermore, lactate levels of both cohorts were differentiated into four periods: preoperative, intraoperative, 24hours after surgery, and 2-4days after surgery. The patients' status differed significantly prior to surgery. Group A (malperfusion) showed an elevated requirement for mechanical resuscitation (A: 10.8%; B: 5.6%; p: 0.173), were significantly more often admitted in an intubated state (A: 14.9%; B: 2.4%; p: 0.001) and showed higher incidences of stroke (A: 18.9% (n = 149); B: 3.2% (n = 4); p: 0.001). Levels of serum lactate from the preoperative period until days 2-4 were significantly increased in the malperfusion cohort at all times. Preexisting malperfusion due to ATAAD may significantly increase the chance of early mortality in patients with ATAAD. Serum lactate levels were a reliable marker for inadequate perfusion from admission until day 4 after surgery. Despite this, early intervention survival in this cohort remains limited.

Racial disparities in surgical treatment of type A acute aortic dissection

ObjectiveTo determine whether there are racial disparities associated with mortality, cost, and length of hospital stay after surgical repair of type A acute aortic dissection (TAAAD). MethodsPatient data from 2015 to 2018 were collected using the National Inpatient Sample. In-hospital mortality was the primary outcome. Multivariable logistical modeling was used to identify factors independently associated with mortality. ResultsAmong 3952 admissions, 2520 (63%) were White, 848 (21%) were Black/African American, 310 (8%) were Hispanic, 146 (4%) were Asian and Pacific Islander (API), and 128 (3%) were classified as Other. Black/African American and Hispanic admissions presented with TAAAD at a median age of 54 years and 55 years, respectively, whereas White and API admissions presented at a median age of 64 years and 63 years, respectively (P < .0001). Additionally, there were higher percentages of Black/African American (54%; n = 450) and Hispanic (32%; n = 94) admissions living in ZIP codes with the lowest median household income quartile. Despite these differences on presentation, when adjusting for age and comorbidity, there was no independent association between race and in-hospital mortality and no significant interactions between race and income on in-hospital mortality. ConclusionsBlack and Hispanic admissions present with TAAAD a decade earlier than White and API admissions. Additionally, Black and Hispanic TAAAD admissions are more likely to come from lower-income households. After adjusting for relevant cofactors, there was no independent association between race and in-hospital mortality after surgical treatment of TAAAD.

Risk factor prediction of severe postoperative acute kidney injury at stage 3 in patients with acute type A aortic dissection using thromboelastography.

Perioperative blood transfusions and postoperative drainage volume not only are the commonly recognized risk factors for acute kidney injury (AKI) but also are indirect indicators of coagulopathy in patients with acute type A aortic dissection (ATAAD). However, standard laboratory tests fail to accurately reflect and assess the overall coagulopathy profile in patients with ATAAD. Thus, this study aimed to explore the association between the hemostatic system and severe postoperative AKI (stage 3) in patients with ATAAD using thromboelastography (TEG). We selected 106 consecutive patients with ATAAD who underwent emergency aortic surgery at Beijing Anzhen Hospital. All participants were categorized into the stage 3 and non-stage 3 groups. The hemostatic system was evaluated using routine laboratory tests and TEG preoperatively. We undertook univariate and multivariate stepwise logistic regression analyses to determine the potential risk factors for severe postoperative AKI (stage 3), with a special investigation on the association between hemostatic system biomarkers and severe postoperative AKI (stage 3). The receiver operating characteristic (ROC) curves were generated to assess the predictive ability of hemostatic system biomarkers for severe postoperative AKI (stage 3). A total of 25 (23.6%) patients developed severe postoperative AKI (stage 3), including 21 patients (19.8%) who required continuous renal replacement therapy (RRT). Multivariate logistic regression analysis demonstrated that the preoperative fibrinogen level (OR, 2.02; 95% CI, 1.03 to 3.00; p = 0.04), platelet function (MA level) (OR, 1.23; 95% CI, 1.09 to 1.39; p = 0.001), and cardiopulmonary bypass (CPB) time (OR, 1.01; 95% CI, 1.00 to 1.02; p = 0.02) were independently associated with severe postoperative AKI (stage 3). The cutoff values of preoperative fibrinogen and platelet function (MA level) for predicting severe postoperative AKI (stage 3) were determined to be 2.56 g/L and 60.7 mm in the ROC curve [area under the curve (AUC): 0.824 and 0.829; p < 0.001]. The preoperative fibrinogen level and platelet function (measured by the MA level) were identified as potential predictive factors for developing severe postoperative AKI (stage 3) in patients with ATAAD. Thromboelastography could be considered a potentially valuable tool for real-time monitoring and rapid assessment of the hemostatic system to improve postoperative outcomes in patients.

Preoperative pericardial hematoma in patients with acute type A aortic dissection (AAAD): Do we need an adjusted treatment?

ObjectiveAn acute type A aortic dissection (AAAD) is a critical emergency and remains one of the most challenging diseases in cardiothoracic surgery. The existence of a pericardial hematoma caused by an aortic rupture can dramatically reduce the chances of survival (Jerzewski and Kulik in J Card Surg 29(4):529–530, 2014; Mehta et al. in Circulation 105(2):200–206, 2002; Gilon et al. in Am J Cardiol 103(7):1029–1031, 2009; Isselbacher et al. in Circulation 90(5):2375–2378, 1994). We assessed the surgical outcome of a high-risk group of patients with AAAD and a pericardial hematoma.MethodsIn this study we included 430 Patients (67% male; median age: 64 years) who received surgical treatment between January 2000 and January 2018 at our facility for acute aortic dissection DeBakey type I. We divided the cohort in two groups: Group A consisted of high-risk patients with a pericardial hematoma (n = 162) and Group B of patients without pericardial hematoma (n = 268).ResultsPatients with a preoperative pericardial hematoma had a significantly higher requirement for preoperative mechanical resuscitation (A: 21%; B: 1.5%; P: < 0.001) and were relevantly more frequently admitted to the operation theater with an intubated status (A: 19.8%; B: 8.6%; P: < 0.001). The incidence of visceral malperfusion differed significantly between both groups (A. 11.7%, B. 6:0%; P: 0.034). Limited aortic arch repair (proximal aortic arch replacement) was preferred in the high-risk group (A: 51.9%; B: 40.3%; P: 0.020). However, survival time was generally reduced in these patients (A: 7.5 y; B: 9.9 y).ConclusionAAAD patients with preoperative pericardial hematoma present themselves in potentially lethal conditions, with a significantly higher rate of visceral malperfusion. Despite the existence of this risk factor, a limited arch repair was favored. We have proven that cardiac compression is associated with preoperative intubation and mechanical resuscitation. Patients with pericardial hematoma must be further evaluated for preoperative pericardial drainage. In the event of long transfer times to an aortic center a slow drainage should be discussed to prevent early mortality.

A nomogram model for assessing predictors and prognosis of postoperative delirium in patients receiving acute type A aortic dissection surgery

BackgroundPostoperative delirium (POD) complicates the postoperative course. There is limited information on POD-related risk factors (RFs) and prognosis in patients with acute type A aortic dissection (ATAAD) after modified triple-branched stent graft implantation (MTBSG) surgery.MethodsWe retrospectively examined consecutive ATAAD patients who received MTBSG surgery in our hospital between January 2013 and December 2019. We employed univariate and multivariate analyses to identify stand-alone RFs for POD. A nomogram was next generated to estimate POD occurrence. The primary outcome was the development of POD, and the secondary outcomes were intensive care unit (ICU) and hospital stays, hospitalization costs, and in-hospital and follow-up mortality.ResultsWe selected 692 patients, of whom 220 experienced POD (31.8%). Based on our analysis, the following factors enhanced the likelihood of POD development: alcohol consumption (p < 0.001), acute physiology and chronic health evaluation II score (p = 0.023), serum total bilirubin (p = 0.007), stage 3 acute kidney injury (p < 0.001), serum interleukin-6 (p = 0.031), post-operative analgesics usage (p = 0.015), and ventilation duration (p = 0.008). POD patients had significantly longer ventilator times (p = 0.003), ICU stays (p < 0.001), and hospital stays (p = 0.038), together with increased hospitalization costs (p < 0.001) and in-hospital mortality (p = 0.019). However, POD was not a RF for mortality during follow-up (log-rank p = 0.611).ConclusionsWe demonstrated a strong link between POD and poor prognosis in ATAAD patients. We also constructed a prognosis estimator model which will benefit early management guidance to minimize the incidence of POD.

S100B predicts neurological injury and 30-day mortality following surgery for acute type A aortic dissection: an observational cohort study

BackgroundNeurological injuries are frequent following Acute Type A Aortic Dissection (ATAAD) repair occurring in 4–30% of all patients. Our objective was to study whether S100B can predict neurological injury following ATAAD repair.MethodsThis was a single-center, retrospective, observational study. The study included all patients that underwent ATAAD repair at our institution between Jan 1998 and Dec 2021 and had recorded S100B-values. The primary outcome measure was neurological injury, defined as focal neurological deficit or coma diagnosed by clinical assessment with or without radiological confirmation and with a symptom duration of more than 24 h. Secondary outcome measure was 30-day mortality.Results538 patients underwent surgery during the study period and 393 patients, had recorded S100B-values. The patients had a mean age of 64.4 ± 11.1 years and 34% were female. Receiver operating characteristic curve for S100B 24 h postoperatively yielded area under the curve 0.687 (95% CI 0.615–0.759) and best Youden’s index corresponded to S100B 0.225 which gave a sensitivity of 60% and specificity of 75%. Multivariable logistic regression identified S100B ≥ 0.23 μg/l at 24 h as an independent predictor for neurological injury (OR 4.71, 95% CI 2.59–8.57; p < 0.01) along with preoperative cerebral malperfusion (OR 4.23, 95% CI 2.03–8.84; p < 0.01) as well as an independent predictor for 30-day mortality (OR 4.57, 95% CI 1.18–11.70; p < 0.01).ConclusionsWe demonstrated that S100B, 24 h after surgery is a strong independent predictor for neurological injury and 30-day mortality after ATAAD repair.Trial registration: As this was a retrospective observational study it was not registered.

The role of neutrophil-lymphocyte platelet ratio in predicting in-hospital mortality after acute Type A aortic dissection operations.

Acute Type A aortic dissection (ATAAD) is an emergency cardiovascular condition. In this current study, we aimed to investigate the prognostic importance of preoperative neutrophil-lymphocyte platelet ratio (NLPR) value in predicting in-hospital mortality, after surgical treatment of ATAAD. Consecutive patients who underwent an emergency operation as a result of ATAAD between August 2012 and August 2021 in our hospital, were retrospectively included in this study. Patients who survived the operation and were released were recorded as Group 1 and those who died in the hospital, as Group 2. Mortality (in-hospital) occurred in 44 (22.5%) patients (Group 2). The median age of the 151 patients included in Group 1 and 44 patients in Group 2 were 55 (37 to 81) and 59 (33 to 72) years, respectively (p = 0.191). In multivariate analysis Model 1, malperfusion (OR: 3.764, 95% CI: 2.140-4.152, p < 0.001), total perfusion time (OR: 1.156, 95% CI: 1.040-1.469, p = 0.012), low platelet counts (OR: 0.894, 95% CI: 0.685-0.954, p = 0.035) and NLR (OR: 1.944, 95% CI: 1.230-2.390, p < 0.001) were determined as independent predictors for mortality. In Model 2, malperfusion (OR: 3.391, 95% CI: 2.426-3.965, p < 0.001) and NLPR (OR: 2.371, 95% CI: 1.892-3.519, p < 0.001) were determined as independent predictors for mortality. According to our study, the NLPR value obtained preoperatively can be used to predict the risk of in-hospital mortality, after ATAAD surgery.

Managing the Root in Acute Type A Aortic Dissections: Are We Ready for a Standardized Approach?

Surgical repair of Type A aortic dissection (TAAD) requires exclusion of the primary entry tear and reestablishment of flow into the distal true lumen. Provided that the majority of tears occur within the ascending aorta (AA), replacing only that segment seems a safe option; however, this strategy leaves the root susceptible to dilatation and need for reintervention. We aimed to review the outcomes of the two strategies: aortic root replacement (ARR) and isolated ascending aortic replacement. Retrospective analysis of prospectively collected data for all consecutive patients who underwent repair of acute TAAD at our institution from 2015 to 2020 was conducted. Patients were divided into two groups: (1) ARR and (2) isolated AA replacement as index operation for TAAD repair. Primary outcomes were mortality and need for reintervention during the follow-up. A total of 194 patients were included in the study; 68 (35%) in the ARR group and 126 (65%) in the AA group. There were no significant differences in postoperative complications or in-hospital mortality (23%; p = 0.51) between groups. Seven patients (4.7%) died during follow-up and eight patients underwent aortic reinterventions, including proximal aortic segments (two patients) and distal procedures (six patients). Both aortic root and AA replacement are acceptable and safe techniques. The growth of an untouched root is slow, and reintervention in this aortic segment is infrequent compared with distal aortic segments, hence preserving the root could be an option for older patients provided that there is no primary tear within the root.

Management Strategies for Acute Type A Aortic Dissection Complicated By Limb Malperfusion

Acute type A aortic dissection complicated by limb malperfusion presents a risk of mortality to the patients. Debates exist regarding management, whether focused on reperfusion first or immediate repair. Here, we aimed to describe our experience with the management of acute type A aortic dissection (ATAAD) complicated by limb malperfusion. From January 1, 2020 to December 31, 2021, 22 consecutive patients were admitted to Xiamen Cardiovascular Hospital, due to acute type A aortic dissection complicated by limb malperfusion. All perioperative variables were recorded and analyzed. Limb malperfusion was diagnosed, according to the clinical symptoms, computed tomography angiography, and laboratory test. We adopted the clinical categories of acute limb ischemia to stratify severity of limb ischemia. Surgery strategies are as follows: Reperfusion first followed by central repair, immediate central repair, and immediate central repair followed by stenting. There were 21 males and one female with an average of 53.3±11.7 years. Management strategies were as follows: immediate central repair using total arch replacement with frozen elephant trunk in 15 patients, endovascular stenting followed by central repair in four patients, and endovascular stenting after central repair in two patients. The average extracorporeal circulation time was 258.8 ± 70.5 min; the average aortic cross-clamp time was 177.9 ± 54.2 min; and the average circulatory arrest time was 45.5 ± 13.1 min. The early mortality rate was 13.6% (3/22). Two patients left the hospital voluntarily, due to cerebral infarction and bleeding. One patient underwent fasciotomy for osteofascial compartment syndrome and uneventfully was discharged. Six patients underwent continuous renal replacement therapy and hemoperfusion. Central repair is safe and feasible for ATAAD complicated with limb malperfusion. For serious limb malperfusion, endovascular stenting followed by central repair is a good choice with continuous renal replacement therapy (CRRT) and hemoperfusion. Hospital mortality rate is high in cases with multiple organ malperfusion.

Investigation of the Effect of Acute to Chronic Glycemic Ratio on the Development of Postoperative Pneumonia After Stanford Type A Acute Aortic Dissection Surgery

Aim: A critical clinical condition called acute Type A aortic dissection (ATAAD) necessitates quick surgical action. Other significant issues include the emergence of postoperative pneumonia and various organ failures. We sought to determine how well the ratio of admission blood glucose (ABG) to estimated average glucose (eAG) might be used to anticipate postoperative pneumonia following ATAAD surgery. Materials and Methods: The study comprised patients who underwent ATAAD surgery between January 2016 and January 2022. In the postoperative phase, patients were divided into two groups: Group 1 for those who did not acquire pneumonia and Group 2 for those who did.Results: The study involved 124 patients in total. Group 1 [N = 92, median age = 51 (32 to 80) years] consisted of those who did not acquire postoperative pneumonia, but Group 2 [N = 32, median age = 53 (30 to 77)] did. ABG/eAG ratio and ventilation time were found to be independent predictors of postoperative pneumonia by multivariate analysis [(OR: 0.886, CI 95%: 0.695-0.990, P=0.009) and (OR: 1.114, 1.030-1.542, P=0.023)].Conclusion: We demonstrated that ABG/eAG ratio, calculated at admission time, is a significant predictor of the development of postoperative pneumonia.

Low preoperative serum fibrinogen level is associated with postoperative acute kidney injury in patients with in acute aortic dissection

ObjectiveAcute kidney injury (AKI) after cardiac surgery is associated with serious complication and high risk of mortality. The relationship between hemostatic system and the prognosis of patients with acute type A aortic dissection (ATAAD) has not been evaluated. The purpose of this study was to investigate the association between preoperative serum fibrinogen level and risk of postoperative AKI in patients with ATAAD.MethodsA total of 172 consecutive patients undergoing urgent aortic arch surgery for ATAAD between April 2020 and December 2021 were identified from Beijing Anzhen Hospital aortic surgery database. The primary outcome was postoperative AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) criteria. The univariate and multivariate logistic regression analysis were done to assess the independent predictors of risk for postoperative AKI. Receiver operating characteristic (ROC) curve was generated to evaluate the predictive probabilities of risk factors for AKI.ResultsIn our study, 51.2% (88/172) patients developed postoperative AKI. Multivariate logistic regression analysis identified low preoperative serum fibrinogen level (OR, 1.492; 95% CI, 1.023 to 2.476; p = 0.021) and increased body mass index (BMI) (OR, 1.153; 95% CI, 1.003 to 1.327; p = 0.046) as independent predictors of postoperative AKI in patients with ATAAD. A mixed effect analysis of variance modeling revealed that obese patients with low preoperative serum fibrinogen level had higher incidence of postoperative AKI (p = 0.04). The ROC curve indicated that low preoperative serum fibrinogen level was a significant predictor of AKI [area under the curve (AUC), 0.771; p < 0.001].ConclusionsLow preoperative serum fibrinogen level and obesity were associated with the risk of postoperative AKI in patients with ATAAD. These data suggested that low preoperative serum fibrinogen level was preferred marker for predicting the postoperative AKI, especially in obese patients with ATAAD.

The preoperative plasma histamine level as a possible protective biomarker for postoperative acute kidney injury

Acute kidney injury (AKI) is a life-threatening complication of acute type A aortic dissection (ATAAD) patients. Increasing evidence suggests that histamine ameliorates the pathology of renal injury. However, data on the association between histamine levels and postoperative AKI in ATAAD patients are limited. The purpose of our study was to explore the incidence and independent risk factors of postoperative AKI, with special emphasis on the relationship between preoperative plasma histamine levels and the severity of postoperative ATAAD-AKI. This retrospective single-center study evaluated 160 patients with ATAAD admitted to the Beijing Anzhen Hospital aortic surgery database between April 2020 and December 2021. Univariate and multivariate logistic regression analyses were performed to determine the potential risk factors for postoperative ATAAD-AKI. A subgroup analysis was performed to investigate the association between preoperative plasma histamine levels and the severity of postoperative ATAAD-AKI or continuous renal replacement therapy (CRRT). ATAAD-AKI occurred in 84 of 160 patients (52.5%), including 32 with stage 1 (38.1%), 14 with stage 2 (16.7%), 38 with stage 3 (45.2%), and 34 (21.3%) received postoperative CRRT. The in-hospital mortality rate was 19.0% (16/84) in the AKI group and 2.6% (2/76) in the non-AKI group (P = .02). Preoperative lower plasma histamine levels (odds ratio [OR], 1.31; 95% confidence interval [CI], 1.10-1.52; P = .004) were an important factor related to postoperative ATAAD-AKI in multivariate logistic regression analysis. Subgroup analysis revealed that low preoperative plasma histamine level was independently associated with postoperative ATAAD-AKI (stage 3) (OR, 1.38; 95% CI, 1.10-1.73; P = .005) and CRRT (OR, 1.44; 95% CI, 1.13-1.79; P = .008). Low preoperative plasma histamine level was an independent prognostic indicator of postoperative AKI in patients with ATAAD, especially for postoperative AKI (stage 3) and CRRT. Preoperative plasma histamine levels may serve as potential protective biomarkers of postoperative ATAAD-AKI.

The Anzhen Risk Scoring System for Acute Type A Aortic Dissection: A Prospective Observational Study Protocol

Introduction: Acute type A aortic dissection (ATAAD) is a catastrophic disease with fatal outcomes. Malperfusion syndrome (MPS) is a serious complication of ATAAD, with an incidence of 20–40%. Many studies have shown that MPS is the main risk factor for poor ATAAD prognosis. However, a risk scoring system for ATAAD based on MPS is lacking. Here, we designed a risk scoring system for ATAAD to assess mortality through quantitative assessment of relevant organ malperfusion and subsequently develop rational treatment strategies. Methods and analysis: This was a prospective observational study. Patients’ perioperative clinical data were collected to establish a database of ATAAD (N≥3000) and determine whether these patients had malperfusion complications. The Anzhen risk scoring system was established on the basis of organ malperfusion by using a random forest survival model and a logistics model. The better method was then chosen to establish a revised risk scoring system. Ethics and dissemination: This study received ethical approval from the Ethics Committees of Beijing Anzhen Hospital, Capital Medical University (KS2019034-1). Patient consent was waived because biological samples were not collected, and no patient rights were violated. Findings will be disseminated at scientific conferences and in peer-reviewed publications.

Predicting late aortic complications after acute type A dissection surgery with volumetric measurements in a Singapore cohort.

This study was conducted to evaluate the efficacy of postoperative computed tomography (CT) measurements of aortic lumen volumes in predicting aortic-related complications following acute type A aortic dissection (ATAAD) repair. We conducted a single-institution retrospective aortic volumetric analysis of patients after ascending aorta replacement performed during 2001-2015. The volumetric measurements of total lumen (total-L), true lumen (TL), false lumen (FL), as well as the TL:FL ratio from the first and second postoperative computer angiograms were obtained. A generalised structural equation model was created to analyse the predictive utility of TL:FL ratio. One hundred and twenty-five patients underwent surgical intervention, of whom 97 patients were eventually discharged and analysed for postoperative complications. A total of 19 patients were included in the final analysis. Patients with late postoperative aortic complications had a significantly higher FL volume and total-L volume on the first (FL volume P = 0.041, total-L volume P = 0.05) and second (FL volume P = 0.01, total-L volume P = 0.007) postoperative scans. The odds of having aortic complications were raised by 1% with a 1 cm3 increase in total-L volume and by 2% with a 1 cm3 increase in FL volume. The TL:FL ratio was significantly lower in patients who developed complications. Postoperative CT volumetric measurements in patients who developed complications are characterised by a significant increase in the FL volume and total-L volume from the first postoperative scans. Patients with disproportionately expanded FL presenting with TL:FL ratios less than 1 were associated with aortic complications. Hence, the TL:FL ratio may be a reliable and useful parameter to monitor postoperative disease progression and to evaluate the risk of late complications in ATAAD patients.