Importance:Selection of patients with a bicuspid aortic valve and aortopathy for prophylactic aortic surgery remains challenging. In thoracic aortopathy, aortic medial elastin fiber fragmentation initially leads to microcalcification but later declines with progressive loss of elastin content and reduced structural integrity. Objective:To determine whether aortic microcalcification detected using fluorine F 18-labeled [18F]-sodium fluoride positron emission tomography (PET) is associated with future aortic diameter expansion. Design, Setting, and Participants:This prospective longitudinal cohort study was conducted in tertiary care centers across Scotland from April 4, 2019, to September 15, 2023. Participants included patients with a bicuspid aortic valve. Data analysis was performed from May 21, 2024, to March 4, 2025. Exposures:Hybrid [18F]-sodium fluoride PET and computed tomography. Main Outcomes and Measures:Baseline ascending aortic [18F]-sodium fluoride uptake was measured as mean tissue to background ratio. The primary outcome was ascending aortic diameter expansion during 24 months on cardiac magnetic resonance imaging (MRI). Results:Seventy-six patients with a bicuspid aortic valve (mean [SD] age, 52.6 [7.5] years; 57 [75.0%] male) underwent baseline [18F]-sodium fluoride PET and MRI. Fifty-six patients underwent follow-up MRI after a median of 723 (IQR, 515-787) days. There was an inverse correlation between baseline ascending aortic [18F]-sodium fluoride uptake and annual change in diameter (Pearson r = -0.37; P = .005), which remained after adjustment for confounders in multivariable regression analysis. Ascending aortic [18F]-sodium fluoride was not correlated with baseline diameter (Pearson r = 0.08; P = .50) but was moderately correlated with baseline ascending aortic stiffness index (Pearson r = 0.38; P < .001). Conclusion and Relevance:In this cohort study of patients with a bicuspid aortic valve, the most rapid aortic growth was seen in those with low [18F]-sodium fluoride ascending aortic uptake, indicating reduced aortic wall integrity. High ascending aortic [18F]-sodium fluoride uptake was associated with a stiffer and slow-growing ascending aortic phenotype. These findings suggest that [18F]-sodium fluoride PET imaging represents a promising new noninvasive approach to identify a microcalcified disease phenotype in thoracic aortopathy among patients with a bicuspid aortic valve.

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 Acute Stanford type A aortic dissection is a severe emergency condition that, if left untreated, is associated with a high mortality rate. The extent of surgical repair may impact the outcomes of these patients. Method Patients operated for acute type A aortic dissection from a multicentre European registry were included. Patients were categorized based on the following types of surgical intervention: isolated ascending aortic replacement, ascending aortic replacement with concomitant aortic valve replacement, aortic root replacement, partial or total arch replacement, and partial or total arch replacement with concomitant aortic root replacement. The primary outcome was mortality rate, both in-hospital and at 10 years. Secondary outcomes were acute kidney injury requiring dialysis, neurological complications, a composite endpoint including in-hospital death, neurological complications and/or dialysis, and proximal endovascular or surgical aortic re-operations at 10 years. Results 3702 patients were included. The adjusted risk of in-hospital mortality was higher in all subsets of patients compared to those who underwent isolated ascending aortic replacement. The adjusted rates of in-hospital mortality ranged from 16.4% (95% c.i. 15.3 to 17.4) among patients who underwent isolated ascending aortic replacement to 27.7% (95% c.i. 23.3 to 31.2) among those who underwent aortic arch and concomitant aortic root replacement. The adjusted risks of neurological complications, renal replacement therapy and of the composite endpoint were significantly higher in patients who underwent partial/total aortic arch replacement. The adjusted risk estimates of 10-year mortality rate were markedly higher in patients who underwent partial/total aortic arch replacement with or without concomitant aortic root replacement. Extensive aortic repair did not significantly reduce the risk of distal or proximal aortic reoperations. Conclusion These findings suggest that, when feasible, limiting the extent of aortic replacement for acute type A aortic dissection may be beneficial in reducing mortality rate and major complications both in the short and long term. Trial Registration ClinicalTrials.gov identifier: NCT04831073.

Abdominal aortic aneurysms (AAA) are common, especially in men, and associated with a high mortality when ruptured. Clinical guidance for surgical repair is based on the maximum aortic diameter (>5.5 cm in men or 5 cm in women) but this is a poor indicator of clinical risk. Here, we examined micromechanical and biochemical properties of tissue excised from 21 patients undergoing repair for degenerative AAA using nanoindentation and biochemical assays (collagen elastin and glycosaminoglycans (GAGs)), along with 6 control aortic samples. AAA tissue properties were compared with peak wall stress (PWS), peak wall rupture risk (PWRR) localised rupture risk index (RRI) and wall stress (WS) determined from patient-specific finite element (FE) models, and with abdominal aortic calcification (AAC) scoring obtained from CT scans. The AAA samples had a lower median elastic modulus (72.4 kPa) and a higher IQR (86.8 kPa) relative to the controls (median 91.2 kPa, IQR 53.8 kPa). A heteroscedastic relationship was found in the AAA samples; patients with the highest median stiffness exhibited the largest IQR. Relative to controls, collagen was higher in the AAAs, whilst GAG and elastin were lower. Microcalcification was higher in the inner and middle layers of the vessel wall, matching the trend observed with stiffness. Correlative analysis showed that E was related to RRI but a complex, interplay of tissue properties contributed to overall PWRR. AAC was found to be inversely correlated with PWRR. Random forest modelling demonstrated that RRI is most influenced by E measured in the belly of the aneurysm, GAG, and collagen. In conclusion, micromechanical properties and calcification may be useful for patient-specific rupture risk prediction. STATEMENT OF SIGNIFICANCE: Abdominal aortic aneurysms (AAA) are more prevalent with age, and rupture is associated with a high mortality rate. Maximum aortic diameter, the main clinical criteria for surgical repair is a poor indicator of rupture risk (RR). We used micromechanical and biochemical characterisation, and computational modelling to understand RR in degenerative AAAs. The tissue elastic modulus was found to be an indicator of RR as was the in vivo abdominal aortic calcification (AAC) score with the latter having an inverse relationship with RR. Collagen and glycosaminoglycans levels were also key to RR. We demonstrate that RR is better indicated by AAC and tissue elastic properties than conventional clinical markers such as diameter alone. These findings can be exploited for patient-specific RR determination.

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.

Central blood pressure (CBP) measurements, compared to brachial blood pressure (bBP), offer a superior predictive accuracy for aortovascular disease outcomes. This emphasises the distinctiveness of central hemodynamic metrics such as CBP, measuring the pressure directly exerted from the cardiac muscle to the major arteries, and provides a more direct assessment of cardiovascular workload than bBP, which measures the pressure against peripheral artery walls. This review synthesises findings evaluating the correlation between CBP and key aortovascular disease markers. Thoracic aortic aneurysm (TAA) growth is a crucial aspect of aortovascular assessment. CBP more accurately correlates with arterial stiffness (AS), the growth of TAA, and cardiovascular diseases, offering a more dependable prediction of aortovascular diseases, adverse cardiovascular events (CVE) and organ damage compared to bBP. The incorporation of CBP into routine clinical practice could enhance aortovascular assessments and therapeutic strategies when compared to bBP, particularly through a deeper understanding of aortic wave dynamics, which could fundamentally alter aortovascular diagnostics and treatment. In conclusion, integrating CBP into aortovascular and cardiovascular risk management is encouraged. Further research is necessary to substantiate these aspects and explore the operative implications of CBP in clinical settings.

OBJECTIVES:Acute kidney injury (AKI) is a common consequence of surgical repair of the thoraco-abdominal aorta (TAA). Perfusion techniques aim to facilitate renal protection through oxygenation or hypothermia. This systematic review assesses renal and mortality outcomes by perfusion techniques to evaluate their ability to provide effective kidney protection. METHODS:PubMed, Web of Science, ClinicalTrials.gov and ClinicalTrialsRegister.EU were searched to identify relevant studies published from 1995 to 2024. Following quality assessment and data extraction, outcomes of the highest quality studies were used to synthesize a narrative discussion. RESULTS:Thirty-eight studies were analysed, featuring three extracorporeal strategies: left heart bypass (LHB; n = 22), cardiopulmonary bypass with deep hypothermic circulatory arrest (DHCA; n = 11) and partial cardiopulmonary bypass (pCPB; n = 10). Three categories of selective renal perfusion (SRP) strategy were identified: warm blood, cold blood and cold crystalloid. Five studies of 'very high' and 'high' quality demonstrate a 0-13.6% incidence of post-operative dialysis and 5.0-13.3% risk of operative mortality following LHB with cold crystalloid SRP. No studies in support of DHCA or pCPB provided a high quality of evidence. CONCLUSIONS:Left heart bypass with crystalloid SRP provides a benchmark for rates of dialysis and mortality following TAA repair. However, AKI remains significant, emphasizing the need for continued innovation in SRP, and a greater understanding of overlooked risk factors. DHCA and pCPB are supported by low-quality evidence, meaning that prospective research is necessary to enable fair comparison. Finally, consensus on data reporting is recommended to improve the quality of future studies in this area.

Acute type A aortic dissection (ATAAD) is traumatic and life-threatening involving a split of the intima media along a variable length of the aorta from aortic root to aortic bifurcation. The pathology results in a local and systemic inflammatory process with elevated inflammatory markers observed at hospital admission. This systematic literature review aimed to compare the effectiveness of admission inflammatory markers in predicting adverse outcomes in postoperative ATAAD patients. Eligibility criteria included studies reporting postoperative outcomes or receiver operating characteristic results stratified by routine admission markers of inflammation in ATAAD patients. The study protocol was registered with PROSPERO (CRD42022366509). Following abstract and full-text screening, 79 studies were included in the analysis, with 39 included in the meta-analysis. Meta-analyses using random effects models of white blood cell count, neutrophil count, and neutrophil to lymphocyte ratio stratified by survival indicated that levels were significantly lower in survivors than nonsurvivors. The mean difference for white blood cell count was 1.51 (confidence interval [CI = 1.07, 1.95]), neutrophil count 1.50 [CI = 1.05, 1.95], and neutrophil to lymphocyte ratio 3.45 [CI = 2.50, 4.41]. Similarly, survivors had lower C-reactive protein levels than nonsurvivors (standardized mean difference = 0.5227 [CI = 0.1781, 0.8672]). Conversely, lymphocyte counts were higher in survivors than nonsurvivors (mean difference = -0.12 [CI = -0.18, -0.06]). All models had significant heterogeneity despite using random effects models, likely due to the multitude of presentations. Hierarchical summary receiver operating characteristic models were performed for neutrophil-to-lymphocyte ratio and C-reactive protein and showed similar sensitivity at detecting mortality in ATAAD patients for each fixed specificity. Data showed that deranged inflammatory markers are associated with poorer outcomes in ATAAD; however, none of these measures provide suitable prognostic markers alone. Continued development of multifactorial risk scores, including inflammatory markers and other factors, such as thrombotic measures, may enable clinically relevant prognostic tools and risk stratification.

BACKGROUND:Cross-seeding and co-assembly of multiple amyloid species are increasingly recognised in various organs and amyloidoses. Medin and wild-type transthyretin (TTR) both form age-related amyloid deposits and have been identified within the aortic wall. Given the emerging role of amyloid in aortic disease, this study investigates the potential colocalisation of TTR and medin in the aorta. METHODS:Medin and TTR levels were measured in thoracic aortic wall samples from 30 patients undergoing surgical replacement for aortic aneurysm. Immunohistochemistry was performed on five aortic wall samples and two excised aortic valves to assess colocalisation patterns. In vitro assays, including Thioflavin T fluorescence and immunogold labelling electron microscopy, evaluated protein co-aggregation and fibril formation. Cellular toxicity assays examined the impact of TTR on medin aggregates. RESULTS:A positive correlation was observed between medin and TTR levels in the aortic wall. In vitro assays revealed enhanced fibril formation and co-aggregation, with TTR reducing the cellular toxicity of medin aggregates, suggesting altered fibril properties. Immunohistochemistry confirmed colocalisation of medin and TTR in both aortic wall and valve samples. CONCLUSIONS:This study identifies a novel association between medin and TTR, highlighting a potential role for co-aggregation in vascular amyloid deposition.

OBJECTIVES:Post-cardiac and aortic surgery stroke is often underreported. We detail our single-centre experience the following introduction of comprehensive consultant-led daily stroke service, to demonstrate the efficacy of a stroke team in recovery from stroke following cardiac and aortic surgeries. METHODS:This retrospective, single-centre observational cohort study analysed consecutive patients undergoing cardiac and aortic surgery at our institution from August 2014 to December 2020. Main outcomes included stroke rate, predictors of stroke, and neurological deficit resolution or persistence at discharge and clinic follow-up. RESULTS:A total of 12,135 procedures were carried out in the reference period. Among these, 436 (3.6%) suffered a stroke. Overall survival to discharge and follow-up were 86.0% and 84.0% respectively. Independent risk factors for post-operative stroke included advanced age (OR 1.033, 95% CI [1.023, 1.044], p < .001), female sex (OR 1.491, 95% [1.212, 1.827], p < .001), history of previous cardiac surgeries (OR 1.670, 95% CI [1.239, 2.218], p < .001), simultaneous coronary artery bypass graft + valve procedures (OR 1.825, 95% CI [1.382, 2.382], p < .001) and CPB time longer than 240 min (OR 3.384, 95% CI [2.413, 4.705], p < .001). Stroke patients managed by the multidisciplinary team demonstrated significantly higher rates of survival at discharge (87.3% vs. 61.9%, p = .001). CONCLUSIONS:Perioperative stroke can be debilitating immediately long term. The involvement of specialist stroke teams plays a key role in reducing the long-term burden and mortality of this condition.

BACKGROUND:The outcomes after prolonged treatment in the intensive care unit (ICU) after surgery for Stanford type A aortic dissection (TAAD) have not been previously investigated. METHODS:This analysis included 3538 patients from a multicenter study who underwent surgery for acute TAAD and were admitted to the cardiac surgical ICU. RESULTS:The mean length of stay in the cardiac surgical ICU was 9.9±9.5 days. The mean overall costs of treatment in the cardiac surgical ICU 24086±32084 €. In-hospital mortality was 14.8% and 5-year mortality was 30.5%. Adjusted analyses showed that prolonged ICU stay was associated with significantly lower risk of in-hospital mortality (adjusted OR 0.971, 95%CI 0.959-0.982), and of five-year mortality (adjusted OR 0.970, 95%CI 0.962-0.977), respectively. Propensity score matching analysis yielded 870 pairs of patients with short ICU stay (2-5 days) and long ICU stay (>5 days) with balanced baseline, operative and postoperative variables. Patients with prolonged ICU stay (>5 days) had significantly lower in-hospital mortality (8.9% vs. 17.4%, <0.001) and 5-year mortality (28.2% vs. 30.7%, P=0.007) compared to patients with short ICU-stay (2-5 days). CONCLUSIONS:Prolonged ICU stay was common after surgery for acute TAAD. However, when adjusted for multiple baseline and operative variables as well as adverse postoperative events and the cluster effect of hospitals, it was associated with favorable survival up to 5 years after surgery.

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.

Objective: To examine the management of distal aortic disease after total arch replacement with the frozen elephant trunk (TAR + FET) in patients with chronic thoracic aortic disease. Methods: Two centre retrospective study of consecutive patients treated between January 2010 and December 2019. The primary endpoint was 30 day or in hospital death. The secondary endpoint was midterm survival. Data are presented as median (interquartile range [IQR]). The X-2 or Fisher's exact test was used as appropriate. Estimated survival (standard error) was assessed by calculating the Kaplan-Meier product limit estimator with right censoring of survival data. A p value of < .050 was considered statistically significant. STROBE guidelines were followed. Results: A total of 158 patients (72 men; median age 70 years, IQR 64, 75; median distal aortic diameter 58 mm, IQR 46, 68; 127 aneurysmal disease, 31 chronic dissection) underwent TAR + FET. The peri-operative mortality rate was 10.1% (9/107 elective, 7/51 non-elective). Of 74 (46.8%) patients with a primary distal seal, seven (9.5%) died peri-operatively, the distal seal was maintained during follow up in 51, nine underwent late distal repair (two planned, seven unplanned; one open, eight endovascular; one peri-operative death) with a median interval to unplanned repair of 777 days (IQR 462, 1480), and seven with loss of seal had no intervention. Distal seal failed in 2/28 (7%) patients with a distal seal length > 30 mm and device oversizing > 10%, compared with 12/39 (31%) patients who did not meet these criteria (p = .031). In 84 patients without a primary distal seal, nine (10.7%) died peri-operatively, the distal aorta remained below the size threshold for repair during follow up in 12 patients, 44 had distal repair (median aortic diameter 64 mm, IQR 60, 75; eight open, one hybrid, 35 endovascular repairs; no deaths) at a median of 256 days (IQR 135, 740), and 19 did not have distal repair at the end of the follow up period: six died before planned repair at a median interval of 115 days (IQR 85, 120); eight were considered unfit; one was assessed as fit but declined; and four patients were awaiting assessment. Median follow up was 46 months (IQR 26, 75): no patients were lost to follow up. Estimated +/- standard error five year survival was 61.5 +/- 4.1%: elective 70.6 +/- 4.7%, non-elective 43.2 +/- 7.2%. Conclusion: TAR + FET achieved primary distal seal in 47% of patients, but late failure occurred in 21%. Distal repair was ultimately indicated in 84% of survivors without a primary distal seal and of these 70% underwent repair, almost 10% died before planned repair, and 13% were considered unfit. Earlier distal endovascular repair and better assessment of patient fitness may improve midterm outcomes.

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)

Objective:To evaluate the benefits of surgical repair acute type A aortic dissection (ATAAD) on survival of octogenarians. Methods:Patients who underwent surgery for acute ATAAD from the multicenter European Registry of Type A Aortic Dissection (ERTAAD) were the subjects of the present analysis. Results:326 (8.4%) patients were aged ≥ 80 years. Among 280 propensity score matched pairs, in-hospital mortality was 30.0% in patients aged ≥ 80 years and 20.0% in younger patients (P = 0.006), while 10-year mortality were 93.2% and 48.0%, respectively (P < 0.001). The hazard of mortality was higher among octogenarians up to two years after surgery, but it became comparable to that of younger patients up to 5 years. Among patients who survived 3 months after surgery, 10-year relative survival was 0.77 in patients aged < 80 years, and 0.46 in patients aged ≥ 80 years. Relative survival of octogenarians decreased markedly 5 years after surgery. Age ≥ 85 years, glomerular filtration rate, preoperative invasive ventilation, preoperative mesenteric mal-perfusion and aortic root replacement were independent predictors of in-hospital mortality among octogenarians (AUC = 0.792; E:O ratio = 0.991; CITL = 0.016; slope = 1.096). An additive score was developed. A risk score ≤ 1 was observed in 68.4% of patients, and their in-hospital mortality was 20.9%. Conclusions:Provided a thoughtful patient selection, surgery may provide a survival benefit in patients aged ≥ 80 years with ATAAD that, when compared to younger patients and the general population, may last up to 5 years after the procedure. These findings have significant epidemiologic and clinical relevance because of the increasing longevity of the population of the Western countries.

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.