Aortic Dissection Repair Research Articles

Case Report: Increase in wall shear stress in a narrowed true lumen after type A aortic dissection repair analyzed by computed fluid dynamics

Case Report: Increase in wall shear stress in a narrowed true lumen after type A aortic dissection repair analyzed by computed fluid dynamics

Polytetrafluoroethylene Felt Inlay Neomedia and Tissue Glue Do Not Prevent Reoperation in Type A Aortic Dissection

Background/Objectives: Type A aortic dissection repair using Polytetrafluorethylene (PTFE) felt inlay and tissue glue has been proposed as a treatment modality. It remains unclear, if this method performs superiorly to tissue glue only. Methods: Between January 2011 and December 2015, 139 patients underwent surgical repair for type A aortic dissection, and 48 patients were excluded (n = 29 after receiving a composite graft, n = 18 in which no tissue glue was used, and n = 1 due to missing data). In the remaining patients, proximal aortic repair was performed either using PTFE felt inlay and tissue glue or tissue glue only. We analyzed the need for repeated surgery on the aorta during follow-up as a primary endpoint. The secondary endpoint was all-cause mortality at follow-up. Inverse probability of treatment weighting was used to balance the distribution of measured baseline covariates. Results: Sixty-six patients (73%) were treated with a tissue-glue-only approach—the Control Group. Twenty-five patients (27%) underwent proximal PTFE felt inlay and tissue glue—the Intervention Group. In the Intervention Group, 40% (n = 10) underwent reoperation due to re-dissection or pseudoaneurysm vs. 12% (n = 8) in the Control Group. The felt inlay increased the hazard of re-operation by 8.38 (1.63 to 43.0) after IPTW with death modeled as competing risk. Conclusions: Reoperation due to aortic complications was 10 times higher in patients treated with a combination of gluing and PTFE felt inlay vs. gluing only. These results are potentially caused by an interaction of PTFE, tissue glue, and aortic tissue.

Aortic arch replacement in patients with previous repair of acute aortic dissection: a systematic review and meta-analysis.

Despite the popularity of the frozen elephant technique procedure in recent years, evidence is scarce regarding its utilisation for aortic arch replacement following previous acute aortic dissection repair. In this systematic review and meta-analysis, we aimed to analyse clinical outcomes of aortic arch replacement in patients with previous repair of acute aortic dissection. A systematic literature search on PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science until March 2024 was performed for studies on open aortic arch replacement with or without frozen elephant technique procedure in adult patients after previous acute aortic dissection repair. Early and late postoperative mortality were primary, while postoperative complications were outcomes of interest. Additionally, a meta-analysis was performed to pool the early and late postoperative mortality. A total of 574 studies were identified, of which 9 studies including a total of 677 patients met the eligibility criteria. In-hospital or 30-day postoperative mortality and stroke were 0-17.5% and 0-7.7%, respectively. Duration of follow-up across all studies varied from 1.1 to 5.1 years. All-cause late mortality rate ranges from 5.9-30.5%. Aortic reintervention rate was 4.8-38.7%. The pooled early and late mortality rate were 8.7% ([95% CI: 5.7-13%], I2=52%) and 24.9% ([95% CI: 19.5-31.1%], I2=54%), respectively. Current evidence suggest that relatively younger patients with chronic post-dissection aneurysm or residual aortic dissection after acute aortic dissection repair can undergo an aortic arch replacement by a dedicated aortic team with acceptable mortality risk. However, postoperative neurological deficit remains an issue.

Association of Intraoperative Transfusion of Blood Products with Postoperative Outcomes and Mid-term Survival in Acute Type A Aortic Dissection Repair

Association of Intraoperative Transfusion of Blood Products with Postoperative Outcomes and Mid-term Survival in Acute Type A Aortic Dissection Repair

Preoperative Depression is Associated With a Higher Risk of Bleeding in Type a Aortic Dissection Repair: A Population Study of National Inpatient Sample From 2015-2020.

Depression is highly prevalent in patients with aortic diseases. While depression has been shown to predispose patients to adverse outcomes after surgery, its impact on postoperative outcomes in Stanford Type A Aortic Dissection (TAAD) has not been established. This study aimed to conduct a population-based examination of the effect of preoperative depression on in-hospital outcomes after TAAD using the National/Nationwide Inpatient Sample (NIS) database, the largest all-layer database in the US. Patients undergoing TAAD repair were identified in NIS from the last quarter of 2015-2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients with and without preoperative depression, adjusted for demographics, comorbidities, hospital characteristics, primary payer status, and transfer status. There were 321 (7.50%) patients with depression and 3961 (92.50%) non-depressive patients who underwent TAAD repair. Patients with and without depression had comparable in-hospital mortality (11.84% vs 15.37%, P = 0.35). However, Patients with depression had a higher risk of hemorrhage/hematoma (83.49% vs 76.6%, aOR 1.593, 95 CI 1.161-2.184, P < 0.01) and a higher rate of transfer out (40.81% vs 32.62%, aOR 1.396, 95 CI 1.077-1.81, P = 0.01). All other in-hospital complications, hospital length of stay (LOS), and total hospital charge were comparable between patients with and without depression. Preoperative depression is associated with a higher risk of bleeding after TAAD repair. This may be due to anti-depression treatment, such as Selective Serotonin Reuptake Inhibitors (SSRIs), that can disrupt platelet function and lead to abnormal bleeding. While depression is not associated with other major outcomes, preoperative depression screening, as well as hemostatic monitoring and appropriate blood management in patients with depression may be crucial in preventing bleeding complications in TAAD repair.

Time critical diagnoses and transfers of patients with acute type A aortic dissection in the UK: national audit of current practice*

SummaryBackgroundType A aortic dissection repair is one of the most common emergency cardiac surgical procedures undertaken in the UK and has a high mortality. Early diagnosis and prompt surgery by an expert cardiac surgical team is crucial. Little is known about the patient's journey from first symptoms until surgery.MethodsThe Association for Cardiothoracic Anaesthesia and Critical Care undertook a prospective national audit of the management of type A aortic dissection in the UK.ResultsThe details of 334 patients with type A aortic dissection were reported by 28 UK cardiac centres over 12 months. Median (IQR [range]) time from onset of symptoms until arrival in an emergency department was 2.3 (1.4–4.7 [0.1–491.6]) h. Median (IQR [range]) time between arrival in the emergency department and the start of surgery was 9.5 (6.1–18.2 [0.8–363.5]) h. Delays in diagnosis and transfers were reported in 158 (47.3%) patients. Fifty‐two patients (15.6%) had an initial misdiagnosis. The condition of 56 patients (16.8%) deteriorated clinically before arrival in the operating theatre. A medical doctor accompanied 50 patients (15.0%) during transfer. Sixty‐four patients (19.2%) died in hospital with 41 (12.3%) dying within the first 5 days after surgery.ConclusionsThis audit provides a snapshot of current practice for patients with type A aortic dissection in the UK. Our findings show the acuity, clinical severity and vulnerability of patients with type A aortic dissection, and the deficits in the process of diagnosis and the quality of transfer. This audit demonstrates the need for the implementation of comprehensive, regionally governed, interdisciplinary medical management for every patient with type A aortic dissection.

RATE OF ASCENDING AORTIC ENLARGEMENT IN A LARGE ECHOCARDIOGRAPHIC COHORT: ASSOCIATED RISK FACTORS AND ADVERSE AORTIC EVENTS

BackgroundUnderstanding ascending aortic aneurysm growth and associated risk factors is critical to advising appropriate echocardiographic follow-up intervals for patients. This study aimed to identify aortic aneurysm growth rate on serial echocardiograms as well as the clinical and demographic variables that contribute to baseline aortic size and subsequent aortic growth. MethodsPatients identified with ascending aortic aneurysm and undergoing serial echocardiograms within five years were evaluated. Ascending aortic size was measured as part of routine echocardiogram exams. Clinical and demographic variables including aortic valve type (trileaflet, bicuspid or prosthetic) were evaluated for association with baseline aortic size as well as with aortic progression rate. Clinical events including aortic dissection, elective or emergent surgical repair were recorded. Results3639 patients were identified, (78% males, median age of 69 years, 175 (4.8%) with bicuspid valve, and 206 (5.6%) with prior aortic valve replacement (AVR). Patients with larger aorta at baseline were older with higher tobacco use and prior prosthetic valves. Over a mean of 2.4 years, aortic growth was observed and differed by valve type (trileaflet valve: 0.08 mm/year , bicuspid valve: 0.4 mm/year , p<0.001). In six patients who developed aortic dissection the estimated average annual growth rate was 0.98 mm/year. ConclusionsIn a large echo cohort, aortic aneurysm growth rate was 0.08 mm/year though higher in those with bicuspid valves ( 0.4 mm/ year), but initial aortic size did not correlate with change in the aortic progression rate. This data may help inform recommended echocardiographic surveillance intervals.

Prevalence and Influence of Genetic Variants on Follow-Up Results in Patients Surviving Thoracic Aortic Therapy.

Background/Objective: To investigate the prevalence and effects of genetic variants (GVs) in survivors of thoracic aortic dissection/aneurysm repair. Methods: Patients aged 18-80 years who survived follow-up after cardiosurgical or endovascular repair of thoracic aortic aneurysm or dissection at a single tertiary center between 2008 and 2019 and underwent genetic testing were enrolled. The exclusion criteria were age >60 years, no offspring, and inflammatory- or trauma-related pathogenesis. Follow-up entailed computed tomography-angiography at 3 and 9 months and annually thereafter. All patients underwent genetic analyses of nine genes using next-generation sequencing. In cases of specific suspicion, the analysis was expanded to include 32 genes. Results: The study included 95 patients. The follow-up period was 3 ± 2.5 years. GVs were detected in 40% of patients. Correlation analysis according to primary diagnosis showed no significant correlation in disease persistence, progression, or in reintervention rates in aneurysm patients and a correlation of disease persistence with genetic variants according to variant class in dissection patients (p = 0.037). Correlation analysis according to follow-up CD finding revealed that patients with detected dissection, irrespective of original pathology, showed a strong correlation with genetic variants regarding disease progression and reintervention rates (p = 0.012 and p = 0.047, respectively). Conclusions: The prevalence of VUS is high in patients with aortic pathology. In patients with dissected aorta in the follow-up, irrespective of original pathology, genetic variants correlate with higher reintervention rates, warranting extended-spectrum genetic testing. The role of VUS may be greater than is currently known.

Perioperative and Long-Term Outcomes of Acute Stanford Type A Aortic Dissection Repair in Octogenarians.

The aims of this study were to assess the perioperative morbidity, mortality and long-term survival of octogenarians undergoing acute type A aortic dissection repair (ATAAD), and to compare open and closed distal anastomosis techniques. This was a single-centre retrospective study (2007-2021). Open versus closed distal anastomosis were compared. Uni- and multivariable logistic regression analyses were performed to identify independent predictors of in-hospital mortality. Kaplan-Meier and Cox proportional hazards methods were used to compare long-term survival. Fifty octogenarian patients were included (median age-82 years; closed distal-22; open distal-28). Median cardiopulmonary bypass time was 187 min (open distal vs. closed distal group; 219 min vs. 115.5 min, p < 0.01, respectively). Median cross-clamp time was 93 min (IQR; 76-130 min). Median circulatory arrest time was 26 min (IQR; 20-39 min) in the open-distal group. In-hospital mortality was 18% (open distal; 14.2% vs. closed distal; 22.7%, p = 0.44). Stroke was 26% (open distal; 28.6% vs. closed distal; 22.7%, p = 0.64). Median survival was 7.2 years (IQR; 4.5-11.6 years). Survival was comparable between open and closed distal groups (median 10.6 vs. 7.2 years, p = 0.35, respectively). Critical preoperative status (HR; 3.2, p = 0.03) and composite endpoint (renal replacement therapy, new neurological event, length of stay > 30 days or return to theatre; HR; 4.1, p = 0.02) predicted adverse survival. Open distal anastomosis did no impact survival. ATAAD repair in selected octogenarians has acceptable short- and long-term survival. There is no significant difference between open versus closed distal anastomosis strategies.

Morphology of true lumen and surgical outcomes of acute type A aortic dissection repair with superior mesenteric artery malperfusion

BackgroundAcute type A aortic dissection (ATAD) can cause visceral malperfusion. Central aortic repair may resolve malperfusion, but some require further intervention. This study aimed to review outcomes after ATAD presenting with visceral malperfusion and to evaluate the predictive value of true lumen (TL) morphologies in preoperative computed tomography scan for persistent superior mesenteric artery (SMA) ischemia after central repair. MethodsOpen surgical repair of ATAD performed between 2008 and 2023 at our institution was reviewed retrospectively. Patients with central repair first approach were included for analysis. Patients with inadequate computed tomography scan data to assess luminal morphology were excluded. TL morphology was reviewed at the diaphragm level and categorized as concave or convex. The malperfusion pattern, static vs dynamic, was assessed at SMA orifices. Data were analyzed using a contingency table and parametric and nonparametric methods. ResultsA total of 543 open ATAD repairs were performed. Of these, 263 patients were eligible under the inclusion criteria and, subsequently, analyzed. The mean age was 57±14, and 83 (31%) patients were female. SMA malperfusion developed in 42 (16%) of the 263 patients, including 26 patients with dynamic obstruction, 6 patients with static obstruction, and 10 patients with dynamic and static obstruction. Regarding dissection flap morphology, 78 patients (30%) exhibited concave morphology, while 185 patients (70%) had convex morphology. TL diameter was significantly larger in convex than concave (concave: 6 mm vs convex: 16 mm; P < .0001). The prevalence of clinically significant SMA malperfusion was higher in concave-shaped TL (concave 41% vs convex 5%; P < .0001). Dynamic SMA obstruction was more frequently observed in the concave group (concave 72% vs convex 30%; P < .001). However, significantly more patients with convex-shaped TL required bowel resection than concave (concave 13% vs convex 70%; P < .001). The operative mortality was higher in the convex group, although statistically insignificant (concave 19% vs convex 50%; P = .0059). ConclusionsCentral repair first strategy could resolve more than 80% of SMA malperfusion in ATAD when the TL is concave-shaped at the level of the diaphragm. Convex-shaped TL morphology was associated with less incidence of SMA malperfusion but was more frequently associated with static obstruction and higher incidence of bowel resection. The morphology evaluation of the TL at the diaphragm level may be simple and beneficial for surgical planning for ATAD presenting with SMA malperfusion.

Early surgical outcomes in the composite-valve root replacement with bioprosthesis after surgery for acute type A aortic dissection.

This study aimed to evaluate the surgical outcomes of composite-valve root replacement with bioprosthesis (b-CVRR) after acute type A aortic dissection (AAAD) repair. We included 41 patients who underwent b-CVRR after surgery for AAAD from 2007 to 2022. We excluded seven patients with VSRR, three with mechanical valve use, one with mycotic aneurysm, and one with cardiopulmonary resuscitation. The overlapping surgical indications for b-CVRR were pseudoaneurysm in 21 patients (51.2%), severe AI in 19 (46.3%), re-dissection in 15 (36.6%), root dilatation (> 50mm) in 12 (41.5%), and rupture in 3 (7.3%). The coronary artery reconstruction methods were bilateral Carrel patch in 13 patients (32%), Carrel patch with Piehler in 16 patients (38%), bilateral Piehler in six patients (15%), and Piehler with coronary artery bypass (CABG) in six patients (15%). Four patients who underwent the Carrel patch technique required additional intraoperative CABG. Three hospital mortality occurred (7.3%; myonephropathic metabolic syndrome, heart failure, bleeding from the thyroid carotid artery without injury). No thrombosis of the reconstructed site was observed with the Piehler procedure. Surgical outcomes for patients treated with b-CVRR after AAAD repair were acceptable. Intraoperative coronary artery events occurred due to stenosis caused by traction on the reconstructed coronary artery due to adhesions.

Reoperative aortic root replacement following previous cardiac surgery or type A aortic dissection repair

ObjectiveReoperative aortic root replacement (ARR) is a technically challenging procedure. This study assesses the influence of reoperation on outcomes following ARR, particularly after prior acute type A aortic dissection repair. MethodsOf the 1823 patients in this study, 1592 (87.3%) underwent primary ARR, and 231 (12.7%) underwent reoperative ARR. Within the reoperative ARR group, 69 patients (29.9%) had previous acute type A aortic dissection repair, and 162 patients (70.1%) underwent reoperative ARR for other indications. ResultsReoperative ARR patients exhibited higher rates of ischemic heart disease (13.9% vs 3%; P < .001), diabetes (10% vs 5.3%; P = .009), chronic pulmonary disease (9.1% vs 5%; P = .018), renal impairment (17.7% vs 5.3%; P < .001), and had lower ejection fraction (45.5% ± 8.1% vs 47.6% ± 7.9%; P < .001) compared with primary ARR. The overall operative mortality was 0.4%, with no significant difference between groups (0.9% vs 0.3%; P = .485). At multivariable analysis, previous operation was the most powerful predictor for major adverse events (odds ratio, 3.20; 95% CI, 2.12-4.79; P < .001). Reoperative ARR had a lower 10-year survival compared with primary ARR (67.4% vs 85.9%; log-rank P < .001). Multivariable analysis further confirmed that reoperation was significantly associated with 10-year mortality (hazard ratio, 1.76; 95% CI, 1.01-3.06; P = .044). Among the reoperative ARR group, operative mortality after previous acute type A aortic dissection repair was similar to that for other etiologies (0% vs 1.2%; P = .880). ConclusionsPatients undergoing reoperative ARR have more comorbidities and extensive aortic disease compared with those undergoing primary surgery. They face a 3.5-fold increased risk of major adverse events but no difference in operative mortality compared with primary ARR.

Outcomes after open repair of aortic aneurysms and dissections in cannabis consumers

ObjectiveTo investigate the influence of cannabis consumption on the mid- and long-term surgical outcomes of patients with aortic aneurysms or dissections. MethodsAll individuals aged 18 years and older with more than 6 months of cannabis use at the time of surgical repair for cardiovascular disease (aortic aneurysms or aortic dissection) between 2007 and 2023 were eligible. Patients were stratified into 2 groups based on their preoperative history of cannabis use: cannabis users and noncannabis users. The primary end point was complications or death within 30 days of intervention. Secondary outcomes included late complications and reinterventions. Data were combined from our institution and inpatient hospital records. ResultsWe identified 134 patients who met the inclusion criteria out of 1543 treated patients (9%). Compared with the nonusing cannabis group, individuals in the cannabis group were significantly younger (cannabis: 48.3 ± 11.8 years vs noncannabis: 58.5 ± 14.9 years; P < .001). The cannabis group included significantly higher patients with Marfan syndrome (cannabis: 11.2% vs noncannabis: 4.4%; P < .001). Furthermore, the cannabis group showed significantly higher history of recreational drug use, including cocaine (25.4% vs 1.6%; P < .001), amphetamines (3.7% vs 0.6%; P < .001), opioids (8.2% vs 0.5%; P < .001), and intravenous drugs (6.7% vs 0.6%; P < .001). Emergency surgeries were significantly more frequent in the cannabis group (cannabis: 56.7% vs noncannabis: 36.2%; P < .001). Surgical mortality was comparable between both groups (cannabis: 9.7% vs noncannabis: 8.6%; P = .662). Postoperative stroke was significantly higher in the cannabis group (cannabis: 14.9% vs noncannabis: 8.2%; P = .009), and the rate of postoperative respiratory complications was also significantly higher in the cannabis group (cannabis: 32.1% vs noncannabis: 19.0%; P < .001). ConclusionsThe increased rates of postoperative cerebrovascular accidents and respiratory complications suggest that cannabis use is a significant risk factor in aortic surgery. Our study showed that young, healthy patients with prolonged cannabis use might be at a higher risk of requiring more emergency surgeries due to their background.

A novel hybrid prosthesis for open repair of acute DeBakey type I dissection with malperfusion: Early results from the PERSEVERE trial

BackgroundOutcomes after hemiarch repair for acute DeBakey type I aortic dissection (ADTI) remain unfavorable, with high rates of major adverse events and negative aortic remodeling. The PERSEVERE study evaluates the safety and effectiveness of the AMDS Hybrid prosthesis, a novel bare metal stent, in patients presenting with preoperative malperfusion. MethodsPERSEVERE is a prospective single-arm investigational study conducted at 26 sites in the United States. Ninety-three patients underwent ADTI aortic dissection repair with AMDS implantation. The 30-day primary endpoints are a composite rate of 4 major adverse events and the rate of distal anastomotic new entry tears. The secondary endpoints include aortic remodeling. ResultsClinical malperfusion was documented in 76 patients (82%); only radiographic malperfusion, in 17 (18%). The median follow-up in the 93 patients was 5.6 months. Within 30 days, 9 patients died (9.7%), 10 patients (10.8%) experienced new disabling stroke, and 18 patients (19.4%) had new-onset renal failure requiring ≥1 dialysis treatment. There were no cases of myocardial infarction. The composite rate of major adverse events (27%) was lower than that reported in the reference cohort (58%). There were no distal anastomotic new entry tears. Technical success was achieved in 99% of patients. Early remodeling indicated total aortic diameter stability, true lumen expansion, and false lumen reduction in the treated aortic segment. ConclusionsEarly results show significant reductions in major adverse events and distal anastomotic new entry tears, successfully meeting both primary endpoints. The technical success rate was high. AMDS can be used safely in patients with ADTI dissection with malperfusion.

Limited vs. Extended Resection of Stanford Type A Acute Aortic Dissections.

Background and Objectives: This is a propensity-matched, single-center study of limited versus extended resection for type A acute aortic dissection (AAAD). Materials and Methods: This study collected retrospective data for 440 patients with acute type A aortic dissection repairs (limited resection, LR-215; extended resection, ER-225), of which 109 pairs were propensity-matched to LR versus ER. Multivariate analysis was performed for inpatient death, long-term survival and the composite outcome of inpatient death/TIA/stroke. Kaplan-Meier survival curves were compared at 1, 3, 5, 10 and 15 years using the log-rank test. Results: Mean age was 66.9 ± 13 years and mean follow-up was 5.3 ± 4.7 years. A total of 48.9% had LR. In-hospital mortality was 10% (LR: 6% vs. ER: 13.8%, p < 0.01). ER, NYHA class, salvage surgery and additional procedures were predictors of increased mortality in unmatched data. Propensity-matched data showed no difference in TIA/stroke rates, LOS, inpatient mortality or composite outcomes. LR had better survival (LR: 77.1% vs. ER: 51.4%, p < 0.001). ER (OR: 1.97, 95% CI: 1.27, 3.08, p = 0.003) was a significant predictor of worse long-term survival. At 15 years, aortic re-operation was 17% and freedom from re-operation and death was 42%. Conclusions: Type A aortic dissection repair has high mortality and morbidity, although results have improved over two decades. ER was a predictor of worse perioperative results and long-term survival.

Peripheral artery disease is an independent risk factor for higher in-hospital mortality in Stanford type A aortic dissection repair.

Type A aortic dissection (TAAD) is an emergent condition that warrants immediate intervention. Peripheral artery disease (PAD) is a prevalent disease associated with worse outcomes in various cardiovascular procedures. However, it remains unclear whether PAD influences outcomes of TAAD repair. This study aimed to undertake a population-based analysis to assess impact of PAD on in-hospital outcomes following TAAD repair. Patients underwent TAAD repair were identified in National Inpatient Sample from Q4 2015 to 2020. Multivariable logistic regressions were used to compare in-hospital outcomes between patients with and without PAD, adjusted for demographics, socioeconomic status, primary payer status, hospital characteristics, comorbidities, and transfer/admission status. 1525 patients with PAD and 2757 non-PAD patients underwent TAAD. PAD patients had higher mortality (18.62% vs 13.17%, aOR = 1.287, p = .01), AKI (51.41% vs 47.48%, aOR = 1.222, p < .01), infection (10.69% vs 8.02%, aOR = 1.269, p = .03), and vascular complication (7.28% vs 3.77%, aOR = 1.846, p < .01) but lower risks of pericardial complications (15.21% vs 19.95%, aOR = 0.696, p < .01). In addition, patients with PAD had longer time from admission to operation (1.29 ± 3.95 vs 0.70 ± 2.09 days, p < .01), longer LOS (14.92 ± 13.98 vs 13.41 ± 11.66 days, p = .01), and higher hospital charge (499,064 ± 519,405 vs 409,754 ± 405,663 US dollars, p < .01). PAD was independently associated with worse outcome after TAAD repair. The elevated mortality rate could be attributed to the delay in surgery, which may be related to preoperative peripheral malperfusion syndrome that is common in PAD patients. A balance between preoperative management and immediate TAAD repair might be essential to prevent the increased mortality risk from treatment delays among PAD patients.

Postoperative stroke in acute type A aortic dissection: incidence, outcomes, and perioperative risk factors

BackgroundDespite advances in surgical techniques, the incidence of stroke following acute type A aortic dissection (ATAAD) repair remains markedly high, with substantial immediate and long-term adverse outcomes such as elevated mortality, extended hospital stays, and persistent neurological impairments. The complexity of managing ATAAD extends beyond the operation itself, highlighting a crucial gap in research concerning modifiable preoperative patient conditions and perioperative anesthetic management strategies.ObjectivesThis investigation aimed to elucidate the incidence, consequences, and perioperative determinants of stroke following surgical intervention for acute type A aortic dissection (ATAAD).MethodsIn a multicenter retrospective analysis, 516 ATAAD surgery patients were evaluated. The data included demographic information, clinical profiles, surgical modalities, and outcomes. The primary endpoint was postoperative stroke incidence, with hospital mortality and other complications serving as secondary endpoints.ResultsPostoperative stroke occurred in 13.6% of patients (70 out of 516) and was associated with significant extension of the ICU (median 10 vs. 5 days, P < 0.001) and hospital stay (median 18 vs. 12 days, P < 0.001). The following key independent stroke risk factors were identified: modified Frailty Index (mFI) ≥ 4 (odds ratio [OR]: 4.18, 95% confidence interval [CI]: 1.24–14.1, P = 0.021), common carotid artery malperfusion (OR: 3.76, 95% CI: 1.23–11.44, P = 0.02), pre-cardiopulmonary bypass (CPB) hypotension (mean arterial pressure ≤ 50 mmHg; OR: 2.17, 95% CI: 1.06–4.44, P = 0.035), ≥ 20% intraoperative decrease in cerebral regional oxygen saturation (rSO2) (OR: 1.93, 95% CI: 1.02–3.64, P = 0.042), and post-CPB vasoactive-inotropic score (VIS) ≥ 10 (OR: 2.24, 95% CI: 1.21–4.14, P = 0.01).ConclusionsPostoperative stroke significantly increases ICU and hospital durations in ATAAD surgery patients. These findings highlight the critical need to identify and mitigate major risks, such as high mFI, common carotid artery malperfusion, pre-CPB hypotension, significant cerebral rSO2 reductions, and elevated post-CPB VIS, to improve outcomes and reduce stroke prevalence.Trial RegistrationThai Clinical Trials Registry (TCTR20230615002). Date registered on June 15, 2023. Retrospectively registered.

Alcohol use disorder is associated with a lower risk of in-hospital mortality in type A aortic dissection repair: a population-based study of National Inpatient Sample from 2015-2020.

While alcohol consumption is implicated in the development of aortic dissection, the impact of alcohol use disorder (AUD) on the outcomes of type A aortic dissection (TAAD) repair is still largely unexplored. This study aimed to conduct a comprehensive, population-based analysis of effect of AUD on in-hospital outcomes following TAAD repair using National/Nationwide Inpatient Sample, the largest all-payer database in the United States. Patients undergoing TAAD repair were identified in National/Nationwide Inpatient Sample from Q4 2015-2020. Demographics, comorbidities, hospital characteristics, primary payer status, and transfer-in status between patients with and without AUD were matched by a 1:3 propensity-score matching. In-hospital outcomes were examined. There were 220 patients with AUD who underwent TAAD repair. Meanwhile, 4062 non-AUD patients went under TAAD repair, where 646 of them were matched to all AUD patients. After propensity-score matching, AUD patients had a lower risk of in-hospital mortality (7.76% vs 13.31%, P = 0.03) while there was no difference in transfer-in status or time from admission to operation. However, patients with AUD had a higher rate of respiratory complications (27.40% vs 19.66%, P = 0.02) and a longer hospital length of stay (16.20 ± 11.61 vs 11.72 ± 1.69days, P = 0.01). All other in-hospital outcomes were comparable between AUD and non-AUD patients. AUD patients had a lower risk of in-hospital mortality but a higher rate of respiratory complications and a longer LOS. These findings can provide insights into preoperative risk stratification of these patients. Nonetheless, reasons underlying the lower mortality rate in AUD patients and their long-term prognosis require further investigation.

Artificial intelligence in cardiac surgery: A systematic review.

Artificial intelligence (AI) has emerged as a tool to potentially increase the efficiency and efficacy of cardiovascular care and improve clinical outcomes. This study aims to provide an overview of applications of AI in cardiac surgery. A systematic literature search on AI applications in cardiac surgery from inception to February 2024 was conducted. Articles were then filtered based on the inclusion and exclusion criteria and the risk of bias was assessed. Key findings were then summarized. A total of 81 studies were found that reported on AI applications in cardiac surgery. There is a rapid rise in studies since 2020. The most popular machine learning technique was random forest (n=48), followed by support vector machine (n=33), logistic regression (n=32), and eXtreme Gradient Boosting (n=31). Most of the studies were on adult patients, conducted in China, and involved procedures such as valvular surgery (24.7%), heart transplant (9.4%), coronary revascularization (11.8%), congenital heart disease surgery (3.5%), and aortic dissection repair (2.4%). Regarding evaluation outcomes, 35 studies examined the performance, 26 studies examined clinician outcomes, and 20 studies examined patient outcomes. AI was mainly used to predict complications following cardiac surgeries and improve clinicians' decision-making by providing better preoperative risk assessment, stratification, and prognostication. While the application of AI in cardiac surgery has greatly progressed in the last decade, further studies need to be conducted to verify accuracy and ensure safety before use in clinical practice.

Indications, safety, and effectiveness of transcatheter electrosurgical septotomy during endovascular repair of aortic dissections

ObjectiveEndovascular repair of aortic dissections may be complicated by inadequate sealing zones, persistent false lumen perfusion, and limited space for catheter manipulation and target artery incorporation. The aim of this study was to describe the indications, technical success, and early outcomes of transcatheter electrosurgical septotomy (TES) during endovascular repair of aortic dissections. MethodsWe reviewed the clinical data of consecutive patients treated by endovascular repair of aortic dissections with adjunctive TES in two centers between 2021 and 2023. End points were technical success, defined by successful septotomy without dislodgment of the lamella or target artery occlusion, and 30-day rates of major adverse events (MAEs). ResultsAmong 197 patients treated by endovascular repair for aortic dissections, 36 patients (18%) (median age, 61.5 years (interquartile range, 55.0-72.5 years; 83% male) underwent adjunctive TES for acute (n = 3 [8%]), subacute (n = 1 [3%]), or chronic postdissection aneurysms (n = 32 [89%]). Indications for TES were severe true lumen (TL) compression (≤16 mm) in 28 patients (78%), target vessel origin from false lumen in 19 (53%), creation of suitable landing zone in 12 (33%), and organ/limb malperfusion in four (11%). Endovascular repair included fenestrated-branched endovascular aortic repair (EVAR) in 18 patients (50%), thoracic EVAR/EVAR/PETTICOAT in 11 (31%), and arch branch repair in 7 (19%). All patients had dissections extending through zones 5 to 7, and 28 patients (78%) underwent TES across the renal-mesenteric segment. Technical success of TES was 92% (33/36) for all patients and 97% (32/33) among those with subacute or chronic postdissection aneurysms. There were three technical failures, including two patients with acute dissections with inadvertent superior mesenteric artery dissection in one patient and distal dislodgement of the dissection lamella in two patients. There were no arterial disruptions. The mean postseptotomy aortic lumen increased from 13.2 ± 4.8 mm to 28.4 ± 6.8 mm (P < .001). All 18 patients treated by fenestrated-branched EVAR had successful incorporation of 78 target arteries. There was one early death (3%) from stroke, and three patients (8%) had major adverse events. After a median follow-up of 8 months (interquartile range, 4.5-13.5 months), 13 patients (36%) had secondary interventions, and two (6%) died from non-aortic-related events. There were no other complications associated with TES. ConclusionsTES is an adjunctive technique that may optimize sealing zones and luminal aortic diameter during endovascular repair of subacute and chronic postdissection. Although no arterial disruptions or target vessel loss occurred, patients with acute dissections are prone to technical failures related to dislodgement of the lamella.