The clinical profiles, presentation, and outcomes of patients with acute aortic dissections and associated periaortic hematomas on aortic imaging have not been described in a large cohort. This study sought to assess the prognostic implications of periaortic hematomas in patients with aortic dissections and to identify factors associated with in-hospital mortality in patients with periaortic hematomas. The study population was 971 patients with acute aortic dissections enrolled in the International Registry of Acute Aortic Dissection with available imaging data on presentation with the presence or absence of periaortic hematomas. Patients with periaortic hematomas (n=227, 23.4%) were more likely to be women, to have a history of hypertension and atherosclerosis, and to present early to the hospital. At presentation, they had greater frequencies of shock, cardiac tamponade, coma, and/or altered consciousness. Clinical outcomes were significantly worse in patients with periaortic hematomas, including significantly greater mortality (33% vs 20.3%, p<0.001). A multivariate model demonstrated periaortic hematomas to be an independent predictor of mortality in patients with aortic dissections (odds ratio 1.71, 95% confidence interval 1.15 to 2.54, p=0.007). In conclusion, this study provides insight into the profiles, presentation, and outcomes of patients with periaortic hematomas and acute aortic dissections. The early identification and aggressive management of patients with periaortic hematomas may potentially improve clinical outcomes. (C) 2005 Elsevier Inc. All rights reserved.

To the Editor: Congestive heart failure (CHF) has long been recognized as a potential complication of aortic dissection (AoD); however, the understanding of the presentation of AoD with concomitant CHF has remained largely restricted to case reports ([1–6][1]). Therefore, we undertook the present

OBJECTIVETo evaluate the clinical characteristics and outcomes of patients with painless acute aortic dissection (AAD).PATIENTS AND METHODSFor this study conducted from 1997 to 2001, we searched the International Registry of Acute Aortic Dissection to identify patients with painless AAD (group 1). Their clinical features and in-hospital events were compared with patients who had painful AAD (group 2).RESULTSOf the 977 patients in the database, 63 (6.4%) had painless AAD, and 914 (93.6%) had painful AAD. Patients in group 1 were older than those in group 2 (mean +/- SD age, 66.6 +/- 13.3 vs 61.9 +/- 14.1 years; P = .01). Type A dissection (involving the ascendIng aorta or the arch) was more frequent in group 1 (74.6% vs 60.9%; P = .03). Syncope (33.9% vs 11.7%; P < .001), congestive heart failure (19.7% vs 3.9%; P < .001), and stroke (11.3% vs 4.7%; P = .03) were more frequent presenting signs in group 1. Diabetes (10.2% vs 4.0%; P = .04), aortic aneurysm (29.5% vs 13.1%; P < .001), and prior cardiovascular surgery (48.1% vs 19.7%; P < .001) were also more common in group 1. In-hospital mortality was higher in group 1 (33.3% vs 23.2%; P = .05), especially due to type B dissection (limited to the descending aorta) (43.8% vs 10.4%; P < .001), and the prevalence of aortic rupture was higher among patients with type B dissection in group 1 (18.8% vs 5.9%; P = .04).CONCLUSIONPatients with painless AAD had syncope, congestive heart failure, or stroke. Compared with patients who have painful AAD, patients who have painless AAD have higher mortality, especially when AAD is type B.

Background Acute type A aortic dissection (AAD) remains a highly lethal entity for which emergent surgical correction is standard care. Prior studies have identified specific clinical findings as being predictive of outcome. The prognostic significance of specific findings on imaging studies is less well described. We sought to identify the prognostic value of transesophageal echocardiography (TEE) in medically and surgically treated patients with AAD.Methods We studied 522 AAD patients enrolled over 6 years in the International Registry of Acute Aortic Dissection who underwent TEE. Multivariate analysis identified independent associations of inhospital mortality, first using clinical variables (model 1), after which TEE data were added to build a final model (model 2).Results Inhospital mortality was 28.7%. Transesophageal echocardiographic evidences of pericardial effusion (P= .04), tamponade (P < .01), periaortic hematoma (P = .02), and patent false lumen (P = .08) were more frequent in nonsurvivors. Dilated ascending aorta (P = .03), dissection localized to the ascending aorta (P = .02), and thrombosed false lumen (P = .08) were less common in nonsurvivors. Model 1 identified age >= 70 years, any pulse deficit, renal failure, and hypotension/shock as independent predictors of death. Model 2 identified dissection flop confined to ascending aorta (odds ratio 0.2, 95% CI 0.1-0.6) and complete thrombosis of false lumen (odds ratio 0.15, 95% CI 0.03-0.86) as protective. In the medically treated group, mortality was 31% for subjects with a partially or completely thrombosed false lumen versus 66% in the presence of a patent false lumen.Conclusions Transesophageal echocardiography provides prognostic information in AAD beyond that provided by clinical risk variables.

As the prevalence of vascular disease increases, the use of invasive diagnostic and therapeutic vascular techniques such as percutaneous revascularization and coronary artery bypass grafting (CABG) will continue to grow. Although relatively rare, aortic dissection (AD) is a major complication of these procedures, and may be life threatening. Despite the potentially catastrophic nature of iatrogenic AD, its associated predisposing risk factors, clinical presentation, and outcome have not been systematically studied. To more accurately define the phenomenon of iatrogenic AD, we utilized the resources of the International Registry of Aortic Dissection (IRAD) to identify such patients and to determine if the risk profile, presentation, and outcome of these patients differed from those with spontaneous AD.

Background — Given the high mortality rates in patients with type A aortic dissection, predictive tools to identify patients at increased risk of death are needed to assist clinicians for optimal treatment. Methods and Results — Accordingly, we evaluated 547 patients with this diagnosis enrolled in the International Registry of Acute Aortic Dissection (IRAD) between January 1996 and December 1999. Univariate testing followed by multivariate logistic regression analysis was performed to identify independent predictors of death. In-hospital mortality rate was 32.5% in type A dissection patients. In-hospital complications (neurological deficits, altered mental status, myocardial or mesenteric ischemia, kidney failure, hypotension, cardiac tamponade, and limb ischemia) were increased in patients who died compared with survivors ( P <0.05 for all). Logistic regression identified the following presenting variables as predictors of death: age ≥70 years (OR, 1.70; 95% CI, 1.05 to 2.77; P =0.03), abrupt onset of chest pain (OR 2.60; 95% CI, 1.22 to 5.54; P =0.01), hypotension/shock/tamponade (OR, 2.97; 95% CI, 1.83 to 4.81; P <0.0001), kidney failure (OR, 4.77; 95% CI, 1.80 to 12.6; P =0.002), pulse deficit (OR, 2.03; 95% CI, 1.25 to 3.29, P =0.004), and abnormal ECG (OR, 1.77; 95% CI, 1.06 to 2.95; P =0.03) (area under receiver operating curve, 0.74; Hosmer-Lemeshow statistic, P =0.75). Conclusions — The in-hospital mortality rate in acute type A aortic dissection is high and can be predicted with the use of a clinical model incorporated in a simple risk prediction tool. This tool can be used to educate patients with dissection about their predicted risk and in clinical research for risk adjustment while comparing outcomes of different therapies.

CONTEXTAcute aortic dissection is a life-threatening medical emergency associated with high rates of morbidity and mortality. Data are limited regarding the effect of recent imaging and therapeutic advances on patient care and outcomes in this setting.OBJECTIVETo assess the presentation, management, and outcomes of acute aortic dissection.DESIGNCase series with patients enrolled between January 1996 and December 1998. Data were collected at presentation and by physician review of hospital records.SETTINGThe International Registry of Acute Aortic Dissection, consisting of 12 international referral centers.PARTICIPANTSA total of 464 patients (mean age, 63 years; 65.3% male), 62.3% of whom had type A dissection.MAIN OUTCOME MEASURESPresenting history, physical findings, management, and mortality, as assessed by history and physician review of hospital records.RESULTSWhile sudden onset of severe sharp pain was the single most common presenting complaint, the clinical presentation was diverse. Classic physical findings such as aortic regurgitation and pulse deficit were noted in only 31.6% and 15.1% of patients, respectively, and initial chest radiograph and electrocardiogram were frequently not helpful (no abnormalities were noted in 12.4% and 31.3% of patients, respectively). Computed tomography was the initial imaging modality used in 61.1%. Overall in-hospital mortality was 27.4%. Mortality of patients with type A dissection managed surgically was 26%; among those not receiving surgery (typically because of advanced age and comorbidity), mortality was 58%. Mortality of patients with type B dissection treated medically was 10.7%. Surgery was performed in 20% of patients with type B dissection; mortality in this group was 31.4%.CONCLUSIONSAcute aortic dissection presents with a wide range of manifestations, and classic findings are often absent. A high clinical index of suspicion is necessary. Despite recent advances, in-hospital mortality rates remain high. Our data support the need for continued improvement in prevention, diagnosis, and management of acute aortic dissection.

We have studied the electrophysiological correlates of atrial repetitive responses, induced by single extrastimuli, in a group of 25 patients undergoing electrophysiologic studies for a variety of supraventricular and ventricular arrhythmias. The incidence of repetitive responses was not related to a previous history of atrial tachyarrhythmias. Repetitive responses were observed only when the extrastimulus elicited a significant intra‐atrial conduction delay, as measured from the extrastimulus artifact, to two or three points in the atria. This condition was fulfilled only when the basic atrial rhythm was paced, and it was also facilitated by increasing atrial rate, which shortened the atrial effective refractory period. Atrial pacing thus seemed to facilitate the production of atrial repetitive responses by both promoting intra‐atrial conduction delays during extrastimulation, and by shortening the atrial refractory period. Alrial repetitive responses are probably a nonspecific phenomenon, unrelated to a tendency towards atrial tachyarrhythmias; their mechanism is probably local re‐entry, related to slow conduction of impulses during incomplete repoiarization, and under favorable conditions they may precipitate atrial flutter or fibrillation in predisposed patients.

IN patients with hypertrophic cardiomyopathy the electrocardiogram often displays deep Q waves that may suggest myocardial infarction.1 2 3 Some investigators have ascribed these Q waves to the activation of the hypertrophied interventricular septum,4 , 5 but others think that they may be due to fibrosis of the septal tissue.6 We have performed an electrophysiologic study of ventricular activation in six patients with hypertrophic cardiomyopathy, normal coronary arteries, and deep Q waves on the electrocardiogram. Our findings suggest that the Q waves are produced by the activation of the septum and that myopathic septal muscle has different electrophysiologic properties from those of the remainder . . .