A Fatal Association of COVID-19 and Acute Type A Aortic Dissection

We represent a case with simultaneous COVID-19 and acute type A aortic dissection. Type A aortic dissection, an aortic catastrophic event, seems to have higher mortality on coexistence with COVID-19.

Impact of GERAADA Score in Patients With Acute Type A Aortic Dissection

Background Despite continuous developments and advances in the perioperative management of patients suffering from acute aortic dissection type A (AADA), the associated postoperative morbidity and mortality remain high and strongly depend on the preoperative clinical status. The associated postoperative mortality is still hard to predict prior to the surgical procedure. The so-called German Registry of Acute Aortic Dissection Type A (GERAADA) score uses very basic and easily retrievable parameters and was specifically designed for predicting the 30-day mortality rate in patients undergoing surgery for AADA. This study evaluated impact of the GERAADA score in the authors’ institutional results. MethodsAmong 101 acute type A aortic dissection patients treated at our hospital during August 2015–March 2021, the GERAADA was calculated individually and retrospectively. Predicted and actual mortalities were assessed, and independent predicted factors were searched. The primary endpoint was defined as comparison of GERAADA scores and early mortality, and the secondary endpoints were defined as comparison of GERAADA scores and other postoperative results, and comparison of preoperative factors and postoperative results regardless to GERAADA scores.ResultsWhile the overall 30-day mortality for the entire study cohort calculated by the GERAADA score was 14.3 (8.1-77.6) %, the actual mortality rate was 6%. However, the GERAADA score was significantly high in some postoperative complications and showed significant correlation with some peri- and post-operative factors. In addition, factors not belonging to GERAADA score such as time from onset to arrival at the hospital, time from onset to arrival at the operation room, spouse presence, and hemodialysis were significantly associated with 30-day mortality.ConclusionsAlthough the actual mortality was lower than predicted, GERAADA score may impact on the postoperative course. In addition, it would be desirable to add parameters such as the time from onset to arrival, family background, and hemodialysis for further accuracy.

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.

The zone 2 concept and distal stent graft positioning in TH 2–3 are associated with high rates of secondary aortic interventions in frozen elephant trunk surgery

OBJECTIVES The goal of this study was to investigate the association between the localization of the distal anastomosis (zone 2/3), the stent graft length (100–160 mm), the position of the distal end of the hybrid prosthesis and the need for secondary aortic intervention (SAI) in acute and chronic thoracic aortic disease after the frozen elephant trunk procedure. METHODS From 2009 through 2020, a total of 232 patients (137 men; mean age, 61.7 ± 13.8 years) were treated with the frozen elephant trunk procedure. The main indications were acute aortic dissection type A (n = 106, 46%), chronic aortic dissection type A (n = 52, 22%) and degenerative thoracic aortic aneurysm (n = 74, 32%). RESULTS The rate of SAI was significantly higher when we performed a distal anastomosis in zone 2 rather than in zone 3, whereas the rate of SAI was less frequent if the distal positioning of the hybrid prosthesis was below TH 4–5. Combining the zone 2 concept and the short stent graft length (100 mm) was associated with a significantly higher rate of SAIs. Patients with a distal anastomosis in zone 2 were significantly less likely to have a recurrent laryngeal nerve injury (P < 0.001). However, no association between a specific arch zone of a distal anastomosis and the occurrence of spinal cord injury was observed. CONCLUSIONS Rates of SAIs are highest in patients who were treated with a distal anastomosis in zone 2 and a short stent graft (100 mm) with the distal end of the hybrid prosthesis at vertebral level TH 2–3.

Epiaortic Ultrasound-Guided True Lumen Cannulation of Ascending Aorta in Acute Aortic Dissection Type A

Background: The choice of arterial inflow for acute Stanford type A aortic dissection repair remains controversial. The axillary artery should be considered as first choice for cannulation, but this technique is time-consuming. The ascending aortic cannulation provides antegrade perfusion and can be performed rapidly but there are several concerns such as aortic rupture, extension of dissection, and false lumen cannulation. Objective: To compare the establishment time of cardiopulmonary bypass (CPB) and postoperative outcomes of the two cannulation techniques that provide antegrade perfusion, which was direct true lumen cannulation on the dissected ascending aorta using epiaortic ultrasound-guided and axillary artery cannulation in Siriraj Hospital. Materials and Methods: The authors retrospectively reviewed all the 30 cases of acute aortic dissection type A using two different cannulation methods performed between February 2011 and May 2017. Direct true lumen ascending aortic cannulation was performed using the epiaortic ultrasound-guide with Seldinger technique in 12 patients, and axillary artery cannulation was performed in 18 patients. Results: The direct true lumen ascending aortic cannulation was safely performed in all patients. None of them had aortic rupture. Skin incision to CPB time was significantly faster in the epiaortic ultrasound-guided ascending aortic cannulation group at 29±8 versus 49±14 minutes (p<0.001). The 30-day mortality and postoperative adverse events, such as ischemic stroke, acute kidney injury, visceral organ and limb malperfusion showed no statistically significant difference from the axillary artery cannulation method. Conclusion: Epiaortic ultrasound-guided true lumen cannulation of ascending aorta in the treatment of acute aortic dissection type A is safe and feasible. Skin incision to CPB time can be performed faster and provided good outcome compared to the axillary artery cannulation technique. Keywords: Acute aortic dissection, Ascending cannulation, Epiaortic ultrasound