Ibrahim Sultan1, Valentino Bianco2, Himanshu J Patel3, George J Arnaoutakis4, Marco Di Eusanio5, Edward P Chen6, Bradley Leshnower6, Thoralf M Sundt7, Udo Sechtem8, Daniel G Montgomery9, Santi Trimarchi10, Kim A Eagle9, Thomas G Gleason2. 1. Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa. Electronic address: sultani@upmc.edu. 2. Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa. 3. Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich. 4. Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla. 5. Cardiac Surgery Department, University of Bologna, Bologna, Italy. 6. Division of Cardiothoracic Surgery, Emory University, Atlanta, Ga. 7. Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass. 8. Division of Cardiology, Robert-Bosch Krankenhaus, Stuttgart, Germany. 9. Cardiovascular Center, University of Michigan, Ann Arbor, Mich. 10. Department of Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Milan, Italy.
Abstract
BACKGROUND: The strategy for intervention remains controversial for patients presenting with type A aortic dissection (TAAAD) and cerebral malperfusion with neurologic deficit. METHODS: Surgically managed patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection were evaluated to determine the incidence and prognosis of patients with cerebral malperfusion. RESULTS: A total of 2402 patients underwent surgical repair of TAAAD. Of these, 362 (15.1%) presented with cerebral malperfusion (CM) and neurologic deficits, and 2040 (84.9%) patients had no neurologic deficits at presentation. Patients with CM were more less likely to present with chest pain (66% vs 86.5%; P < .001) and back pain (35.9% vs 44.4%; P = .008). Patients with CM were more likely to present with syncope (48.4% vs 10.1%; P < .001), peripheral malperfusion (52.7% vs 38.0%; P < .001), and shock (16.2% vs 4.1%; P < .001). There was no difference in the incidence of Marfan syndrome (2.8% vs 3.0%; P = .870) or history of known aortic aneurysm (11.7% vs 13.9%; P = .296). Patients with CM were more likely to have a DeBakey I (63.8% vs 47.1%; P < .001) and a pericardial effusion (53.8% vs 40.6; P < .001) on presentation. There was no difference in total arch replacement (21.3% for CM vs 19.5% for no CM; P = .473). Patients with CM had an increased incidence of postoperative cerebrovascular accident (17.5% vs 7.2%; P < .001) and acute kidney injury (28.3% vs 18.1%; P < .001). In-hospital mortality was greater in patients with CM (25.7% vs 12.0%; P < .001). CONCLUSIONS: Fifteen percent of patients with TAAAD presented with CM and neurologic deficits. Despite the fact that this subset of the population was older and more likely to present with peripheral malperfusion, cardiac tamponade, and in shock, in-hospital survival was noted in nearly 75% of the patients. Surgeons may continue to offer lifesaving surgery for TAAAD to this critically ill cohort of patients with acceptable morbidity and mortality.
BACKGROUND: The strategy for intervention remains controversial for patients presenting with type A aortic dissection (TAAAD) and cerebral malperfusion with neurologic deficit. METHODS: Surgically managed patients with TAAAD enrolled in the International Registry of Acute Aortic Dissection were evaluated to determine the incidence and prognosis of patients with cerebral malperfusion. RESULTS: A total of 2402 patients underwent surgical repair of TAAAD. Of these, 362 (15.1%) presented with cerebral malperfusion (CM) and neurologic deficits, and 2040 (84.9%) patients had no neurologic deficits at presentation. Patients with CM were more less likely to present with chest pain (66% vs 86.5%; P < .001) and back pain (35.9% vs 44.4%; P = .008). Patients with CM were more likely to present with syncope (48.4% vs 10.1%; P < .001), peripheral malperfusion (52.7% vs 38.0%; P < .001), and shock (16.2% vs 4.1%; P < .001). There was no difference in the incidence of Marfan syndrome (2.8% vs 3.0%; P = .870) or history of known aortic aneurysm (11.7% vs 13.9%; P = .296). Patients with CM were more likely to have a DeBakey I (63.8% vs 47.1%; P < .001) and a pericardial effusion (53.8% vs 40.6; P < .001) on presentation. There was no difference in total arch replacement (21.3% for CM vs 19.5% for no CM; P = .473). Patients with CM had an increased incidence of postoperative cerebrovascular accident (17.5% vs 7.2%; P < .001) and acute kidney injury (28.3% vs 18.1%; P < .001). In-hospital mortality was greater in patients with CM (25.7% vs 12.0%; P < .001). CONCLUSIONS: Fifteen percent of patients with TAAAD presented with CM and neurologic deficits. Despite the fact that this subset of the population was older and more likely to present with peripheral malperfusion, cardiac tamponade, and in shock, in-hospital survival was noted in nearly 75% of the patients. Surgeons may continue to offer lifesaving surgery for TAAAD to this critically ill cohort of patients with acceptable morbidity and mortality.
Authors: George J Arnaoutakis; Takuya Ogami; Edgar Aranda-Michel; Yancheng Dai; Reed Holmes; Thomas M Beaver; Derek Serna-Gallegos; Tomas D Martin; Forozan Navid; Sarah Yousef; Ibrahim Sultan Journal: J Am Heart Assoc Date: 2022-06-29 Impact factor: 6.106
Authors: Igor Vendramin; Miriam Isola; Daniela Piani; Francesco Onorati; Stefano Salizzoni; Augusto D'Onofrio; Luca Di Marco; Giuseppe Gatti; Maria De Martino; Giuseppe Faggian; Mauro Rinaldi; Gino Gerosa; Davide Pacini; Aniello Pappalardo; Ugolino Livi Journal: JTCVS Open Date: 2022-03-26