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Surgery for type A aortic dissection in patients with cerebral malperfusion: Results from the International Registry of Acute Aortic Dissection.

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.

Authors+Show Affiliations

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.Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.Division of Thoracic and Cardiovascular Surgery, University of Florida, Gainesville, Fla.Cardiac Surgery Department, University of Bologna, Bologna, Italy.Division of Cardiothoracic Surgery, Emory University, Atlanta, Ga.Division of Cardiothoracic Surgery, Emory University, Atlanta, Ga.Thoracic Aortic Center, Massachusetts General Hospital, Boston, Mass.Division of Cardiology, Robert-Bosch Krankenhaus, Stuttgart, Germany.Cardiovascular Center, University of Michigan, Ann Arbor, Mich.Department of Surgery, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico Milan, Milan, Italy.Cardiovascular Center, University of Michigan, Ann Arbor, Mich.Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31959445

Citation

Sultan, Ibrahim, et al. "Surgery for Type a Aortic Dissection in Patients With Cerebral Malperfusion: Results From the International Registry of Acute Aortic Dissection." The Journal of Thoracic and Cardiovascular Surgery, 2019.
Sultan I, Bianco V, Patel HJ, et al. Surgery for type A aortic dissection in patients with cerebral malperfusion: Results from the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg. 2019.
Sultan, I., Bianco, V., Patel, H. J., Arnaoutakis, G. J., Di Eusanio, M., Chen, E. P., ... Gleason, T. G. (2019). Surgery for type A aortic dissection in patients with cerebral malperfusion: Results from the International Registry of Acute Aortic Dissection. The Journal of Thoracic and Cardiovascular Surgery, doi:10.1016/j.jtcvs.2019.11.003.
Sultan I, et al. Surgery for Type a Aortic Dissection in Patients With Cerebral Malperfusion: Results From the International Registry of Acute Aortic Dissection. J Thorac Cardiovasc Surg. 2019 Nov 15; PubMed PMID: 31959445.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Surgery for type A aortic dissection in patients with cerebral malperfusion: Results from the International Registry of Acute Aortic Dissection. AU - Sultan,Ibrahim, AU - Bianco,Valentino, AU - Patel,Himanshu J, AU - Arnaoutakis,George J, AU - Di Eusanio,Marco, AU - Chen,Edward P, AU - Leshnower,Bradley, AU - Sundt,Thoralf M, AU - Sechtem,Udo, AU - Montgomery,Daniel G, AU - Trimarchi,Santi, AU - Eagle,Kim A, AU - Gleason,Thomas G, Y1 - 2019/11/15/ PY - 2019/07/01/received PY - 2019/11/05/revised PY - 2019/11/06/accepted PY - 2020/1/22/entrez KW - International Registry for Acute Aortic Dissection KW - aortic dissection KW - cerebral malperfusion KW - type A JF - The Journal of thoracic and cardiovascular surgery JO - J. Thorac. Cardiovasc. Surg. N2 - 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. SN - 1097-685X UR - https://www.unboundmedicine.com/medline/citation/31959445/Surgery_for_type_A_aortic_dissection_in_patients_with_cerebral_malperfusion:_Results_from_the_International_Registry_of_Acute_Aortic_Dissection L2 - https://linkinghub.elsevier.com/retrieve/pii/S0022-5223(19)32762-X DB - PRIME DP - Unbound Medicine ER -