Background: The nature and prognosis of type A intramural hematoma (TAIMH) are not well established. In this study, we evaluated the early and late outcome after surgery for this emergency condition. Methods: The ERTAAD registry included consecutive patients who underwent surgery for acute type A aortic dissection (TAAD) or TAIMH at 18 European centers for cardiac surgery. In this study, we compared the early and late outcomes of TAIMH and typical TAAD. Results: In total, 3902 consecutive patients were included in the ERTAAD registry, and 386 (9.9%) patients had TAIMH. Penn class a was present in 43.1% TAAD patients and in 34.5% TAIMH patients (p < 0.001). Among 3-month survivors, 10-year relative survival was 0.80 (95%CI 0.77-0.84) in TAAD patients and 0.76 (95%CI 0.63-0.88) in TAIMH patients. Propensity-score matching yielded 386 pairs of patients, and no significant difference was observed between the study groups in terms of early and late outcomes. In-hospital mortality rates were comparable (TAIMH 13.5% vs. TAAD 16.3%, p = 0.266). Ten-year mortality was 51.3% among TAIMH patients and 51.6% among TAAD patients (p = 0.274). TAIMH and TAAD had similar 10-year cumulative incidence rates of proximal (4.2% vs. 3.3%, p = 0.738) and distal aortic reoperations (12.6% vs. 7.6%, p = 0.779). Conclusions: This cohort study showed that the prevalence of patients with TAIMH requiring surgery is low and their risk profile is significantly different as shown by the Penn classification. The early and late outcomes of the study groups were not statistically different compared to typical TAAD when adjusted for baseline and operative variables. The relative survivals of 90-day TAIMH and TAAD survivors were low compared to the matched general population, indicating that surgically treated TAIMH demonstrated postoperative outcomes are poor and comparable to surgically treated TAAD after adjustment. Post-hoc power analysis suggested that much larger studies are needed to confirm these findings. These results are limited to TAIMH patients who underwent surgery, and this study did not address the outcome of patients who were conservatively treated.

BACKGROUND:Data on the prognostic impact of type A aortic dissection involving the common carotid arteries (CCAs) are scarce. METHODS:Data on the status of the CCAs were available in 1106 patients who underwent surgery for acute DeBakey type 1 aortic dissection who were recruited in a retrospective, multicentre European registry, that is, the ERTAAD. Postoperative neurological complications were defined as ischaemic stroke, haemorrhagic stroke and/or global brain ischaemia. RESULTS:Patients without carotid artery dissection, those with unilateral or bilateral CCA dissection had in-hospital mortality rates of 19.5%, 16.9% (OR 1.006, 95% CI 0.614 to 1.647) and 27.3% (p<0.001, OR 1.719, 95% CI 1.086 to 2.722), respectively. Bilateral, but not unilateral, dissection of the CCAs increased the risk of neurological complications (40.0% vs 18.9%, OR 2.453, 95% CI 1.683 to 3.576). The negative prognostic effect of bilateral dissection of the CCAs was increased among patients without cerebral malperfusion who underwent surgery with the use of hypothermic circulatory arrest (28.7% vs 4.3%, p=0.014). CONCLUSIONS:Bilateral, but not unilateral, dissection of the CCAs may increase the risk of neurological complications and in-hospital mortality after surgery for DeBakey type 1 aortic dissection. TRIAL REGISTRATION NUMBER:NCT04831073.

Objectives: Several conditions associated with type A aortic dissection may require preoperative invasive mechanical ventilation (IMV). The current literature lacks data on this subset of patients’ prevalence and postoperative outcomes. This study aims to investigate this unexplored issue in a multicenter European registry. Methods: Data from 3735 patients included in the European Registry of Type A Aortic Dissection (ERTAAD) were the subject of this analysis. Bootstrapped Least Absolute Shrinkage and Selection Operator (LASSO) logistic regression was performed for variable selection to identify key predictors of hospital death. In the second step, a multilevel multivariable logistic regression (MMLR) was carried out, given the clustered structure of the data. Results: A total of 346 (9.3%) out of 3735 patients required preoperative IMV. Compared to the non-IMV patients, patients requiring IMV had a significantly higher rate of organ malperfusion (52% vs. 35%, p < 0.001) and a higher proportion of tears in the aortic root (p = 0.048). The in-hospital mortality rate among IMV patients was 38% vs. 15% in non-IMV patients (p < 0.001), without a difference in post-discharge survival (p = 0.84). At the MMLR, patients who required IMV had 135% higher odds of in-hospital death compared to the remaining patients. IMV yielded the second highest odds in the prediction model for in-hospital mortality (OR 2.13, CI 1.60 to 2.85, p < 0.001). Among IMV patients, the extension of surgery to the aortic arch was significantly associated with increased in-hospital mortality (p < 0.001, OR 2.98). In multivariable analysis, preoperative IMV was independently associated with increased odds of in-hospital mortality. Conclusions: The need for invasive mechanical ventilation before surgical repair for type A aortic dissection is not infrequent. In this subpopulation, the in-hospital mortality rate was twofold compared to patients who did not require IMV. The awareness of the preoperative risk profile and outcomes of this subset of patients should urge surgeons to tailor the surgical strategy more appropriately to improve the immediate postoperative results.

OBJECTIVES:We aimed to investigate the differences in early and late outcomes after daytime compared to nighttime surgery for type A aortic dissection. METHODS:From 2005 to 2021, patients undergoing surgery for type A aortic dissection at 18 European centres participating in the European registry of type A aortic dissection were included in this study. Based on the time of procedure, patients were allocated into groups (8 a.m. to 8 p.m. vs 8 p.m. to 8 a.m.). After propensity-score matching, short- and long-term all-cause mortality and reoperation rate as well as secondary end-points including myocardial infarction, neurological outcome and renal failure were compared. RESULTS:A total of 3902 patients were included in this study. After propensity-score matching, outcomes of 1475 pairs of patients were compared. No differences were found regarding rates of surgical techniques. Daytime surgery was associated with an increased rate of global brain injury [daytime 5.4% (n = 80) vs nighttime 3.6% (n = 53); P = 0.021]. No significant differences were found in the rates of myocardial infarction, renal failure or neurological outcome other than global brain ischaemia. Significantly higher 1-year mortality (24.8% vs 21.7%, P = 0.049) and 10-year mortality (48.7% vs 45.1%, P = 0.022) was demonstrated in the daytime group. No significant differences in the rates of reoperation at 10 years were found. CONCLUSIONS:This study demonstrates that surgery for type A aortic dissection performed during nighttime is not associated with adverse outcomes compared to daytime surgery, suggesting that nighttime procedures can be safely performed without compromising short- or long-term outcomes. CLINICAL TRIAL REGISTRATION NUMBER:European Registry of Type A Aortic Dissection (ERTAAD) (Identifier: NCT04831073. URL: https://clinicaltrials.gov/study/NCT04831073).

Background The present study aimed to report the early and late clinical outcomes of patients who underwent surgical repair for acute type A aortic dissection requiring concomitant coronary artery bypass grafting (CABG), and to explore potential risk factors associated with the need for this additional procedure. Methods Data were retrieved from the multicenter European Registry of Type A Aortic Dissection (ERTAAD). Bootstrapped least absolute shrinkage and selection operator logistic regression and multilevel multivariate logistic regression were performed for variable selection to identify predictors of hospital death, and logistic regression was used for the prediction of CABG. Results A total of 292 (8.04%) of 3633 patients required additional CABG. The in-hospital mortality rate was 33% for patients undergoing CABG vs 16% of non-CABG recipients (P < .001; odds ratio [OR], 2.52; 95% CI, 1.93-3.35). Dissection of the aortic root involving the right coronary cusp (P < .001; OR, 7.83; 95% CI, 5.55-11.0), a tear in the aortic root (P = .002; OR, 2.08; 95% CI, 1.29-3.32), mitral valve insufficiency (P = .034; OR, 1.33; 95% CI, 1.01-1.71), and a genetic syndrome (P < .001; OR, 3.23; 95% CI, 1.66-5.99) independently predicted the need for CABG. Conclusions The need for additional CABG is not a rare occurrence during repair of type A aortic dissection and is associated with an increased mortality risk. Intimal tear localization and right coronary sinus dissection should be carefully examined in the preoperative image evaluation to stratify the risk of revascularization and plan the most appropriate approach.

BackgroundSurgery for type A aortic dissection (TAAD) is associated with high risk of mortality. Current risk scoring methods have a limited predictive accuracy.MethodsSubjects were patients who underwent surgery for acute TAAD at 18 European centers of cardiac surgery from the European Registry of Type A Aortic Dissection (ERTAAD).ResultsOut of 3,902 patients included in the ERTAAD, 2,477 fulfilled the inclusion criteria. In the validation dataset (2,229 patients), the rate of in-hospital mortality was 18.4%. The rate of composite outcome (in-hospital death, stroke/global ischemia, dialysis, and/or acute heart failure) was 41.2%, and 10-year mortality rate was 47.0%. Logistic regression identified the following patient-related variables associated with an increased risk of in-hospital mortality [area under the curve (AUC), 0.755, 95% confidence interval (CI), 0.729–0.780; Brier score 0.128]: age; estimated glomerular filtration rate; arterial lactate; iatrogenic dissection; left ventricular ejection fraction ≤50%; invasive mechanical ventilation; cardiopulmonary resuscitation immediately before surgery; and cerebral, mesenteric, and peripheral malperfusion. The estimated risk score was associated with an increased risk of composite outcome (AUC, 0.689, 95% CI, 0.667–0.711) and of late mortality [hazard ratio (HR), 1.035, 95% CI, 1.031–1.038; Harrell's C 0.702; Somer's D 0.403]. In the validation dataset (248 patients), the in-hospital mortality rate was 16.1%, the composite outcome rate was 41.5%, and the 10-year mortality rate was 49.1%. The estimated risk score was predictive of in-hospital mortality (AUC, 0.703, 95% CI, 0.613–0.793; Brier score 0.121; slope 0.905) and of composite outcome (AUC, 0.682, 95% CI, 0.614–0.749). The estimated risk score was predictive of late mortality (HR, 1.035, 95% CI, 1.031–1.038; Harrell's C 0.702; Somer's D 0.403), also when hospital deaths were excluded from the analysis (HR, 1.024, 95% CI, 1.018–1.031; Harrell's C 0.630; Somer's D 0.261).ConclusionsThe present analysis identified several baseline clinical risk factors, along with preoperative estimated glomerular filtration rate and arterial lactate, which are predictive of in-hospital mortality and major postoperative adverse events after surgical repair of acute TAAD. These risk factors may be valuable components for risk adjustment in the evaluation of surgical and anesthesiological strategies aiming to improve the results of surgery for TAAD.Clinical Trial Registrationhttps://clinicaltrials.gov, identifier NCT04831073.

Surgery for type A aortic dissection (TAAD) is associated with a high risk of early mortality. The prognostic impact of a new classification of the urgency of the procedure was evaluated in this multicenter cohort study. Data on consecutive patients who underwent surgery for acute TAAD were retrospectively collected in the multicenter, retrospective European Registry of TAAD (ERTAAD). The rates of in-hospital mortality of 3,902 consecutive patients increased along with the ERTAAD procedure urgency grades: urgent procedure 10.0%, emergency procedure grade 1 13.3%, emergency procedure grade 2 22.1%, salvage procedure grade 1 45.6%, and salvage procedure grade 2 57.1% (p <0.0001). Preoperative arterial lactate correlated with the urgency grades. Inclusion of the ERTAAD procedure urgency classification significantly improved the area under the receiver operating characteristics curves of the regression model and the integrated discrimination indexes and the net reclassification indexes. The risk of postoperative stroke/global brain ischemia, mesenteric ischemia, lower limb ischemia, dialysis, and acute heart failure increased along with the urgency grades. In conclusion, the urgency of surgical repair of acute TAAD, which seems to have a significant impact on the risk of in-hospital mortality, may be useful to improve the stratification of the operative risk of these critically ill patients. This study showed that salvage surgery for TAAD is justified because half of the patients may survive to discharge.

Surgery for type A aortic dissection (TAAD) is frequently complicated by neurologic complications. The prognostic impact of neurologic complications of different nature has been investigated in this study. The subjects of this analysis were 3,902 patients who underwent surgery for acute TAAD from the multicenter European Registry of Type A Aortic Dissection (ERTAAD). During the index hospitalization, 722 patients (18.5%) experienced stroke/global brain ischemia. Ischemic stroke was detected in 539 patients (13.8%), hemorrhagic stroke in 76 patients (1.9%) and global brain ischemia in 177 patients (4.5%), with a few patients having had findings of more than 1 of these conditions. In-hospital mortality was increased significantly in patients with postoperative ischemic stroke (25.6%, adjusted odds ratio [OR] 2.422, 95% confidence interval [CI] 1.825 to 3.216), hemorrhagic stroke (48.7%, adjusted OR 4.641, 95% CI 2.524 to 8.533), and global brain ischemia (74.0%, adjusted OR 22.275, 95% CI 14.537 to 35.524) compared with patients without neurologic complications (13.5%). Similarly, patients who experienced ischemic stroke (46.3%, adjusted hazard ratio [HR] 1.719, 95% CI 1.434 to 2.059), hemorrhagic stroke (62.8%, adjusted HR 3.236, 95% CI 2.314 to 4.525), and global brain ischemia (83.9%, adjusted HR 12.777, 95% CI 10.325 to 15.810) had significantly higher 5-year mortality than patients without postoperative neurologic complications (27.5%). The negative prognostic effect of neurologic complications on survival vanished about 1 year after surgery. In conclusion, postoperative ischemic stroke, hemorrhagic stroke, and global cerebral ischemia increased early and midterm mortality after surgery for acute TAAD. The magnitude of risk of mortality increased with the severity of the neurologic complications, with postoperative hemorrhagic stroke and global brain ischemia being highly lethal complications. (c) 2024 Elsevier Inc. All rights reserved. (Am J Cardiol 2024;219:85 - 91)

BACKGROUND:Extended aortic repair is considered a key issue for the long-term durability of surgery for DeBakey type 1 aortic dissection. The risk of aortic degeneration may be higher in young patients due to their long life expectancy. The early outcome and durability of aortic surgery in these patients were investigated in the present study. METHODS:The subjects of the present analysis were patients under 60 years old who underwent surgical repair for acute DeBakey type 1 aortic dissection at 18 cardiac surgery centres across Europe between 2005 and 2021. Patients underwent ascending aortic repair or total aortic arch repair using the conventional technique or the frozen elephant trunk technique. The primary outcome was 5-year cumulative incidence of reoperation on the distal aorta. RESULTS:Overall, 915 patients underwent surgical ascending aortic repair and 284 patients underwent surgical total aortic arch repair. The frozen elephant trunk procedure was performed in 128 patients. Among 245 propensity score-matched pairs, total aortic arch repair did not decrease the rate of distal aortic reoperation compared to ascending aortic repair (5-year cumulative incidence, 6.7% versus 6.7%, subdistributional hazard ratio 1.127, 95% c.i. 0.523 to 2.427). Total aortic arch repair increased the incidence of postoperative stroke/global brain ischaemia (25.7% versus 18.4%, P = 0.050) and dialysis (19.6% versus 12.7%, P = 0.003). Five-year mortality was comparable after ascending aortic repair and total aortic arch repair (22.8% versus 27.3%, P = 0.172). CONCLUSIONS:In patients under 60 years old with DeBakey type 1 aortic dissection, total aortic arch replacement compared with ascending aortic repair did not reduce the incidence of distal aortic operations at 5 years. When feasible, ascending aortic repair for DeBakey type 1 aortic dissection is associated with satisfactory early and mid-term outcomes. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT04831073.

BACKGROUND:The current study aims to report the presentation of the malperfusion syndrome in patients with acute type A aortic dissection admitted to surgery and its impact on mortality. METHODS:Data were retrieved from the multicenter European Registry of Type A Aortic Dissection. The Penn classification was used to categorize malperfusion syndromes. A machine-learning algorithm was applied to assess the multivariate interaction's importance regarding in-hospital mortality. RESULTS:A total of 3902 consecutive patients underwent repair for acute type A aortic dissection. Local malperfusion syndrome occurred in 1584 (40.59%) patients. Multiorgan involvement occurred in 582 patients (36.74%) whereas 1002 patients (63.26%) had single-organ malperfusion. The prevalence was the greatest for cerebral (21.27%) followed by peripheral (13.94%), myocardial (9.7%), renal (9.33%), mesenteric (4.15%), and spinal malperfusion (2.10%). Multiorgan involvement predominantly occurred in organs perfused by the downstream aorta. Malperfusion significantly increased the risk of mortality (P < .001; odds ratio, 1.94 ± 0.29). The Boruta machine-learning algorithm identified the Penn classification as significantly associated with in-hospital mortality (P < .0001, variable importance = 7.91); however, 8 other variables yielded greater prediction importance. According to the Penn classification, mortality rates were 12.38% for Penn A, 20.71% for Penn B, 28.90% for Penn C, and 31.84% for Penn BC, respectively. CONCLUSIONS:Nearly one half of the examined cohort presented with signs of malperfusion syndrome predominantly attributable to local involvement. More than one third of patients with local malperfusion syndrome had a multivessel involvement. Furthermore, different levels of Penn classification can be used only as a first tool for preliminary stratification of early mortality risk.

BACKGROUND:Surgery for Stanford type A aortic dissection (TAAD) is associated with an increased risk of late aortic reoperations due to degeneration of the dissected aorta. METHODS:The subjects of this analysis were 990 TAAD patients who survived surgery for acute TAAD and had complete data on the diameter and dissection status of all aortic segments. RESULTS:After a mean follow-up of 4.2 ± 3.6 years, 60 patients underwent 85 distal aortic reoperations. Ten-year cumulative incidence of distal aortic reoperation was 9.6%. Multivariable competing risk analysis showed that the maximum preoperative diameter of the abdominal aorta (SHR 1.041, 95%CI 1.008-1.075), abdominal aorta dissection (SHR 2.133, 95%CI 1.156-3.937) and genetic syndromes (SHR 2.840, 95%CI 1.001-8.060) were independent predictors of distal aortic reoperation. Patients with a maximum diameter of the abdominal aorta >30 mm and/or abdominal aortic dissection had a cumulative incidence of 10-year distal aortic reoperation of 12.0% compared to 5.7% in those without these risk factors (adjusted SHR 2.076, 95%CI 1.062-4.060). CONCLUSION:TAAD patients with genetic syndromes, and increased size and dissection of the abdominal aorta have an increased the risk of distal aortic reoperations. A policy of extensive surgical or hybrid primary aortic repair, completion endovascular procedures for aortic remodeling and tight surveillance may be justified in these patients. TRIAL REGISTRATION:ClinicalTrials.gov Identifier: NCT04831073.

BackgroundThe benefits and harms associated with femoral artery cannulation over other sites of arterial cannulation for surgical repair of acute Stanford type A aortic dissection (TAAD) are not conclusively established.MethodsWe evaluated the outcomes after surgery for TAAD using femoral artery cannulation, supra-aortic arterial cannulation (i.e., innominate/subclavian/axillary artery cannulation), and direct aortic cannulation.Results3751 (96.1%) patients were eligible for this analysis. In-hospital mortality using supra-aortic arterial cannulation was comparable to femoral artery cannulation (17.8% vs. 18.4%; adjusted OR 0.846, 95% CI 0.799-1.202). This finding was confirmed in 1028 propensity score-matched pairs of patients with supra-aortic arterial cannulation or femoral artery cannulation (17.5% vs. 17.0%, p = 0.770). In-hospital mortality after direct aortic cannulation was lower compared to femoral artery cannulation (14.0% vs. 18.4%, adjusted OR 0.703, 95% CI 0.529-0.934). Among 583 propensity score-matched pairs of patients, direct aortic cannulation was associated with lower rates of in-hospital mortality (13.4% vs. 19.6%, p = 0.004) compared to femoral artery cannulation. Switching of the primary site of arterial cannulation was associated with increased rate of in-hospital mortality (36.5% vs. 17.0%; adjusted OR 2.730, 95% CI 1.564-4.765). Ten-year mortality was similar in the study cohorts.ConclusionsIn this study, the outcomes of surgery for TAAD using femoral arterial cannulation were comparable to those using supra-aortic arterial cannulation. However, femoral arterial cannulation was associated with higher in-hospital mortality than direct aortic cannulation.Trial registrationClinicalTrials.gov registration code: NCT04831073.

To evaluate the impact of individual institutions on the outcome after surgery for Stanford type A aortic dissection (TAAD). This is an observational, multicenter, retrospective cohort study including 3902 patients who underwent surgery for TAAD at 18 university and non-university hospitals. Logistic regression showed that four hospitals had increased risk of in-hospital mortality, while two hospitals were associated with decreased risk of in-hospital mortality. Risk-adjusted in-hospital mortality rates were lower in four hospitals and higher in other four hospitals compared to the overall in-hospital mortality rate (17.7

Background: Acute type A aortic dissection (TAAD) is associated with significant mortality and morbidity. In this study we evaluated the prognostic significance of preoperative arterial lactate concentration on the outcome after surgery for TAAD.Methods: The ERTAAD registry included consecutive patients who underwent surgery for acute type A aortic dissection (TAAD) at 18 European centers of cardiac surgery.Results: Data on arterial lactate concentration immediately before surgery were available in 2798 (71.7 %) patients. Preoperative concentration of arterial lactate was an independent predictor of in-hospital mortality (mean, 3.5 +/- 3.2 vs 2.1 +/- 1.8 mmol/L, adjusted OR 1.181, 95%CI 1.129-1.235). The best cutoff value preoperative arterial lactate concentration was 1.8 mmol/L (in-hospital mortality, 12.0 %, vs. 26.6 %, p < 0.0001). The rates of in-hospital mortality increased along increasing quintiles of arterial lactate and it was 12.1 % in the lowest quintile and 33.6 % in the highest quintile (p < 0.0001). The difference between multivariable models with and without preoperative arterial lactate was statistically significant (p = 0.0002). The NRI was 0.296 (95%CI 0.200-0.391) (p < 0.0001) with -17 % of events correctly reclassified (p = 0.0002) and 46 % of non-events correctly reclassified (p < 0.0001). The IDI was 0.025 (95%CI 0.016-0.034) (p < 0.0001). Six studies from a systematic review plus the present one provided data for a pooled analysis which showed that the mean difference of preoperative arterial lactate between 30-day/in-hospital deaths and survivors was 1.85 mmol/L (95%CI 1.22-2.47, p < 0.0001, I-2 64 %).Conclusions: Hyperlactatemia significantly increased the risk of mortality after surgery for acute TAAD and should be considered in the clinical assessment of these critically ill patients.

OBJECTIVE:The aim of this study was to evaluate the outcomes of different surgical strategies for acute Stanford type A aortic dissection (TAAD). SUMMARY BACKGROUND DATA:The optimal extent of aortic resection during surgery for acute TAAD is controversial. METHODS:This is a multicenter, retrospective cohort study of patients who underwent surgery for acute TAAD at 18 European hospitals. RESULTS:Out of 3902 consecutive patients, 689 (17.7%) died during the index hospitalization. Among 2855 patients who survived 3 months after surgery, 10-year observed survival was 65.3%, while country-adjusted, age-adjusted, and sex-adjusted expected survival was 81.3%, yielding a relative survival of 80.4%. Among 558 propensity score-matched pairs, total aortic arch replacement increased the risk of in-hospital (21.0% vs. 14.9%, P =0.008) and 10-year mortality (47.1% vs. 40.1%, P =0.001), without decreasing the incidence of distal aortic reoperation (10-year: 8.9% vs. 7.4%, P =0.690) compared with ascending aortic replacement. Among 933 propensity score-matched pairs, in-hospital mortality (18.5% vs. 18.0%, P =0.765), late mortality (at 10-year: 44.6% vs. 41.9%, P =0.824), and cumulative incidence of proximal aortic reoperation (at 10-year: 4.4% vs. 5.9%, P =0.190) after aortic root replacement was comparable to supracoronary aortic replacement. CONCLUSIONS:Replacement of the aortic root and aortic arch did not decrease the risk of aortic reoperation in patients with TAAD and should be performed only in the presence of local aortic injury or aneurysm. The relative survival of TAAD patients is poor and suggests that the causes underlying aortic dissection may also impact late mortality despite surgical repair of the dissected aorta.

In this study we evaluated the impact of direct aortic cannulation versus innominate/subclavian/axillary artery cannulation on the outcome after surgery for type A aortic dissection. The outcomes of patients included in a multicenter European registry (ERTAAD) who underwent surgery for acute type A aortic dissection with direct aortic cannulation versus those with innominate/subclavian/axillary artery cannulation, i.e. supra-aortic arterial cannulation, were compared using propensity score matched analysis. Out of 3902 consecutive patients included in the registry, 2478 (63.5

OBJECTIVES To compare the outcomes of patients with postcardiotomy shock treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) only compared with VA-ECMO and intra-aortic balloon pump (IABP). DESIGN A retrospective multicenter registry study. SETTING At 19 cardiac surgery units. PARTICIPANTS A total of 615 adult patients who required VA-ECMO from 2010 to 2018. The patients were divided into 2 groups depending on whether they received VA-ECMO only (ECMO only group) or VA-ECMO plus IABP (ECMO-IABP group). MEASUREMENTS AND MAIN RESULTS The overall series mean age was 63 ± 13 years, and 33% were female. The ECMO-only group included 499 patients, and 116 patients were in the ECMO-IABP group. Urgent and/or emergent procedures were more common in the ECMO-only group. Central cannulation was performed in 47% (n = 54) in the ECMO-IABP group compared to 27% (n = 132) in the ECMO-only group. In the ECMO-IABP group, 58% (n = 67) were successfully weaned from ECMO, compared to 46% (n = 231) in the ECMO-only group (p = 0.026). However, in-hospital mortality was 63% in the ECMO-IABP group compared to 65% in the ECMO-only group (p = 0.66). Among 114 propensity score-matched pairs, ECMO-IABP group had comparable weaning rates (57% v 53%, p = 0.51) and in-hospital mortality (64% v 58%, p = 0.78). CONCLUSIONS This multicenter study showed that adjunctive IABP did not translate into better outcomes in patients treated with VA-ECMO for postcardiotomy shock.

(1) Background: Acute Stanford type A aortic dissection (TAAD) may complicate the outcome of cardiovascular procedures. Data on the outcome after surgery for iatrogenic acute TAAD is scarce. (2) Methods: The European Registry of Type A Aortic Dissection (ERTAAD) is a multicenter, retrospective study including patients who underwent surgery for acute TAAD at 18 hospitals from eight European countries. The primary outcomes were in-hospital mortality and 5-year mortality. Twenty-seven secondary outcomes were evaluated. (3) Results: Out of 3902 consecutive patients who underwent surgery for acute TAAD, 103 (2.6%) had iatrogenic TAAD. Cardiac surgery (37.8%) and percutaneous coronary intervention (36.9%) were the most frequent causes leading to iatrogenic TAAD, followed by diagnostic coronary angiography (13.6%), transcatheter aortic valve replacement (10.7%) and peripheral endovascular procedure (1.0%). In hospital mortality was 20.5% after cardiac surgery, 31.6% after percutaneous coronary intervention, 42.9% after diagnostic coronary angiography, 45.5% after transcatheter aortic valve replacement and nihil after peripheral endovascular procedure (p = 0.092), with similar 5-year mortality between different subgroups of iatrogenic TAAD (p = 0.710). Among 102 propensity score matched pairs, in-hospital mortality was significantly higher among patients with iatrogenic TAAD (30.4% vs. 15.7%, p = 0.013) compared to those with spontaneous TAAD. This finding was likely related to higher risk of postoperative heart failure (35.3% vs. 10.8%, p < 0.0001) among iatrogenic TAAD patients. Five-year mortality was comparable between patients with iatrogenic and spontaneous TAAD (46.2% vs. 39.4%, p = 0.163). (4) Conclusions: Iatrogenic origin of acute TAAD is quite uncommon but carries a significantly increased risk of in-hospital mortality compared to spontaneous TAAD.

OBJECTIVE:Data on patients requiring a second run of venoarterial extracorporeal membrane oxygenation (VA-ECMO) support in patients affected by postcardiotomy cardiogenic shock (PCS) are very limited. The authors aimed to investigate the effect of a second run of VA-ECMO on PCS patient survival. DESIGN:Retrospective analysis of an international registry. SETTING:Multicenter study, tertiary university hospitals. PARTICIPANTS:Data on adult PCS patients receiving a second run of VA-ECMO. MEASUREMENTS AND MAIN RESULTS:A total of 674 patients with a mean age of 62.9 ± 12.7 years were analyzed, and 21 (3.1%) patients had a second run of VA-ECMO. None of them required more than two VA-ECMO runs. The median duration of VA-ECMO therapy was 135 hours (interquartile range [IQR] 61-226) in patients who did not require a VA-ECMO rerun. In the rerun VA-ECMO group the median overall duration of VA-ECMO therapy was 183 hours (IQR 107-344), and the median duration of the first run was 114 hours (IQR 66-169). Nine (42.9%) of the patients who required a second run of VA-ECMO died during VA-ECMO therapy, whereas five (23.8%) survived to hospital discharge. No differences between patients treated with single or second VA-ECMO runs were observed in terms of hospital mortality and late survival. In patients requiring a second VA-ECMO run, the actuarial survival estimates at three and 12 months after VA-ECMO weaning were 23.8% ± 9.3% and 19.6% ± 6.4%, respectively. CONCLUSIONS:Repeat VA-ECMO therapy is a valid treatment strategy for PCS patients. Early and late survivals are similar between patients who have undergone a single or second run of VA-ECMO.