Evolving Controversies in Acute Type A Dissection
Activity: 103rd Annual Meeting
University of Virginia
Charlottesville, VA
United States - Contact Me
Ourania Preventza is the George Minor Professor of Surgery at the Department of Surgery, and Chief of Cardiothoracic Surgery at the University of Virginia. She is also adjunct Professor of Surgery at Baylor College of Medicine, in Houston where she spent 15 years of her career , and an associate professional staff at The Texas Heart Institute, in Houston. Dr. Preventza is triple-boarded; American Board of Surgery, American Board of Surgery (Surgical Critical Care), and American Board of Thoracic Surgery. She is the immediate Past President of the International Society of Endovascular Specialists 2021-2023( ISEVS). Prior leader of Adult Cardiac Surgery within the Women in Thoracic Surgery, immediate Past Program Committee Chair of the Southern Thoracic Surgical Association, and immediate past co chair of the adult cardiac surgery program of the AATS Annual Meeting and a holder of a management and business administration degree on Health Care leadership from Brandeis University in Boston. She is the Co –chair of the 2022 ACC/AHA guidelines on aortic disease and co –authored of more than 200 articles in peer review journals. Her interest includes education, health outcomes research, aortic surgery, heart valve surgery, new technologies and cardiovascular disease and women.
Northwestern University Feinberg School of Medicine
Chicago, IL
United States - Contact Me
Dr Johnston received his undergraduate degree in Anthropology and Classics from Dartmouth College, and subsequently his MD from Harvard Medical School where he was a Harvard National Scholar. He completed general surgery training at the Massachusetts General Hospital, and cardiothoracic surgery training at the Cleveland Clinic, where he joined the staff in 2008. He currently serves as Vice Chairman of the Department of Thoracic and Cardiovascular Surgery at Cleveland Clinic Dr Johnston’s clinical and research interests are in the areas of aortic valve and root disease, minimally invasive valve operations, complex reoperative heart surgery, health care quality and outcomes, and education for surgical teams.
As Program Director for Thoracic Surgery Residency and Advanced Fellowships, Dr Johnston oversees the largest training program for cardiothoracic surgeons in the US. He is a two-time recipient of the Bruce W Lytle Surgical Educator Award. In addition to training the next generation of surgeons, Dr Johnston is passionate about the importance of training medical teams to function well in situations of high stress and anxiety which are a necessary part of the practice of medicine. He collaborates with thought leaders from military special operations, sports, and the arts to re-imagine the training of 21st century leaders in surgery.
Saturday, May 6, 2023: 8:00 AM - 9:30 AM
Los Angeles Convention Center
Posted Room Name: 515B
Track
Adult Cardiac
103rd Annual Meeting
Presentations
Evolving Thoughts on the Frozen Elephant Trunk in Acute A Dissection
Total Time: 15 Minutes
1. Hemiarch Replacement in Acute Type A Aortic Dissection in Patients with Arch Branch Vessel Dissection is a Risk Factor for Later Re-Intervention of the Distal Aorta
Total Time: 15 Minutes
Objective:
The study was performed to identify the long-term outcome after hemiarch replacement for patients with acute type A aortic dissection and arch branch dissection.
Method:
From January 2008 to December 2021, 466 patients underwent open acute type A aortic dissection surgery. After excluding those who underwent total arch replacement(n=56), 411 patients met the criteria. Patients were divided into those with arch branch vessel dissection(n=204) and those without arch vessel dissection(n=207).
Result:
The median age of the entire cohort was 72 years, and other preoperative comorbidities were similar between the two groups. Both groups received aortic root replacement similarly (10% vs. 9%, P=0.60), and other intraoperative outcomes are similar. However, Deep hypothermic circulatory arrest time is a little longer in those without arch branch vessel dissection (41min vs. 45min, P=0.007). Postoperative outcomes were similar between the two groups, including operative mortality (9% vs. 7% P=0.478) and stroke (8% vs. 12% P=0.11). An anastomosis-related new entry was seen more in the arch branch dissection group (53% vs. 12% P<0.001). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation for distal aorta (5-year 30% vs. 12% P<0.001) with a hazard ratio of 9.75(95% confidence interval, 6.92-14.6 P<0.001). The 10-year survival was similar between the arch-branch vessel dissection and no arch-branch vessel dissection groups (50% vs. 55% P=0.39).
An anastomosis-related new entry was associated with re-operation for the distal aorta (hazard ratio 3.17, P<0.001).
Conclusions:
Hemiarch replacement for patients with acute aortic dissection with arch branch vessel dissection was associated with the anastomosis-related new entry and later re-intervention of the distal aorta
The study was performed to identify the long-term outcome after hemiarch replacement for patients with acute type A aortic dissection and arch branch dissection.
Method:
From January 2008 to December 2021, 466 patients underwent open acute type A aortic dissection surgery. After excluding those who underwent total arch replacement(n=56), 411 patients met the criteria. Patients were divided into those with arch branch vessel dissection(n=204) and those without arch vessel dissection(n=207).
Result:
The median age of the entire cohort was 72 years, and other preoperative comorbidities were similar between the two groups. Both groups received aortic root replacement similarly (10% vs. 9%, P=0.60), and other intraoperative outcomes are similar. However, Deep hypothermic circulatory arrest time is a little longer in those without arch branch vessel dissection (41min vs. 45min, P=0.007). Postoperative outcomes were similar between the two groups, including operative mortality (9% vs. 7% P=0.478) and stroke (8% vs. 12% P=0.11). An anastomosis-related new entry was seen more in the arch branch dissection group (53% vs. 12% P<0.001). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation for distal aorta (5-year 30% vs. 12% P<0.001) with a hazard ratio of 9.75(95% confidence interval, 6.92-14.6 P<0.001). The 10-year survival was similar between the arch-branch vessel dissection and no arch-branch vessel dissection groups (50% vs. 55% P=0.39).
An anastomosis-related new entry was associated with re-operation for the distal aorta (hazard ratio 3.17, P<0.001).
Conclusions:
Hemiarch replacement for patients with acute aortic dissection with arch branch vessel dissection was associated with the anastomosis-related new entry and later re-intervention of the distal aorta
View Submission
Invited Discussant
*Bradley Leshnower, Emory University School of Medicine - Contact Me Atlanta, GAUnited States
Abstract Presenter
MAKOTO MATSUURA, Kishiwada Tokusyukai hospital - Contact Me Izumisano Shi, OsakaJapan
2. Concomitant Coronary Artery Bypass Grafting in Acute Type A Aortic Dissection
Total Time: 15 Minutes
Objective: Concomitant coronary artery bypass grafting (CABG) is infrequently performed during surgery for acute type A aortic dissection (ATAAD), therefore available data are scarce. Aim of this study is to investigate the outcomes of this subgroup from a single-center experience.
Methods: 169 patients underwent concomitant CABG during surgical treatment for ATAAD between 01/2000 and 12/2021. Patients with iatrogenic dissections (n=63), reimplantation of old bypass grafts (n=4), chronical dissections (n=4) and missing data (n=1) were excluded. After descriptive analysis of the cohort, a multivariable binary logistic regression analysis based on multiple stepwise regression was performed to identify independent risk factors for thirty-day mortality.
Results: 97 patients were enrolled in this study. Indications for CABG were coronary dissection (n=66; 69%) and/or primary coronary artery disease (n=31; 32%). Preoperative coronary malperfusion was present in 70% of patients (n=68). The right coronary artery (RCA) was the most frequently revascularized vessel (n=78; 80%), followed by left anterior descending artery (LAD) (n=34; 35%). Revascularization of the RCA was mainly performed in the setting of coronary dissection (p<0.001), whereas the LAD was treated mainly in cases of coronary artery disease (p=0.019). Post-cardiopulmonary bypass right heart failure was present in 22 patients (21%) and 27 patients (28%) received postoperative mechanical circulatory support. Thirty-day mortality was 43% (n=42) and rate of new postoperative stroke 13% (n=13). In terms of solely coronary dissection (n=56), thirty-day mortality was almost twice as high (50% vs. 27%) as in cases of solely coronary artery disease (n=30) but did not differ significantly (p=0.063). Mean survival was 3.7 years (median=162 days). Follow up reached up to 20 years according to the operation date. Multivariable analysis identified preoperative coronary malperfusion (p=0.022), left ventricular dysfunction (p=0.016), cardiopulmonary bypass time (p=0.005), bypass grafting of the LAD (p=0.013), coronary dissection (p=0.020) and post-cardiopulmonary bypass right heart failure (p=0.005) as independent risk factors for thirty-day mortality.
Conclusions: Patients who require concomitant CABG during surgery for ATAAD are subject to high perioperative morbidity and mortality. Signs of coronary malperfusion on admission, coronary dissection and prolonged cardiopulmonary bypass time impact outcomes.
Methods: 169 patients underwent concomitant CABG during surgical treatment for ATAAD between 01/2000 and 12/2021. Patients with iatrogenic dissections (n=63), reimplantation of old bypass grafts (n=4), chronical dissections (n=4) and missing data (n=1) were excluded. After descriptive analysis of the cohort, a multivariable binary logistic regression analysis based on multiple stepwise regression was performed to identify independent risk factors for thirty-day mortality.
Results: 97 patients were enrolled in this study. Indications for CABG were coronary dissection (n=66; 69%) and/or primary coronary artery disease (n=31; 32%). Preoperative coronary malperfusion was present in 70% of patients (n=68). The right coronary artery (RCA) was the most frequently revascularized vessel (n=78; 80%), followed by left anterior descending artery (LAD) (n=34; 35%). Revascularization of the RCA was mainly performed in the setting of coronary dissection (p<0.001), whereas the LAD was treated mainly in cases of coronary artery disease (p=0.019). Post-cardiopulmonary bypass right heart failure was present in 22 patients (21%) and 27 patients (28%) received postoperative mechanical circulatory support. Thirty-day mortality was 43% (n=42) and rate of new postoperative stroke 13% (n=13). In terms of solely coronary dissection (n=56), thirty-day mortality was almost twice as high (50% vs. 27%) as in cases of solely coronary artery disease (n=30) but did not differ significantly (p=0.063). Mean survival was 3.7 years (median=162 days). Follow up reached up to 20 years according to the operation date. Multivariable analysis identified preoperative coronary malperfusion (p=0.022), left ventricular dysfunction (p=0.016), cardiopulmonary bypass time (p=0.005), bypass grafting of the LAD (p=0.013), coronary dissection (p=0.020) and post-cardiopulmonary bypass right heart failure (p=0.005) as independent risk factors for thirty-day mortality.
Conclusions: Patients who require concomitant CABG during surgery for ATAAD are subject to high perioperative morbidity and mortality. Signs of coronary malperfusion on admission, coronary dissection and prolonged cardiopulmonary bypass time impact outcomes.
View Submission
Invited Discussant
*Jennifer Lawton, Johns Hopkins Univerity - Contact Me Baltimore, MDUnited States
Abstract Presenter
Leonard Pitts, Deutsches Herzzentrum der Charité - Contact Me Berlin, GermanyGermany
3. Outcomes of Lower Extremity Malperfusion Syndrome in Patients Undergoing Proximal Type A Aortic Dissection Repair
Total Time: 15 Minutes
OBJECTIVE: In the setting of type A aortic dissection (TAAD), there is limited literature comparing outcomes in patients presenting with lower extremity malperfusion (LEM). The purpose of this study was to compare outcomes in acute TAAD with concomitant LEM in patients undergoing lower extremity revascularization to no revascularization.
METHODS: Consecutive patients undergoing surgery for acute TAAD were identified from a prospectively maintained database. Perioperative variables were then compared between patients with and without LEM. Predictors of LEM, revascularization, and mortality were determined using univariable cox regression and Firth's penalized likelihood modeling.
RESULTS: A total of 601 patients from January 2007 to December 2021 underwent proximal aortic repair for acute TAAD at a quaternary care center. Of these, 85/601 (14%) patients presented with concomitant LEM. A comparison of perioperative variables between patients with and without LEM are described in Table 1. Kaplan-Meier estimated survival fared worse in patients with LEM compared to no LEM at 1, 5, and 10 years (84% vs 77%, 74% vs 71%, 65% vs 52%, p=0.03).
Within the LEM group, 15/85 (17%) patients underwent lower extremity revascularization. There were no significant differences in postoperative mortality and morbidity between the revascularization and no revascularization groups except for more frequent lower extremity fasciotomy after revascularization (p=0.003). No patients required lower extremity amputations. Preoperative CT imaging showed iliac artery thrombosis (p=0.03) and partial false lumen thrombosis (p=0.05) more frequently in the revascularization group. Significant predictors of revascularization included peripheral vascular disease (HR 3.7 [1.0-14.0], p=0.05) and pulse deficit (HR 5.6 [1.3-24.0], p=0.02) at presentation. Multivariable analysis revealed Caucasian race (HR 0.37 [0.2-0.8], p=0.02) and atrial fibrillation (HR 5.0 [1.6-14.9], p=0.004) were associated with worse survival.
CONCLUSION: This study finds patients with TAAD and LEM more often have significant underlying comorbidities, higher complication rates, and decreased survival compared to those without LEM. Within the LEM group, lower extremity revascularization did not lead to significant differences in postoperative morbidity and mortality. Careful consideration and optimization of predictors of revascularization and mortality as described in this study may improve clinical outcomes.
METHODS: Consecutive patients undergoing surgery for acute TAAD were identified from a prospectively maintained database. Perioperative variables were then compared between patients with and without LEM. Predictors of LEM, revascularization, and mortality were determined using univariable cox regression and Firth's penalized likelihood modeling.
RESULTS: A total of 601 patients from January 2007 to December 2021 underwent proximal aortic repair for acute TAAD at a quaternary care center. Of these, 85/601 (14%) patients presented with concomitant LEM. A comparison of perioperative variables between patients with and without LEM are described in Table 1. Kaplan-Meier estimated survival fared worse in patients with LEM compared to no LEM at 1, 5, and 10 years (84% vs 77%, 74% vs 71%, 65% vs 52%, p=0.03).
Within the LEM group, 15/85 (17%) patients underwent lower extremity revascularization. There were no significant differences in postoperative mortality and morbidity between the revascularization and no revascularization groups except for more frequent lower extremity fasciotomy after revascularization (p=0.003). No patients required lower extremity amputations. Preoperative CT imaging showed iliac artery thrombosis (p=0.03) and partial false lumen thrombosis (p=0.05) more frequently in the revascularization group. Significant predictors of revascularization included peripheral vascular disease (HR 3.7 [1.0-14.0], p=0.05) and pulse deficit (HR 5.6 [1.3-24.0], p=0.02) at presentation. Multivariable analysis revealed Caucasian race (HR 0.37 [0.2-0.8], p=0.02) and atrial fibrillation (HR 5.0 [1.6-14.9], p=0.004) were associated with worse survival.
CONCLUSION: This study finds patients with TAAD and LEM more often have significant underlying comorbidities, higher complication rates, and decreased survival compared to those without LEM. Within the LEM group, lower extremity revascularization did not lead to significant differences in postoperative morbidity and mortality. Careful consideration and optimization of predictors of revascularization and mortality as described in this study may improve clinical outcomes.
View Submission
Invited Discussant
*Eric Roselli, Cleveland Clinic - Contact Me Cleveland, OHUnited States
Abstract Presenter
Irsa Hasan, University of Pittsburgh Medical Center - Contact Me Pittsburg, PAUnited States
4. Current Status of Surgical Treatment for Acute Aortic Dissection in Japan: Nation-wide Database Analysis
Total Time: 15 Minutes
Objective: Acute aortic dissection (AAD) is a sudden-onset and life-threating disease. For life saving, emergency surgical treatments for most of type A (AAAD) and a part of type B (BAAD) are required. We report the surgical outcome using the prospectively collected Japanese nation-wide database. Methods: A total of 7,194 patients (68.1±13.3 years) undergoing surgical treatment for AAD in 2021 were enrolled from the Japan Cardiovascular Database (JCVSD): AAAD in 89.2% and BAAD in 10.8%. The false lumen was patent in 60.3%. Preoperative critical co-morbidities such as loss of consciousness in 11.0%, acute myocardial ischemia in 4.4%, shock in 11.1%, and cardiopulmonary resuscitation (CPR) in 2.8% were recognized. Including these, 12.0% had organ malperfusion: carotid artery in 4.4%, coronary artery in 1,4%, super mesenteric artery (SMA) in 4.5%, and iliac artery in 4.9%. Open repairs in 6,449 patients (AAAD 6,285 : BAAD 164) and endovascular repairs in 769 (148 : 621) were performed: emergent in 77.7%, urgent in 17.3%, elective in 3.6%, and salvage in 1.4%. The graft replacement was root alone in 56, ascending (+ root) in 2,331 (248), partial arch (+ root) in 1,149 (119), and total arch (+ root) in 2,784 (181). Frozen elephant trunk was used in 1,956 (AAAD 1,876 : BAAD 80). Results: The primary entry was located in root in 3.1%, zone 0 in 50.8%, zone 1 in 8.6%, zone 2 in 7.5%, zone 3 in 10.4%, distal from zone 4 in 5.2%, arch-vessel in 1.2%, and unknown in 5.4%. It was resected in 65.1% of AAAD. The in-hospital mortality was 9.9% in all (AAAD 9.8 : BAAD 10.3). The major morbidities were stroke in 12.2%, coma in 5.1%, paraplegia/paraparesis in 4.3%, acute renal failure in 17.6%, dialysis required in 7.2%, multi-system failure in 3.1%, bleeding in 5.5%. In all, age over 80 years, SMA malperfusion, shock, CPR, mechanical circulatory support, impaired left ventricular function, classical dissection, old cerebral infarction, old myocardial infarction, and rather rapid surgery within 2 hours from admission were independent risk factor for mortality. In AAAD, chronic kidney disease was added in the above risk factors for mortality. Conclusions: The current status of surgical treatments of AAD were demonstrated with favorable outcomes for A/B AAD. However, advanced age and preoperative comorbidities including shock, CPR, and vital organ malperfusion were risk factors. To improve the entire outcome, preoperative critical cares for such comorbidities are mandatory.
View Submission
Invited Discussant
*Alberto Pochettino, Mayo Clinic - Contact Me Rochester, MNUnited States
Abstract Presenter
*Hitoshi Ogino, Tokyo Medical University Hospital - Contact Me Tokyo, TokyoJapan
Regionalization of Acute Type A Dissection: Who Benefits?
Total Time: 15 Minutes
Speaker
*Michael Fischbein, Stanford University Medical Center - Contact Me Stanford, CAUnited States