Aggregate Analysis And Risk Factor Investigation Of Acute Stanford Type Aaortic Dissection

【Objective】This topic is designed to analyze the clinical data of acute type A aortic dissection in our center,including epidemiology characteristics,treatment status and risk factors for in hospital death,basing on the establishment of the aortic dissection surgery database from January 1,2014 to May 31,2016.In this study,the clinical data of acute type A aortic dissection were analyzed retrospectively to discuss the main problems in present treatment process and seek improvement measures.【Methods】1.Establishment of the single center database of aortic dissection.Collecting the clinical date of patients with aortic dissection from January 1,2014 to May 31,2016 in our center by a registration form,which was made previously reference to the date content of the first multi-center aortic dissection registration in China and expert consultation.Transforming the registration forms into electronic database with the software designed in the cooperation with the computer network center of the Second Military Medical University.2.Clinical analysis of acute type A aortic dissection（1）In this part we screen patients diagnosed as acute Stanford A type aortic dissection in the database,and analyzes gender,age composition,onset season,regional distribution and other epidemiological distribution characteristics.（2）The analysis of the patient’s clinical manifestations,disease history,examination and blood tests after admission,etc.（3）The analysis the treatment process and prognosis in hospital.3.Analysis of risk factors for rupture death before surgery of the acute type A aortic dissection patients.（1）In this part we divide the acute type A aortic dissection into the rupture group and non-rupture group,then analysis the data by contrast,including the gender,age,time of onset,time of admission,time of rupture to death,time of underwent surgery,clinical manifestations after onset,disease history,examination and blood tests after admission.（2）According to the results of comparative analysis,we select clinical variables may related to rupture death to make single factor statistical analysis.（3）According to the results of the single factor statistical analysis,statistically significant factors were screened for independent risk factors by Logistic regression.4.Analysis of risk factors for surgery death of the acute type A aortic dissection patients.（1）In this part we screen patients underwent surgery in the database and divide them into death group and survival group,then analysis the data by contrast,including the gender,age,time of onset,time of admission,time of underwent surgery,clinical manifestations after onset,disease history,examination and blood tests after admission,operation content and surgical complications.（2）According to the results of comparative analysis,we select clinical variables may related to surgical death to make single factor statistical analysis.（3）According to the results of the single factor statistical analysis,statistically significant factors were screened for independent risk factors by Logistic regression.【Results】1.Establishment of the single center database of aortic dissection.（1）According to the discharge and admission registration of our department and the ICU,and the record of cardiopulmonary bypass surgery,verify the 456 patients with aortic dissection and collecte their clinical data,complete the data registration.（2）Input the data of every single patient by an electronic form and upload to the network information platform.An extensible single center database of aortic dissection was builted.2.Analysis of the clinical data of acute type A aortic dissection patients.（1）A total of 329 patients enrolled in this study and 96.4%of them were disgnosised as Debakey typeⅠ.The incidence of ATAAD patients increased significantly from November to March.The peak age of this group was 41 to 60 years old.The ratio of the male and female was 3.9:1（262:67）,and the female had a higher average age（54.5±12.8years VS 50.2±13.1 years,P=0.017）.Sixty-six percent of the patients had hypertension.Mafan syndrome was diagnosed in 32 patients and two-leaf aortic valve malformation was in four.（2）Most of the patients had an intimal tear in the ascending aortic（31.9%）and the aortic arch（37.1%）,and few had an aortic root tear（8.8%）.The white blood cell count raised above 10×10⁹ in sixty-two percent of the patients and it was correlated with the age,the time of onset and the oxygen saturation.We also find that the D-dimer raised rapidly after onset in 87.2%of the patients,reaching a peak with 6 to 8 hours,and was still high within 14 days.（3）The overall in hospital mortality was 20.1%（66/329）.The operation rate was75.1%（247/329）and the operative mortality was 9.3%（23/47）.The non-operative mortality was 52.4%（43/82）and the rupture death accounted for 47 percent of all in hospital death（31/66）.3.Analysis of risk factors for rupture death before surgery of the acute type A aortic dissection patients.（1）Three hundred and twenty-nine patients was enrolled in this study and thirty-one paients died of aortic rupture before surgery.By multivariate analysis,four independent risk factors for rupture death of ATAAD were identified:shock（OR:19.11,P<0.001）,pain requiring medication（OR:10.88,P<0.001）,a troponin level>0.7ng/ml（OR:6.24,P=0.002）,and a D-dimer level≥10μg/ml（OR:25.8,P<0.001）.（2）In this study,the ratio of the male and female was 3.9 and the ratio was 2.9 in the rupture group patients（23:8）.But the gender was not the risk factor for rupture death（P=0.135）.An age≥60 years（P<0.001）was an influential factor for rupture death but not an independent one,and further research was need to verify.（3）Coma（P<0.001）,weakness or absence of the limb pulse（P=0.002）,PaO₂<80mmHg（P=0.027）,an Urea nitrogen>8mmol/L（P=0.037）,ALT≥130U/L（P<0.001）,and a lactic acid≥3mmol/L（P=0.007）were influential factors of rupture death for ATAAD patients,but none was an independent risk factor.4.Analysis of risk factors for surgery death of the acute type A aortic dissection patients.（1）In this study,247 ATAAD patients underwent surgery and 23 died within 30 days after operation.The independent risk factors of operative death for ATAAD patients were an age≥68 years（OR:14.78,P=0.005）,preoperative shock（OR:13.50,P=0.034）,a troponin level>0.67ng/ml（OR:34.95,P<0.001）,a D-dimer level>13.1μg/ml（OR:11.79,P=0.002）,postoperative respiratory insufficiency（OR:4.58,P=0.032）,and postoperative hepatic dysfunction（OR:32.47,P<0.001）.（2）We can’t prove that the gender（P=0.416）,BMI（P=0.434）,and history of disease are risk factors of operative death for ATAAD patients.The systolic blood pressure on admission<105mmHg（P=0.004）,preoperative hepatic（P=0.001）or kidney（P=0.006）dysfunction,heart valve or myocardial function,had important influence on operative prognosis by single factor analysis.The operation process had no significant effect on the prognosis in this study.【Conclusions】1.The single-center aortic dissection database was successfully constructed by collecting patient information through a standard form,inputing data thourgh an electronic form,uploading to the network information platform for data storage and management.2.The incidence of acute type A aortic dissection was significantly increased in winter and male had priority,which was consistent with the previous results reported in the literature.Hypertension was the main etiology.The D-dimer raised rapidly after onset and reached a peak with 6 to 8 hours,but was still high within 14 days.The mortality was high for ATAAD patients and the aortic rupture was the main cause for in hospital death.The operative mortality was much lower than overall in hospital mortality.The operative rate in this study,and improving the operation rate could reduce the in hospital mortality and ameliorate the prognosis of patients.3.Shock concomitant,pain requiring medication or poor control with medication,a troponin level>0.7ng/ml,and a D-dimer level≥10μg/ml,were independent risk factors of rupture death for ATAAD patient before surgery.The age,syncope,coma,hemiplegia,respiratory insufficiency,weakness or absence of the limb pulse,and a lactic acid≥3mmol/L were influential factors of rupture death for ATAAD patients,but none was an independent risk factor.4.The independent risk factors of operative death for ATAAD patients were an age≥68 years,preoperative shock,a troponin level>0.67ng/ml,a D-dimer level>13.1μg/ml,postoperativerespiratoryinsufficiency,andpostoperativehepaticdysfunction.Hypotension on admission,preoperative hepatic or kidney dysfunction,heart valve or myocardial function,were influence factors for operation prognosis.5.Compared with previous literature,the conclusions of this project has similarities and differences,which was closely related to the source of the patients in this study.