Publications by authors named "Sven Peterss"

74 Publications

New anatomical frozen elephant trunk graft for zone 0: endovascular technology reduces invasiveness of open surgery to the max.

Eur J Cardiothorac Surg 2021 Sep 7. Epub 2021 Sep 7.

Department of Cardiac Surgery, LMU University Hospital, Munich, Germany.

The first-in-man implant of a custom-made branched frozen elephant trunk graft designed for an anastomosis in aortic arch zone 0 is reported. Combining endovascular technology with open surgical techniques has allowed for simplification of the open procedure with substantial reduction in circulatory arrest time and in the extent of the surgical preparations.
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http://dx.doi.org/10.1093/ejcts/ezab394DOI Listing
September 2021

Thrombotic microangiopathy following aortic surgery with hypothermic circulatory arrest: a single-centre experience of an underestimated cause of acute renal failure.

Interact Cardiovasc Thorac Surg 2021 Aug 20. Epub 2021 Aug 20.

Department of Cardiac Surgery, LMU University Hospital, Munich, Germany.

Objectives: Acute kidney injury (AKI) following surgery involving the heart-lung-machine is associated with high mortality and morbidity. In addition to the known mechanisms, thrombotic microangiopathy (TMA) triggered by the dysregulation of complement activation was recently described as another pathophysiological pathway for AKI following aortic surgery. The aim of this retrospective study was to analyse incidence, predictors and outcome in these patients.

Methods: Between January 2018 and September 2019, consecutive patients undergoing aortic surgery requiring hypothermic circulatory arrest were retrospectively reviewed. If suspected, diagnostic algorithm was initiated to identify a TMA and its risk factors, and postoperative outcome parameters were comparably investigated.

Results: The incidence of TMA in the analysed cohort (n = 247) was 4.5%. Multivariable logistic regression indicated female gender {odds ratio (OR) 4.905 [95% confidence interval (CI) 1.234-19.495], P = 0.024} and aortic valve replacement [OR 8.886 (95% CI 1.030-76.660), P = 0.047] as independent predictors of TMA, while cardiopulmonary bypass, X-clamp and hypothermic circulatory arrest times showed no statistically significance. TMA resulted in postoperative AKI (82%), neurological disorders (73%) and thrombocytopaenia [31 (interquartile range 25-42) G/l], corresponding to the diagnostic criteria. Operative mortality and morbidity were equal to patients without postoperative TMA, despite a higher incidence of re-exploration for bleeding (27 vs 6%; P = 0.027). After 6 months, survival, laboratory parameters and need for dialysis were comparable between the groups.

Conclusions: TMA is a potential differential diagnosis for the cause of AKI following aortic surgery regardless of the hypothermic circulatory arrest time. Timely diagnosis and appropriate treatment resulted in a comparable outcome concerning mortality and renal function.
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http://dx.doi.org/10.1093/icvts/ivab231DOI Listing
August 2021

What do we know? The dilemma of modelling risk for aortic dissection.

Eur J Cardiothorac Surg 2021 Aug 4. Epub 2021 Aug 4.

Department of Cardiac Surgery, LMU University Hospital, Munich, Germany.

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http://dx.doi.org/10.1093/ejcts/ezab361DOI Listing
August 2021

Push and pull-frozen elephant trunks in aortic dissection.

Eur J Cardiothorac Surg 2021 Aug 4. Epub 2021 Aug 4.

Department of Cardiac Surgery, LMU University Hospital, Munich, Germany.

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http://dx.doi.org/10.1093/ejcts/ezab347DOI Listing
August 2021

Percutaneous dilatational tracheotomy in high-risk ICU patients.

Ann Intensive Care 2021 Jul 28;11(1):116. Epub 2021 Jul 28.

Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377, Munich, Germany.

Background: Percutaneous dilatational tracheotomy (PDT) has become an established procedure in intensive care units (ICU). However, the safety of this method has been under debate given the growing number of critically ill patients with high bleeding risk receiving anticoagulation, dual antiplatelet therapy (DAPT) or even a combination of both, i.e. triple therapy. Therefore, the purpose of this study, including such a high proportion of patients on antithrombotic therapy, was to investigate whether PDT in high-risk ICU patients is associated with elevated procedural complications and to analyse the risk factors for bleeding occurring during and after PDT.

Methods: PDT interventions conducted in ICUs at 12 European sites between January 2016 and October 2019 were retrospectively analysed for procedural complications. For subgroup analyses, patient stratification into clinically relevant risk groups based on anticoagulation and antiplatelet treatment regimens was performed and the predictors of bleeding occurrence were analysed.

Results: In total, 671 patients receiving PDT were included and stratified into four clinically relevant antithrombotic treatment groups: (1) intravenous unfractionated heparin (iUFH, prophylactic dosage) (n = 101); (2) iUFH (therapeutic dosage) (n = 131); (3) antiplatelet therapy (aspirin and/or P2Y receptor inhibitor) with iUFH (prophylactic or therapeutic dosage) except for triple therapy (n = 290) and (4) triple therapy (DAPT with iUFH in therapeutic dosage) (n = 149). Within the whole cohort, 74 (11%) bleedings were reported to be procedure-related. Bleeding occurrence during and after PDT was independently associated with low platelet count (OR 0.73, 95% CI [0.56, 0.92], p = 0.009), chronic kidney disease (OR 1.75, 95% CI [1.01, 3.03], p = 0.047) and previous stroke (OR 2.13, 95% CI [1.1, 3.97], p = 0.02).

Conclusion: In this international, multicenter study bronchoscopy-guided PDT was a safe and low-complication airway management option, even in a cohort of high risk for bleeding on cardiovascular ICUs. Low platelet count, chronic kidney disease and previous stroke were identified as independent risk factors of bleeding during and after PDT but not triple therapy.
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http://dx.doi.org/10.1186/s13613-021-00906-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8319261PMC
July 2021

Time is of the essence: where can we improve care in acute aortic dissection?

Interact Cardiovasc Thorac Surg 2021 Jul 12. Epub 2021 Jul 12.

Department of Cardiac Surgery, LMU University Hospital, Munich, Germany.

Objectives: In acute aortic dissection type A various components of the diagnostic and logistic pathways may affect the time to definitive treatment. This study aimed to characterize these components and to identify factors delaying the optimal management within our institutional referral network.

Methods: Between January 2017 and January 2020, 96 consecutive patients with classical aortic dissection type A were admitted (28%) or referred (72%) to our tertiary care centre and analysed retrospectively. Data are presented as medians (25th-75th quartile).

Results: Median age was 66 years (56-74), 63% were male. Most of the patients were primarily admitted to a cardiology department (40%), whereas about a fourth were admitted to departments for internal medicine (26%) and general surgery (27%). The median interval from the onset of symptoms to hospital admission was 2.1 (1-4.4) h. From admission to confirmed diagnosis it took 2.1 (0.6-9.5) h and the median interval from confirmed diagnosis to admission at our specialized tertiary care aortic centre was 1.5 (0.9-2.4) h. Following admission to our centre, 1.1 (0.5-1.9) h passed until the induction of anaesthesia and 0.8 (0.0-1.1) h until the start of surgery. The total interval from the onset of symptoms to the start of surgery was 7.6 h (5.1-12.3).

Conclusions: The marked variability of the time from symptoms to diagnosis at any medical facility demonstrates the importance of awareness in the optimization of the treatment of acute aortic dissection type A.
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http://dx.doi.org/10.1093/icvts/ivab190DOI Listing
July 2021

Routine Stent-Bridging to the Supraaortic Vessels in Aortic Arch Replacement - 10 year-experience.

Ann Thorac Surg 2021 Jun 26. Epub 2021 Jun 26.

Department of Cardiac Surgery, LMU University Hospital, Munich, Germany.

Background: The SAVSTEB technique (Supra-Aortic Vessel anastomosis STEnt Bridging) simplifies the reattachment of the supraaortic vessels in aortic arch surgery; however, follow-up data are limited. The study aimed to investigate the stent-related performance and complications.

Methods: Between 02/2009 and 09/2020, 112 patients underwent total arch replacement with a tetrabranched graft and using the SAVSTEB technique. Mean age was 59.3±12.7 years, male gender prevailed. Nineteen percent suffered from acute aortic dissection extending into the supraaortic vessels, 12% showed chronic dissected vessels and 70% showed unaffected vessels. Left subclavian artery, left common carotid artery and innominate artery were bridged in 88%, 75% and 2%, respectively, an aberrant right subclavian artery in 2%.

Results: Total stent experience was 341 stent-years, stent patency was found in 98%. Technical success was achieved in all but one case. One percent showed major stent thrombosis requiring reintervention. Minor stent thrombosis was found in 2%. No endoleak was found and the number of new onset dissections distally to the stent was 4%. Freedom from stent-related events was estimated 89.1±0.5% at 3 years. Stroke rate was 10% with highest incidence among non-dissected vessels. The vertebral artery was overstented in 15%, 2% were associated radiographically with stroke.

Conclusions: SAVSTEB is a comparatively simple, safe and efficacious technique to create the anastomosis between tetrabranched arch grafts and the supra-aortic arteries in the short and intermediate term. Bleeding from the anastomoses, kinking and scar associated stenosis are negligible; however, vertebral overstenting remains a critical technical issue.
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http://dx.doi.org/10.1016/j.athoracsur.2021.05.074DOI Listing
June 2021

Impact of Operative Timing in Infective Endocarditis with Cerebral Embolism-The Risk of Intermediate Deterioration.

J Clin Med 2021 May 15;10(10). Epub 2021 May 15.

Department of Cardiac Surgery, University Hospital, LMU Munich, 81377 Munich, Germany.

Cerebral embolism due to infective endocarditis (IE) is associated with significant morbidity and mortality. The optimal time-interval between symptomatic stroke and cardiac surgery remains unclear. This study aimed to analyze the patients' outcomes and define the potential risk factors with regard to surgical timing for IE patients with preoperative symptomatic cerebral embolism (CE). A total of 119 IE patients with CE were identified and analyzed with regard to operative timing: early (1-7 days), intermediate (8-21 days), and late (>22 days). The preoperative patient data, comorbidities and previous cardiac surgical procedures were analyzed to identify potential predictors and independent risk factors for in-hospital mortality using univariate and multivariate regression analysis. Actuarial survival was estimated by the Kaplan-Meier method. In-hospital mortality for the entire study cohort was 15.1% ( = 18), and in comparison, between groups was found to be highest in the intermediate surgical group (25.7%). Univariate analysis identified preoperative mechanical ventilation dependent respiratory insufficiency ( = 0.006), preoperative renal insufficiency ( = 0.019), age ( = 0.002), large vegetations ( = 0.018) as well as intermediate ( = 0.026), and late ( = 0.041) surgery as predictors of in-hospital mortality. The presence of large vegetations (>8 mm) ( = 0.019) and increased age ( = 0.037)-but not operative timing-were identified as independent risk factors for in-hospital mortality. In the presence of large vegetations (>8 mm), cardiac surgery should be performed early and independently from the entity of cerebral embolic stroke. Postponing surgery to achieve clinical stabilization and better postoperative outcomes of IE patients with CE is reasonable, however, worsening of the disease process with deterioration and resulting heart failure during the first 3 weeks after CE results in a significantly higher in-hospital mortality and inferior long-term survival.
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http://dx.doi.org/10.3390/jcm10102136DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8156108PMC
May 2021

Cardiac surgery following transcatheter aortic valve replacement.

Eur J Cardiothorac Surg 2021 May 21. Epub 2021 May 21.

Department of Cardiac Surgery, LMU University Hospital, Munich, Germany.

Objectives: The objective of this study was to retrospectively analyse surgical outcomes of patients undergoing secondary cardiac surgery after initial transcatheter aortic valve replacement (TAVR).

Methods: Between December 2012 and February 2020, a total of 41 consecutive patients underwent cardiac surgery after a TAVR procedure at our institution. Patients who underwent emergency operations due to periprocedural complications such as ventricular rupture and TAVR dislocation were excluded from this study (n = 12). Thus, 29 patients were included in the analysis. Data are presented as medians (25th-75th quartiles) or as absolute numbers (percentages).

Results: The median age was 76 years (68-80); 58.6% were men. The median time to a secondary conventional procedure was 23 months (8-40), with 8 patients requiring surgical intervention within the first year post TAVR. The indications for secondary conventional procedures were prosthesis endocarditis (n = 15), prosthesis degeneration or dysfunction (n = 7) and progression of valvular, aortic or coronary artery disease (n = 7). Surgical redo aortic valve replacement was performed in 24 patients (82.8%). No complications involving the aortic root or the aortomitral continuity were observed. The operative mortality was 10.3%. Extracorporeal life support was required in 3 patients (10.3%) for a median duration of 3 days (3-3 days). No adverse cerebrovascular events were observed postoperatively. Postoperatively, 4 patients (13.8%) required a pacemaker and 7 patients (24.1%) required renal replacement therapy. Overall survival at 1 year was 83.0%.

Conclusions: Conventional cardiac surgical procedures following TAVR are feasible with reasonable results and a low complication rate.
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http://dx.doi.org/10.1093/ejcts/ezab217DOI Listing
May 2021

Functional Testing for Tranexamic Acid Duration of Action Using Modified Viscoelastometry.

Transfus Med Hemother 2021 Mar 9;48(2):109-117. Epub 2020 Nov 9.

Department of Anaesthesiology, University Hospital, LMU Munich, Munich, Germany.

Introduction: Tranexamic acid (TXA) is the standard medication to prevent or treat hyperfibrinolysis. However, prolonged inhibition of lysis (so-called "fibrinolytic shutdown") correlates with increased mortality. A new viscoelastometric test enables bedside quantification of the antifibrinolytic activity of TXA using tissue plasminogen activator (TPA).

Materials And Methods: Twenty-five cardiac surgery patients were included in this prospective observational study. In vivo, the viscoelastometric TPA test was used to determine lysis time (LT) and maximum lysis (ML) over 96 h after TXA bolus. Additionally, plasma concentrations of TXA and plasminogen activator inhibitor 1 (PAI-1) were measured. Moreover, dose effect curves from the blood of healthy volunteers were performed in vitro. Data are presented as median (25-75th percentile).

Results: In vivo TXA plasma concentration correlated with LT ( = 0.55; < 0.0001) and ML ( = 0.62; < 0.0001) at all time points. Lysis was inhibited up to 96 h (LT: baseline: 398 s [229-421 s] vs. at 96 h: 886 s [626-2,175 s]; = 0.0013). After 24 h, some patients ( = 8) had normalized lysis, but others ( = 17) had strong lysis inhibition (ML <30%; < 0.001). The high- and low-lysis groups differed regarding kidney function (cystatin C: 1.64 [1.42-2.02] vs. 1.28 [1.01-1.52] mg/L; = 0.002) in a post hoc analysis. Of note, TXA plasma concentration after 24 h was significantly higher in patients with impaired renal function (9.70 [2.89-13.45] vs.1.41 [1.30-2.34] µg/mL; < 0.0001). In vitro, TXA concentrations of 10 µg/mL effectively inhibited fibrinolysis in all blood samples.

Conclusions: Determination of antifibrinolytic activity using the TPA test is feasible, and individual fibrinolytic capacity, e.g., in critically ill patients, can potentially be measured. This is of interest since TXA-induced lysis inhibition varies depending on kidney function.
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http://dx.doi.org/10.1159/000511230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8077595PMC
March 2021

New challenges in cardiac intensive care units.

Clin Res Cardiol 2021 Sep 9;110(9):1369-1379. Epub 2021 May 9.

Cardiac Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, Marchioninistraße 15, 81377, Munich, Germany.

Critical care cardiology is a steadily and rapidly developing sub-specialization within cardiovascular medicine, since the first emergence of a coronary care unit in the early 1960s. Today, modern cardiac intensive care units (CICU) serve a complex patient population with a high burden of cardiovascular and non-cardiovascular critical illnesses. Treatment of these patients requires a multidisciplinary approach, with a combination of highly specialized knowledge and skills in cardiovascular diseases, as well as emergency, critical-care and internal medicine. The CICU has always posed special challenges to both experienced intensivists as well as fellows-in-training (FIT) and is certainly one of the most demanding training phases. In recent years, these challenges have grown significantly owing to technological innovations, with new and steadily rising numbers of complex interventional procedures and new options for temporary circulatory support for critically ill patients, such as venoarterial extracorporeal membrane oxygenation (VA-ECMO). Herein, we focus on the successful CICU management of these special patient cohorts, which must become an integral part of critical-care training.
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http://dx.doi.org/10.1007/s00392-021-01869-0DOI Listing
September 2021

Passing a Mechanical Aortic Valve With a Short Tip Dilator to Facilitate Aortic Arch Endovascular Branched Repair.

J Endovasc Ther 2021 06 31;28(3):388-392. Epub 2021 Mar 31.

Department of Vascular surgery, University Hospital, LMU Munich, Munich, Germany.

Purpose: To present a novel technique to successfully cross a mechanical aortic valve prosthesis.

Technique: A 55-year-old female patient with genetically verified Marfan syndrome presented with a 5-cm anastomotic aneurysm of the proximal aortic arch after previous ascending aortic replacement due to a type A aortic dissection in 2007. The patient also underwent mechanical aortic valve replacement in 1991. A 3-stage hybrid repair was planned. The first 2 steps included debranching of the supra-aortic vessels. In the third procedure, a custom-made double branched endovascular stent-graft with a short 35-mm introducer tip was implanted. The mechanical valve was passed with the tip of the dilator on the lateral site of the leaflet, without destructing the valve and with only mild symptoms of aortic insufficiency, as one leaflet continued to work. This allowed the implantation of the stent-graft directly distally of the coronary arteries. Postoperative computed tomography angiography showed no endoleaks and patent coronary and supra-aortic vessels.

Conclusion: Passing a mechanical aortic valve prosthesis at the proper position is feasible and allows adequate endovascular treatment in complex arch anatomy. However, caution should be taken during positioning of the endovascular graft as the tip may potentially damage the valve prosthesis.
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http://dx.doi.org/10.1177/15266028211002506DOI Listing
June 2021

Impact of the coronavirus disease 2019 (COVID-19) pandemic on the care of patients with acute and chronic aortic conditions.

Eur J Cardiothorac Surg 2021 05;59(5):1096-1102

Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy.

Objectives: To evaluate the impact of the coronavirus disease 2019 (COVID-19) pandemic on acute and elective thoracic and abdominal aortic procedures.

Methods: Forty departments shared their data on acute and elective thoracic and abdominal aortic procedures between January and May 2020 and January and May 2019 in Europe, Asia and the USA. Admission rates as well as delay from onset of symptoms to referral were compared.

Results: No differences in the number of acute thoracic and abdominal aortic procedures were observed between 2020 and the reference period in 2019 [incidence rates ratio (IRR): 0.96, confidence interval (CI) 0.89-1.04; P = 0.39]. Also, no difference in the time interval from acute onset of symptoms to referral was recorded (<12 h 32% vs > 12 h 68% in 2020, < 12 h 34% vs > 12 h 66% in 2019 P = 0.29). Conversely, a decline of 35% in elective procedures was seen (IRR: 0.81, CI 0.76-0.87; P < 0.001) with substantial differences between countries and the most pronounced decline in Italy (-40%, P < 0.001). Interestingly, in Switzerland, an increase in the number of elective cases was observed (+35%, P = 0.02).

Conclusions: There was no change in the number of acute thoracic and abdominal aortic cases and procedures during the initial wave of the COVID-19 pandemic, whereas the case load of elective operations and procedures decreased significantly. Patients with acute aortic syndromes presented despite COVID-19 and were managed according to current guidelines. Further analysis is required to prove that deferral of elective cases had no impact on premature mortality.
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http://dx.doi.org/10.1093/ejcts/ezaa452DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7799089PMC
May 2021

[Characteristics and outcome of 70 ventilated COVID-19 patients : Summary after the first wave at a university center].

Anaesthesist 2021 07 28;70(7):573-581. Epub 2020 Dec 28.

Klinik für Anästhesiologie, LMU Klinikum, Marchioninistr. 15, 81377, München, Deutschland.

Background: In a pandemic situation the overall mortality rate is of considerable interest; however, these data must always be seen in relation to the given healthcare system and the availability of local level of care. A recently published German data evaluation of more than 10,000 COVID-19 patients treated in 920 hospitals showed a high mortality rate of 22% in hospitalized patients and of more than 50% in patients requiring invasive ventilation. Because of the high infection rates in Bavaria, a large number of COVID-19 patients with considerable severity of disease were treated at the intensive care units of the LMU hospital. The LMU hospital is a university hospital and a specialized referral center for the treatment of patients with acute respiratory distress syndrome (ARDS).

Objective: Data of LMU intensive care unit (ICU) patients were systematically evaluated and compared with the recently published German data.

Methods: Data of all COVID-19 patients with invasive and noninvasive ventilation and with completed admission at the ICU of the LMU hospital until 31 July 2020 were collected. Data were processed using descriptive statistics.

Results: In total 70 critically ill patients were included in the data evaluation. The median SAPS II on admission to the ICU was 62 points. The median age was 66 years and 81% of the patients were male. More than 90% were diagnosed with ARDS and received invasive ventilation. Treatment with extracorporeal membrane oxygenation (ECMO) was necessary in 10% of the patients. The median duration of ventilation was 16 days, whereby 34.3% of patients required a tracheostomy. Of the patients 27.1% were transferred to the LMU hospital from external hospitals with reference to our ARDS/ECMO program. Patients from external hospitals had ARDS of higher severity than the total study population. In total, nine different substances were used for virus-specific treatment of COVID-19. The most frequently used substances were hydroxychloroquine and azithromycin. Immunomodulatory treatment, such as Cytosorb® (18.6%) and methylprednisolone (25.7%) were also frequently used. The overall in-hospital mortality rate of ICU patients requiring ventilation was 28.6%. The mortality rates of patients from external hospitals, patients with renal replacement therapy and patients with ECMO therapy were 47.4%, 56.7% and 85.7%, respectively.

Conclusion: The mortality rate in the ventilated COVID-19 intensive care patients was considerably different from the general rate in Germany. The data showed that treatment in an ARDS referral center could result in a lower mortality rate. Low-dose administration of steroids may be another factor to improve patient outcome in a preselected patient population. In the authors' opinion, critically ill COVID-19 patients should be treated in an ARDS center provided that sufficient resources are available.
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http://dx.doi.org/10.1007/s00101-020-00906-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7768596PMC
July 2021

Extracorporeal life support in therapy-refractory cardiocirculatory failure: looking beyond 30 days.

Interact Cardiovasc Thorac Surg 2021 04;32(4):607-615

Department of Cardiac Surgery, University Hospital Munich, Ludwig-Maximilian-University, Munich, Germany.

Objectives: Venoarterial extracorporeal life support (ECLS) has emerged as a potentially life-saving treatment option in therapy-refractory cardiocirculatory failure, but longer-term outcome is poorly defined. Here, we present a comprehensive follow-up analysis covering all major organ systems.

Methods: From February 2012 to December 2016, 180 patients were treated with ECLS for therapy-refractory cardiogenic shock or cardiac arrest. The 30-day survival was 43.9%, and 30-day survivors (n = 79) underwent follow-up analysis with the assessment of medium-term survival, quality of life, neuropsychological, cardiopulmonary and end-organ status.

Results: After a median of 1.9 (1.1-3.6) years (182.4 patient years), 45 of the 79 patients (57.0%) were alive, 35.4% had died and 7.6% were lost to follow-up. Follow-up survival estimates were 78.0% at 1, 61.2% at 3 and 55.1% at 5 years. NYHA class at follow-up was ≤II for 83.3%. The median creatinine was 1.1 (1.0-1.4) mg/dl, and the median bilirubin was 0.8 (0.5-1.0) mg/dl. No patient required dialysis. Overall, 94.4% were free from moderate or severe disability, although 11.1% needed care. Full re-integration into social life was reported by 58.3%, and 39.4% were working. Quality of life was favourable for mental components, but a subset showed deficits in physical aspects. While age was the only peri-implantation parameter significantly predicting medium-term survival, adverse events and functional status at discharge or 30 days were strong predictors.

Conclusions: This study demonstrates positive medium-term outcome with high rates of independence in daily life and self-care but a subset of 10-20% suffered from sustained impairments. Our results indicate that peri-implantation parameters lack predictive power but downstream morbidity and functional status at discharge or 30 days can help identify patients at risk for poor recovery.
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http://dx.doi.org/10.1093/icvts/ivaa312DOI Listing
April 2021

Outcome of patients treated with extracorporeal life support in cardiogenic shock complicating acute myocardial infarction: 1-year result from the ECLS-Shock study.

Clin Res Cardiol 2021 Sep 12;110(9):1412-1420. Epub 2020 Nov 12.

Department of Cardiac Surgery, Munich University Hospital, Ludwig-Maximilian-University, Marchioninistr. 15, 81377, Munich, Germany.

Background: Treatment with extracorporeal life support (ECLS) in acute myocardial infarction (AMI) complicated by cardiogenic shock (CS) fell short of improving myocardial recovery measured by 30 day ejection fraction in the ECLS-SHOCK trial. However, to date, no data regarding impact of ECLS on long-term outcomes exist.

Methods: In this randomized, controlled, prospective, open-label trial, 42 patients with CS complicating AMI were randomly assigned to ECLS (ECLS group, n = 21) or no ECLS (control group, n = 21). The primary endpoint was left ventricular ejection fraction (LVEF) after 30 days. Secondary endpoints included mortality and neurological outcome after 12 months. Evaluation of neurological outcome used the modified Rankin Scale.

Results: The 12-month all-cause mortality was 19% in the ECLS group versus 38% in the control group (p = 0.31). Only one patient (control group) died after the initial 30 days. Three patients underwent elective percutaneous coronary intervention (PCI) during follow-up (one in the control and two in the ECLS group). Favorable neurological outcome (modified Rankin Score ≤ 2) was seen in 61.9% of patients in the ECLS group versus 57.1% in the control group (p = 1).

Conclusion: This pilot study showed that randomized studies with ECLS in CS patients are feasible and safe. Small numbers of included patients impede meaningful conclusions about mortality and neurological outcome. Our findings of numerical differences in mortality and survival with severe neurological impairment give an urgent call for larger multi-centric randomized trials assessing the endpoint of all-cause mortality but also considering the effects on neurological outcome measures.
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http://dx.doi.org/10.1007/s00392-020-01778-8DOI Listing
September 2021

Severe Acute Kidney Injury in Cardiovascular Surgery: Thrombotic Microangiopathy as a Differential Diagnosis to Ischemia Reperfusion Injury. A Retrospective Study.

J Clin Med 2020 Sep 8;9(9). Epub 2020 Sep 8.

Division of Nephrology, Department of Medicine IV, University Hospital, LMU Munich, D-81377 Munich, Germany.

Background: Acute kidney injury (AKI) after cardiovascular surgery (CVS) infers high morbidity and mortality and may be caused by thrombotic microangiopathy (TMA). This study aimed to assess incidence, risk factors, kidney function, and mortality of patients with a postoperative TMA as possible cause of severe AKI following cardiovascular surgery.

Methods: We analyzed retrospectively all patients admitted to the ICU after a cardiovascular procedure between 01/2018 and 03/2019 with severe AKI and need for renal replacement therapy (RRT). TMA was defined as post-surgery-AKI including need for RRT, hemolytic anemia, and thrombocytopenia. TMA patients were compared to patients with AKI requiring RRT without TMA.

Results: Out of 893 patients, 69 (7.7%) needed RRT within one week after surgery due to severe AKI. Among those, 15 (21.7%) fulfilled TMA criteria. Aortic surgery suggested an increased risk for TMA (9/15 (60.0%) vs. 7/54 (31.5%), OR 3.26, CI 1.0013-10.64). Ten TMA patients required plasmapheresis and/or eculizumab, and five recovered spontaneously. Preoperative kidney function was significantly better in TMA patients than in controls (eGFR 92 vs. 60.5 mL/min, = 0.004). However, postoperative TMA resulted in a more pronounced GFR loss (ΔeGFR -54 vs. -17 mL/min, = 0.062). There were no deaths in the TMA group.

Conclusion: Our findings suggest TMA as an important differential diagnosis of severe AKI following cardiovascular surgery, which may be triggered by aortic surgery. Therefore, early diagnosis and timely treatment of TMA could reduce kidney damage and improve mortality of AKI following cardiovascular surgery, which should be further investigated.
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http://dx.doi.org/10.3390/jcm9092900DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7565159PMC
September 2020

Natriuretic Peptides as a Prognostic Marker for Delirium in Cardiac Surgery-A Pilot Study.

Medicina (Kaunas) 2020 May 27;56(6). Epub 2020 May 27.

Department of Anaesthesiology, University Hospital, LMU Munich, 81377 Munich, Germany.

Delirium is a common and major complication subsequent to cardiac surgery. Despite scientific efforts, there are no parameters which reliably predict postoperative delirium. In delirium pathology, natriuretic peptides (NPs) interfere with the blood-brain barrier and thus promote delirium. Therefore, we aimed to assess whether NPs may predict postoperative delirium and long-term outcomes. To evaluate the predictive value of NPs for delirium we retrospectively analyzed data from a prospective, randomized study for serum levels of atrial natriuretic peptide (ANP) and the precursor of C-type natriuretic peptide (NT-proCNP) in patients undergoing coronary artery bypass grafting (CABG) with or without cardiopulmonary bypass (off-pump coronary bypass grafting; OPCAB). Delirium was assessed by a validated chart-based method. Long-term outcomes were assessed 10 years after surgery by a telephone interview. The overall incidence of delirium in the total cohort was 48% regardless of the surgical approach (CABG vs. OPCAB). Serum ANP levels >64.6 pg/mL predicted delirium with a sensitivity (95% confidence interval) of 100% (75.3-100) and specificity of 42.9% (17.7-71.1). Serum NT-proCNP levels >1.7 pg/mL predicted delirium with a sensitivity (95% confidence interval) of 92.3% (64.0-99.8) and specificity of 42.9% (17.7-71.1). Both NPs could not predict postoperative survival or long-term cognitive decline. We found a positive correlation between delirium and preoperative plasma levels of ANP and NT-proCNP. A well-powered and prospective study might identify NPs as biomarkers indicating the risk of delirium and postoperative cognitive decline in patients at risk for postoperative delirium.
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http://dx.doi.org/10.3390/medicina56060258DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7353880PMC
May 2020

Isoflurane Sedation in Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation Treatment for Cardiogenic Shock-An Observational Propensity-Matched Study.

Crit Care Explor 2020 Mar 24;2(3):e0086. Epub 2020 Mar 24.

Intensive Care Unit and Department of Cardiology, University Hospital, LMU Munich, Munich, Germany.

The feasibility and hemodynamic effects of isoflurane sedation in cardiogenic shock in the presence of venoarterial extracorporeal membrane oxygenation treatment are currently unknown.

Design: Retrospective single-center study.

Setting: Cardiac ICU of Munich university hospital.

Patients/subjects: Cardiogenic shock patients with venoarterial extracorporeal membrane oxygenation treatment under sedation with volatile isoflurane between November 2018 and October 2019 have been enrolled in this study and were matched by propensity score in a 1:1 ratio with IV sedated patients treated between January 2013 and November 2018 from the cardiogenic shock registry of the university hospital of Munich.

Measurements And Main Results: Isoflurane sedation was used in 32 patients with cardiogenic shock and venoarterial extracorporeal membrane oxygenation treatment. The mean age of conventionally sedated patients was 58.4 ± 13.8 years and 56.3 ± 11.5 years for patients with isoflurane sedation ( = 0.51). Administration of isoflurane was associated with lower IV sedative drug use during venoarterial extracorporeal membrane oxygenation treatment (86% vs 32%; = 0.01). Mean systolic arterial pressure was similar (94.3 ± 12.6 vs 92.9 ± 10.5 mm Hg; = 0.65), but mean heart rate was significantly higher in the conventional sedation group, when compared with the isoflurane group (85.2 ± 20.5 vs 74.7 ± 15.0 beats/min; = 0.02). Catecholamine doses, venoarterial extracorporeal membrane oxygenation blood and gas flow, ventilation time (304 ± 143 vs 398 ± 272 hr; = 0.16), bleeding complications bleeding academic research consortium 3a or higher (59.3% vs 65.3%; = 0.76), and 30-day mortality (59.2% vs 63.4%, = 0.80) were similar in both groups. The overall sedation costs per patient were significantly lower in the conventional group, when compared with the isoflurane group (537 ± 624 vs 1280 ± 837 €; < 0.001).

Conclusions: Volatile sedation with isoflurane is feasible-albeit at higher costs-in patients with cardiogenic shock and venoarterial extracorporeal membrane oxygenation treatment and was not associated with higher catecholamine dosage or extracorporeal membrane oxygenation flow rate compared with IV sedation.
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http://dx.doi.org/10.1097/CCE.0000000000000086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7098543PMC
March 2020

Update on Weaning from Veno-Arterial Extracorporeal Membrane Oxygenation.

J Clin Med 2020 Apr 2;9(4). Epub 2020 Apr 2.

Intensive Care Unit, Medizinische Klinik und Poliklinik I, Klinikum der Universität München, 81377 Munich, Germany.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides temporary cardiac and respiratory support and has emerged as an established salvage intervention for patients with hemodynamic compromise or shock. It is thereby used as a bridge to recovery, bridge to permanent ventricular assist devices, bridge to transplantation, or bridge to decision. However, weaning from VA-ECMO differs between centers, and information about standardized weaning protocols are rare. Given the high mortality of patients undergoing VA-ECMO treatment, it is all the more important to answer the many questions still remaining unresolved in this field Standardized algorithms are recommended to optimize the weaning process and determine whether the VA-ECMO can be safely removed. Successful weaning as a multifactorial process requires sufficient recovery of myocardial and end-organ function. The patient should be considered hemodynamically stable, although left ventricular function often remains impaired during and after weaning. Echocardiographic and invasive hemodynamic monitoring seem to be indispensable when evaluating biventricular recovery and in determining whether the VA-ECMO can be weaned successfully or not, whereas cardiac biomarkers may not be useful in stratifying those who will recover. This review summarizes the strategies of weaning of VA-ECMO and discusses predictors of successful and poor weaning outcome.
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http://dx.doi.org/10.3390/jcm9040992DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230450PMC
April 2020

Chronologic and Climatic Factors of Acute Aortic Dissection: Study of 1642 Patients in Two Continents.

Ann Thorac Surg 2020 08 28;110(2):575-581. Epub 2019 Dec 28.

Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing, China; Beijing Institute of Heart, Lung, and Blood Vessel Diseases, Beijing, China; Aortic Institute at Yale-New Haven Hospital, Yale School of Medicine, New Haven, Connecticut.

Background: The purpose of this study was to examine whether chronologic and climatic factors and lunar phases affect the onset of acute aortic dissection (AAD).

Methods: The frequencies of AAD were analyzed with regard to the chronologic and climatic factors and lunar phases on the day when AAD occurred for 1642 patients with AAD from two aortic referral centers in the United States and China.

Results: Mean age of patients was 51.6 ± 13.1 years, and 1260 (76.7%) were men. Dissection was type A in 1125 patients (68.5%) and type B in 517 (31.5%). Early mortality rate was 11.6% (190 of 1642), including 89 aortic ruptures before operation and 101 operative deaths. There was a winter peak in occurrence (33.6%, P < .01) with a relative risk of 1.519. In a week, the frequency was highest on Wednesday (15.5%) and Monday (15.2%), and lowest on Sunday (12.8%). Month-specific incidence was significantly inversely correlated to the mean temperature (rho = -0.650, P = .022) and directly correlated to the atmospheric pressure (rho = 0.706, P = .001). The proportion of type A dissection was significantly higher in the full moon phase compared with type B dissection (73.7% vs 66.9%, P = .012).

Conclusions: Acute aortic dissection exhibits significant chronologic variation in the frequency of occurrence, with a peak in winter and on Wednesdays, and nadir in summer and on Sundays. The incidence is significantly correlated to the mean temperature and atmospheric pressure. The proportion of type A dissection is higher in the full moon phase. These results are important for understanding the mechanisms involved in triggering AAD events and helpful for improving disease prevention and patient care.
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http://dx.doi.org/10.1016/j.athoracsur.2019.11.013DOI Listing
August 2020

Incidence and Surgical Outcomes of Patients With Native and Prosthetic Aortic Valve Endocarditis.

Ann Thorac Surg 2020 07 30;110(1):93-101. Epub 2019 Nov 30.

Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany.

Background: The aim of this study was to retrospectively evaluate the incidence and surgical outcomes of patients with native infective endocarditis (IE) and prosthetic aortic valve endocarditis (PVE) over the past decade at a single institution.

Methods: Between January 2005 and December 2015, 289 patients (mean age, 63.3 ± 14.2 years) suffering from native IE (n = 186) and PVE (n = 103) of the aortic valve underwent surgical procedures. Perioperative data were acquired retrospectively for statistical analysis.

Results: During the study period the mean incidence of endocarditis increased from 22.0 ± 4.2 (2005-2009) to 29.8 ± 10.1 (2010-2015) cases per year. In-hospital mortality was significantly increased in PVE (22.3%) versus IE (9.1%) patients (P < .001). In elective cases in-hospital mortality between the 2 groups was comparable (2.2% vs 4.6%; P = .288). Multivariate analysis identified urgent surgery (odds ratio [OR], 6.461; 95% CI, 1.941-21.509; P = .002), mitral regurgitation II (OR, 4.230; 95% CI, 1.249-14.331; P = .021), previous homograft operation (OR, 66.096; 95% CI, 2.369-1844.272; P = .0.14), and left ventricular ejection fraction < 40% (OR, 8.267; 95% CI, 1.931-35.388; P = .004) as independent risk factors for in-hospital mortality, whereas pathogen identification by preoperative blood cultures (OR, .228; 95% CI, 0.063-0.817; P = .023) was found to be independently protective.

Conclusions: Surgery for native IE and PVE of the aortic valve may be performed with satisfactorily results at experienced cardiac surgical centers. In comparison PVE patients suffer from a more than twice as high in-hospital mortality, more postoperative complications, and inferior long-term survival. However preoperative identification of causative pathogens in IE and PVE allows for improved in-hospital survival.
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http://dx.doi.org/10.1016/j.athoracsur.2019.10.029DOI Listing
July 2020

Chronic aortic dissection type A: simply an overlooked acute event?

Eur J Cardiothorac Surg 2020 02;57(2):397-398

Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany.

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http://dx.doi.org/10.1093/ejcts/ezz218DOI Listing
February 2020

Haemadsorption improves intraoperative haemodynamics and metabolic changes during aortic surgery with hypothermic circulatory arrest.

Eur J Cardiothorac Surg 2019 Oct;56(4):731-737

Department of Cardiac Surgery, University Hospital, LMU Munich, Munich, Germany.

Objectives: Aortic surgery involving hypothermic circulatory arrest (HCA) results in a systemic inflammatory response that may negatively influence outcome. An extracorporeal haemadsorption (HA) device (CytoSorb®) that removes inflammatory triggers may improve haemodynamic and metabolic reactions due to excessive inflammation and, ultimately, outcome.

Methods: As a single-centre experience, the data of 336 patients who had undergone aortic surgery with HCA between 2013 and 2017 were retrospectively analysed. Patients with HA were matched to patients receiving standard therapy without HA (Control) by propensity score matching and compared subsequently.

Results: During aortic surgery with HCA, HA significantly reduced the requirement of norepinephrine (HA: 0.102 µg/kg/min; Control: 0.113; P = 0.043). Severe disturbances of acid-base balance as reflected by a pH lower than 7.19 (HA: 7.1%; Control: 11.6%; P = 0.139), maximum lactate concentrations (HA: 3.75 mmol/l; Control: 4.23 P = 0.078) and the need for tris-hydroxymethylaminomethane buffer (HA: 6.5%; Control: 13.7%; P = 0.045) were less frequent with HA. Compared to standard therapy, HA decreased the need for transfusion of packed red blood cells (1 unit; P = 0.021) and fresh frozen plasma (3 units; P = 0.001), but increased the requirement of prothrombin complex concentrate (800 IE, P = 0.0036). HA did not affect inflammatory laboratory markers on the first postoperative day. Differences in operative mortality (HA: 4.8%; Control: 8.8%) and the length of hospital stay (HA: 13.5 days; Control: 14) were not statistically significant.

Conclusions: HA significantly reduces the need for vasopressors, the amount of transfusion and improves acid-base balance in aortic surgery with HCA. Multicentre prospective trials are required to confirm these results.
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http://dx.doi.org/10.1093/ejcts/ezz074DOI Listing
October 2019

Outcomes After Thoracic Endovascular Aortic Repair With Overstenting of the Left Subclavian Artery.

Ann Thorac Surg 2019 May 30;107(5):1372-1379. Epub 2018 Nov 30.

Department of Cardiovascular Surgery, Heart Centre Freiburg University, Faculty of Medicine, Freiburg, Germany.

Background: Our study aim was to evaluate the impact of left subclavian artery (LSA) flow preservation during thoracic endovascular aortic repair (TEVAR) on outcome.

Methods: Between August 2001 and October 2016, 176 patients (mean age, 61.3 ± 15.8 years) underwent TEVAR with complete LSA coverage. Fifty-five of those patients (31.3%) also underwent LSA revascularization, whereas 121 patients (68.7%) did not. Perioperative data were acquired retrospectively for statistical analysis at the three study institutions.

Results: Overall in-hospital and follow-up mortality was 8.5% (n = 15) and 9.1% (n = 16), respectively, including 88 urgent and emergent cases (50%). Stroke (independent of location) and permanent paraplegia rates were 6.8% and 6.3%, respectively, for the entire cohort. Isolated upper-left extremity malperfusion exclusively occurred in 12 (9.9%) of the 121 patients without LSA revascularization. Left-hemispheric stroke was observed four times more often in patients without LSA revascularization and left arm malperfusion (16.7% versus 3.7%, p = 0.095). Multivariate analysis identified no LSA revascularization (odds ratio [OR] 3.779, 95% confidence interval [CI]: 1.096 to 13.029, p = 0.035), two or more endografts (OR 3.814, 95% CI: 1.557 to 9.343, p = 0.003), and coronary artery disease (OR 3.276, 95% CI: 1.262 to 8.507, p = 0.015) as independent risk factors for procedure-related adverse events (left-hemispheric stroke, left arm malperfusion, and permanent paraplegia) after TEVAR with complete LSA overstenting.

Conclusions: Every 10th patient with LSA overstenting and no revascularization experienced left arm malperfusion. No LSA revascularization, extensive aortic coverage with two or more endografts, and coronary artery disease increased the risk of permanent paraplegia, left-hemispheric stroke, and left arm malperfusion. Patients should undergo LSA revascularization to prevent left vertebral artery-associated central neurologic complications and to maintain upper-left extremity perfusion.
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http://dx.doi.org/10.1016/j.athoracsur.2018.10.051DOI Listing
May 2019

Height alone, rather than body surface area, suffices for risk estimation in ascending aortic aneurysm.

J Thorac Cardiovasc Surg 2018 05 6;155(5):1938-1950. Epub 2017 Dec 6.

Aortic Institute at Yale-New Haven Hospital, Yale University School of Medicine, New Haven, Conn. Electronic address:

Background: In international guidelines, risk estimation for thoracic ascending aortic aneurysm (TAAA) is based on aortic diameter. We previously introduced the aortic size index (ASI), defined as aortic size/body surface area (BSA), as a predictor of aortic dissection, rupture, and death. However, weight might not contribute substantially to aortic size and growth. We seek to evaluate the height-based aortic height index (AHI) versus ASI for risk estimation and revisit our natural history calculations.

Methods: Aortic diameters and long-term complications of 780 patients with TAAA were analyzed. Growth rate estimates, yearly complication rates, and survival were assessed. Risk stratification was performed using regression models. The predictive value of AHI and ASI was compared.

Results: Patients were stratified into 4 categories of yearly risk of complications based on their ASI and AHI. ASIs (cm/m) of ≤2.05, 2.08 to 2.95, 3.00 to 3.95 and ≥4, and AHIs (cm/m) of ≤2.43, 2.44 to 3.17, 3.21 to 4.06, and ≥4.1 were associated with a 4%, 7%, 12%, and 18% average yearly risk of complications, respectively. Five-year complication-free survival was progressively worse with increasing ASI and AHI. Both ASI and AHI were shown to be significant predictors of complications (P < .05). AHI categories 3.05 to 3.69, 3.70 to 4.34, and ≥4.35 cm/m were associated with a significantly increased risk of complications (P < .05). The overall fit of the model using AHI was modestly superior according to the concordance statistic.

Conclusions: Compared with indices including weight, the simpler height-based ratio (excluding weight and BSA calculations) yields satisfactory results for evaluating the risk of natural complications in patients with TAAA.
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http://dx.doi.org/10.1016/j.jtcvs.2017.10.140DOI Listing
May 2018

Reply.

Ann Thorac Surg 2018 02;105(2):663-664

Anzhen Aortic Surgery, Capital Medical University, 2 Anzhen Rd, Beijing 100029, China. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2017.09.024DOI Listing
February 2018

Prevention of Aortic Dissection Suggests a Diameter Shift to a Lower Aortic Size Threshold for Intervention.

Cardiology 2018;139(3):139-146. Epub 2018 Jan 19.

Background: Multiple studies have quantified the relationship between aortic size and risk of dissection. However, these studies estimated the risk of dissection without accounting for any increase in aortic size from the dissection process itself.

Objectives: This study aims to compare aortic size before and after dissection and to evaluate the change in size consequent to the dissection itself.

Methods: Fifty-five consecutive patients (29 type A; 26 type B) with aortic dissection and incidental imaging studies prior to dissection were identified and compared to a control group of aneurysm patients (n = 205). The average time between measurement at and prior to dissection was 1.7 ± 1.9 years (1.9 ± 2.0 years mean inter-image time in the control group). A multivariate regression model controlling for growth rate, age, and gender was created to estimate the effect of dissection itself on aortic size.

Results: The mean aortic sizes at and prior to dissection were 54.2 ± 7.0 and 45.1 ± 5.7 mm for the ascending aorta, and 47.1 ± 13.8 and 39.5 ± 13.1 mm for the descending aorta, respectively. The multivariable analysis revealed a significant impact of the dissection itself (p < 0.001) and estimated an increase in size of 7.65 mm (ascending aorta) and 6.38 mm (descending aorta). Thus, a proportional estimate of 82.8% (ascending aorta) and 80.8% (descending aorta) of dissections are made at a size lower than the guideline-recommended threshold (55 mm).

Conclusions: The aortic diameter increases substantially due to aortic dissection itself and, thus, aortas are being dissected at clinically meaningfully smaller sizes than natural history analyses have previously suggested. These findings have important implications regarding the size at which the risk of dissection is increased.
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http://dx.doi.org/10.1159/000481930DOI Listing
October 2018
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