https://orcid.org/0000-0002-0069-3690
Figures
Abstract
Background
Acute type A aortic dissection (ATAAD) is a critical cardiovascular emergency that requires prompt surgical intervention for preserving life, particularly in patients with critical preoperative status. This retrospective study aimed to investigate the clinical features, early and late outcomes, and prognostic factors in patients undergoing aortic repair surgery for ATAAD complicated with preoperative shock.
Methods
Between April 2007 and July 2020, 694 consecutive patients underwent emergency ATAAD repair at our institution, including 162 (23.3%) presenting with preoperative shock (systolic blood pressure <90 mm Hg), who were classified into the survivor (n = 125) and non-survivor (n = 37) groups according to whether they survived to hospital discharge. The clinical demographics, surgical information, and postoperative complications were compared. Five-year survival and freedom from reoperation rates of survivors were analyzed using the Kaplan–Meier actuarial method. Multivariate logistic regression analysis was used to identify independent risk factors for in-hospital mortality.
Results
The in-hospital surgical mortality rate in patients with ATAAD and shock was 22.8%. The non-survivor group showed higher rates of preoperative cardiopulmonary resuscitation, acute myocardial infarction, and cerebral infarction, and was associated with longer cardiopulmonary bypass time, higher rates of total arch replacement and intraoperative extracorporeal membrane oxygenation implementation. The non-survivor group had higher blood transfusion volumes and rates of malperfusion-related complications. Multivariate analysis revealed that preoperative cardiopulmonary resuscitation, prolonged cardiopulmonary bypass time, and total arch replacement were risk factors for in-hospital mortality. For patients who survived to discharge, the 5-year cumulative survival and freedom from aortic reoperation rates were 75.6% (95% confidence interval, 67.6%–83.6%) and 82.6% (95% confidence interval, 74.2%–91.1%), respectively.
Conclusions
Preoperative shock in ATAAD is associated with a high risk of in-hospital mortality, particularly in patients who undergo cardiopulmonary resuscitation and complex aortic repair procedures with extended cardiopulmonary bypass. However, late outcomes are acceptable for patients who were stabilized through surgical treatment and survived to discharge.
Citation: Lin C-Y, Kao M-C, Lee H-F, Wu M-Y, Tseng C-N (2024) Analysis of outcomes and prognostic factor in acute type A aortic dissection complicated with preoperative shock: A single-center study. PLoS ONE 19(4): e0302669. https://doi.org/10.1371/journal.pone.0302669
Editor: Vincenzo Lionetti, Scuola Superiore Sant’Anna, ITALY
Received: January 8, 2024; Accepted: April 6, 2024; Published: April 30, 2024
Copyright: © 2024 Lin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: As containing identifying information, including individual patient’s age, gender, the specific date and details of hospital admission/surgical procedures, the data that we collected cannot be made publicly available for ethical and legal reasons. It is the requirement of the Institutional Review Board of Chang Gung Medical Foundation to review any request to share data publicly in order to protect patients' privacy. Requests for data can be sent to the Chang Gung Medical Foundation Institutional Review Board at irb1@cgmh.org.tw.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Acute type A aortic dissection (ATAAD) is a critical cardiovascular disease associated with high mortality and perioperative complication rates [1,2]. Prompt surgical intervention is essential to save lives, particularly in patients presenting with hemodynamic instability, rupture of the dissected aorta, or malperfusion of vital organs. It is also challenging for cardiothoracic surgeons because of the individual patient’s complexity of aorta anatomy and the rapid progression of disease. Despite improvements in management algorithms, surgical strategies, and cardiopulmonary bypass (CPB) techniques in the last few decades, preoperative hypotensive shock remains an important prognostic factor for ATAAD treatment [3]. The reported incidence of preoperative shock in the ATAAD population is 16–57% according to different international aortic dissection data registries [3–6]. It is associated with adverse clinical outcomes, including reduced surgical survival rates and increased risks of malperfusion-related complications such as cerebral injury and myocardial ischemia in patients undergoing ATAAD repair surgery [7]. Nevertheless, a detailed comparison of the clinical features and surgical outcomes between survivors and non-survivors in this high-risk population has been underreported in previous literatures. In this study, we performed a retrospective analysis using a database from an individual aortic intervention center to investigate the clinical demographics, surgical information, early and late outcomes, and prognostic factors of patients who underwent aortic repair surgery for ATAAD complicated with preoperative hypotensive shock.
Materials and methods
Patient enrollment and preoperative management
The study protocol was approved by the Institutional Review Board of Chang Gung Medical Foundation (registration number 202301843B0). All data were accessed and analyzed using the institutional database of aortic dissection. The data were accessed for research purposes on December 18, 2023. The need for informed consent was waived due to the retrospective nature of the study, and all patients’ data were anonymized before being accessed by researchers. A total of 694 consecutive patient records undergoing emergency aortic repair surgery for ATAAD at our institution were collected between April 2007 and July 2020. After excluding those hemodynamically stable before surgery, this study investigated 162 patients classified with preoperative hypotensive shock (systolic blood pressure <90 mmHg) according to the vital sign data recorded upon emergency department admission. The annual cases of the overall cohort, shock, and non-shock patients during the study period are shown in Fig 1. All patients were diagnosed using helical computed tomography and transferred to the operating room for emergency aortic repair surgery within 60 min after the initial diagnosis. The 162 investigated patients were dichotomized into the survivor (n = 125) and non-survivor (n = 37) groups according to whether they survived to hospital discharge. For preoperative hemodynamic support, medical resuscitation was applied first, including intravenous fluid supplementation and/or inotropic infusion, according to the established guidelines for advanced cardiovascular life support (ACLS) developed by the American Heart Association during the study period [8–10]. Cardiopulmonary resuscitation (CPR) and/or surgical rescue managements were implemented promptly if patients presented with refractory hemodynamic instability or cardiac arrest based on the standardized protocols of our institute [11,12]. Patients underwent standard external CPR, which was performed by physicians with ACLS certification. Surgical resuscitation procedures, including emergent subxiphoid pericardiotomy and emergent cardiopulmonary bypass, were implemented according to the individual patient’s circumstance. In general, emergent subxiphoid pericardiotomy was performed if cardiac tamponade was confirmed based on preoperative imaging studies and on-site echocardiography; emergent cardiopulmonary bypass was performed if aortic rupture was suspected or if patients presented with refractory cardiac arrest without return of spontaneous circulation after CPR and medical resuscitation. European system for cardiac operative risk evaluation score (EuroSCORE) II, Leontyev score, and Rampoldi score were used for evaluate the surgical risk [13–15].
Aortic repair procedures and postoperative treatment
The aortic repair procedures for ATAAD were standardized at this institute, as discussed in previous studies [16,17]. For patients who presented with unstable conditions preoperatively, including shock, CPR, and vital organ malperfusion, femoral artery cannulation was commonly adapted first to establish prompt CPB to stabilize the patient’s hemodynamic status. Additional right axillary artery cannulation was used with combining the femoral arterial access, which generated double artery cannulation with antegrade cerebral perfusion strategy if the patient’s hemodynamics were relatively stabilized under medication and CPB. In contrast, isolated femoral artery cannulation combining superior vena cava cannulation with retrograde cerebral perfusion was preferred for patients with persistent critical hemodynamics refractory to medical and surgical resuscitation. Full sternotomy was routinely performed in all patients. Following the cannulation of the right atrium or vena cava, CPB with systemic hypothermia was performed. The tubular ascending aorta (AsAo) was completely resected and replaced with Dacron prosthetic grafts. Proximal anastomosis is usually performed first, followed by open distal anastomosis under deep hypothermic circulatory arrest (18–22°C). In general, the dissected aorta was replaced with Dacron prosthetic grafts according to the location of the entry tears and preoperative presentation. Concomitant aortic root and arch replacement were performed using a composite Valsava graft and branched Dacron graft, respectively, according to the location of the entry tear and preoperative clinical presentation, if feasible. All graft-aorta anastomoses were reinforced with Teflon strips and surgical sealants. During circulatory arrest, the femoral arterial flow was temporarily suspended, and selective antegrade cerebral perfusion through the right axillary artery or retrograde cerebral perfusion through the superior vena cava was implemented depending on the vascular access of CPB. After surgical repair of ATAAD, all patients were transferred to a specialized cardiovascular intensive care unit for further treatment and close observation of postoperative complications, including bleeding tendencies, arrhythmia, myocardial failure, organ malperfusion, and hemodynamic instability.
Statistical analyses
Statistical analyses were performed using SPSS for Windows (version 26.0; IBM Corp., Armonk, NY, USA). Data are presented as means ± standard deviation for continuous variables and numbers (n) and percentages (%) for categorical variables, respectively. To compare the intergroup disparities between the survivor and non-survivor groups, we used an independent t-test for continuous variables and the chi-square test for categorical variables, respectively. The preoperative and surgical variables were first tested using univariate logistic regression analysis. The significant variables in the univariate logistic regression analysis were further analyzed via the multivariate logistic regression analysis to identify the independent risk factors for in-hospital mortality. The Kaplan–Meier method was used to estimate the 5-year cumulative survival and freedom from aortic reoperation rates of the survivors. For all analyses, the statistical significance was set at P<0.05.
Results
Patient demographics
Table 1 lists the preoperative demographics, which showed no significant differences in age, sex, and chronic comorbidities. The mean age was 61.9±13.8 years, and 36.4% of the patients were females. The non-survivor group revealed a more critical preoperative condition, including lower systolic blood pressure (73.5±11.5 mmHg versus 68.3±14.7 mmHg; P = 0.027), higher rates of CPR (8.0% versus 35.1%; P<0.001), cerebral infarction (3.2% versus 13.5%; P = 0.016), myocardial infarction (0.8% versus 8.1%; P = 0.012), a higher EuroSCORE II estimated in-hospital mortality rate (22.1±3.9% versus 54.5±5.6%; P<0.001), higher Leontyev score (5.3±1.6 versus 9.6±1.5; P<0.001) and Rampoldi score (1.8±0.4 versus 3.8±0.5; P<0.001). Chest or back pain was the most common clinical presentation in both groups, followed by hemopericardium/cardiac tamponade, organ malperfusion, and severe aortic regurgitation.
Surgical information
Table 2 provides detailed information on surgical variables. The vascular access of cannulation and cerebral perfusion strategies did not differ significantly between the two groups. However, the non-survivor group exhibited a higher rate of total arch replacement (4.8% versus 16.2%; P = 0.020), as well as longer CPB (249.5±70.8 min versus 316.7±117.3 min; P<0.001) and aortic clamping (161.4±51.4 min versus 186.5±79.1 min; P<0.001) times. A higher rate of intraoperative myocardial failure with extracorporeal membrane oxygenation support (2.4% versus 10.8%; P = 0.027) was observed in the non-survivor group.
Postoperative complications
Table 3 shows the postoperative mortality and morbidity. The overall in-hospital mortality rate was 22.8%. Myocardial failure was the most common cause of mortality (40.5%), followed by bleeding (27.0%), brain stem failure (21.6%), and sepsis (10.8%). The blood transfusion volumes within 24 h after surgery were higher in the non-survivor group. The non-survivor group also had higher rates of malperfusion-related complications, including brain infarction (12.8% versus 32.4%; P = 0.006) and limb ischemia (1.6% versus 10.8%; P = 0.009) than the survivor group.
Risk factors associated with in-hospital mortality
Table 4 shows the logistic regression analyses for patients with shock at risk of in-hospital mortality, including preoperative systolic blood pressure, CPR, myocardial infarction, cerebral infarction, total arch replacement, CPB time, aortic clamping time, and intraoperative extracorporeal membrane oxygenation implementation. Three significant risk factors were identified: preoperative CPR (odds ratio [OR], 5.60; 95% confidence interval [CI], 1.10–28.62; P = 0.038), total arch replacement (OR, 4.98; 95% CI, 1.21–20.55; P = 0.026), and CPB time (OR, 1.01; 95% CI, 1.00–1.02; P = 0.005).
Cumulative 5-year survival and freedom from reoperation rates
The average duration of follow-up was 4.8 ± 3.9 years (median, 4.2; range, 0.1–14.5 years). The cumulative survival rates for patients who survived to discharge were 89.60% (95% CI, 84.25%–94.95%), 77.98% (95% CI, 70.45%–85.51%), and 75.61% (95% CI, 67.61%–83.61%) at 1, 3, and 5 years, respectively (Fig 2). The freedom from aortic reoperation rates were 93.35% (95% CI, 88.90%–97.80%), 88.10% (95% CI, 81.93%–94.27%), and 82.64% (95% CI, 74.23%–91.05%) at 1, 3, and 5 years, respectively (Fig 3).
Discussion
Presenting low blood pressure is reportedly a major risk factor for mortality and adverse events in the treatment of cardiovascular emergencies, including acute coronary syndromes, cardiogenic shock, acute heart failure, and acute aortic dissection [3,18,19]. However, comparisons of clinical features and surgical outcomes between the survivors and non-survivors among patients undergoing ATAAD repair complicated with preoperative shock have been underreported in previous studies. In this retrospective cohort study, we investigated 162 consecutive patients (125 survived and 37 non-survived to hospital discharge) who underwent emergency aortic repair for ATAAD during the study period. This study had several clinical implications. First, the incidence of preoperative hypotensive shock (162/694; 23.3%) was considerable in the ATAAD population and associated with a high risk of mortality and perioperative complications. Second, patients who underwent preoperative CPR, total arch replacement, and prolonged CPB time are at risk for in-hospital mortality in ATAAD with shock. Patients complicated by shock, particularly those with CPR, may adapt to conservative surgical strategies under comprehensive preoperative assessment to reduce the complexity of aortic repair procedure and subsequent complications, if feasible. Third, with timely surgical treatment to stabilize critical hemodynamics, patients who survived to discharge had acceptable late outcomes, including the 5-year survival and aortic reoperation rates.
The pathophysiology associated with shock complicated by ATAAD could be multifactorial, including malperfused vital organ systems, severe neurological dysfunction, acute heart failure, cardiac tamponade, and aortic rupture [20,21]. Furthermore, cardiac tamponade caused by hemorrhagic pericardial effusion leaking from the dissected AsAo is the leading cause of preoperative hemodynamic instability and death in patients with ATAAD before they present for emergency medical intervention [22,23]. It is also identified as a primary risk factor for perioperative mortality and morbidity [24,25]. In dissected AsAo, the persistent pressurized aortic false lumen could cause elastic microstructure injuries of the adventitia and aortic wall weakening, which could lead to severe bleeding or even frank rupture of AsAo into the pericardial space. Rapid accumulation of hemorrhagic pericardial fluid under pressure would compress the cardiac chambers, causing the blockage of systemic venous return to the right atrium and compromised cardiac output. Furthermore, this severe complication is also characterized by increased risks of organ malperfusion, neurologic deficits, and postoperative bleeding owing to the influence of unstable hemodynamics and related consumption coagulopathy.
The reported incidence of hemopericardium is approximately 24–29% in the general ATAAD population [26,27]. In contrast, 30–61% of patients in ATAAD with shock were complicated by periaortic hematoma or hemopericardium [3,7]. Similar outcomes were observed in this study. A total of 51.9% of patients were diagnosed with preoperative hemopericardium according to imaging studies, 34.6% of whom presented with cardiac tamponade. In previous studies reported from this institute investigating the general ATAAD population, the incidence rates of preoperative hemopericardium and cardiac tamponade were only approximately 28–33% and 11–13%, respectively [12,15,28,29]. At our institute, an aggressive surgical rescue strategy was adopted for this high-risk subgroup. A total of 30.2% of patients underwent surgical resuscitation procedures, including 20.4% of emergent subxiphoid pericardiotomy and 15.4% of emergent CPB, to temporarily stabilize the patient’s critical hemodynamics before implementing aortic repair surgeries. Furthermore, we found that the in-hospital mortality rates were 16.1% (9/56) and 26.4% (28/106) in patients with shock caused by cardiac tamponade and other etiologies, respectively. This result could be explained by that prompt and accurate management including medical resuscitation and surgical rescue procedures, would efficiently reverse the critical hemodynamics resulting from cardiac tamponade. Therefore, the treatment of ATAAD complicated by cardiac tamponade should be prioritized to achieve better survival. We suggest that an aggressive strategy of surgical rescue and early management decisions based on timely diagnostic studies are essential to stabilize patients with refractory hemodynamic instability and optimize surgical outcomes in this disastrous scenario. Otherwise, a large proportion of patients may not survive until surgery.
This study identified several risk factors associated with in-hospital mortality, including preoperative CPR for hemodynamic collapse. The reported incidence of preoperative CPR ranges from 3.4% to 6.8% in previous studies [12,30,31]. As a recognized preoperative risk factor for ATAAD, the early surgical mortality rate ranges from 43% to 95% [12,30,32], which is approximately three to five times higher than that of the general ATAAD population [1,2]. In the present study, 14.2% (23/162) of patients underwent CPR before ATAAD repair, and 56.5% (13/23) did not survive to discharge. We suggest several interpretations for this unfavorable outcome. First, manual external cardiac compression can generate only 20–30% of the normal cardiac output under standard CPR [33]. Furthermore, maintaining the quality of external cardiac massage during the emergency transportation of patients is challenging, prolonging the time of systemic hypoperfusion before surgical intervention. The performer’s fatigue could also reduce CPR efficiency. In this low-flow state, tissue hypoxia persists until effective spontaneous perfusion is restored, or extracorporeal circulation is initiated. However, an irreversible damage could have developed to the vital organs, particularly the heart and brain. Second, according to previous studies, if patients do not return to spontaneous circulation after utilizing immediate medical and surgical resuscitation, the mortality rate is high, which ranges 57–100% [12,30,34]. In this study, a total 14.2% of patients underwent CPR and 30.2% underwent surgical resuscitation procedures before surgery. Seven patients did not return to spontaneous circulation after resuscitation, and only one patient survived after surgery. According to our experience, most of these patients presented with extensive non-viable myocardial tissue and significant cardiac failure after sternotomy. Furthermore, the cardiac contractility of these patients generally showed limited improvement after completion of the aortic repair procedure. These patients usually died within 48 h after surgery. Except for surgical intervention, no further effective treatments are available for ATAAD post CPR, and decisions about the discontinuation of life-saving processes could be difficult after making huge efforts for emergency preoperative treatment and in consideration of the will of patients and their families [34]. However, we suggest that conservative surgical strategies may be reasonable for patients complicating with refractory cardiopulmonary failure without spontaneous circulation because an extremely unfavorable survival is expected. Furthermore, patients complicated by shock, particularly those with CPR, may adapt to conservative aortic repair strategies under comprehensive preoperative assessment to reduce the complexity of surgical procedure and CPB duration for optimal outcome, if feasible. Several operative risk scoring systems, including EuroSCORE II, Leontyev score, and Rampoldi score were used to evaluate the surgical risk for patients undergoing ATAAD repair in this study. The non-survivor group revealed significant higher scores in all of these risk-prediction models, which were consistent with the observed outcomes in the present study. Therefore, in addition to preoperative CPR, surgeons may also take into consideration the appropriate surgical strategies for patients exhibiting high operative risks based on the established prediction systems.
Limitations
This study had several limitations. First, as a retrospective and non-randomized controlled study, potential bias may have existed that could influence the homogeneity of preoperative and operative variables between the investigated groups. Furthermore, the pathophysiology associated with shock complicated by ATAAD could be complex and multifactorial. The definite cause of preoperative shock for each individual patient might be difficult to clearly categorize. Second, the treatment protocols for ATAAD were based on the institutional consensus and established guidelines. However, the final decision was at the operating surgeon’s discretion, according to a comprehensive consideration of each individual patient’s clinical condition. Therefore, a conservative aortic repair strategy may be implemented in patients with critical conditions, including cardiopulmonary failure, sustained hypotension, CPR, and aortic rupture detected through imaging studies. Third, because this retrospective cohort study spanned a period of nearly 14 years, the technology of CPB, myocardial protection, and cerebral protection strategies for ATAAD surgery, as well as advanced cardiovascular life support management and intensive care protocols may have changed over time. Finally, despite the substantial early and late outcomes presented in this study, an extended follow-up study should be conducted in the future to further analyze the long-term outcomes in patients who undergo surgical treatment for ATAAD complicated by preoperative shock.
Conclusions
The presence of hypotensive shock before ATAAD repair surgery is associated with a high risk of in-hospital mortality and postoperative complications, particularly in patients who undergo cardiopulmonary resuscitation, complex aortic repair procedures, and prolonged cardiopulmonary bypass time. However, once these high-risk patients are stabilized through surgery and survive to hospital discharge, the late outcomes, including survival and aortic reoperation rates during a 5-year follow-up, are acceptable.
References
- 1. Pape LA, Awais M, Woznicki EM, Suzuki T, Trimarchi S, Evangelista A, et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the International Registry of Acute Aortic Dissection. J Am Coll Cardiol. 2015;66:350–358.
- 2. Conzelmann LO, Krüger T, Hoffmann I, Rylski B, Easo J, Oezkur M, et al. German Registry for Acute Aortic Dissection Type A (GERAADA): initial results. Herz. 2011;36:513–524. pmid:21887529.
- 3. Bossone E, Gorla R, LaBounty TM, Suzuki T, Gilon D, Strauss C, et al. Presenting Systolic Blood Pressure and Outcomes in Patients With Acute Aortic Dissection. J Am Coll Cardiol. 2018;71:1432–1440. pmid:29598863.
- 4. Ghoreishi M, Sundt TM, Cameron DE, Holmes SD, Roselli EE, Pasrija C, et al. Factors associated with acute stroke after type A aortic dissection repair: An analysis of the Society of Thoracic Surgeons National Adult Cardiac Surgery Database. J Thorac Cardiovasc Surg. 2020;159:2143–2154.e3. pmid:31351776.
- 5. Conzelmann LO, Weigang E, Mehlhorn U, Abugameh A, Hoffmann I, Blettner M, et al. Mortality in patients with acute aortic dissection type A: analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac Surg. 2016;49:e44–52. pmid:26510701.
- 6. Zindovic I, Gudbjartsson T, Ahlsson A, Fuglsang S, Gunn J, Hansson EC, et al. Malperfusion in acute type A aortic dissection: An update from the Nordic Consortium for Acute Type A Aortic Dissection. J Thorac Cardiovasc Surg. 2019;157:1324–1333.e6. pmid:30578066.
- 7. Bossone E, Pyeritz RE, Braverman AC, Peterson MD, Ehrlich M, O’Gara P, et al. Shock complicating type A acute aortic dissection: Clinical correlates, management, and outcomes. Am Heart J. 2016;176:93–99. pmid:27264225.
- 8. ECC Committee, Subcommittees and Task Forces of the American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2005;112:IV1–IV203. pmid:16314375.
- 9. Field JM, Hazinski MF, Sayre MR, Chameides L, Schexnayder SM, Hemphill R, et al. Part 1: executive summary: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:S640–S656. pmid:20956217.
- 10. Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, et al. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132:S444–S464. pmid:26472995.
- 11. Lin CY, Wu MY, Tseng CN, Chang YS, Liu YC, Lu CH, et al. Surgical rescues for critical hemopericardium complicated by acute type A aortic dissection: Emergent subxiphoid pericardiotomy or cardiopulmonary bypass first? PLoS One. 2020;15:e0229648. pmid:32119707.
- 12. Lin CY, Tseng CN, Lu CH, Tung TH, Tsai FC, Wu MY. Surgical results in acute type A aortic dissection with preoperative cardiopulmonary resuscitation: Survival and neurological outcome. PLoS One. 2020;15:e0237989. pmid:32834010.
- 13. Nashef SA, Roques F, Sharples LD, Nilsson J, Smith C, Goldstone AR, et al. EuroSCORE II. Eur J Cardiothorac Surg. 2012;41:734–744. pmid:22378855.
- 14. Leontyev S, Légaré JF, Borger MA, Buth KJ, Funkat AK, Gerhard J, et al. Creation of a Scorecard to Predict In-Hospital Death in Patients Undergoing Operations for Acute Type A Aortic Dissection. Ann Thorac Surg. 2016;101:1700–1706. pmid:26794886.
- 15. Rampoldi V, Trimarchi S, Eagle KA, Nienaber CA, Oh JK, Bossone E, et al. Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score. Ann Thorac Surg. 2007;83:55–61. pmid:17184630.
- 16. Lin CY, See LC, Tseng CN, Wu MY, Han Y, Lu CH, et al. Surgical outcomes analysis in patients with uncomplicated acute type A aortic dissection: a 13-year institutional experience. Sci Rep. 2020;10:14883. pmid:32913262.
- 17. Lin CY, Tseng CN, Lee HA, Ho HT, Tsai FC. Double arterial cannulation strategy for acute type A aortic dissection repair: A 10-year single-institution experience. PLoS One. 2019;14:e0211900. pmid:30726302.
- 18. Dorresteijn JA, van der Graaf Y, Spiering W, Grobbee DE, Bots ML, Visseren FL, et al. Relation between blood pressure and vascular events and mortality in patients with manifest vascular disease: J-curve revisited. Hypertension. 2012;59:14–21. pmid:22068865.
- 19. Eagle KA, Lim MJ, Dabbous OH, Pieper KS, Goldberg RJ, Van de Werf F, et al. A validated prediction model for all forms of acute coronary syndrome: estimating the risk of 6-month postdischarge death in an international registry. JAMA. 2004;291:2727–2733. pmid:15187054.
- 20. Hiratzka LF, Bakris GL, Beckman JA, Bersin RM, Carr VF, Casey DE Jr, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with Thoracic Aortic Disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation. 2010;121:e266–369. pmid:20233780.
- 21. Conzelmann LO, Weigang E, Mehlhorn U, Abugameh A, Hoffmann I, Blettner M, et al. Mortality in patients with acute aortic dissection type A: analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac Surg. 2016;49:e44–52. pmid:26510701.
- 22. Hagan PG, Nienaber CA, Isselbacher EM, Bruckman D, Karavite DJ, Russman PL, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 2000;283:897–903. pmid:10685714.
- 23. Murai T, Baba M, Ro A, Murai N, Matsuo Y, Takada A, et al. Sudden death due to cardiovascular disorders: a review of the studies on the medico-legal cases in Tokyo. Keio J Med 2001;50:175–181. pmid:11594040.
- 24. Apaydin AZ, Buket S, Posacioglu H, Islamoglu F, Calkavur T, Yagdi T, et al. Perioperative risk factors for mortality in patients with acute type A aortic dissection. Ann Thorac Surg. 2002;74:2034–2039. pmid:12643392.
- 25. Tsukube T, Okita Y. Cardiac tamponade due to aortic dissection: clinical picture and treatment with focus on pericardiocentesis. E-J Cardiol Pract 2017;15:18.
- 26. Buonocore M, Amarelli C, Scardone M, Caiazzo A, Petrone G, Majello L, et al. Cerebral perfusion issues in acute type A aortic dissection without preoperative malperfusion: how do surgical factors affect outcomes? Eur J Cardiothorac Surg. 2016;50:652–659. pmid:27165770.
- 27. Wong DR, Coselli JS, Palmero L, Bozinovski J, Carter SA, Murariu D, et al. Axillary artery cannulation in surgery for acute or subacute ascending aortic dissections. Ann Thorac Surg. 2010;90:731–737. pmid:20732486.
- 28. Lin CY, Tung TH, Wu MY, Tseng CN, Tsai FC. Surgical outcomes of DeBakey type I and type II acute aortic dissection: a propensity score-matched analysis in 599 patients. J Cardiothorac Surg. 2021;16:208. pmid:34330304.
- 29. Lin CY, Lee CY, Lee HF, Wu MY, Tseng CN, Tsai FC, et al. Postoperative Stroke After Type A Aortic Dissection Repair: Hemorrhage Versus Ischemia. World J Surg. 2022;46:690–700. pmid:34751804.
- 30. Pan E, Wallinder A, Peterström E, Geirsson A, Olsson C, Ahlsson A, et al. Outcome after type A aortic dissection repair in patients with preoperative cardiac arrest. Resuscitation. 2019;144:1–5. pmid:31505231.
- 31. Chien TM, Li WY, Wen H, Huang JW, Hsieh CC, Chen HM, et al. Stable haemodynamics associated with no significant electrocardiogram abnormalities is a good prognostic factor of survival for acute type A aortic dissection repair. Interact Cardiovasc Thorac Surg. 2013;16:158–165. pmid:23166202.
- 32. Meron G, Kürkciyan I, Sterz F, Tobler K, Losert H, Sedivy R, et al. Non-traumatic aortic dissection or rupture as cause of cardiac arrest: presentation and outcome. Resuscitation. 2004;60:143–150. pmid:15036731.
- 33. Jiang L, Zhang JS. Mechanical cardiopulmonary resuscitation for patients with cardiac arrest. World J Emerg Med. 2011;2:165–168. pmid:25215003.
- 34. Uehara K, Matsuda H, Matsuo J, Inoue Y, Shijo T, Omura A, et al. Surgical outcomes of acute type A aortic dissection in patients undergoing cardiopulmonary resuscitation. J Thorac Cardiovasc Surg. 2021;161:1173–1180. pmid:32008759.