Validation of Risk Model of Operative Mortality in the Presence of Severe Acidosis and Malperfusion with Acute Type A Aortic Dissection

Background: The feasibility and effectiveness of delaying surgery to transfer patients with acute type A aortic dissection—a catastrophic disease that requires prompt intervention—to higher-volume aortic surgery hospitals is unknown. We investigated the hypothesis that regionalizing care at high-volume hospitals for acute type A aortic dissections will lower mortality. We further decomposed this hypothesis into subparts, investigating the isolated effect of transfer and the isolated effect of receiving care at a high-volume versus a low-volume facility. Methods: We compared the operative mortality and long-term survival between 16 886 Medicare beneficiaries diagnosed with an acute type A aortic dissection between 1999 and 2014 who (1) were transferred versus not transferred, (2) underwent surgery at high-volume versus low-volume hospitals, and (3) were rerouted versus not rerouted to a high-volume hospital for treatment. We used a preference-based instrumental variable design to address unmeasured confounding and matching to separate the effect of transfer from volume. Results: Between 1999 and 2014, 40.5% of patients with an acute type A aortic dissection were transferred, and 51.9% received surgery at a high-volume hospital. Interfacility transfer was not associated with a change in operative mortality (risk difference, –0.69%; 95% CI, –2.7% to 1.35%) or long-term mortality. Despite delaying surgery, a regionalization policy that transfers patients to high-volume hospitals was associated with a 7.2% (95% CI, 4.1%–10.3%) absolute risk reduction in operative mortality; this association persisted in the long term (hazard ratio, 0.81; 95% CI, 0.75–0.87). The median distance needed to reroute each patient to a high-volume hospital was 50.1 miles (interquartile range, 12.4–105.4 miles). Conclusions: Operative and long-term mortality were substantially reduced in patients with acute type A aortic dissection who were rerouted to high-volume hospitals. Policy makers should evaluate the feasibility and benefits of regionalizing the surgical treatment of acute type A aortic dissection in the United States.

Download Full-text

Comparison of Risk Scores for the Prediction of Outcomes after Surgery for Acute Type A Aortic Dissection

Journal of Cardiology Research ◽

10.36879/jcr.19.000122 ◽

2019 ◽

pp. 1-4

Keyword(s):

Aortic Dissection ◽

Acute Aortic Dissection ◽

Operative Mortality ◽

External Validation ◽

Type A ◽

Risk Scores ◽

Acute Type ◽

Risk Models ◽

Type A Aortic Dissection ◽

Malperfusion Syndrome

We compared the performance of four existing risk models and a newly developed risk score for type A acute aortic dissection surgery. In 327 consecutives with type A aortic dissection surgery patients during 2003/03-2017/03 at our centre, operative mortality occurred in 65 (19.9%). Independent predictors of operative mortality were critical pre-operative state and malperfusion syndrome, and a novel additive “CritMal” Score was constructed from this. C-statistics (95% confidence interval) for operative mortality were EuroSCORE 0.60 (0.52-0.67), EuroSCORE II 0.64 (0.57-0.72), Rampoldi 0.68 (0.59-0.76), Leontyev 0.56 (0.48-0.64), and CritMal 0.72 (0.64-0.80) respectively. This is the first study externally assessing surgical scores for aortic dissection surgery, with modest accuracy for all and moderate for CritMal. There is room for improvement of these risk models, and further refinements and external validation are warranted for clinical application.

Download Full-text

Techniques of Proximal Root Reconstruction and Outcomes Following Repair of Acute Type A Aortic Dissection

Aorta ◽

10.12945/j.aorta.2016.14.039 ◽

2016 ◽

Vol 04 (02) ◽

pp. 33-41 ◽

Cited By ~ 1

Author(s):

Tyler Gunn ◽

Sotiris Stamou ◽

Nicholas Kouchoukos ◽

Kevin Lobdell ◽

Kamal Khabbaz ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Dissection ◽

Operative Mortality ◽

Survival Rates ◽

Surgical Techniques ◽

Type A ◽

Acute Type ◽

Actuarial Survival ◽

Type A Aortic Dissection ◽

Replacement Procedure

Background: The goal of this study was to compare the early and late outcomes of different techniques of proximal root reconstruction during the repair of acute Type A aortic dissection, including aortic valve (AV) resuspension, aortic valve replacement (AVR), and a root replacement procedure. Methods: All patients who underwent acute Type A aortic dissection repair between January 2000 and October 2010 at four academic institutions were compiled from each institution’s Society of Thoracic Surgeons Database. This included 189 patients who underwent a concomitant aortic valve (AV) procedure; 111, 21, and 57 patients underwent AV resuspension, AVR, and the Bentall procedure, respectively. The median age of patients undergoing a root replacement procedure was significantly younger than the other two groups. Early clinical outcomes and 10-year actuarial survival rates were compared. Trends in outcomes and surgical techniques throughout the duration of the study were also analyzed. Results: The operative mortality rates were 17%, 29%, and 18%, for AV resuspension, AVR, and root replacement, respectively. Operative mortality (p = 0.459) was comparable between groups. Hemorrhage related re-exploration did not differ significantly between groups (p = 0.182); however, root replacement procedures tended to have decreased rates of bleeding when compared to AVR (p = 0.067). The 10-year actuarial survival rates for the AV resuspension, Bentall, and AVR groups were 72%, 56%, and 36%, respectively (log-rank p = 0.035). Conclusions: The 10-year actuarial survival was significantly lower in those receiving AVR compared to those receiving root replacement procedures or AV resuspension. Operative mortality was comparable between the three groups.

Download Full-text

Impact of transesophageal echocardiographic detection of intimal tears on operative mortality in acute type A aortic dissection

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(96)82313-8 ◽

1996 ◽

Vol 27 (2) ◽

pp. 350

Author(s):

Keisuke Ueda ◽

Makoto Matsumura ◽

Hiroaki Tnabe ◽

Chifumi Takayama ◽

Shunei Kyo ◽

...

Keyword(s):

Aortic Dissection ◽

Operative Mortality ◽

Type A ◽

Acute Type ◽

Type A Aortic Dissection

Download Full-text

Repair of Acute Type-A Aortic Dissection in the Present Era: Outcomes and Controversies

Aorta ◽

10.1055/s-0039-3401810 ◽

2019 ◽

Vol 07 (06) ◽

pp. 155-162 ◽

Cited By ~ 1

Author(s):

Ellie Moeller ◽

Marcos Nores ◽

Sotiris C. Stamou

Keyword(s):

Aortic Dissection ◽

Operative Mortality ◽

Cochrane Review ◽

False Lumen ◽

Surgical Techniques ◽

Type A ◽

Acute Type ◽

Close Monitoring ◽

Type A Aortic Dissection ◽

The Past

AbstractAcute Type-A aortic dissection (AAAD) remains a surgical emergency with a relatively high operative mortality despite advances in medical and surgical management over the past three decades. In spite of the severity of disease, there is a paucity of studies reviewing key controversies surrounding AAAD repair and management. A systematic literature search was performed using Cochrane review and PubMed bibliography review. Abstracts were first reviewed for general pertinence and then articles were reviewed in full. Literature review indicates that use of moderate hypothermia and antegrade cerebral perfusion is a safe alternative to deep hypothermia. In hemodynamically stable patients, axillary cannulation may be substituted for femoral cannulation. With regard to the technical aspects of repair, preserving the aortic root whenever possible and performing the distal anastomosis with the open distal technique rather than with the clamp on is the preferred approach. In patients with a patent false lumen, close monitoring is indicated. As demonstrated by the literature, significant improvement of early and late mortality over the past years has occurred in patients presenting with AAAD. Repair of acute Type-A aortic dissection remains a challenge with high operative mortality; however, improvement of surgical techniques and management have resulted in improvement of early and late clinical outcomes.

Download Full-text

Renal malperfusion affects operative mortality rather than late death following acute type A aortic dissection repair

Asian Journal of Surgery ◽

10.1016/j.asjsur.2019.02.004 ◽

2020 ◽

Vol 43 (1) ◽

pp. 213-219 ◽

Cited By ~ 5

Author(s):

Si-Chong Qian ◽

Wei-Guo Ma ◽

Xu-Dong Pan ◽

Hong Liu ◽

Kai Zhang ◽

...

Keyword(s):

Aortic Dissection ◽

Operative Mortality ◽

Type A ◽

Acute Type ◽

Type A Aortic Dissection ◽

Late Death

Download Full-text

Is Axillary Better Than Femoral Artery Cannulation in Repair of Acute Type A Aortic Dissection?

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/1556984519836879 ◽

2019 ◽

Vol 14 (2) ◽

pp. 124-133 ◽

Cited By ~ 1

Author(s):

Eilon Ram ◽

Yoav Krupik ◽

Alexander Lipey ◽

Ami Shinfeld ◽

Yael Peled ◽

...

Keyword(s):

Renal Failure ◽

Aortic Dissection ◽

Femoral Artery ◽

Operative Mortality ◽

Axillary Artery ◽

Type A ◽

Acute Type ◽

Complication Rates ◽

Type A Aortic Dissection ◽

Artery Cannulation

Objective We compared early and late outcomes of patients who underwent femoral versus axillary artery cannulation for repair of acute type A aortic dissection. Methods Between 2004 and 2017, we retrospectively evaluated the clinical outcomes of 135 consecutive patients who underwent emergency surgery for acute type A aortic dissection repair. Patients were divided into 2 groups: those who underwent femoral ( n = 84) and those who underwent right axillary ( n = 51) artery cannulation. Mean patient age was 63 ± 13 years and 88 (65%) were male. Results Overall operative mortality was 12.6% (axillary 15.7%, femoral 10.7%; P = 0.564). Patients who underwent axillary compared to femoral artery cannulation had a statistically nonsignificant higher operative mortality rate among both stable and unstable patients (13% vs. 6.5%, P = 0.405 and 40% vs. 22.7%, P = 0.818, respectively). While there was no difference in major complication rates, such as stroke, low cardiac output, and surgical revision for bleeding/tamponade, there was a higher incidence of renal failure that required dialysis in patients who underwent axillary cannulation (12% vs. 1%, P = 0.022). Multivariate analysis demonstrated that predictors for the composite endpoint of operative mortality or severe organ malperfusion, such as renal failure or cerebrovascular accident, were hemodynamic instability on admission (OR 3.87; 95% CI, 1.23 to 12.63; P = 0.021), lower preoperative creatinine clearance (OR 0.94; 95% CI, 0.90 to 0.97; P < 0.001); and the use of axillary artery cannulation (OR 4.1; 95% CI, 1.43 to 12.78; P = 0.011). Among those discharged from hospital, the 3-year survival rate was 91% in the axillary group and 87% in the femoral group ( P = 0.772). Conclusions Based on our experience, emergent surgery for both stable and unstable patients with acute type A aortic dissection demonstrated similar survival rates and significantly less renal impairment when using the femoral cannulation approach.

Download Full-text