predictors for in hospital mortality in patients with type a aortic dissection from a two centre...
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PREDICTORS FOR IN HOSPITAL PREDICTORS FOR IN HOSPITAL MORTALITY IN PATIENTS WITH TYPE A MORTALITY IN PATIENTS WITH TYPE A
AORTIC DISSECTION FROM A TWO AORTIC DISSECTION FROM A TWO CENTRE EXPERIENCECENTRE EXPERIENCE
S Leontyev, J Légaré, MA Borger, K Buth, AK Funkat, J Gerhard, S Lehmann, J Seeburger, FW Mohr
Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany.
Department of Cardiac Surgery, Heart Center, University of Leipzig, Germany.
Background
• Acute type A aortic dissection a cardiovascular emergency with a high potential for death.
worldwide prevalence 0.5 to 2.95 per 100,000 per year; the prevalence ranges from 0.2 to 0.8 per 100,000 per year in the U.S. - 2000 new cases per year (1).
Surgical mortality rates 9% to 36% (2,3)
• 3-year survival - 86% (4) and 5-year survival to 50-80%(3).
1Cohn et all 2007 2 Trimarchi et all 2005;
3 Thiappini et all 2005
4 Tsai et all 2006
Aim / Methods
Analysis of all patients (n=465)undergoing aortic surgery for acute Type A dissection in
Leipzig (Germany)(n=374) and Halifax (Canada) (n=91) over the same period between 1996
and 2010.
To evaluate predictors for in hospital mortality after surgical treatment in patients with type A
aortic dissection
Totaln=465
Age (years) 61 13Female 36 %
NYHA III-IV 38% Coronary artery disease 20%
Diabetes 12 %Peripheral vascular disease 13 %
Marfan Syndrome 4 %
Demographics
Total (n=465)
Critical preoperative state 31 %CPR 11 %
Preoperative intubation 19 %Preoperative inotropic support 19 %
Preoperative pericardial tamponade 38 %
Preoperative state
Total (n=465)
Preoperative malperfision syndrome 35 %
Coronary malperfusion Coronary malperfusion 14 %Cerebral malperfusionCerebral malperfusion 10 %
Malperfusion of extremitiesMalperfusion of extremities 12 %Visceral malperfusionVisceral malperfusion 8 %
Preoperative malperfision
Total (n=465)
Ascending aorta 94 %Aortic arch 87 %Descending aorta 59 % Abdominal aorta 48 %
Operative data
Totaln=465
Cardio-pulmonary bypass [min] 202 ± 77
X-clamp time [min] 104 ± 52
Circulatory arrest 90%
Circulatory arrest time [min] 29 ± 20
Total(n = 465)
Modified Bental procedure 32 %32 %
Aortic valve sparing procedure (modified Yacoub or David) 23 %23 %
Isolated supracoronare aorta ascending replacement 25 %25 %
Partial or total aortic arch replacement 75 %75 %
Aortic arch replacement with elephant trunk 17%17%
Concomitant procedure - MV surgery or CABG 16%16%
Operation
Odds ratio CI p
critical preoperative critical preoperative statestate
3.13.1 1.7-5.61.7-5.6 <0.01<0.01
visceral malperfusionvisceral malperfusion 5.15.1 2.0-12.52.0-12.5 <0.01<0.01
malperfusion of malperfusion of extremitiesextremities
2.62.6 1.2-5.51.2-5.5 0.010.01
Multivariate analysis all patients( Preoperative risk factors)
Critical preoperative state - preoperative ventilation, inotropic support, cardiopulmonary resuscitation and unstable preoperative
status
Mortality
Total(n=465)
30 day mortality
23 %(n=107)
Mortality without critical preoperative
state and malperfusion syndrom (n=217)
10%(n=22)
Mortality
The reasons of death
• low cardiac output 50.5%• neurological complication 13.7%• multi-organ failure 7.5%• aortic rupture 5.3%• other 20%
107 patients died during first 30 days
Conclusion
•This represents one of the largest series of patients with Type A aortic dissection in which a risk model could be created
•The surgical treatment of patients with acute aortic Type A Dissection is associated with high operative mortality.
•We identified the following independent predictors of poor outcome:
•The critical preoperative state
•The presence of malperfusion
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