Long-term outcomes after recurrent acute thoracic aortic dissection: Insights from the International Registry of Aortic Dissection.

OBJECTIVE: With an aging population and advancements in imaging, recurrence of thoracic aortic dissection is becoming more common. METHODS: All patients enrolled in the International Registry of Aortic Dissection from 1996 to 2023 with type A and type B acute aortic dissection were identified. Among them, initial dissection and recurrent dissection were discerned. The study period was categorized into 3 eras: historic era, 1996 to 2005; middle era, 2006 to 2015; most recent era, 2016 to 2023. Propensity score matching was applied between initial dissection and recurrent dissection. Outcome of interests included long-term survival and cumulative incidence of major aortic events defined by the composite of reintervention, aortic rupture, and new dissection. RESULTS: The proportion of recurrent dissection increased from 5.9% in the historic era to 8.0% in the most recent era in the entire dissection cohort. In patients with type A dissection, propensity score matching between initial dissection and recurrent dissection yielded 326 matched pairs. Kaplan-Meier curves showed similar long-term survival between the 2 groups. However, the cumulative incidence of major aortic events was significantly higher in the recurrent dissection group (40.3% ± 6.2% vs 17.8% ± 5.1% at 4 years in the initial dissection group, P = .02). For type B dissection, 316 matched pairs were observed after propensity score matching. Long-term survival and the incidence of major aortic events were equivalent between the 2 groups. CONCLUSIONS: The case volume of recurrent dissection or the ability to detect recurrent dissection has increased over time. Acute type A recurrent dissection was associated with a higher risk of major aortic events than initial dissection. Further judicious follow-up may be crucial after type A recurrent dissection.

The impact of reoperative surgery on aortic root replacement in the United States.

OBJECTIVE: Reoperative sternotomy is associated with poor outcomes after cardiac surgery. We aimed to investigate the impact of reoperative sternotomy on the outcomes after aortic root replacement. METHODS: All patients who underwent aortic root replacement from January 2011 to June 2020 were identified using the Society of Thoracic Surgeons Adult Cardiac Surgery Database. We compared outcomes between patients who underwent first-time aortic root replacement with those with a history of sternotomy undergoing reoperative sternotomy aortic root replacement using propensity score matching. Subgroup analysis was performed among the reoperative sternotomy aortic root replacement group. RESULTS: A total of 56,447 patients underwent aortic root replacement. Among them, 14,935 (26.5%) underwent reoperative sternotomy aortic root replacement. The annual incidence of reoperative sternotomy aortic root replacement increased from 542 in 2011 to 2300 in 2019. Aneurysm and dissection were more frequently observed in the first-time aortic root replacement group, whereas infective endocarditis was more common in the reoperative sternotomy aortic root replacement group. Propensity score matching yielded 9568 pairs in each group. Cardiopulmonary bypass time was longer in the reoperative sternotomy aortic root replacement group (215 vs 179 minutes, standardized mean difference = 0.43). Operative mortality was higher in the reoperative sternotomy aortic root replacement group (10.8% vs 6.2%, standardized mean difference = 0.17). In the subgroup analysis, logistic regression demonstrated that individual patient repetition of (second or more resternotomy) surgery and annual institutional volume of aortic root replacement were independently associated with operative mortality. CONCLUSIONS: The incidence of reoperative sternotomy aortic root replacement might have increased over time. Reoperative sternotomy is a significant risk factor for morbidity and mortality in aortic root replacement. Referral to high-volume aortic centers should be considered in patients undergoing reoperative sternotomy aortic root replacement.

Postoperative acute kidney injury after thoracic endovascular aortic repair for acute type B aortic dissection.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) has evolved as the standard for treating complicated acute type B aortic dissection (ATBAD). Acute kidney injury (AKI) is a common complication in critically ill patients and is commonly observed in patients with ATBAD. The purpose of the study was to characterize AKI after TEVAR. METHODS: All patients who underwent TEVAR for ATBAD from 2011 through 2021 were identified using the International Registry of Acute Aortic Dissection. The primary end point was AKI. A generalized linear model analysis was performed to identify a factor associated with postoperative AKI. RESULTS: A total of 630 patients presented with ATBAD and underwent TEVAR. The indication for TEVAR was complicated ATBAD in 64.3%, high-risk uncomplicated ATBAD in 27.6%, and uncomplicated ATBAD in 8.1%. Of 630 patients, 102 (16.2%) developed postoperative AKI (AKI group) and 528 patients (83.8%) did not (non-AKI group). The most common indication for TEVAR was malperfusion (37.5%). In-hospital mortality was significantly higher in the AKI group (18.6% vs 4%; P < .001). Postoperatively, cerebrovascular accident, spinal cord ischemia, limb ischemia, and prolonged ventilation were more commonly observed in the AKI group. The expected mortality was similar at 2 years between the two groups (P = .51). Overall, the preoperative AKI was observed in 95 (15.7%) in the entire cohort consisting of 60 (64.5%) in the AKI group and 35 (6.8%) in the non-AKI group. A history of CKD (odds ratio, 4.6; 95% confidence interval, 1.5-14.1; P = .01) and preoperative AKI (odds ratio, 24.1; 95% confidence interval, 10.6-55.0; P < .001) were independently associated with postoperative AKI. CONCLUSIONS: The incidence of postoperative AKI was 16.2% in patients undergoing TEVAR for ATBAD. Patients with postoperative AKI had a higher rate of in-hospital morbidities and mortality than those without. A history of CKD and preoperative AKI were independently associated with postoperative AKI.