TY - JOUR
T1 - Patients with type A acute aortic dissection presenting with major brain injury
T2 - Should we operate on them?
AU - Di Eusanio, Marco
AU - Patel, Himanshu J.
AU - Nienaber, Christoph A.
AU - Montgomery, Daniel M.
AU - Korach, Amit
AU - Sundt, Thoralf M.
AU - Devincentiis, Carlo
AU - Voehringer, Matthias
AU - Peterson, Mark D.
AU - Myrmel, Truls
AU - Folesani, Gianluca
AU - Larsen, Magnus
AU - Desai, Nimesh D.
AU - Bavaria, Joseph E.
AU - Appoo, Jehangir J.
AU - Kieser, Teresa M.
AU - Fattori, Rossella
AU - Eagle, Kim
AU - Di Bartolomeo, Roberto
AU - Trimarchi, Santi
PY - 2013/3
Y1 - 2013/3
N2 - Objectives: The management strategy remains controversial for patients presenting with type A acute aortic dissection with cerebrovascular accident or coma. The present study aimed to help guide surgeons treating these high-risk patients. Methods: Of 1873 patients with type A acute aortic dissection enrolled in the International Registry for Acute Dissection, 87 (4.7%) presented with cerebrovascular accident and 54 (2.9%) with coma. The hospital and 5-year results were stratified by the presence and type of brain injury (no injury vs stroke vs coma) and management type (medical vs surgical). Independent predictors of short- and mid-term survival were identified. Results: Presentation with shock, hypotension, or tamponade (46.8% vs 25.2%; P <.001) and arch vessel involvement (55.0% vs 36.1%; P <.001) was more likely in patients with brain injury. Surgical management was avoided more often in patients with coma (33.3%) or cerebrovascular accident (24.1%) than in those without brain injury (11.1%; P <.001). The overall hospital mortality was 22.7% without brain injury, 40.2% with cerebrovascular accident, and 63.0% with coma (P <.001). Mortality varied among the management types for both cerebrovascular accident (76.2% medical vs 27.0% surgical; P <.001) and coma (100% medical vs 44.4% surgical; P <.001). Postoperatively, cerebrovascular accident and coma resolved in 84.3% and 78.8% of cases, respectively. On logistic regression analysis, surgery was protective against mortality in patients presenting with brain injury (odds ratio 0.058; P <.001). The 5-year survival of patients presenting with cerebrovascular accident and coma was 23.8% and 0% after medical management versus 67.1% and 57.1% after surgery (log rank, P <.001), respectively. Conclusions: Brain injury at presentation adversely affects hospital survival of patients with type A acute aortic dissection. In the present observational study, the patients selected to undergo surgery demonstrated improved late survival and frequent reversal of neurologic deficits.
AB - Objectives: The management strategy remains controversial for patients presenting with type A acute aortic dissection with cerebrovascular accident or coma. The present study aimed to help guide surgeons treating these high-risk patients. Methods: Of 1873 patients with type A acute aortic dissection enrolled in the International Registry for Acute Dissection, 87 (4.7%) presented with cerebrovascular accident and 54 (2.9%) with coma. The hospital and 5-year results were stratified by the presence and type of brain injury (no injury vs stroke vs coma) and management type (medical vs surgical). Independent predictors of short- and mid-term survival were identified. Results: Presentation with shock, hypotension, or tamponade (46.8% vs 25.2%; P <.001) and arch vessel involvement (55.0% vs 36.1%; P <.001) was more likely in patients with brain injury. Surgical management was avoided more often in patients with coma (33.3%) or cerebrovascular accident (24.1%) than in those without brain injury (11.1%; P <.001). The overall hospital mortality was 22.7% without brain injury, 40.2% with cerebrovascular accident, and 63.0% with coma (P <.001). Mortality varied among the management types for both cerebrovascular accident (76.2% medical vs 27.0% surgical; P <.001) and coma (100% medical vs 44.4% surgical; P <.001). Postoperatively, cerebrovascular accident and coma resolved in 84.3% and 78.8% of cases, respectively. On logistic regression analysis, surgery was protective against mortality in patients presenting with brain injury (odds ratio 0.058; P <.001). The 5-year survival of patients presenting with cerebrovascular accident and coma was 23.8% and 0% after medical management versus 67.1% and 57.1% after surgery (log rank, P <.001), respectively. Conclusions: Brain injury at presentation adversely affects hospital survival of patients with type A acute aortic dissection. In the present observational study, the patients selected to undergo surgery demonstrated improved late survival and frequent reversal of neurologic deficits.
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U2 - 10.1016/j.jtcvs.2012.11.054
DO - 10.1016/j.jtcvs.2012.11.054
M3 - Article
C2 - 23410778
AN - SCOPUS:84873642562
VL - 145
JO - Journal of Thoracic and Cardiovascular Surgery
JF - Journal of Thoracic and Cardiovascular Surgery
SN - 0022-5223
IS - 3 SUPPL.
ER -