Type A Acute Aortic Dissection Detected By Coronary Angiography:Clinical Features And Outcome With Emergency Operation

Background: Patients with type A acute aortic dissection(TAAAD)might be misdiagnosed as acute coronary syndrome(ACS)when the aortic roots were involved,many of who were then transferred to receive coronary angiography(CAG)and found out to be TAAAD according to the imaging findings.As patients in this circumstance always received antiplatelet therapy and might suffer from aortic dissection and concomitant myocardial ischemia,they were traditionally considered as a relative contraindication to emergency operation.However,delayed repair or cancellation of operation always resulted in poor outcomes for patients with TAAAD.This retrospective study was designed to demonstrate the clinical character of this unique subgroup of TAAAD,to clarify their clinical outcome and postoperative complications after emergency operations,and to show the effect of detection by CAG on their early mortality and overall survival.Part Ⅰ: Type A Acute Aortic Dissection Detected by Coronary Angiography: Preoperative Clinical Features Objective.To study the preoperative clinical features of patients with TAAAD who was detected by CAG.Methods.Clinical information of TAAAD patients undergoing emergency operation in Shanghai Delta Health Hospital from October 2016 to April 2019 was collected.Patients were divided into CAG group and Non-CAG group depending on whether preoperative CAG were performed.The parameters of baseline demographic,circulatory stability,coagulopathy,myocardial ischemia,pathological changes and preoperative comorbidity were analyzed.Results.129 TAAAD patients treated with emergency operation were enrolled in the study,among which 21(16.3%)patients were discovered by preoperative CAG.In comparison with Non-CAG group,patients in CAG group were male predominant(90.5% vs 66.7%,P=0.030),experienced more preoperative hypotension(92.0% vs46.0%,P=0.001),higher AA-induced and ADP-induced platelet inhibition rates(92.0% vs 46.0%,P=0.001;91.4% vs 71.0%,P=0.042;respectively),more ischemia changes in electrocardiogram(66.7% vs 37.0%,P=0.012),and more coronary involvement by dissection(66.7% vs 30.6%,P=0.002).Conclusion.Patients with TAAAD detected by preoperative CAG were not rare.In comparison with TAAAD patients without CAG,this group might suffer more serious hemodynamic compromise,complete platelet inhibition and severe coagulopathy,higher risk of perioperative myocardial ischemia,and more complicated pathological changes in aortic root and coronary artery.Part Ⅱ: Type A Acute Aortic Dissection Detected by Coronary Angiography: Surgical Strategies and Clinical Outcome Objective.To study the effect of emergency operation on TAAAD patients discovered by CAG and the postoperative complications in this circumstance.Methods.Emergency surgical strategies(including aortic repair strategies,coronary repair strategies and surgical hemostatic strategies)especially designed for TAAAD were applied in all patients.The operative time,aortic repair strategies,coronary involvement and repair strategies,in-hospital mortality,cardiovascular complications,bleeding complications and inpatient related factors were analyzed between CAG group and Non-CAG group.Results.No difference was found in in-hospital mortality(4.8% vs 3.7%,CAG group vs Non-CAG group,P=1.000),operation time,cardiopulmonary bypass time and aortic repair strategies between groups.In comparison with Non-CAG group,patients in CAG group received more coronary repairs(66.7% vs 30.6%,P=0.003)and were associated with higher prevalence of new-onset atrial fibrillation(47.6% vs 19.4%,P=0.006).However,there was no difference in the incidence of postoperative myocardial ischemia,wall motion abnormality and cardiopulmonary resuscitation between groups.Incidence of low cardiac output syndrome,serum level of brain natriuretic peptides and ejection fraction accessed by echocardiography were also comparable between groups.Patients in CAG group had higher intraoperative bleeding(1900 [1925]ml vs 1500 [1100]ml,P=0.013)and volume of drainage on the first postoperative day(1040 [1030]ml vs 595 [685]ml,P=0.028),and need more transfusion of platelet(1.0±1.0U vs 0.4±0.8U,P=0.003)and cryoprecipitate(5.6±9.8U vs 2.1±5.2U,P=0.024),but no difference was found in re-exploration for bleeding,postoperative cardiac tamponade,and volume of red blood cell and plasma transfusion.Patients in CAG group experienced a higher risk of intensive care unit(ICU)readmission(30.0% vs 7.7%,P=0.012).No difference was detected in duration of ICU stay,hospitalization time and 30-day readmission between groups.Conclusion.Emergency surgical strategies applied in this study improved clinical outcome for TAAAD patients discovered by CAG,which resulted in satisfactory quality of aortic and coronary repair and good recovery of myocardial ischemia and cardiac function as compared with other TAAAD patients.Systemic hemostatic surgical techniques produced acceptable perioperative bleeding control even in circumstances of severe coagulopathy without serious bleeding-related complications.Part Ⅲ: Type A Acute Aortic Dissection Detected by Coronary Angiography: Risk Factors in Early Mortality and Overall Survival Objective.To reveal risk factors in association with early postoperative mortality and overall survival in TAAAD patients who received surgical repair and the effect of detection by preoperative CAG on survival for patients with TAAAD.Methods.Follow-up was carried out for all patients enrolled in this study to identify their survival conditions.Factors identified by univariate analysis were entered into a bivariate Logistic regression model for multivariate analysis to clarify independent risk factors for 30-day mortality.Factors detected by univariate analysis were entered into a Cox regression model for multivariate analysis to clarify independent predictors associated with overall survival.Kaplan-Meier analysis was utilized to find the effect of preoperative CAG on accumulative survival rate.An adjusted bivariate Logistic regression model was used to clarify the effect of preoperative CAG on early postoperative mortality.An adjusted Cox regression model was used to determine the effect of preoperative CAG on overall survival.Results.30-day mortality was 8.5% in our study.No difference was found in 30-day mortality between groups(CAG vs Non-CAG = 4.8% vs 9.3%,P=0.804).1-year survival was 88.0% in all patients and no difference was identified between groups in overall survival(P=0.739).Intramural hematoma,cardiopulmonary time,postoperative hemodialysis,and postoperative cerebral hemorrhage were detected to be associated with 30-day mortality.Preoperative creatinine,preoperative lactic acid,intramural hematoma,cardiopulmonary time,reintubation,and postoperative cerebral hemorrhage were identified as independent predictors of overall survival.Grouping had no significant impact on 30-day mortality(odds ratio 0.171,95% confidence interval 0.013-2.174,P=0.173)and overall survival(hazard ratio 0.407,95% confidence interval 0.080-2.057,P=0.277).Conclusion.Emergency surgical strategies applied in this study resulted in satisfactory survival benefits for patients with TAAAD.Early and overall survival in patients with TAAAD detected by CAG were comparable to other TAAAD patients when treated with these techniques.Preoperative CAG did not offer any negative impact on early and overall survival.