Acute thoracic aortic dissection (ATAD) is a devastating condition associated with a high mortality rate. Recent reports suggest that its incidence is rising. Utilizing nationwide data comprising the ...whole Icelandic population, we aimed to determine the incidence, mortality rate and time-dependent mortality risk of ATAD.
Data were retrospectively collected using centralized hospital discharge registries, autopsy records and Cause of Death Registry in Iceland from 1992 to 2013.
Age- and gender-adjusted incidence of ATAD was 2.53/100 000/year, and no significant change in incidence was observed during the study period. The mean age was 66.9 ± 13.6 years and 66.0% (101/153) were Stanford type A. Of the whole group, 17.6% (27/153) died prior to hospital arrival, whereas the risk of death for patients who arrived alive to a hospital was 21.4% (27/126) within 24 h and 45.2% (57/126) at 30 days. During the course of the study, patients with type A dissection were more likely to undergo an operation and the management of type B dissection changed from open to endovascular repair. The 30-day mortality rate declined every year and the 5-year survival rate improved in the last third of the study.
The incidence of ATAD was 2.53/100 000/year and remained constant throughout the study, contradicting recent perceptions of a rising incidence. ATAD, type A in particular, remains a highly lethal condition: Over half of all patients die within 30 days of the index event. A reduced 30-day mortality rate and an increased long-term survival rate indicate improved overall outcomes in patients with this complex condition.
The aim of this study was to examine the incidence, risk factors, and outcomes of patients with acute kidney injury (AKI) after surgery for acute type A aortic dissection (ATAAD) using the Nordic ...Consortium for Acute Type A Aortic Dissection registry.
Patients who underwent ATAAD surgery at 8 Nordic centers from 2005 to 2014 were analyzed for AKI according to the RIFLE criteria. Patients who died intraoperatively, those who had missing baseline or postoperative serum creatinine, and patients on preoperative renal replacement therapy were excluded.
AKI occurred in 382 of 941 patients (40.6%), and postoperative dialysis was required for 105 patients (11.0%). Renal malperfusion was present preoperatively in 42 patients (5.1%), of whom 69.0% developed postoperative AKI. In multivariable analysis patient-related predictors of AKI included age (per 10 years; odds ratio OR, 1.30; 95% confidence interval CI, 1.15-1.48), body mass index >30 kg/m
(OR, 2.16; 95% CI, 1.51-3.09), renal malperfusion (OR, 4.39; 95% CI, 2.23-9.07), and other malperfusion (OR, 2.10; 95% CI, 1.55-2.86). Perioperative predictors were cardiopulmonary bypass time (per 10 minutes; OR, 1.04; 95% CI, 1.02-1.07) and red blood cell transfusion (OR per transfused unit, 1.08; 95% CI, 1.06-1.10). Rates of 30-day mortality were 17.0% in the AKI group compared with 6.6% in the non-AKI group (P < .001). In 30-day survivors AKI was an independent predictor of long-term mortality (hazard ratio, 1.86; 95% CI; 1.24-2.79).
AKI is a common complication after surgery for ATAAD and independently predicts adverse long-term outcome. Of note one-third of patients presenting with renal malperfusion did not develop postoperative AKI, possibly because of restoration of renal blood flow with surgical repair. Mortality risk persists beyond the perioperative period, indicating that close clinical follow-up of these patients is required.
Mediastinitis continues to be an important and life-threatening complication after median sternotomy despite advances in prevention and treatment strategies, with an incidence of 0.25-5%. It can also ...occur as extension of infection from adjacent structures such as the oesophagus, airways and lungs, or as descending necrotizing infection from the head and neck. In addition, there is a chronic form of 'chronic fibrosing mediastinitis' usually caused by granulomatous infections. In this expert consensus, the evidence for strategies for treatment and prevention of mediatinitis is reviewed in detail aiming at reducing the incidence and optimizing the management of this serious condition.
To evaluate the effect of preoperative malperfusion on 30-day and late mortality and postoperative complications using data from the Nordic Consortium for Acute Type A Aortic Dissection (ATAAD) ...registry.
We studied 1159 patients who underwent ATAAD surgery between January 2005 and December 2014 at 8 Nordic centers. Multivariable logistic and Cox regression analyses were performed to identify independent predictors of 30-day and late mortality.
Preoperative malperfusion was identified in 381 of 1159 patients (33%) who underwent ATAAD surgery. Thirty-day mortality was 28.9% in patients with preoperative malperfusion and 12.1% in those without. Independent predictors of 30-day mortality included any malperfusion (odds ratio, 2.76; 95% confidence interval CI, 1.94-3.93), cardiac malperfusion (odds ratio, 2.37; 95% CI, 1.34-4.17), renal malperfusion (odds ratio, 2.38; 95% CI, 1.23-4.61) and peripheral malperfusion (odds ratio, 1.95; 95% CI, 1.26-3.01). Any malperfusion (hazard ratio, 1.72; 95% CI, 1.21-2.43), cardiac malperfusion (hazard ratio, 1.89; 95% CI, 1.24-2.87) and gastrointestinal malperfusion (hazard ratio, 2.25; 95% CI, 1.18-4.26) were predictors of late mortality. Malperfusion was associated with significantly poorer survival at 1, 3, and 5 years (95.0% ± 0.9% vs 88.7% ± 1.9%, 90.1% ± 1.3% vs 84.0% ± 2.4%, and 85.4% ± 1.7% vs 80.8% ± 2.7%; log rank P = .009).
Malperfusion has a significant influence on early and late outcomes in ATAAD surgery. Management of preoperative malperfusion remains a major challenge in reducing mortality associated with surgical treatment of ATAAD.
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Acute kidney injury (AKI) is a serious complication after major surgical procedures. We examined the incidence, risk factors, and mortality of patients who sustained AKI after abdominal surgery in a ...large population-based cohort.
All patients who underwent open and laparoscopic abdominal surgery (excluding genitourinary and abdominal vascular procedures), between 2007 and 2014 at the University Hospital in Reykjavik were identified and their perioperative serum creatinine (SCr) measurements used to identify AKI after surgery employing the Kidney Disease: Improving Global Outcome (KDIGO) criteria. Risk factors were evaluated using multivariate logistic regression analysis and 30-day mortality compared with a propensity score-matched control group.
During the 8-year period, a total of 11,552 abdominal surgeries were performed on 10,022 patients. Both pre- and postoperative SCr measurements were available for 3902 (33.8%) of the surgical cases. Of these, 264 (6.8%) were complicated by AKI; 172 (4.4%), 49 (1.3%), and 43 (1.1%) were classified as KDIGO stages 1, 2 and 3, respectively. The overall incidence of AKI for patients with available SCr values was 67.7 (99% confidence interval CI, 57.7-78.6) per 1000 surgeries. In logistic regression analysis, independent risk factors for AKI were female sex (odds ratio OR = 0.68; 99% CI, 0.47-0.98), hypertension (OR = 1.75; 99% CI, 1.10-2.74), preoperative chronic kidney disease (OR= 1.68; 99% CI, 1.12-2.50), ASA physical status classification of IV (OR = 9.48; 99% CI, 3.66-29.2) or V (OR = 21.4; 99% CI, 5.28-93.6), and reoperation (OR = 4.30; 99% CI, 2.36-7.70). Patients with AKI had greater 30-day mortality (18.2% vs 5.3%; P < 0.001) compared with propensity score-matched controls.
AKI is an important complication of abdominal surgery. In addition to sex, hypertension, and chronic kidney disease, ASA physical status classification is an independent predictor of AKI. Individuals who develop AKI have substantially worse short-term outcomes, including higher 30-day mortality, even after correcting for multiple patient- and procedure-related risk factors.
To describe the relationship between the extent of primary aortic repair and the incidence of reoperations after surgery for type A aortic dissection.
A retrospective cohort of 1159 patients treated ...for type A aortic dissection at eight Nordic low- to medium-sized cardiothoracic centers from 2005 to 2014. Data were gathered from patient records and national registries. Patients were separately divided into 3 groups according to the distal anastomoses technique (ascending aorta n = 791, hemiarch n = 247, and total arch n = 66), and into 2 groups for proximal repair (aortic root replacement n = 285 and supracoronary repair n = 832). Freedom from reoperation was estimated with cumulative incidence survival and Fine-Gray competing risk regression model was used to identify independent risk factors for reoperation.
The median follow-up was 2.7 years (range, 0-10 years). Altogether 51 out of 911 patients underwent reoperation. Freedom from distal reoperation at 5 years was 96.9%, with no significant difference between the groups (P = .22). Freedom from proximal reoperation at 5 years was 97.8%, with no difference between the groups (P = .84). Neither DeBakey classification nor the extent of proximal or distal repair predicted freedom from a later reoperation. The only independent risk factor associated with a later proximal reoperation was a history of connective tissue disease.
Type A aortic dissection repair in low- to medium-volume centers was associated with a low reoperation rate and satisfactory midterm survival. The extent of the primary repair had no significant influence on reoperation rate or midterm survival.
Open-distal anastomosis is the preferred technique over clamp-on technique for surgical repair of acute type A aortic dissection (ATAAD). The aim of this study was to define how outcomes of ATAAD ...were affected by the use of either technique.
Nordic Consortium for Acute Type A Aortic Dissection includes 8 academic cardiothoracic hospitals in 4 Nordic countries. The cohort consisted of 1134 patients, 153 clamp-on and 981 open-distal, from 2005 to 2014.
Patients who underwent operation with the clamp-on were younger, more frequently had coronary artery disease, bicuspid aortic valve, hypotension/shock or syncope, and a greater PennClass than open-distal patients. Postoperative cerebral vascular accident occurred less frequently in clamp-on (14/153, 10%) compared with the open-distal group (190/981, 20%). Clamp-on had greater 30-day mortality (39/153, 25%) than the open-distal group (158/981, 16%), and 5-year survival was also worse in clamp-on (61.8% ± 4.4%) compared with the open-distal group (73.0% ± 1.6%). The open-distal technique was used more frequently in greater-volume hospitals but was not independently associated with 30-day mortality. Preoperative condition was an independent risk factor whereas hospital volume and later year of operation were beneficial in regard to short-term outcome. Open-distal was independently associated with improved mid-term survival.
Patients who underwent operation with the clamp-on were sicker on presentation and had worse short- and mid-term survival compared with the open-distal group. Patients in the open-distal group had greater rates of cerebrovascular complications. The results support the routine use of open-distal anastomosis as the primary operative strategy for ATAAD, although clamp-on can be performed successfully in select cases.
Middle lobe syndrome (MLS) is a rare but important clinical entity that has been poorly defined in the literature. It is characterized by recurrent or chronic collapse of the middle lobe of the right ...lung but can also involve the lingula of the left lung. Pathophysiologically, there are two forms of MLS, namely obstructive and nonobstructive. Obstructive MLS is usually caused by endobronchial lesions or extrinsic compression of the middle lobe bronchus such as from hilar lymphadenopathy or tumors of neoplastic origin, resulting in postobstructive atelectasis and pneumonitis. In the nonobstructive type, no obstruction of the middle lobe bronchus is evident during bronchoscopy or with computerized tomography of the chest. The etiology of the nonobstructive form is not completely understood. Inefficient collateral ventilation, infection and inflammation in the middle lobe or lingula are thought to play a role, and bronchiectasis is the most common histological finding. Patients with proven endobronchial lesions or malignancy are usually offered surgical resection directly. This contrasts with nonobstructive MLS, where most patients respond to medical treatment consisting of bronchodilators, mucolytics and broad-spectrum antibiotics. However, some patients do not respond to conservative treatment and may suffer irreversible damage of the middle lobe or lingula, in addition to having recurrent symptoms of infection or inflammation. These selected patients can be offered surgical resection of the middle lobe or lingula, which is associated with a low mortality rate and favorable outcome.
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