Rapid Response in Type A Aortic Dissection: Is There a Decisive Time Interval for Surgical Repair?

Abstract

Background and Aim of the Study The objective was to evaluate whether there is a decisive time interval for patients to undergo surgery and to analyze if a rapid response in acute aortic dissection type A (AADA) affects patient selection.

Methods In 283 patients undergoing surgery for AADA, median time from onset of initial symptoms to skin incision was 6.9 hours (interquartile range [IQR], 5.0–11.7 hours). Patients were divided into three groups according to median time point of surgery (median ± 3 hours, i.e., 4–10; < 4; and >10 hours).

Results Almost 50% of patients presented in a critical preoperative state at hospital admission. Subanalysis identified patients being operated within 4 hours as an exclusive high-risk cohort (higher rates of preoperative neurologic dysfunction, tamponade, and cardiopulmonary resuscitation). Patients undergoing surgery between 4 and 10 hours showed a significantly better long-term survival (p = 0.021). Surgery within this time interval had a clear protective effect on 30-day mortality (odds ratio [OR]: 0.448. 95% confidence interval [CI]: 0.219–0.915). High age (OR: 1.037; 95% CI: 1.008–1.067), preoperative malperfusion syndrome (OR: 2.802; 95% CI: 1.351–5.811), and preoperative tamponade (OR: 2.621; 95% CI: 1.171–5.866) were factors predicting 30-day mortality.

Conclusion Rapid response in AADA interacts with the natural course of the disease resulting in an overrepresentation of critical patients. While the cohort below 4 hours represents the high-risk patients, time from symptom onset to initiation of surgery should not exceed 10 hours.

Keywords

aorta/aortic - aortic valve - cardiac - outcomes - mortality - morbidity

Ethics

The article reports on retrospective research. All data analyzed were collected as part of routine diagnosis and treatment. No ethical considerations apply.

Authors' Contribution

Simone Gasser: concept/design, data analysis/interpretation, drafting article, statistics.

Lukas Stastny; Severin Semsroth; Christoph Krapf; Nikolaos Bonaros; and Thomas Schachner: critical revision of the article.

Markus Kofler: cirtical revision of the article, statistics.

Michael Grimm: concept/design, critical revision of article, approval of article.

Julia Dumfarth: concept/design, data acquisition, critical revision of the article, statistics, approval of the article.

Publikationsverlauf

Eingereicht: 22. Juli 2019

Angenommen: 03. Dezember 2019

Artikel online veröffentlicht:
01. März 2020

• References

• 1 Lee TC, Kon Z, Cheema FH. et al. Contemporary management and outcomes of acute type A aortic dissection: an analysis of the STS adult cardiac surgery database. J Card Surg 2018; 33 (01) 7-18
• 2 Nishida H, Tabata M, Fukui T, Sato Y, Kin H, Takanashi S. A systematic approach to improve the outcomes of type A aortic dissection. J Thorac Cardiovasc Surg 2017; 154 (01) 89-96.e1
• 3 Conzelmann LO, Weigang E, Mehlhorn U. et al; GERAADA Investigators. Mortality in patients with acute aortic dissection type A: analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac Surg 2016; 49 (02) e44-e52
• 4 Trimarchi S, Nienaber CA, Rampoldi V. et al; International Registry of Acute Aortic Dissection Investigators. Contemporary results of surgery in acute type A aortic dissection: the International Registry of Acute Aortic Dissection experience. J Thorac Cardiovasc Surg 2005; 129 (01) 112-122
• 5 Erbel R, Aboyans V, Boileau C. et al; ESC Committee for Practice Guidelines; The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. Eur Heart J 2014; 35 (41) 2873-2926
• 6 Narayan P, Rogers CA, Benedetto U, Caputo M, Angelini GD, Bryan AJ. Malperfusion rather than merely timing of operative repair determines early and late outcome in type A aortic dissection. J Thorac Cardiovasc Surg 2017; 154 (01) 81-86
• 7 Leontyev S, Légaré JF, Borger MA. et al. Creation of a scorecard to predict in-hospital death in patients undergoing operations for acute type A aortic dissection. Ann Thorac Surg 2016; 101 (05) 1700-1706
• 8 Mejàre-Berggren H, Olsson C. Validation and adjustment of the Leipzig-Halifax acute aortic dissection type A scorecard. Ann Thorac Surg 2017; 104 (05) 1577-1582
• 9 Bonser RS, Ranasinghe AM, Loubani M. et al. Evidence, lack of evidence, controversy, and debate in the provision and performance of the surgery of acute type A aortic dissection. J Am Coll Cardiol 2011; 58 (24) 2455-2474
• 10 Higa C, Guetta J, Borracci RA. et al. Multicenter registry of acute aortic dissection. The Radar study. Preliminary results. Rev Argent Cardiol 2009; 77 (05) 354-360
• 11 Hirst Jr AE, Johns Jr VJ, Kime Jr SW. Dissecting aneurysm of the aorta: a review of 505 cases. Medicine (Baltimore) 1958; 37 (03) 217-279
• 12 Lindsay Jr J, Hurst JW. Clinical features and prognosis in dissecting aneurysm of the aorta. A re-appraisal. Circulation 1967; 35 (05) 880-888
• 13 Raghupathy A, Nienaber CA, Harris KM. et al; International Registry of Acute Aortic Dissection (IRAD) Investigators. Geographic differences in clinical presentation, treatment, and outcomes in type A acute aortic dissection (from the International Registry of Acute Aortic Dissection). Am J Cardiol 2008; 102 (11) 1562-1566
• 14 Evangelista A, Isselbacher EM, Bossone E. et al; IRAD Investigators. Insights from the International Registry of Acute Aortic Dissection: a 20-year experience of collaborative clinical research. Circulation 2018; 137 (17) 1846-1860
• 15 Qiu J, Zhang L, Luo X. et al. Higher mortality in patients undergoing nighttime surgical procedures for acute Type A aortic dissection. Ann Thorac Surg 2018; 106 (04) 1164-1170
• 16 Bennett JM, Wise ES, Hocking KM, Brophy CM, Eagle SS. Hyperlactemia predicts surgical mortality in patients presenting with acute Stanford type-A aortic dissection. J Cardiothorac Vasc Anesth 2017; 31 (01) 54-60
• 17 Santini F, Pessotto R, Restivo S, Montalbano G, Gatti G, Mazzucco A. Factors influencing outcome after emergency surgical repair of acute type A aortic dissection. G Ital Cardiol 1999; 29 (09) 1015-1019
• 18 Lawton JS, Moon MR, Liu J. et al. The profound impact of combined severe acidosis and malperfusion on operative mortality in the surgical treatment of type A aortic dissection. J Thorac Cardiovasc Surg 2018; 155 (03) 897-904
• 19 Boening A, Karck M, Conzelmann LO. et al. German Registry for Acute Aortic Dissection Type A: structure, results, and future perspectives. Thorac Cardiovasc Surg 2017; 65 (02) 77-84
• 20 Morimoto N, Okada K, Okita Y. Lack of neurologic improvement after aortic repair for acute type A aortic dissection complicated by cerebral malperfusion: predictors and association with survival. J Thorac Cardiovasc Surg 2011; 142 (06) 1540-1534
• 21 Wiedemann D, Kocher A, Dorfmeister M. et al. Effect of cerebral protection strategy on outcome of patients with Stanford type A aortic dissection. J Thorac Cardiovasc Surg 2013; 146 (03) 647-55.e1
• 22 Rice RD, Sandhu HK, Leake SS. et al. Is total arch replacement associated with worse outcomes during repair of acute type A aortic dissection?. Ann Thorac Surg 2015; 100 (06) 2159-2165 , discussion 2165–2166