OBJECTIVE: Stroke remains a serious complication after total arch replacement (TAR). To prevent this, deep hypothermia is commonly employed during TAR. We evaluated the effectiveness of cerebral protection using deep hypothermic circulatory arrest (DHCA) during TAR with the arch-first technique, focusing particularly on patients with acute aortic dissection (AAD).
METHODS: This retrospective study included 109 consecutive patients with AAD who underwent emergency TAR using the arch-first technique under DHCA, and 147 patients with non-ruptured aneurysm who underwent scheduled TAR using the same technique between October 2009 and July 2022. We reviewed these patients for major adverse events, including stroke and 30-day mortality after surgery. We also analyzed the impact of clinical variables and anatomical features on the occurrence of newly developed stroke after TAR in patients with AAD.
RESULTS: A newly developed stroke after TAR occurred in 11 (10.1%) patients with AAD. These were attributed to embolism in eight patients, malperfusion in two patients (including one who had been comatose), and low output syndrome in one patient. A stroke occurred in 3 (2.0%) patients with aneurysm, all due to embolism (P = 0.005). The DHCA time was 37 ± 7 minutes for patients with AAD and 36 ± 6 minutes for patients with aneurysm (P = 0.122). The 30-day mortality rate was 10 (9.2%) for patients with AAD and 2 (1.4%) for patients with aneurysm (P = 0.003). In our multivariable analysis, arch vessel dissection with a patent false lumen (double-barreled dissection) was the only significant predictor of newly developed stroke after TAR for AAD (odds ratio, 33.02; P < 0.001).
CONCLUSIONS: Patients with aneurysm undergoing TAR using the arch-first technique under DHCA experienced significantly better outcomes, in terms of newly developed stroke and 30-day mortality, than those with AAD. Cerebral protection with DHCA during TAR using the arch-first technique continues to be a viable option. Newly developed stroke in patients undergoing TAR for AAD appears to be associated with air emboli deriving from the residual dissection with a patent false lumen in the repaired arch vessels.

UNASSIGNED: The inflammatory response of the body is intimately linked to the quick onset and high in-hospital mortality of Acute Type A Aortic Dissection (ATAAD). The purpose of the study was to examine the connection between in-hospital mortality in patients with ATAAD upon admission and the Pan-Immune-Inflammation Value (PIV).
UNASSIGNED: 308 patients who were diagnosed with ATAAD between September 2018 and October 2021 at Fujian Provincial Center for Cardiovascular Medicine had their clinical data retrospectively examined. PIV was assessed at the time of study population admission, with in-hospital mortality serving as the main outcome measure. Patients were divided into two groups, the high PIV group (PIV > 1807.704) and the low PIV group (PIV < 1807.704), based on the PIV ROC curve and the best threshold of the Youden index. The clinical results of the two groups were then compared.
UNASSIGNED: Among ATAAD patients, postoperative in-hospital mortality was higher in the high PIV group (54.7% vs 10.6%, P < 0.001), and the high PIV group had significantly higher rates of postoperative acute kidney injury, acute liver insufficiency, and gastrointestinal hemorrhage (P < 0.05). Additionally, the high PIV group\'s ICU stays lasted longer than the low PIV group\'s (P < 0.05). The results of multifactorial logistic regression analysis, which controlled for other variables, indicated that the mechanical ventilation time (OR = 1.860, 95% CI: 1.437, 2.408; P < 0.001), the high PIV group (> 1807.704) (OR = 1.939, 95% CI: 1.257, 2.990; P = 0.003), the cardiopulmonary bypass time (OR = 1.011, 95% CI: 1.004, 1.018; P = 0.002), and the white blood cell count (OR = 1.188, 95% CI: 1.054, 1.340; P = 0.005) were independent risk factors for postoperative in-hospital mortality in ATAAD patients.
UNASSIGNED: Postoperative death in ATAAD patients was independently predicted by high PIV levels at admission. Patients should be informed about their preoperative inflammatory status and actively participate in prompt clinical decision-making and treatment.

UNASSIGNED: Surgical treatment strategy for acute type A aortic dissection (aTAAD) with mesenteric malperfusion (MMP) is quite challenging as it is often associated with poor patient outcomes, and optimal management strategies remain controversial.
UNASSIGNED: We conducted MEDLINE and EMBASE database searches up to December 31, 2021 for studies on aTAAD with MMP. Data on study design, patient demographics, patient management strategy, mortality, complications, and follow-up were extracted, analyzed, and investigated.
UNASSIGNED: Our literature search identified 941 potentially relevant studies, of which 19 were deemed eligible for this study. A total of 352 patients, mean age: 58.4 ± 11.9 years, diagnosed with aTAAD complicated with MMP were included with an overall prevalence of 4%. Patients for which MMP was observed preoperatively were also included in this analysis. The overall in-hospital mortality amongst these patients was 43.5%, and bowel necrosis and/or multiorgan failure were the major causes of death. Four management strategies for first-line treatment were recognized and these included central aortic repair (191, 54.3%), reperfusion of superior mesenteric artery (SMA) (121, 34.3%), exclusively endo-intervention (11, 3.1%), and exclusively medical intervention (29, 8.2%). These various first-line strategies showed mortality rates of 40.3%, 33.9%, 72.7% and 93.1%, respectively. There was no significant difference in the mortality rate between central aortic repair and reperfusion of SMA as first-line therapies ( χ 2 = 1.302, p = 0.254). When compared with central aortic repair and reperfusion of SMA, exclusively medical care exhibited a significantly greater mortality rate (p < 0.01).
UNASSIGNED: aTAAD complicated with MMP is a rare complication that carries a high mortality rate. Central aortic repair and reperfusion of SMA as first-line treatment strategies appear to be associated with better outcomes compared with exclusively endo-intervention and medical care. Clinical decisions may have introduced biases as no differences were indicated in regards to the way patients were being prioritized for the central aortic repair versus reperfusion of SMA. In regards to variable clinical features and pathology of aTAAD complicated with MMP, an individualized approach is recommended.

UNASSIGNED: To investigate short- and intermediate-term outcomes of immediate (on table) recognition and surgical treatment of iatrogenic acute type A aortic dissection (ATAD) that occurred during the course of the cardiac surgical procedures.
UNASSIGNED: Of 23,143 adult patients undergoing cardiac surgical procedures at our institution from January 2016 to December 2020, 21 (0.09%) suffered from intraoperative iatrogenic ATAD and underwent immediate aortic repair. Their clinical characteristics, in-hospital outcomes and follow-up results were analyzed.
UNASSIGNED: Among the 21 patients, 13 (61.9%) suffered from hypertension, and 14 (66.7%) had a dilated ascending aorta. In-hospital mortality was 9.5%, and new onset of permanent neurologic deficit was recorded in one patient. During a median follow-up of 36.0 months, all 18 follow-up patients survived without repeated surgeries. A follow-up computed tomography (CT) examination revealed a residual false lumen in the aortic arch in 3 patients and in the descending aorta in 8, with residual false lumen perfusion in one.
UNASSIGNED: Immediate recognition and surgical repair of ATAD that developed as a complication during cardiac surgical procedures are associated with low mortality and high intermediate-term survival.

BACKGROUND: Despite advances in surgical techniques, the incidence of stroke following acute type A aortic dissection (ATAAD) repair remains markedly high, with substantial immediate and long-term adverse outcomes such as elevated mortality, extended hospital stays, and persistent neurological impairments. The complexity of managing ATAAD extends beyond the operation itself, highlighting a crucial gap in research concerning modifiable preoperative patient conditions and perioperative anesthetic management strategies.
OBJECTIVE: This investigation aimed to elucidate the incidence, consequences, and perioperative determinants of stroke following surgical intervention for acute type A aortic dissection (ATAAD).
METHODS: In a multicenter retrospective analysis, 516 ATAAD surgery patients were evaluated. The data included demographic information, clinical profiles, surgical modalities, and outcomes. The primary endpoint was postoperative stroke incidence, with hospital mortality and other complications serving as secondary endpoints.
RESULTS: Postoperative stroke occurred in 13.6% of patients (70 out of 516) and was associated with significant extension of the ICU (median 10 vs. 5 days, P < 0.001) and hospital stay (median 18 vs. 12 days, P < 0.001). The following key independent stroke risk factors were identified: modified Frailty Index (mFI) ≥ 4 (odds ratio [OR]: 4.18, 95% confidence interval [CI]: 1.24-14.1, P = 0.021), common carotid artery malperfusion (OR: 3.76, 95% CI: 1.23-11.44, P = 0.02), pre-cardiopulmonary bypass (CPB) hypotension (mean arterial pressure ≤ 50 mmHg; OR: 2.17, 95% CI: 1.06-4.44, P = 0.035), ≥ 20% intraoperative decrease in cerebral regional oxygen saturation (rSO2) (OR: 1.93, 95% CI: 1.02-3.64, P = 0.042), and post-CPB vasoactive-inotropic score (VIS) ≥ 10 (OR: 2.24, 95% CI: 1.21-4.14, P = 0.01).
CONCLUSIONS: Postoperative stroke significantly increases ICU and hospital durations in ATAAD surgery patients. These findings highlight the critical need to identify and mitigate major risks, such as high mFI, common carotid artery malperfusion, pre-CPB hypotension, significant cerebral rSO2 reductions, and elevated post-CPB VIS, to improve outcomes and reduce stroke prevalence.
BACKGROUND: Thai Clinical Trials Registry (TCTR20230615002). Date registered on June 15, 2023. Retrospectively registered.

暂无摘要。

OBJECTIVE: The objective of the present study was to model the effects of a reduced number of treatment centres for acute type A aortic dissection on preclinical transportation distance and time. We examined whether treatment in selected centres in Germany would be implementable with respect to time to treatment.
METHODS: For our transportation model, the number of aortic dissections and respective mean annual volume were collected from the annual quality reports (2015-2017) of all German cardiac surgery centres (n = 76). For each German postal code, the fastest and shortest routes to the nearest centre were calculated using Google Maps. Furthermore, we analysed data from the German Federal Statistical Office from January 2005 to December 2015 to identify all surgically treated patients with acute type A aortic dissection (n = 14 102) and examined the relationship between in-hospital mortality and mean annual volume of medical centres.
RESULTS: Our simulation showed a median transportation distance of 27.13 km and transportation time of 35.78 min for 76 centres. Doubling the transportation time (70 min) would allow providing appropriate care with only 12 medical centres. Therefore, a mean annual volume of >25 should be obtained. High mean annual volume was associated with significantly lower in-hospital mortality rates (P < 0.001). A significantly lower mortality rate of 14% was observed (P < 0.001) if a mean annual volume of 30 was achieved.
CONCLUSIONS: Operationalizing the volume-outcome relationship with fewer but larger medical centres results in lower mortality, which outweighs the disadvantage of longer transportation time.

UNASSIGNED: There is no consensus regarding the strategies for repairing acute type A aortic dissection (ATAAD) in patients with bicuspid aortic valve (BAV). This meta-analysis aimed to compare the treatment strategies and outcomes of ATAAD repair between patients with BAV and those with tricuspid aortic valve (TAV).
UNASSIGNED: A systematic review of databases were performed from inception through March 2023. The primary outcome of interest was all-cause mortality, with a minimum follow-up of 1 year. The secondary outcomes of interest included ratios of performed procedures and rate of distal aortic reoperation. Data were extracted, and pooled analysis was performed using a random-effects model.
UNASSIGNED: Eight observational studies including a total of 3701 patients (BAV, n = 349; TAV, n = 3352) were selected for a meta-analysis. Concerning proximal aortic procedures, BAV patients exhibited a higher incidence of necessary root replacement (odds ratio [OR], 6.53; 95% confidence interval [CI], 3.84 to 11.09; P < .01). Regarding distal aortic procedures, extended arch replacement was performed less frequently in BAV patients (OR, 0.69; 95% CI, 0.49 to 0.99; P = .04), whereas hemiarch procedure rates were comparable in the 2 groups. All-cause mortality was lower in the BAV group (hazard ratio, 0.68; 95% CI, 0.50 to 0.92; P = .01). Distal aortic reoperation rates were comparable in the 2 groups.
UNASSIGNED: This study highlights distinct procedural patterns in ATAAD patients with BAV and TAV. Despite differing baseline characteristics, BAV patients exhibited superior survival compared to TAV patients, with comparable distal aortic reoperation rates. These findings may be useful for decision making regarding limited versus extended aortic arch repair.

OBJECTIVE: To evaluate the impact of previous cardiac surgery (PCS) on clinical outcomes after reoperative extended arch repair for acute type A aortic dissection.
METHODS: This study included 37 acute type A aortic dissection patients with PCS (PCS group) and 992 without PCS (no-PCS group). Propensity score-matching yielded a subgroup of 36 pairs (1:1). In-hospital outcomes and mid-term survival were compared between the 2 groups.
RESULTS: The PCS group was older (56.7 ± 14.2 vs 52.2 ± 12.6 years, P = 0.036) and underwent a longer cardiopulmonary bypass (median, 212 vs 183 min, P < 0.001) compared with the no-PCS group. Operative death occurred in 88 (8.6%) patients, exhibiting no significant difference between groups (13.5% vs 8.4%, P = 0.237). Major postoperative morbidity was observed in 431 (41.9%) patients, also showing no difference between groups (45.9% vs 41.7%, P = 0.615). Moreover, the multivariable logistic regression analysis revealed that PCS was not significantly associated with operative mortality (adjusted odds ratio 2.58, 95% confidence interval 0.91-7.29, P = 0.075) or major morbidity (adjusted odds ratio 1.92, 95% confidence interval 0.88-4.18, P = 0.101). The 3-year cumulative survival rates were 71.1% for the PCS group and 83.9% for the no-PCS group (log-rank P = 0.071). Additionally, Cox regression indicated that PCS was not significantly associated with midterm mortality (adjusted hazard ratio 1.40, 95% confidence interval 0.44-4.41, P = 0.566). After matching, no significant differences were found between groups in terms of operative mortality (P > 0.999), major morbidity (P > 0.999) and midterm survival (P = 0.564).
CONCLUSIONS: No significant differences were found between acute type A aortic dissection patients with PCS and those without PCS regarding in-hospital outcomes and midterm survival after extended arch repair.

OBJECTIVE: The goal of this study was to investigate the impact of onset-to-cut time on mortality in patients undergoing surgery for stable acute type A aortic dissection.
METHODS: Patients who underwent surgery for acute type A aortic dissection between January 2006 and December 2021 and available onset-to-cut times were included. Patients with unstable aortic dissection (preoperative shock, intubation, resuscitation, coma, pericardial tamponade and local/systemic malperfusion syndromes) were excluded. After descriptive analysis, a multivariable binary logistic regression for 30-day mortality was performed. A receiver operating characteristic curve for onset-to-cut time and 30-day mortality was calculated. Restricted cubic splines were designed to investigate the association between onset-to-cut time and survival.
RESULTS: The final cohort comprised 362 patients. The median onset-to-cut time was 543 (376-1155) min. The 30-day mortality was 9%. Only previous myocardial infarction (P = 0.018) and prolonged cardiopulmonary bypass time (P < 0.001) were identified as independent risk factors for 30-day mortality. The corresponding area under the receiver operating characteristic curve showed a value of 0.49. Restricted cubic splines did not indicate an association between onset-to-cut time and survival (P = 0.316).
CONCLUSIONS: Onset-to-cut time in the setting of stable acute type A aortic dissection does not seem to be a valid predictor of 30-day mortality in patients undergoing surgery and stayed stable during the preoperative course.