Epidemiology of acute traumatic aortic injuries in Galicia, Spain. Development and validation of a score for early diagnosis of aortic injuries in major blunt chest trauma patients and optimization of management algorithm

Acute traumatic aortic injury (ATAI) usually occurs in patients with major blunt chest trauma and has devastating consequences. An early diagnosis with risk stratification, control of blood pressure and cardiac contractility is the cornerstone of the approach to aortic injuries in these patients. Optimization of diagnostic resources and a specific management is mandatory to both prevent potentially lethal aortic-related complications in high-risk major trauma patients, and to avoid unnecessary costs and radiation exposure in low-risk trauma patients. This thesis describes two clinical studies designed to characterise the epidemiology and clinical profile of major trauma patients with ATAI among overall major blunt chest trauma patients in our Spanish region, Galicia, whose population is more than 2,700,000 inhabitants, and to develop and further validate a predictive score of the probability of presenting an ATAI in major trauma patients, which was named Traumatic Aortic Injury Score (TRAINS). In the first instance a retrospective descriptive study was undertaken in all major trauma patients with blunt chest trauma admitted to a public hospital in Galicia from 2006 to 2010 (1,760 patients), followed by a comparison of the distinct clinical profile between trauma patients with (44 patients) and without an associated ATAI (1,716 patients). This epidemiological part of the research showed that overall importance in terms of percentage of ATAIs among major trauma patients with blunt chest trauma between 2006 and 2010 in our institution and region was 4.4% and 2.5% respectively. Likewise, the yearly proportion of ATAIs among major trauma patients in Galicia was 1.1%-3.3%, whereas it ranged from 2.5% to 7.8% in our institution. After estimation of the number of major trauma patients with ATAI who die at the site of accident or during transportation, the actual resulting incidence of ATAI in Galicia would be 3 to 6.1 cases per 100,000 inhabitants per year. Our research confirmed that in Galicia major trauma patients with associated ATAIs present a different epidemiological profile, prognosis, initial clinical presentation and the number and distribution of associated injuries. While major trauma patients without aortic injury distribute fairly homogeneously through the whole age span, ATAIs concentrate among 16 to 35 years old trauma patients, where 54.6% of overall ATAI occurs. The motor vehicle collision is the commonest cause of accident among ATAI victims in Galicia, but we have found a higher proportion of motorcycle collisions, falls and crush traumas and a lower proportion of auto-pedestrian accidents among patients with ATAI compared to those reported in ATAI victims by other authors. The proportion of “atypical or non-isthmal” aortic injuries (43.2%) is significantly higher than the 7% to 15% reported in other clinical series, also highlighting a remarkably higher proportion of injuries at the aortic arch (25%). Major trauma patients with ATAIs presented with haemodynamic instability on admission more frequently than major trauma patients without aortic injury, and they also had a higher proportion of severe extra-thoracic injuries, which justify their worse prognosis. The second part of the research was a cross-sectional study of a diagnostic procedure. The development of a predictive score for the risk of ATAI in major trauma patients with blunt chest trauma was carried out in two stages. In the first stage, we analysed the clinical and radiological characteristics of major blunt chest trauma patients in order to develop the screening tool for ATAIs among major trauma patients. In the second stage, we validated the predictive score in an independent external population of major trauma patients. In the predictive score development, the overall study population consisted of 640 major trauma patients (all of them with blunt chest trauma) divided into two datasets: a score dataset provided only by the Complejo Hospitalario Universitario de A Coruña (76 consecutive major trauma patients with ATAI and 304 without aortic injury), and an independent validation dataset provided by other three different institutions: Complejo Hospitalario Universitario de Vigo, Complejo Hospitalario Universitario de Santiago de Compostela, and Hospital Clínic Universitari de Valencia (52 consecutive major trauma patients with ATAI and 208 without aortic injury). Bivariate analysis identified variables of potential influence in presenting aortic injury among major blunt chest trauma patients. Subsequently, confirmed variables by stepwise forward logistic regression were assigned a score according to their corresponding beta coefficient which was rounded to the closest integer value (1-4). The predictors of aortic injury that we identified included: widened mediastinum (OR: 30.82; CI: 12.05-78.81); hypotension 93% and a specificity >85%. The small number of ATAI patients who were misdiagnosed by TRAINS (false negatives) presented low-degree aortic injuries. The scoring method also proved its accuracy in both an internal and an external validation process. The TRAINS demonstrated its ability to diagnose ATAIs among major trauma patients with a sensitivity >92% and a specificity >85% in a current multicentre population of major trauma patients, thus confirming its applicability at the current time and in different geographical areas. We demonstrated that the conventional trauma risk scores fail to show statistical relationship between the severity of the trauma and the degree of severity of the aortic injury. Thus, the conventional trauma severity scores are useless to cast suspicion on the diagnosis of ATAI. On the contrary, TRAINS score has proven to be related with the severity of the aortic injury and to be useful even in the diagnosis of low-degree ATAI. In summary, the TRAINS and associated algorithm have been designed to be used in daily practice to easily and rapidly identify major trauma patients who are at risk of aortic injury, thus avoiding unnecessary costs and radiation exposure in low-risk trauma patients. On the other hand, the TRAINS may raise suspicion of ATAI even in the cases of low-degree aortic injuries, which require a close imaging surveillance to determine whether or not those patients will need a further intervention. The TRAINS algorithm is also useful for resource allocation planning, enabling clinicians to refer patients at high risk of traumatic aortic injuries to specialized units, providing the ability to rapidly diagnose and therapeutically manage this critical subset of trauma patients in order to avoid potentially lethal aortic-related complications

Indexed left atrial size predicts all-cause and cardiovascular mortality in patients undergoing aortic valve surgery

[Abstract] OBJECTIVES: The enlargement of the left atrium has been identified as a marker of chronically increased left ventricular filling pressure and left ventricular diastolic dysfunction. This study aims to evaluate the association of indexed left atrial diameter with stroke, cardiovascular mortality, the combined event, and all-cause mortality in patients who underwent aortic valve surgery. METHODS: Indexed left atrial diameter was measured in 2011 adult patients (mean age, 70.9 ± 10.8 years; 58.7% were men) who underwent aortic valve surgery between January 2008 and March 2016. RESULTS: On the basis of the criteria of the American Society of Echocardiography, indexed left atrial diameter was normal in 64% of patients, mildly enlarged in 12.4% of patients, moderately enlarged in 9.2% of patients, and severely enlarged in 14.3% of patients. Over a mean follow-up period of 3.2 ± 2.1 years, there were 334 deaths and 97 strokes. Cardiovascular mortality survival at 5 years among patients with normal, mild, moderate, and severe left atrial enlargement was 91.6%, 86.8%, 77.9%, and 77.4%, respectively (P < .001). After covariable adjustment, Cox regression analysis showed indexed left atrial diameter as an independent predictor of all-cause mortality (hazard ratio per 1-cm/m2 increment, 1.545; 95% confidence interval, 1.252-1.906, P < .001), cardiovascular death (hazard ratio per 1-cm/m2 increment, 1.971; 95% confidence interval, 1.541-2.520; P < .001), and the combined event (hazard ratio per 1-cm/m2 increment, 1.673; 95% confidence interval, 1.321-2.119; P < .001). CONCLUSIONS: Indexed left atrial diameter is a strong predictor of long-term outcomes in patients with aortic valve diseases who undergo surgery

Long-Term outcomes and durability of the mitroflow aortic bioprosthesis

[Abstract] Background. This study aims to determine the incidence and causes of structural valve deterioration (SVD) among all models of Mitroflow bioprostheses (A12/LX/DL), as well as to define their long-term clinical and hemodynamic performance. Methods and Results. We retrospectively reviewed a series of 1023 patients who underwent aortic valve replacement with Mitroflow bioprostheses between 2001 and 2014. A small aortic root was found in 22.4% of patients. There were two cases of severe patient-prosthesis mismatch. Only 31 patients developed SVD. The rate of incidence was 8.1 cases per 1000 patient-years. Cumulative incidence of SVD was 1.4% and 3% at five and 10 years, respectively. Freedom from SVD was 97.4% and 88.2% at five and 10 years, respectively. Anticalcification phospholipid reduction treatment (PRT) for model DL was a protective factor for SVD. Multivariable analysis confirmed age <70 years and use of 19 mm valve as independent predictors of SVD. Cumulative survival was 76.6% at five years and 42.3% at 10 years (mean follow-up 3.8 ± 3.1 years). In multivariable analysis, neither the use of small aortic prosthesis (p = 0.18) nor the occurrence of SVD (p = 0.85) was found to be independent predictors of long-term survival. Conclusions. Mitroflow valves demonstrate an acceptable rate of SVD and satisfactory long-term hemodynamic performance, particularly in patients with small aortic roots, age >70 years, and cases with severe left ventricular hypertrophy. PRT might contribute to improved long-term durability

Role of conservative management in traumatic aortic injury: comparison of long-term results of conservative, surgical, and endovascular treatment

[Abstract] Objective. The purpose of this study is to compare early and long-term results in terms of survival and cardiovascular complications of patients with acute traumatic aortic injury who were conservatively managed with patients who underwent surgical or endovascular repair. Methods. From January 1980 to December 2009, 66 patients with acute traumatic aortic injury were divided into 3 groups according to treatment intention at admission: 37 patients in a conservative group, 22 patients in a surgical group, and 7 patients in an endovascular group. Groups were similar with regard to gender, age, Injury Severity Score, Revised Trauma Score, and Trauma Injury Severity Score. Results. In-hospital mortality was 21.6% in the conservative group, 22.7% in the surgical group, and 14.3% in the endovascular group (P = .57). In-hospital aortic-related complications occurred only in the conservative group. Median follow-up time was 75 months (range, 5–327 months). Conservative group survival was 75.6% at 1 year, 72.3% at 5 years, and 66.7% at 10 years. Surgical group survival remained at 77.2% at 1, 5, and 10 years, whereas survival in the endovascular group was 85.7% at 1 and 5 years (P = .18). No patient in the surgical or endovascular group required reintervention because of aortic-related complications, whereas 37.9% of the conservative group had an aortic-related complication that required surgery or caused the patient’s death during the follow-up period. Cumulative survival free from aortic-related complications in the conservative group was 93% at 1 year, 88.5% at 5 years, and 51.2% at 10 years. Cox regression confirmed the initial type of aortic lesion (hazard ratio, 2.94; P = .002) and a Trauma Score-Injury Severity Score greater than 50% on admission (hazard ratio, 1.49; P = .042) as risk factors for the appearance of aortic-related complications. Two peaks in the complication rate of the conservative group were detected in the first week and between the first and third months after blunt thoracic trauma. Conclusions. The advent of thoracic aortic endografting has enabled a revolution in the management of acute traumatic aortic injury in patients with multisystem trauma with a low in-hospital morbimortality. Nonoperative management may be only a therapeutic option with acceptable survival in carefully selected patients. The natural history of these patients has revealed a marked trend of late aortic-related complications developing, which may justify an endovascular repair even in some low-risk patients

The importance of the mediastinal triangle in traumatic lesions of the aorta

[Abstract] Background: Trauma-induced aortic injuries continue to be an important factor in morbimortality in patients with blunt trauma. Objectives: To determine the characteristics of aortic lesions in patients with closed thoracic trauma and associated thoracic injuries. Methods: Multicenter cohort study conducted during the years 1994 to 2014 in the radiology service in the University Hospital Complex of A Coruña. Patients >15 years with closed thoracic trauma were included. Sociodemographic and clinical variables were studied in order to determine the lesion cause, location, and degree. Results: We analyzed 232 patients with a mean age of 46.9 ± 18.7 years, consisting of 81.4% males. The most frequent location was at the level of the isthmus (55.2%). The most frequent causes of injury were traffic accidents followed by falls. Patients with aortic injury had more esophageal, airway, and cardiopericardial lesions. More than 85% of the patients had lung parenchyma and/or chest wall injury, which was more prevalent among those who did not have an aortic lesion. Conclusions: Patients with trauma due to traffic accidents or being run over presented three times more risk of aortic injury than from other causes. Those with an aortic lesion also had a higher frequency of cardiopericardial, airway, and esophageal lesions

Blunt traumatic aortic injuries of the ascending aorta and aortic arch: a clinical multicentre study

[Abstract] Objective. To report the clinical and radiological characteristics, management and outcomes of traumatic ascending aorta and aortic arch injuries. Methods. Historic cohort multicentre study including 17 major trauma patients with traumatic aortic injury from January 2000 to January 2011. Results. The most common mechanism of blunt trauma was motor-vehicle crash (47%) followed by motorcycle crash (41%). Patients sustaining traumatic ascending aorta or aortic arch injuries presented a high proportion of myocardial contusion (41%); moderate or greater aortic valve regurgitation (12%); haemopericardium (35%); severe head injuries (65%) and spinal cord injury (23%). The 58.8% of the patients presented a high degree aortic injury (types III and IV). Expected in-hospital mortality was over 50% as defined by mean TRISS 59.7 (SD 38.6) and mean ISS 48.2 (SD 21.6) on admission. Observed in-hospital mortality was 53%. The cause of death was directly related to the ATAI in 45% of cases, head and abdominal injuries being the cause of death in the remaining 55% cases. Long-term survival was 46% at 1 year, 39% at 5 years, and 19% at 10 years. Conclusions. Traumatic aortic injuries of the ascending aorta/arch should be considered in any major thoracic trauma patient presenting cardiac tamponade, aortic valve regurgitation and/or myocardial contusion. These aortic injuries are also associated with a high incidence of neurological injuries, which can be just as lethal as the aortic injury, so treatment priorities should be modulated on an individual basis

Traumatic aortic injuries associated with major visceral vascular injuries in major blunt trauma patients

[Abstract] Background. The objectives of this study were to report the clinical and radiological characteristics and outcomes of a series of acute traumatic aortic injuries (ATAIs) with associated injury to major aortic abdominal visceral branches (MAAVBs). Methods. From January 2000 to August 2011, 10 consecutive major blunt trauma patients with associated ATAI and injury to MAAVBs (group A) and 42 major blunt trauma patients presenting only an ATAI without MAAVB injuries (group B) were admitted to our institution. Results. Overall in-hospital mortality was 32.7%. In-hospital mortality in group A was 40% and in group B it was 31% (p = 0.86). Observed in-hospital mortality was slightly lower than the expected in-hospital mortality in both groups. Mean peak creatine phosphokinase was significantly higher in group A than in group B patients (23,008 ± 33,400 vs. 3,970 ± 3,495 IU/L; p < 0.001). Acute renal injury occurred in 50% of group A and in 26.2% of group B patients. Hemodiafiltration was required in 30% of group A and in 9.5% of group B patients. Median follow-up time was 64 months (range = 1–130 months). Group A survival was 60% at 1, 5 and 10 years. Group B survival was 69% at 1 year and 63.3% at 5 and 10 years (p = 0.15). Conclusions. Aortic injuries associated with MAAVB injuries in major trauma patients seem to present in a different clinical scenario. These patients present increased risk of rhabdomyolysis, visceral ischemia, and acute renal failure, as well as higher in-hospital mortality. A multidisciplinary approach combining endovascular and open surgical techniques for a staged treatment of these life-threatening aortic and MAAVB injuries is mandatory in this critical subset of trauma patients

Traumatic aortic injury score (TRAINS): an easy and simple score for early detection of traumatic aortic injuries in major trauma patients with associated blunt chest trauma

[Abstract] Purpose. To develop a risk score based on physical examination and chest X-ray findings to rapidly identify major trauma patients at risk of acute traumatic aortic injury (ATAI). Methods. A multicenter retrospective study was conducted with 640 major trauma patients with associated blunt chest trauma classified into ATAI (aortic injury) and NATAI (no aortic injury) groups. The score data set included 76 consecutive ATAI and 304 NATAI patients from a single center, whereas the validation data set included 52 consecutive ATAI and 208 NATAI patients from three independent institutions. Bivariate analysis identified variables potentially influencing the presentation of aortic injury. Confirmed variables by logistic regression were assigned a score according to their corresponding beta coefficient which was rounded to the closest integer value (1–4). Results. Predictors of aortic injury included widened mediastinum, hypotension less than 90 mmHg, long bone fracture, pulmonary contusion, left scapula fracture, hemothorax, and pelvic fracture. Area under receiver operating characteristic curve was 0.96. In the score data set, sensitivity was 93.42 %, specificity 85.85 %, Youden’s index 0.79, positive likelihood ratio 6.60, and negative likelihood ratio 0.08. In the validation data set, sensitivity was 92.31 % and specificity 85.1 %. Conclusions. Given the relative infrequency of traumatic aortic injury, which often leads to missed or delayed diagnosis, application of our score has the potential to draw necessary clinical attention to the possibility of aortic injury, thus providing the chance of a prompt specific diagnostic and therapeutic management