Challenges in prompt identification and surgical correction of Marfan Syndrome aortic disease in a middle-income country: a case series study.

BACKGROUND: Marfan Syndrome is an autosomal dominant disease caused by pathogenetic variants in the FBN1 gene. The progressive dilatation of the aorta and the potential risk of acute aortic syndromes influence the prognosis of these patients. We aim to describe population characteristics, long-term survival, and re-intervention patterns in patients who underwent aortic surgery with a previously confirmed clinical diagnosis of Marfan Syndrome in a middle-income country. METHODS: A retrospective single-center case series study was conducted. All Marfan Syndrome patients who underwent aortic procedures from 2004 until 2021 were included. Qualitative variables were frequency-presented, while quantitative ones adopted mean ± standard deviation. A subgroup analysis between elective and emergent procedures was conducted. Kaplan-Meier plots depicted cumulative survival and re-intervention-free. Control appointments and government data tracked out-of-hospital mortality. RESULTS: Fifty patients were identified. The mean age was 38.79 ± 14.41 years, with a male-to-female ratio of 2:1. Common comorbidities included aortic valve regurgitation (66%) and hypertension (50%). Aortic aneurysms were observed in 64% without dissection and 36% with dissection. Surgical procedures comprised elective (52%) and emergent cases (48%). The most common surgery performed was the David procedure (64%), and the Bentall procedure (14%). The in-hospital mortality rate was 4%. Complications included stroke (10%), and acute kidney injury (6%). The average follow-up was 8.88 ± 5.78 years. Survival rates at 5, 10, and 15 years were 89%, 73%, and 68%, respectively. Reintervention rates at 1, 2.5, and 5 years were 10%, 14%, and 17%, respectively. The emergent subgroup was younger (37.58 ± 14.49 years), had the largest number of Stanford A aortic dissections, presented hemodynamic instability (41.67%), and had a higher requirement of reinterventions in the first 5 years of follow-up (p = 0.030). CONCLUSION: In our study, surveillance programs played a pivotal role in sustaining high survival rates and identifying re-intervention requirements. However, challenges persist, as 48% of the patients required emergent surgery. Despite not affecting survival rates, a greater requirement for reinterventions was observed, emphasizing the necessity of timely diagnosis. Enhanced educational initiatives for healthcare providers and increased patient involvement in follow-up programs are imperative to address these concerns.

Emergent hybrid surgical approaches for non-dissecting ruptured Kommerell's aneurysm: a case report series.

BACKGROUND: Kommerell's aneurysm is a saccular or fusiform dilatation found in 3-8% of Kommerell's diverticulum cases. A non-dissecting rupture rate of 6% has been reported. If ruptured, emergent surgical correction is usually granted. However, evidence regarding the optimal surgical approach in this acute setting is scarce. In this case report series, we aim to describe our experience managing type-1 non-dissecting ruptured Kommerell's aneurysm with hybrid emergent surgical approaches. CASES PRESENTATION: From January 2005 to December 2020, three cases of type-1 non-dissecting ruptured Kommerell's aneurysm requiring emergent surgical repair were identified. The mean age was 66.67 ± 7.76 years, and 3/3 were male. The most common symptoms were atypical chest pain, dyspnoea, and headache (2/3). The mean aneurysm's diameter was 63.67 ± 5.69 mm. Frozen Elephant Trunk was the preferred surgical approach (2/3). The Non-Frozen Elephant Trunk patient underwent a hybrid procedure consisting of a supra-aortic debranching and a zone-2 stent-graft deployment. We found a mean clamp time of 140 ± 60.75 min, cardiac arrest time of 51.33 ± 3.06 min, and a hospital stay of 13.67 ± 5.51 days. The most common complications were surgical-site infection and shock (2/3). Only one patient died (1/3). CONCLUSION: Evidence of management for non-dissecting ruptured Kommerell's aneurysms is scarce. Additional, robust, and more extensive studies are required. The selection of the appropriate surgical approach is challenging, and each patient should be individualized. Frozen Elephant Trunk was feasible for patients requiring emergent surgical repair in our centre. However, other hybrid or open procedures can be performed.

Atrial approaches in mitral valve surgery: a propensity analysis of differences in the incidence of clinically relevant adverse effects.

BACKGROUND: The lack of evidence on complications using mitral valve approaches leaves the choice of risk exposure to the surgeon's preference, based on individual experience, speed, ease, and quality of exposure. METHODS: The present study analysed patients undergoing mitral valve surgery using a superior transseptal approach or a left-atrial approach between 2006 and 2018. We included first-time elective mitral valve procedures, isolated, or combined, without a history of rhythm disturbances. We used propensity score matching based on 26 perioperative variables. The primary endpoint was the association between the superior transeptal approach and clinically significant adverse outcomes, including arrhythmias, need for a permanent pacemaker, cerebrovascular events, and mortality. RESULTS: A total of 652 patients met the inclusion criteria; 391 received the left atrial approach, and 261 received the superior transseptal approach. After matching, 96 patients were compared with 69 patients, respectively. The distribution of the preoperative and perioperative variables was similar. There was no difference in the incidence of supraventricular tachyarrhythmias or the need for treatment. The incidence of nodal rhythm (p = 0.008) and length of stay in intensive care (p = 0.04) were higher in the superior transseptal group, but the need for permanent pacemaker implantation was the same. Likewise, there was no difference in the need for anticoagulation due to arrhythmia, the incidence of cerebrovascular events or mortality in the postoperative period or in the long-term follow-up. CONCLUSION: We did not find an association with permanent heart rhythm disorders or any other significant adverse clinical outcome. Therefore, the superior transeptal approach is useful and safe for mitral valve exposure.

Management of primary cardiac paraganglioma.

OBJECTIVE: Cardiac paraganglioma is a rare tumor that most surgeons have limited experience treating. The objective of this study is to examine the management and outcomes for cardiac paraganglioma treatment when cared for by a multidisciplinary cardiac tumor team. METHODS: We reviewed our institutionally approved cardiac tumor database from March 2004 to June 2020 for cardiac paraganglioma. These prospectively collected data were retrospectively reviewed. Patient characteristics were presented for individual patients and as summary statistics. Demographic and clinical data were also reported as median and interquartile range for continuous variables and frequencies and proportions for categoric variables. Kaplan-Meier curves were used to depict the patient survival from surgery. RESULTS: There were 21 cases of primary cardiac paraganglioma, 19 of whom had surgical resection with 3 refusing offered surgery. Of 19 resected tumors, 13 originated from the left atrium and 6 originated from the roots of the pulmonary artery and the aorta. Complex procedures were required, including aortic and pulmonary root replacement and 8 autotransplants. All tumors had complete gross resection with no identifiable disease left behind, but 4 of these had microscopically positive margins. None of the patients had local recurrence of disease. There was 1 case of metastatic paraganglioma with death at 4 years postsurgery. Operative mortality was 10.6%. Survival from surgery was 88.2%, 71.8%, and 71.8% and 1, 5, and 10 years, respectively. CONCLUSIONS: Cardiac paraganglioma presents a surgical challenge. Mortality and long-term survival after surgical resection are acceptable but may require complex resection and reconstruction.

Medicina cardiovascular moderna: un llamado al trabajo en equipo / Modern cardiovascular medicine: Time to work in a team?

Las enfermedades cardiovasculares incluyen cardiopatía isquémica, enfermedad cardiaca estructural, accidente cerebrovascular, insuficiencia cardíaca, enfermedad arterial periférica y otras afecciones cardíacas y vasculares, que constituyen la principal causa de morbimortalidad global. De igual forma, contribuyen de manera importante a la reducción de la calidad de vida y son la principal causa de costos a los sistemas de salud en el mundo. En el 2017, las enfermedades cardiovasculares ocasionaron aproximadamente 17,8 millones de muertes en todo el mundo, lo que corresponde a 330 millones de años de vida perdidos y otros 35,6 millones de años vividos con discapacidad.

Wide Dissection and Intercostal Vessel Division Allows for Repair of Hypoplastic Aortic Arch Through Thoracotomy.

BACKGROUND: The approach to coarctation of the aorta with hypoplastic aortic arch is controversial. We evaluated the outcomes in patients with coarctation of the aorta with or without hypoplastic aortic arch operated through a posterior left lateral thoracotomy. METHODS: A retrospective cohort of patients with aortic coarctation, who underwent repair between January 2009 and October 2017, was analyzed. Preoperative, postoperative, and echocardiographic characteristics were reviewed. Statistical analysis examined survival, freedom from reintervention, and freedom from recoarctation. RESULTS: In nine years, 389 patients who underwent surgical treatment for coarctation of the aorta were identified; after exclusion criteria and complete echocardiographic reports, 143 patients were analyzed, of which 29 patients had hypoplastic aortic arch. The modification in the extended end-to-end anastomosis technique was a wide dissection and mobilization of the descending aorta that was achieved due to the ligation and division of 3 to 5 intercostal vessels. In both groups, patients were close to one month of age and had a median weight of 3.6 and 3.4 kg for hypoplastic and nonhypoplastic arch, respectively. In postoperative events, there was no statistically significant difference between the groups ( P = .57 for renal failure, P = .057 for transient, nonpermanent neurologic events, P = .496 for sepsis), as for intensive care unit ( P = .502) and total in-hospital stay ( P = .929). There was one case of postoperative mortality in each group and both were associated with noncardiac comorbidities. Regarding survival (log-rank = 0.060), freedom from reintervention (log-rank = 0.073), and freedom from recoarctation (log-rank = 0.568), there was no statistically significant difference between the groups. CONCLUSION: We believe that it is the modified technique that allowed greater mobilization of the aorta and successful repair of hypoplastic arch through thoracotomy, without an increase in paraplegia or other adverse outcomes.

Mitral valve repair, how to make volume not matter; techniques, tendencies, and outcomes, a single center experience.

BACKGROUND: Recent evidence has showed us that quality of mitral valve repair is strongly related to volume. However, this study shows how low-volume centers can achieve results in mitral valve repair surgery comparable to those reported by referral centers. It compares outcomes of mitral valve repair using resection versus noresection techniques, tendencies, and rates of repair. METHODS: Between 2004 and 2017, 200 patients underwent mitral valve repair for degenerative mitral valve disease at Fundación Cardioinfantil-Institute of Cardiology. Fifty-eight (29%) patients underwent resection and 142 (71%) noresection. RESULTS: Follow-up was 94% complete, mean follow-up time was 2.3 years. There was no 30-day mortality. Five patients required mitral valve replacement after an average of 5.3 years (Resection = 2; Noresection = 3). Freedom from severe mitral regurgitation was 98% at 6.6 years of follow-up for the noresection group, and 92.5% at 7 years for the resection group (log rank: 0.888). At last follow-up, two patients died of cardiovascular disease related to mitral valve, 181 patients (86%) showed no or grade I mitral regurgitation. Patients with previous myocardial infarction had increased risk of recurrent mitral regurgitation (p = 0,030). Within four years, we inverted the proportion of mitral valve replacement and repair, and in 2016 we achieved a mitral valve repair rate of 96%. CONCLUSION: This study suggests that resection and noresection techniques are safe and effective. Recurrence of severe mitral regurgitation and need for mitral valve replacement are rare. We show that low-volume centers can achieve results comparable to those reported worldwide by establishing a mitral valve repair team. We encourage hospitals to follow this model of mitral valve repair program to decrease the proportion of mitral valve replacement, while increasing mitral valve repair.

Mechanical circulatory support as bridge therapy for heart transplant: case series report.

BACKGROUND: Mechanical circulatory support (MCS) represents an effective urgent therapy for patients with cardiac arrest or end-stage cardiac failure. However, its use in developing countries as a bridge therapy remains controversial due to costs and limited duration. This study presents five patients who underwent MSC as bridge therapy for heart transplantation in a developing country. CASE PRESENTATION: We present five patients who underwent MCS as bridge therapy for heart transplant between 2010 and 2015 at Fundación Cardioinfantil-Instituto de Cardiología. Four were male, median age was 36 (23-50) years. One patient had an ischemic cardiomyopathy, one a lymphocytic myocarditis, two had electrical storms (recurrent ventricular tachycardia) and one an ischemic cardiomyopathy with an electrical storm. Extracorporeal life support (ECLS) was used in three patients, left ventricular assistance in one, and double ventricular assistance in one (Levitronix® Centrimag®). Median assistance time was 8 (2.5-13) days. Due to the inability of cardiopulmonary bypass weaning, two patients required ECLS after transplant. One patient died in the intensive care unit due to type I graft rejection. Endpoints assessed were 30-day mortality, duration of bridge therapy and complications related to MCS. Patients that died on ECLS, or were successfully weaned off ECLS were not included in this study. CONCLUSIONS: MCS is often the only option of support for critically ill patients waiting for a heart transplant and could be considered as a short-term bridge therapy.

Estenosis aórtica severa asintomática ¿Observar mejor que operar? / Asymptomatic severe aortic stenosis ¿Is it better to observe than to operate?

La estenosis aórtica es la valvulopatía primaria más frecuente en el mundo; alcanza una prevalencia estimada en 7,6 millones de personas mayores de 75 años en Europa y Estados Unidos, aunado al aumento en la expectativa de vida de la población mundial que hará que esta tasa continúe en ascenso1. En el momento del diagnóstico de esta valvulopatía, aproximadamente el 50% de los pacientes son asintomáticos y varios pueden tener a fracción de eyección (FE) preservada; a este tipo de pacientes se les ha clasificado en un estadio C1 según la guía de la Asociación americana del corazón/Colegio americano de Cardiología (AHA/ACC, sus siglas en inglés) del año 2014. Su manejo consiste en un seguimiento clínico y ecocardiográfico cada 6 a 12 meses (recomendación dada por expertos y basada en estudios retrospectivos) (2. Sin embargo, se benefician de un reemplazo valvular temprano aquellos que tienen riesgo quirúrgico bajo (puntaje < 4 según la Sociedad de cirujanos del tórax -STS, su sigla en inglés-) y tienen características adicionales de mal pronóstico, tales como síntomas desencadenados por una prueba de esfuerzo, calcificación severa de la válvula con limitación para su apertura, velocidad de flujo transvalvular > 5 m/s, gradiente medio > 60 mm Hg y aumento de la velocidad de flujo valvular de más de 0,3 m/s/año3. Recientemente, la actualización de la guía AHA/ACC de 2017 recomienda el reemplazo valvular aórtico quirúrgico tanto para los pacientes con estenosis aórtica severa sintomáticos (estadio D), como para los asintomáticos (estadio C) que cumplan con alguna indicación quirúrgica, siempre y cuando el riesgo quirúrgico sea bajo o intermedio3. Dicha recomendación podría interpretarse de dos formas: todos los pacientes con estenosis aórtica severa independientemente de los síntomas deberán ser llevados a reemplazo valvular aórtico quirúrgico, o los pacientes asintomáticos deberán tener alguna característica de mal pronóstico para ser llevados a cirugía; esta última interpretación es la que concuerda con el texto de las guías del 2014. Por su parte, la guía de la Sociedad Europea de Cardiología de 20174 propone que la observación en pacientes sin factores de mal pronóstico parece ser segura, mientras que es poco probable que la cirugía temprana traiga beneficio.

Resultados del tratamiento quirúrgico de los aneurismas de aorta abdominal infrarrenal / Results of surgical treatment of infrarenal abdominal aortic aneurysms

Introducción: Los resultados del tratamiento quirúrgico de los aneurismas de aorta abdominal dependen de múltiples factores asociados al paciente y a la experiencia del grupo tratante. Objetivos: Describir los resultados obtenidos en el tratamiento quirúrgico de aneurismas de aorta abdominal por un grupo multidisciplinario y evaluar el impacto del volumen de casos año y de la experiencia adquirida. Métodos: Cohorte histórica de pacientes con diagnóstico de aneurisma de aorta abdominal sometidos a tratamiento quirúrgico desde junio de 1994 a junio de 2013, en la que se establecieron tres grupos: Grupo 1, aneurisma roto reparo abierto; Grupo 2, pacientes electivos reparo abierto; Grupo 3, pacientes electivos reparo endovascular. El desenlace primario a evaluar fue mortalidad hospitalaria, y el secundario, morbilidad asociada con el procedimiento. Para el análisis, la cohorte se dividió en dos: casos intervenidos de 1994 a 2002 y casos de 2002 a 2013, fundamentado en la implementación del programa endovascular en la institución en 2002. Resultados: Se intervinieron 573 pacientes en total. En el Grupo 1, 65; en el 2, 433, y en el 3, 75. La mortalidad global fue de 28,6, 2,8 y 1,3% respectivamente. Se demostró un incremento significativo en el volumen de casos (233%) y una reducción importante en la mortalidad de los casos abiertos después de 2002 (4,8 vs. 2,0%, p = 0,19). Conclusiones: La implemetación de la terapia endovascular ha contribuido a aumentar el número de pacientes tratados con aneurisma de aorta abdominal en nuestra institución. El aumento del volumen se tradujo en disminución efectiva de la mortalidad.

Introduction: Surgical treatment outcomes for infrarenal abdominal aortic aneurysm repair depend on patient factors and attending vascular team expertise. Objetives: To describe the outcomes of surgical treatment of abdominal aortic aneurysm performed by an interdisciplinary team and to evaluate the effects of annual caseload and acquired expertise. Methods: Historic cohort of patients with abdominal aortic aneurysm diagnosis surgically treated from January 1994 to June 2013. Three groups were established: Group 1 was for open ruptured abdominal aortic aneurysm repair, Group 2 was for open elective repair and Group 3 was for elective endovascular aneurysm repairs. Primary outcome was in-hospital mortality, and secondary outcomes were peri-procedural morbidity. For analysis the cohort was divided in two: cases repaired from 1994 to 2002 and from 2002 to 2013. This was based in the implementation of endovascular therapy from 2002 at the institution. Results: 573 patients were treated; Group 1: 65 patients; Group 2: 433 patients; Group 3: 75 patients. Mortality was 28.6%, 2.8% and 1.3% respectively. A significant rise in annual caseload (233%) was demonstrated and a trend toward lowering in surgical mortality (4.8 vs. 2.0%, p = 0.19) after 2002. Conclusions: Implementation of endovascular repair has contributed to rising annual caseload of patients with abdominal aortic aneurysm at our institution. This rising in volume correlates with effective lowering in mortality.

Factores asociados a la aparición de mediastinitis en 2073 revascularizaciones miocárdicas / Factors associated with the onset of mediastinitis in 2073 myocardial revascularizations

Introducción: La mediastinitis, entidad de etiología multifactorial, ocurre hasta en 4% de los pacientes sometidos a revascularización miocárdica, y se reporta una mortalidad hospitalaria de 14% a 47%, que genera aumento en los costos de atención y deterioro de la calidad de vida así como de la sobrevida del paciente a largo plazo. Objetivo: Determinar cuáles antecedentes clínicos del paciente y factores relacionados con el procedimiento quirúrgico se asocian con la aparición de mediastinitis. Materiales y métodos: Diseño de casos y controles anidado en una cohorte histórica de pacientes sometidos a revascularización miocárdica en el periodo de enero de 2005 a julio de 2011. Los pacientes con mediastinitis se compararon con un grupo control sin mediastinitis tomados del mismo grupo de riesgo en una relación 1:4, y pareados por fecha de cirugía. El diagnóstico de mediastinitis se hizo con criterios clínicos, de laboratorio y hallazgos quirúrgicos. Resultados: Se identificaron treinta casos en el periodo relacionado. Los factores asociados a la aparición del evento fueron: diabetes mellitus OR 2,3 (1,1-4,9), uso de circulación extracorpórea OR 2,4 (1,1-5,5), tiempo de perfusión OR 1,1 (1,1-1,3) y pacientes mayores de 70 años OR 1,1 (1,2-1,4). Conclusiones: La mediastinitis sigue siendo una complicación de baja prevalencia con consecuencias devastadoras. El impacto clínico y económico de esta complicación debe obligar a los grupos quirúrgicos a crear estrategias de prevención con base en el conocimiento de los factores de riesgo de su población.

Introduction: Mediastinitis is a multifactorial entity which occurs in up to 4% of patients undergoing coronary artery bypass graft (CABG). It has a hospital mortality of 14% to 47%, which generates increased costs of care and deterioration of the quality of life and patient survival in the long term. Objective: To determine which clinical antecedents and factors related to the surgical procedure are associated with the occurrence of mediastinitis. Materials and methods: A nested case control study in a historical cohort of patients undergoing CABG in the period January 2005 to July 2011. Patients with mediastinitis were compared with a control group without mediastinitis taken from the same risk group in a 1:4 ratio and matched for date of surgery. The diagnosis of mediastinitis was made on clinical and laboratory criteria and surgical findings. Results: Thirty cases were identified in the related period. Factors associated with the occurrence of the event were: diabetes mellitus OR 2.3 (1.1 to 4.9), use of extracorporeal circulation OR 2.4 (1.1-5.5), OR 1 perfusion time, 1 (1.1 to 1.3) and patients older than 70 years OR 1.1 (1.2-1.4). Conclusions: Mediastinitis remains complications of low prevalence with devastating consequences. The clinical and economic impact of this complication should compel surgical groups to create prevention strategies based on knowledge of the risk factors of the population.

Risk factors associated with postoperative seizures in patients undergoing cardiac surgery who received tranexamic acid: a case-control study.

Antifibrinolytic agents are used during cardiac surgery to minimize bleeding and reduce exposure to blood products. Several reports suggest that tranexamic acid (TA) can induce seizure activity in the postoperative period. To examine factors associated with postoperative seizures in patients undergoing cardiac surgery who received TA. University-affiliated hospital. Case-control study. Patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) between January 2008 and December 2009 were identified. During this time, all patients undergoing heart surgery with CPB received TA. Cases were defined as patients who developed seizures that required initiation of anticonvulsive therapy within 48 h of surgery. Exclusion criteria included subjects with preexisting epilepsy and patients in whom the convulsive episode was secondary to a new ischemic lesion on brain imaging. Controls who did not develop seizures were randomly selected from the initial cohort. From an initial cohort of 903 patients, we identified 32 patients with postoperative seizures. Four patients were excluded. Twenty-eight cases and 112 controls were analyzed. Cases were more likely to have a history of renal impairment and higher preoperative creatinine values compared with controls (1.39 ± 1.1 vs. 0.98 ± 0.02 mg/dL, P = 0.02). Significant differences in the intensive care unit, postoperative and total lengths of stay were observed. An association between high preoperative creatinine value and postoperative seizure was identified. TA may be associated with the development of postoperative seizures in patients with renal dysfunction. Doses of TA should be reduced or even avoided in this population.

The vasodilatory effects of levosimendan on the human internal mammary artery.

BACKGROUND: Levosimendan, an inotropic drug that enhances myocardial contractility through myofilment calcium sensitazion, induces peripheral vasodilation via opening ATP-dependent K(+) channels. It is unknown whether this drug can be used for the treatment of perioperative vasospasm of arterial conduits used for coronary artery bypass grafting. METHODS: We investigated the effects of levosimendan on human internal mammary artery (IMA) specimens taken from patients undergoing coronary artery bypass surgery. The rings were carefully prepared and placed between two wire hooks in organ bath chambers and then constricted submaximally with norepinephrine and thromboxane A(2) analog (U46619). Nitroglycerin, milrinone, and levosimendan were separately added in a cumulative fashion and concentration response curves for relaxation were constructed. In parallel experiments, the response to levosimendan was evaluated on rings with and without functional endothelium. Levosimendan prevention of norepinephrine-induced contraction was also estimated. RESULTS: Nitroglycerin, milrinone, and levosimendan completely reversed the contraction of the IMA segments induced by U46619 and norepinephrine. Levosimendan produced a potent, concentration-dependent preventive effect on the norepinephrine-induced contraction of IMA. The responses to levosimendan were similar in preparations with or without endothelium.

What is the best treatment for patients with acute type B aortic dissections--medical, surgical, or endovascular stent-grafting?

BACKGROUND: Controversy continues regarding treatment for patients with acute type B aortic dissection. METHODS: One hundred eighty-nine patients with acute type B aortic dissection managed over a 36-year period were analyzed retrospectively for three outcome endpoints: survival; freedom from reoperation, and freedom from late aortic-related complications or late death. Risk factors for death were identified using a multivariable Cox proportional hazards model. Then to account for patient selection bias, heterogeneity of the population, and continuous evolution in techniques, propensity score analysis was used to identify risk-matched cohorts (quintiles I and II) in which the results of medical (n = 111) or surgical (n = 31) therapy were compared more comprehensively. RESULTS: The two main determinants of death were shock (hazard ratio [HR] = 14.5, 95% confidence level [CL] 4.7, 44.5; p < 0.001) and visceral ischemia (HR = 10.9, 95% CL 3.9, 30.3; p < 0.001). Arch involvement, rupture, stroke, previous sternotomy, and coronary or lung disease roughly doubled the hazard. Female sex was also a significant but weaker independent predictor of death. Actuarial survival estimates for all patients were 71%, 60%, 35%, and 17% at 1, 5, 10, and 15 years, respectively, and were similar for the medical and surgical patients. The Marfan syndrome predicted reoperation and late aortic complications or late death. In a separate analysis of the 142 patients in quintiles I and II, survival, freedom from reoperation, as well as freedom from late aortic complications or death were almost identical in the medical and surgical subsets. CONCLUSIONS: The poor long-term prognosis of patients with acute type B aortic dissection is determined primarily by dissection-related and patient-specific risk factors, which are not readily modifiable. Whether the outlook in the future will be improved using stent-grafts remains to be determined.

Is medical therapy still the optimal treatment strategy for patients with acute type B aortic dissections?

OBJECTIVE: The optimal treatment of patients with acute type B dissections continues to be debated. METHODS: A 36-year clinical experience of medical and surgical treatments in 189 patients was retrospectively analyzed (multivariable Cox proportional hazards model) with respect to three outcome end points: all deaths, freedom from reoperation, and freedom from late aortic complications or death. Propensity score analysis identified 2 quintiles (quintiles I and II, consisting of 142 comparable patients) for further comparison of the effects of surgical versus medical treatment. RESULTS: Shock (hazard ratio 14.5, 95% confidence interval 4.7-44.5, P <.001) and visceral ischemia (hazard ratio 10.9, 95% confidence interval 3.9-30.3, P <.001) largely predominated as determinants of death, along with 6 other risk factors (arch involvement, rupture, stroke, previous sternotomy, and coronary or lung disease), which roughly doubled the hazard of death. Female sex was a significant but weaker predictor of death. Renal dysfunction, year of presentation, age, and mode of therapy (medical vs surgical) had no important bearing on overall survival. The actuarial survival estimates for all patients were 71%, 60%, 35%, and 17% at 1, 5, 10, and 15 years, respectively, and were similar for the medical and surgical patients. Reoperation and late aortic complications were predicted by the presence of Marfan syndrome. For the propensity-matched patients in quintiles I and II, survival, freedom from reoperation, and freedom from aortic complications were almost identical in the medically treated and surgical subsets. CONCLUSIONS: The prognosis for patients with acute type B aortic dissection is bleak and determined primarily by dissection-related and patient-specific risk factors, which do not appear to be readily modifiable.