Treatment strategies and in-hospital mortality in patients with type A acute aortic dissection and coronary artery involvement

doi:10.1016/j.jtcvs.2022.03.016

The Journal of Thoracic and Cardiovascular Surgery

Volume 167, Issue 2, February 2024, Pages 596-601.e3

https://doi.org/10.1016/j.jtcvs.2022.03.016 Get rights and content

Abstract

Objective

Type A acute aortic dissection (AAD), especially that with coronary artery involvement and malperfusion, is a life-threatening disease. In the present study we aimed to investigate the association of surgical treatment and percutaneous coronary intervention (PCI) with in-hospital mortality in patients with type A AAD and coronary artery involvement.

Methods

This retrospective multicenter registry in Japan included 225 patients with type A AAD and coronary artery involvement. Treatment strategies including surgical treatment and/or PCI were left to treating physicians. The primary end point was in-hospital death.

Results

Of 225 patients, dissection extended into the right and left coronary arteries and both in 115 (51.1%), 105 (46.7%), and 5 (2.2%), respectively. Overall, 94 (41.8%) patients died during the hospitalization. Coronary angiography was performed in 53 (23.6%) patients, among whom 39 (73.6%) underwent PCI. Surgical repair was performed in 188 (83.6%) patients. In patients who received neither procedure, 33 of 35 (94.3%) died during the hospitalization. PCI was performed as a bridge to surgical repair in 37 of 39 (94.9%) patients, and in-hospital mortality of patients who underwent PCI and surgical procedures was 24.3%. Multivariable analysis identified PCI and surgical procedures as factors associated with lower in-hospital mortality rates.

Conclusions

Coronary artery involvement in type A AAD was associated with high in-hospital mortality of more than 40% in the current era. An early reperfusion strategy with PCI as a bridge to surgical repair might improve clinical outcomes in this fatal condition.

Graphical abstract

Video Abstract

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Section snippets

Methods

This was a retrospective, multicenter, observational study. From January 2008, to May 2018, a total of 4230 patients were diagnosed with type A AAD and were admitted to 15 tertiary centers across Japan, collaborating with the Angina Pectoris-Myocardial Infarction Multicenter Investigators (Table E1),⁸^,⁹ among whom 225 (5.3%) had coronary artery involvement. Type A AAD was defined as any dissection including intramural hematoma that involved the ascending aorta, presenting within 14 days of

Results

Of 225 patients with type A AAD and coronary artery involvement, dissection extended into the RCA, LCA, and both in 115 (51.1%), 105 (46.7%), and 5 (2.2%), respectively. During the hospitalization, 94 (41.5%) patients died. The rates of Killip class IV and cardiac arrest on admission were lower in patients who survived to discharge than their counterpart (Tables 1 and E2). Mode of surgical and percutaneous intervention is listed in Table 2, and baseline characteristics according to treatment

Discussion

The present multicenter registry data confirmed that coronary artery involvement was found in approximately 5% in patients with type A AAD and was associated with a high in-hospital mortality rate of more than 40%. CAG was performed in selected patients in 23.6%, among whom approximately three-quarters underwent PCI. Almost all PCI procedures were done as a bridge to surgical repair, resulting in better outcomes. Multivariable analysis identified PCI and surgical procedures as factors

Conclusions

The present multicenter registry showed that coronary artery involvement in type A AAD was not infrequent and was associated with high in-hospital mortality rates of more than 40%. An early reperfusion strategy with PCI as a bridge procedure to surgical repair might improve clinical outcomes in patients with type A AAD complicated with coronary artery involvement (Video Abstract).

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Cited by (11)

Reply to: The role of CT in acute type A aortic intramural hematoma
2024, International Journal of Cardiology
Biomarkers for Risk Stratification in Patients With Type A Acute Aortic Dissection
2024, American Journal of Cardiology
Type A acute aortic dissection (AAD) is a fatal disease and thus, accurate and objective risk stratification is essential. In this study, we evaluated the prognostic value of readily available and assessable biomarkers in patients with type A AAD. This was a retrospective, multicenter, observational study. A total of 703 patients with type A AAD diagnosed using contrast-enhanced computed tomography were included. Therapeutic strategies were left to the physician's discretion in a real-world clinical setting. The prognostic value for in-hospital mortality was examined in 15 circulating biomarkers on admission, which are routinely available in clinical practice. Of the 703 patients, 126 (17.9%) died during the hospitalization. Of the 15 biomarkers, the multivariable analysis identified positive cardiac troponin, a low total bilirubin (T-Bil) level, and increased levels of brain natriuretic peptide (BNP) and lactate dehydrogenase (LDH) as significant predictors of in-hospital death. The receiver operating characteristics curve analysis showed that these 4 biomarkers had an independent additive prognostic value. With the cut-off values of T-Bil, BNP, and LDH, in combination with positive troponin, the increase in the number of positive biomarkers was progressively associated with higher in-hospital mortality from 1.3% to 9.8%, 20.5%, 36.4%, and 75.0% (p <0.001). In conclusion, in patients with type A AAD, positive cardiac troponin, a low T-Bil level, and increased levels of BNP and LDH on admission were related to higher in-hospital mortality, with an incremental prognostic value, suggesting that the readily available and assessable biomarkers can aid in decision-making in therapeutic strategies.
EACTS/STS Guidelines for Diagnosing and Treating Acute and Chronic Syndromes of the Aortic Organ
2024, Annals of Thoracic Surgery
Timing of Recognition of Type A Acute Aortic Dissection in Acute Myocardial Infarction
2023, American Journal of Cardiology
Clinical characteristics and outcomes in patients with acute type A aortic intramural hematoma
2023, International Journal of Cardiology
Although type A acute aortic dissection (AAD) including classic double-channel aorta and intramural hematoma (IMH) is a life-threatening condition, the prognostic impact and predictors of IMH remain to be established. The present study evaluated the prevalence, baseline characteristics, and outcomes of IMH as compared with classic non-thrombosed type A AAD.
This multicenter registry in Japan retrospectively included 703 patients with type A AAD. IMH was defined as a crescentic or circular area along the ascending aortic wall without contrast enhancement on computed tomography (CT). Non-thrombosed type A AAD was defined as the classic double-channel ascending aorta on contrast-enhanced CT. The primary endpoint was in-hospital mortality.
Of the 703 patients with type A AAD, 312 (44.3%) had IMH. Older age was an only baseline patient factor significantly associated with the presence of IMH in the multivariable analysis. The longitudinal extent of dissection was greater in patients with classic non-thrombosed AAD than those with IMH, resulting in an increased risk of end-organ malperfusion in the classic AAD group. During the hospitalization, 41 (13.1%) and 85 (21.7%) patients with and without IMH died (p < 0.001). IMH was associated with lower in-hospital mortality in a multivariable model, irrespective of age and the implementation of surgery.
The present study showed that IMH on CT was frequent among patients with type A AAD. Although IMH was more likely to be present in the elderly, its effect on the better survival was independent of age and surgical treatment.
Prognostic impact of branch vessel involvement on organ malperfusion and mid-term survival in patients with acute type A aortic dissection
2023, International Journal of Cardiology
This study aimed to investigate the impact of branch vessel involvement on organ malperfusion and mid-term survival in patients with acute type A aortic dissection (ATAAD).
Between January 2019 and December 2020, 493 consecutive patients with angiographically confirmed ATAAD were retrospectively analysed. Preoperative computed tomography angiography parameters (branch artery involvement, longitudinal extent of dissection) were reviewed. The incidence of organ malperfusion, in-hospital mortality, and mid-term outcomes of patients with and without branch vessel involvement were compared.
Branch vessel involvement was detected in 407 patients (82.6%), and organ malperfusion was observed in 234 patients (47.5%). The incidence of organ malperfusion was significantly higher in patients with branch vessel involvement compared with patients without it (52.6% vs. 23.3%, p < 0.001). Patients with coronary artery involvement (32.5%) were more likely to manifest as clinical malperfusion, whereas it occurred only 19.4% in patients with renal artery involvement. In-hospital mortality was higher in patients with branch vessel involvement (19.9% vs. 8.1%, p = 0.010). Median follow-up time was 16.1 months. Two-year survival rate was lower in patients with branch vessel involvement (76.3% vs. 84.5%, p = 0.085) or organ malperfusion (68.3% vs. 86.0%, p < 0.001). Multivariable analysis identified cardiac, cerebral, visceral and renal malperfusion as independent predictors for in-hospital mortality.
Only a small proportion of branch vessel involvement was associated with corresponding organ malperfusion in patients with ATAAD. Branch vessel involvement had a greater effect on short-term outcomes than mid-term survival, and organ malperfusion was related to a worse prognosis beyond it.

View all citing articles on Scopus

: Drs Hashimoto and Saito contributed equally to this work.

^∗: Angina Pectoris-Myocardial Infarction Multicenter Investigators.

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Adult: AortaTreatment strategies and in-hospital mortality in patients with type A acute aortic dissection and coronary artery involvement

Abstract

Objective

Methods

Results

Conclusions

Graphical abstract

Video Abstract

Section snippets

Methods

Results

Discussion

Conclusions

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

Int J Cardiol

Semin Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease

JAMA

Insights from the International Registry of Acute Aortic Dissection: a 20-year experience of collaborative clinical research

Circulation

Acute type A aortic dissection: significance of multiorgan malperfusion

Eur J Cardiothorac Surg

Adult: Aorta
Treatment strategies and in-hospital mortality in patients with type A acute aortic dissection and coronary artery involvement