Document Detail


Patients with type A acute aortic dissection presenting with major brain injury: Should we operate on them?
MedLine Citation:
PMID:  23410778     Owner:  NLM     Status:  In-Data-Review    
Abstract/OtherAbstract:
OBJECTIVES: The management strategy remains controversial for patients presenting with type A acute aortic dissection with cerebrovascular accident or coma. The present study aimed to help guide surgeons treating these high-risk patients.
METHODS: Of 1873 patients with type A acute aortic dissection enrolled in the International Registry for Acute Dissection, 87 (4.7%) presented with cerebrovascular accident and 54 (2.9%) with coma. The hospital and 5-year results were stratified by the presence and type of brain injury (no injury vs stroke vs coma) and management type (medical vs surgical). Independent predictors of short- and mid-term survival were identified.
RESULTS: Presentation with shock, hypotension, or tamponade (46.8% vs 25.2%; P < .001) and arch vessel involvement (55.0% vs 36.1%; P < .001) was more likely in patients with brain injury. Surgical management was avoided more often in patients with coma (33.3%) or cerebrovascular accident (24.1%) than in those without brain injury (11.1%; P < .001). The overall hospital mortality was 22.7% without brain injury, 40.2% with cerebrovascular accident, and 63.0% with coma (P < .001). Mortality varied among the management types for both cerebrovascular accident (76.2% medical vs 27.0% surgical; P < .001) and coma (100% medical vs 44.4% surgical; P < .001). Postoperatively, cerebrovascular accident and coma resolved in 84.3% and 78.8% of cases, respectively. On logistic regression analysis, surgery was protective against mortality in patients presenting with brain injury (odds ratio 0.058; P < .001). The 5-year survival of patients presenting with cerebrovascular accident and coma was 23.8% and 0% after medical management versus 67.1% and 57.1% after surgery (log rank, P < .001), respectively.
CONCLUSIONS: Brain injury at presentation adversely affects hospital survival of patients with type A acute aortic dissection. In the present observational study, the patients selected to undergo surgery demonstrated improved late survival and frequent reversal of neurologic deficits.
Authors:
Marco Di Eusanio; Himanshu J Patel; Christoph A Nienaber; Daniel M Montgomery; Amit Korach; Thoralf M Sundt; Carlo Devincentiis; Matthias Voehringer; Mark D Peterson; Truls Myrmel; Gianluca Folesani; Magnus Larsen; Nimesh D Desai; Joseph E Bavaria; Jehangir J Appoo; Teresa M Kieser; Rossella Fattori; Kim Eagle; Roberto Di Bartolomeo; Santi Trimarchi
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Publication Detail:
Type:  Editorial    
Journal Detail:
Title:  The Journal of thoracic and cardiovascular surgery     Volume:  145     ISSN:  1097-685X     ISO Abbreviation:  J. Thorac. Cardiovasc. Surg.     Publication Date:  2013 Mar 
Date Detail:
Created Date:  2013-02-15     Completed Date:  -     Revised Date:  -    
Medline Journal Info:
Nlm Unique ID:  0376343     Medline TA:  J Thorac Cardiovasc Surg     Country:  United States    
Other Details:
Languages:  eng     Pagination:  S213-S221.e1     Citation Subset:  AIM; IM    
Copyright Information:
Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
Affiliation:
Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, Bologna, Italy. Electronic address: marco.dieusanio2@unibo.it.
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