23 research outputs found

    13-year single-center experience with the treatment of acute type B aortic dissection

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    Background. Acute type B aortic dissection (TBAD) is catastrophic event associated with significant mortality and lifelong morbidity. The optimal treatment strategy of TBAD is still controversial. Methods. This analysis includes patients treated for TBAD at the Helsinki University Hospital, Finland in 2007-2019. The endpoints were early and late mortality, and intervention of the aorta. Results. There were 205 consecutive TBAD patients, 59 complicated and 146 uncomplicated patients (mean age of 66 +/- 14, females 27.8%). In-hospital and 30-day mortality rates were higher in complicated patients compared with uncomplicated patients with a statistically significant difference (p = 0.035 and p = 0.015, respectively). After a mean follow-up of 4.9 +/- 3.8 years, 36 (25.0%) and 22 (37.9%) TBAD -related adverse events occurred in the uncomplicated and complicated groups, respectively (p = 0.066). Freedom from composite outcome was 83 +/- 3% and 69 +/- 6% at 1 year, 75 +/- 4% and 63 +/- 7% at 5 years, 70 +/- 5% and 59 +/- 7% at 10 years in the uncomplicated group and in the complicated group, respectively (p = 0.052). There were 25 (39.1%) TBAD-related deaths in the overall series and prior aortic aneurysm was the only risk factor for adverse aortic-related events in multivariate analysis (HR 3.46, 95% CI 1.72-6.96, p < 0.001). Conclusion. TBAD is associated with a significant risk of early and late adverse events. Such a risk tends to be lower among patients with uncomplicated dissection, still one fourth of them experience TBAD-related event. Recognition of risk factors in the uncomplicated group who may benefit from early aortic repair would be beneficial.Peer reviewe

    Late Outcome after Surgery for Type-A Aortic Dissection

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    The aim of this study was to evaluate all-cause mortality and aortic reoperations after surgery for Stanford type A aortic dissection (TAAD). We evaluated the late outcome of patients who underwent surgery for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. We studied 309 patients (DeBakey type I TAAD: 89.3%) who underwent repair of TAAD. Aortic root repair was performed in 94 patients (30.4%), hemiarch repair in 264 patients (85.4%) and partial/total aortic arch repair in 32 patients (10.4%). Hospital mortality was 13.6%. At 10 years, all-cause mortality was 34.9%, and the cumulative incidence of aortic reoperation or late aortic-related death was 15.6%, of any aortic reoperation 14.6%, reoperation on the aortic root 6.6%, on the aortic arch, descending thoracic and/or abdominal aorta 8.7%, on the descending thoracic and/or abdominal aorta 6.4%, and on the abdominal aorta 3.8%. At 10 years, cumulative incidence of reoperation on the distal aorta was higher in patients with a diameter of the descending thoracic aorta >= 35 mm at primary surgery (cumulative incidence in the overall series: 13.2% vs. 4.0%, SHR 3.993, 95%CI 1.316-12.120; DeBakey type I aortic dissection: 13.6% vs. 4.5%, SHR 3.610, 95%CI 1.193-10.913; patients with dissected descending thoracic aorta: 15.8% vs. 5.9%, SHR 3.211, 95%CI 1.067-9.664). In conclusion, surgical repair of TAAD limited to the aortic segments involved by the intimal tear was associated with favorable survival and a low rate of aortic reoperations. However, patients with enlarged descending thoracic aorta at primary surgery had higher risk of late reoperation. Half of the distal aortic reinterventions were performed on the abdominal aorta.Peer reviewe

    Spinal cord injury during selective cerebral perfusion and segmental artery occlusion: an experimental study

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    OBJECTIVESSince selective cerebral perfusion (SCP) has been used in aortic arch surgical procedures, the core temperature during lower body circulatory arrest (LBCA) has been steadily rising. Simultaneously, the use of a frozen elephant trunk (FET) graft has been increasing. The safe period of LBCA in relation to spinal cord ischaemic tolerance in combination with segmental artery occlusion by the FET procedure has not been defined.METHODSSixteen pigs were assigned to undergo 65 (n = 10) or 90 min (n = 6) of SCP at 28°C with LBCA in combination with occlusion of the 8 uppermost segmental arteries in the thoracic (Th) aorta (15–20 cm FET, Th8-level). The follow-up period consisted of a 6-h intensive period and a 5-day observation period. Near-infrared spectroscopy of the collateral network was used to determine spinal cord oxygenation. The neurological status of the patients was evaluated daily, and the brain and the spinal cord were harvested for a histopathological analysis.RESULTSFive out of 6 pigs after 90 min and 1 out of 10 pigs after 65 min of LBCA died within 48 h of multiorgan failure. Of the survivors in the 65-min group, 6 out of 9 had paraparesis/paraplegia; the remaining 3 reached normal function. The lone survivor after 90 min of LBCA was paraplegic. Nadir near-infrared spectroscopy of the collateral network values at Th8 and Th10 were 34 (±5) and 39 (±4), and they were reached within 35 min of SCP in both groups.CONCLUSIONSAn extended FET graft with LBCA and SCP durations >65 min at 28°C results in a poor outcome.</p

    Long-term outcomes after ascending aortic replacement and aortic root replacement for type A aortic dissection

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    OBJECTIVES: We investigated whether the selective use of supracoronary ascending aorta replacement achieves late outcomes comparable to those of aortic root replacement for acute Stanford type A aortic dissection (TAAD). METHODS: Patients who underwent surgery for acute type A aortic dissection from 2005 to 2018 at the Helsinki University Hospital, Finland, were included in this analysis. Late mortality was evaluated with the Kaplan-Meier method and proximal aortic reoperation, i.e. operation on the aortic root or aortic valve, with the competing risk method. RESULTS: Out of 309 patients, 216 underwent supracoronary ascending aortic replacement and 93 had aortic root replacement. At 10 years, mortality was 33.8% after aortic root replacement and 35.2% after ascending aortic replacement (P = 0.806, adjusted hazard ratio 1.25, 95% confidence interval, 0.77-2.02), and the cumulative incidence of proximal aortic reoperation was 6.0% in the aortic root replacement group and 6.2% in the ascending aortic replacement group (P = 0.65; adjusted subdistributional hazard ratio 0.53, 95% confidence interval 0.15-1.89). Among 71 propensity score matched pairs, 10-year survival was 34.4% after aortic root replacement and 36.2% after ascending aortic replacement surgery (P = 0.70). Cumulative incidence of proximal aortic reoperation was 7.0% after aortic root replacement and 13.0% after ascending aortic replacement surgery (P = 0.22). Among 102 patients with complete imaging data [mean follow-up, 4.7 (3.2) years], the estimated growth rate of the aortic root diameter was 0.22 mm/year, that of its area 7.19 mm(2)/year and that of its perimeter 0.43 mm/year. CONCLUSIONS: When stringent selection criteria were used to determine the extent of proximal aortic reconstruction, aortic root replacement and ascending aortic replacement for type A aortic dissection achieved comparable clinical outcomes.Peer reviewe

    Late Outcome after Surgery for Type-A Aortic Dissection

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    The aim of this study was to evaluate all-cause mortality and aortic reoperations after surgery for Stanford type A aortic dissection (TAAD). We evaluated the late outcome of patients who underwent surgery for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. We studied 309 patients (DeBakey type I TAAD: 89.3%) who underwent repair of TAAD. Aortic root repair was performed in 94 patients (30.4%), hemiarch repair in 264 patients (85.4%) and partial/total aortic arch repair in 32 patients (10.4%). Hospital mortality was 13.6%. At 10 years, all-cause mortality was 34.9%, and the cumulative incidence of aortic reoperation or late aortic-related death was 15.6%, of any aortic reoperation 14.6%, reoperation on the aortic root 6.6%, on the aortic arch, descending thoracic and/or abdominal aorta 8.7%, on the descending thoracic and/or abdominal aorta 6.4%, and on the abdominal aorta 3.8%. At 10 years, cumulative incidence of reoperation on the distal aorta was higher in patients with a diameter of the descending thoracic aorta >= 35 mm at primary surgery (cumulative incidence in the overall series: 13.2% vs. 4.0%, SHR 3.993, 95%CI 1.316-12.120; DeBakey type I aortic dissection: 13.6% vs. 4.5%, SHR 3.610, 95%CI 1.193-10.913; patients with dissected descending thoracic aorta: 15.8% vs. 5.9%, SHR 3.211, 95%CI 1.067-9.664). In conclusion, surgical repair of TAAD limited to the aortic segments involved by the intimal tear was associated with favorable survival and a low rate of aortic reoperations. However, patients with enlarged descending thoracic aorta at primary surgery had higher risk of late reoperation. Half of the distal aortic reinterventions were performed on the abdominal aorta

    Baseline risk factors of in-hospital mortality after surgery for acute type A aortic dissection: an ERTAAD study

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    Background Surgery for type A aortic dissection (TAAD) is associated with high risk of mortality. Current risk scoring methods have a limited predictive accuracy.Methods Subjects were patients who underwent surgery for acute TAAD at 18 European centers of cardiac surgery from the European Registry of Type A Aortic Dissection (ERTAAD).Results Out of 3,902 patients included in the ERTAAD, 2,477 fulfilled the inclusion criteria. In the validation dataset (2,229 patients), the rate of in-hospital mortality was 18.4%. The rate of composite outcome (in-hospital death, stroke/global ischemia, dialysis, and/or acute heart failure) was 41.2%, and 10-year mortality rate was 47.0%. Logistic regression identified the following patient-related variables associated with an increased risk of in-hospital mortality [area under the curve (AUC), 0.755, 95% confidence interval (CI), 0.729-0.780; Brier score 0.128]: age; estimated glomerular filtration rate; arterial lactate; iatrogenic dissection; left ventricular ejection fraction &lt;= 50%; invasive mechanical ventilation; cardiopulmonary resuscitation immediately before surgery; and cerebral, mesenteric, and peripheral malperfusion. The estimated risk score was associated with an increased risk of composite outcome (AUC, 0.689, 95% CI, 0.667-0.711) and of late mortality [hazard ratio (HR), 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403]. In the validation dataset (248 patients), the in-hospital mortality rate was 16.1%, the composite outcome rate was 41.5%, and the 10-year mortality rate was 49.1%. The estimated risk score was predictive of in-hospital mortality (AUC, 0.703, 95% CI, 0.613-0.793; Brier score 0.121; slope 0.905) and of composite outcome (AUC, 0.682, 95% CI, 0.614-0.749). The estimated risk score was predictive of late mortality (HR, 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403), also when hospital deaths were excluded from the analysis (HR, 1.024, 95% CI, 1.018-1.031; Harrell's C 0.630; Somer's D 0.261).Conclusions The present analysis identified several baseline clinical risk factors, along with preoperative estimated glomerular filtration rate and arterial lactate, which are predictive of in-hospital mortality and major postoperative adverse events after surgical repair of acute TAAD. These risk factors may be valuable components for risk adjustment in the evaluation of surgical and anesthesiological strategies aiming to improve the results of surgery for TAAD.Clinical Trial Registration https://clinicaltrials.gov, identifier NCT04831073

    Outcome after Surgery for Iatrogenic Acute Type A Aortic Dissection

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    (1) Background: Acute Stanford type A aortic dissection (TAAD) may complicate the outcome of cardiovascular procedures. Data on the outcome after surgery for iatrogenic acute TAAD is scarce. (2) Methods: The European Registry of Type A Aortic Dissection (ERTAAD) is a multicenter, retrospective study including patients who underwent surgery for acute TAAD at 18 hospitals from eight European countries. The primary outcomes were in-hospital mortality and 5-year mortality. Twenty-seven secondary outcomes were evaluated. (3) Results: Out of 3902 consecutive patients who underwent surgery for acute TAAD, 103 (2.6%) had iatrogenic TAAD. Cardiac surgery (37.8%) and percutaneous coronary intervention (36.9%) were the most frequent causes leading to iatrogenic TAAD, followed by diagnostic coronary angiography (13.6%), transcatheter aortic valve replacement (10.7%) and peripheral endovascular procedure (1.0%). In hospital mortality was 20.5% after cardiac surgery, 31.6% after percutaneous coronary intervention, 42.9% after diagnostic coronary angiography, 45.5% after transcatheter aortic valve replacement and nihil after peripheral endovascular procedure (p = 0.092), with similar 5-year mortality between different subgroups of iatrogenic TAAD (p = 0.710). Among 102 propensity score matched pairs, in-hospital mortality was significantly higher among patients with iatrogenic TAAD (30.4% vs. 15.7%, p = 0.013) compared to those with spontaneous TAAD. This finding was likely related to higher risk of postoperative heart failure (35.3% vs. 10.8%, p < 0.0001) among iatrogenic TAAD patients. Five-year mortality was comparable between patients with iatrogenic and spontaneous TAAD (46.2% vs. 39.4%, p = 0.163). (4) Conclusions: Iatrogenic origin of acute TAAD is quite uncommon but carries a significantly increased risk of in-hospital mortality compared to spontaneous TAAD

    Outcome after Surgery for Iatrogenic Acute Type A Aortic Dissection

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    (1) Background: Acute Stanford type A aortic dissection (TAAD) may complicate the outcome of cardiovascular procedures. Data on the outcome after surgery for iatrogenic acute TAAD is scarce. (2) Methods: The European Registry of Type A Aortic Dissection (ERTAAD) is a multicenter, retrospective study including patients who underwent surgery for acute TAAD at 18 hospitals from eight European countries. The primary outcomes were in-hospital mortality and 5-year mortality. Twenty-seven secondary outcomes were evaluated. (3) Results: Out of 3902 consecutive patients who underwent surgery for acute TAAD, 103 (2.6%) had iatrogenic TAAD. Cardiac surgery (37.8%) and percutaneous coronary intervention (36.9%) were the most frequent causes leading to iatrogenic TAAD, followed by diagnostic coronary angiography (13.6%), transcatheter aortic valve replacement (10.7%) and peripheral endovascular procedure (1.0%). In hospital mortality was 20.5% after cardiac surgery, 31.6% after percutaneous coronary intervention, 42.9% after diagnostic coronary angiography, 45.5% after transcatheter aortic valve replacement and nihil after peripheral endovascular procedure (p = 0.092), with similar 5-year mortality between different subgroups of iatrogenic TAAD (p = 0.710). Among 102 propensity score matched pairs, in-hospital mortality was significantly higher among patients with iatrogenic TAAD (30.4% vs. 15.7%, p = 0.013) compared to those with spontaneous TAAD. This finding was likely related to higher risk of postoperative heart failure (35.3% vs. 10.8%, p &lt; 0.0001) among iatrogenic TAAD patients. Five-year mortality was comparable between patients with iatrogenic and spontaneous TAAD (46.2% vs. 39.4%, p = 0.163). (4) Conclusions: Iatrogenic origin of acute TAAD is quite uncommon but carries a significantly increased risk of in-hospital mortality compared to spontaneous TAAD

    Cerebral protection in aortic arch surgery with a special reference to Acute Type A Aortic Dissection

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    Abstract Acute Stanford Type A Aortic Dissection (ATAAD) is one of the most life-threatening acute pathologies in the human body; without treatment mortality nears 100%. One third of ATAAD patients suffer from cerebral malperfusion, and permanent ischaemic brain injury occurs in approximately 10% of patients. ATAAD is treated with open aortic arch surgery that involves cardiopulmonary bypass (CPB) and deep or profound (18–24 °C) hypothermic circulatory arrest (HCA); they can provide sufficient cerebral protection for up to 20–30 minutes by lowering the glucose and oxygen consumption of the brain. However, additional strategies on cerebral protection are still needed. ATAAD patients often present with shock, cardiac tamponade, malperfusion, or they could be still resuscitated while they are brought to the operation room. The rapid institution of antegrade cerebral blood flow through the CPB circuit is particularly vital for these patients and a new aortic cannulation strategy of direct true lumen cannulation after venous exsanguination (DTLC) was developed accordingly. However, associated normothermic circulatory arrest carries an inherent risk for neurologic sequalae. Our research group has studied the field of cerebral protection in aortic arch surgery extensively for the last 20 years through the use of a porcine model that closely simulates the clinical situation. One of the most promising neuroprotective strategies that has emerged from this research has been remote ischaemic preconditioning (RIPC), which is based on the notion that applying short ischaemia-reperfusion periods to a skeletal muscle increases ischaemic tolerance in other organs including the brain. Therefore, the present thesis studied whether DTLC with a 5-minute normothermic circulatory arrest was safe in terms of cerebral ischaemia (I), if RIPC would prolong the permissible period of HCA (II), and if it would improve the neurologic outcome combined with moderate hypothermia (III). The first study suggested that DTLC would not impair the neurologic outcome, even with a prolonged cannulation process. The second study proposed that RIPC would prolong the permissible period of HCA to up to nine minutes at 18 °C. The third study suggested that RIPC at 24 °C would provide five additional minutes of permissible HCA as compared to HCA alone at 18 °C. It also proposed that moderate HCA at 24 °C combined with RIPC would provide a superior neurologic outcome as compared to deep HCA alone at 18 °C.TiivistelmĂ€ Tyypin A akuutti aortan dissekoituma (ATAAD) on edelleen yksi ihmiskehon hengenvaarallisimmista akuuteista sairaustiloista. Kolmanneksella potilaista aivojen verenkierto hĂ€iriintyy ja noin 10 prosenttia potilaista saa pysyvĂ€n aivovaurion joko itse sairaustilasta tai operaatiosta johtuen. ATAAD hoidetaan sydĂ€n-keuhkokoneen avulla syvĂ€ssĂ€ (18–24°C) hypotermiassa eli alilĂ€mpöisyydessĂ€ tapahtuvan verenkierron seisautuksen (HCA) aikana. HCA vĂ€hentÀÀ sekĂ€ aivojen sokeriaineenvaihduntaa ettĂ€ hapen kĂ€yttöÀ, jolloin saadaan aikaa 20–30 minuuttia kirurgiselle toimenpiteelle riippuen lĂ€mpötilasta. ATAAD-potilaat ovat usein kriittisessĂ€ tilassa saapuessaan leikkaussaliin. HeillĂ€ voi olla verenkiertoshokki, verenkierto pÀÀte-elimiin voi olla estynyt, tai heitĂ€ voidaan elvyttÀÀ. Erityisesti nĂ€iden potilaiden kohdalla on tĂ€rkeÀÀ edetĂ€ nopeasti kehonulkoiseen verenkiertoon sydĂ€n-keuhkokoneen avulla. TĂ€tĂ€ varten kehitettiin uusi nousevan aortan kanylaatiomenetelmĂ€. Potilaan verenkierto pysĂ€ytetÀÀn valuttamalla veri sydĂ€n-keuhkokoneeseen, nouseva aortta avataan ja aorttakanyyli asetetaan aorttaan nĂ€kökontrollissa (DTLC). Normaalissa kehon lĂ€mpötilassa tapahtuva verenkierron seisautus kuitenkin altistaa nopeasti neurologisille vaurioille. TutkimusryhmĂ€mme on tutkinut aivojen suojaamista aortan kaaren kirurgian aikana jo 20 vuoden ajan kliinisesti merkittĂ€vĂ€n kokeellisen porsasmallin avulla. EtĂ€inen iskeeminen esialtistus (RIPC) on osoittautunut lupaavaksi aivojen suojausmenetelmĂ€ksi. SiinĂ€ raajan lihaskudokseen kohdistetaan lyhyitĂ€ verenkierron pysĂ€ytyksiĂ€ ja palautuksia tavallisella verenpainemansetilla, minkĂ€ on osoitettu lisÀÀvĂ€n aivojen sietokykyĂ€ hapenpuutteelta. TĂ€ssĂ€ vĂ€itöskirjassa tutkittiin, onko DTLC-kanylointimenetelmĂ€ aivojen kannalta turvallista, jos oletetaan sen kestĂ€vĂ€n viisi minuuttia (I). LisĂ€ksi tutkimme, pidentÀÀkö RIPC turvallista HCA:n kestoa (II) ja parantaako RIPC maltilliseen (24 °C) hypotermiaan yhdistettynĂ€ neurologista toipumista (III). EnsimmĂ€inen tutkimus nĂ€ytti, ettĂ€ DTLC ei vaikuta huonontavan neurologista lopputulosta. Toisen tutkimuksen perusteella RIPC pidentÀÀ turvallista HCA:n kestoa yhdeksĂ€llĂ€ minuutilla 18 asteen lĂ€mpötilassa. Kolmannen tutkimuksen mukaan RIPC pidentÀÀ turvallista HCA:n kestoa kymmenellĂ€ minuutilla 24 asteen lĂ€mpötilassa ja RIPC yhdessĂ€ maltillisen hypotermian kanssa parantaa neurologista lopputulosta

    Direct Aortic versus Peripheral Arterial Cannulation in Surgery for Type-A Aortic Dissection

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    Background It is controversial whether peripheral arterial cannulation may achieve better results than direct aortic cannulation during surgery for Stanford type A aortic dissection (TAAD). Methods Three-hundred and nine consecutive patients underwent surgical repair for acute TAAD from January 2005 to December 2017 at the Helsinki University Hospital, Finland. The early outcomes of patients who underwent surgery with direct aortic cannulation were compared with those in whom peripheral arterial cannulation was employed. Results Direct aortic cannulation was employed in 80 patients and peripheral arterial cannulation in 229 patients. Patients who underwent surgery with direct aortic cannulation had hospital mortality (13.8% vs. 13.5%, p=0.962) and stroke/global brain ischemia (22.3% vs. 25.0%, p=0.617) similar to those with peripheral arterial cannulation. The other secondary outcomes were equally distributed between the unmatched study cohorts. Among 74 propensity score matched pairs, direct aortic cannulation had hospital mortality (12.2% vs. 9.5%, p=0.804) and stroke/global brain ischemia rates (21.6% vs. 21.6%, p=1.000) comparable to peripheral arterial cannulation. The composite outcome of hospital mortality/stroke/global brain ischemia (29.7% vs. 27.0%, p=0.855), multiple stroke (16.2% vs. 17.6%, p=1.000), renal replacement therapy (11.8% vs. 13.0%, p=1.000) and length of stay in the intensive care unit (mean, 4.9±4.5 vs. 4.8±4.9 days, p=0.943) were also equally distributed between these matched cohorts. Conclusions In this institutional series, central arterial cannulation allowed a straightforward surgical repair of TAAD and achieved similar early outcomes to those of peripheral arterial cannulation.Peer reviewe
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