High positive end-expiratory pressure ventilation mitigates the progression from unilateral pulmonary contusion to ARDS: An animal study.

BACKGROUND: Pulmonary contusion (PC) is common in severely traumatized patients and can lead to respiratory failure requiring mechanical ventilation (MV). Ventilator-induced lung injury (VILI) might aggravate lung damage. Despite underrepresentation of trauma patients in trials on lung-protective MV, results are extrapolated to these patients, potentially disregarding important pathophysiological differences. METHODS: Three MV protocols with different positive end-expiratory pressure (PEEP) levels: ARDSnetwork lower PEEP (ARDSnet-low), ARDSnetwork higher PEEP (ARDSnet-high), and open lung concept (OLC) were applied in swine for 24 hours following PC. Gas exchange, lung mechanics, quantitative computed tomography, and diffuse alveolar damage (DAD) score were analyzed. Results are given as median (interquartile range) at 24 hours. Statistical testing was performed using general linear models (group effect) over all measurement points and pairwise Mann-Whitney U tests for DAD. RESULTS: There were significant differences between groups: PEEP ( p < 0.0001) ARDSnet-low (8 [8-10] cmH 2 O), ARDSnet-high (12 [12-12] cmH 2 O), OLC (21 [20-22] cmH 2 O). The fraction of arterial partial pressure of oxygen and inspired oxygen fraction ( p = 0.0016) was lowest in ARDSnet-low (78 (73-111) mm Hg) compared with ARDSnet-high (375 (365-423) mm Hg) and OLC (499 (430-523) mm Hg). The end-expiratory lung volume (EELV) differed significantly ( p < 0.0001), with highest values in OLC (64% [60-70%]) and lowest in ARDSnet-low (34% [24-37%]). Costa's surrogate for mechanical power differed significantly ( p < 0.0001), with lowest values for ARDSnet-high (73 [58-76]) compared with OLC (105 [108-116]). Diffuse alveolar damage was lower in ARDSnet-high compared with ARDSnet-low (0.0007). CONCLUSION: Progression to ARDS, 24 hours after PC, was mitigated by OLC and ARDSnet-high. Both concepts restored EELV. ARDSnet-high had the lowest mechanical power surrogate and DAD. Our data suggest, that ARDSnet-high restored oxygenation and functional lung volume and reduced physiological and histological surrogates for VILI. ARDSnet-low generated unfavorable outcomes, such as loss of EELV, increased mechanical power and DAD after PC in swine. The high respiratory rate in the OLC may blunt favorable effects of lung recruitment.

[Methemoglobinemia Induced by Sildenafil Tablets Ordered in the Darknet - Importance of Syncopes' Causes]. / Methämoglobinämie durch Sildenafil-Tabletten aus dem Darknet.

Drug-induced methemoglobinemia is a well-known phenomenon as well as induction by poppers (alcylnitrites substance group). Usually, suspicion is thrown in the right direction by a thorough medical history and environmental survey. But if intoxication is unintended and happens within the very private environment diagnosis might be very tricky. We report on an unusual case of accidental intoxication with probably contaminated tablets which were bought in the darknet. Finally, diagnosis was made by blood gas analysis' methemoglobine values.

When too much closeness harms: circumflex artery injury during mitral valve surgery.

Occlusion of the left coronary circumflex artery (LCX) during surgical procedures of the mitral valve is an infrequent but potentially life-threatening complication (1-3). Due to its close anatomical relationship to the posterior mitral valve annulus, there is a relevant risk of causing a stenosis or an occlusion of the left circumflex artery, especially by surgical annular sutures. The perioperative clinical course is heterogeneous, ranging from-initially-asymptomatic or solely electrocardiographic abnormalities to cardiogenic shock. Both severely impaired ventricular contractility or malignant arrhythmia may potentially lead to a weaning failure from cardiopulmonary bypass (CPB) and eventually result in chronic heart failure with persistently reduced ejection fraction. Possible therapeutic strategies include the immediate reopening of causal sutures, aortocoronary bypass grafting or percutaneous coronary intervention (PCI), yet PCI seems to be the preferred method at present.

[Anesthesiological and postinterventional management in percutaneous hepatic melphalan perfusion (chemosaturation)]. / Anästhesiologisches und postinterventionelles Management bei perkutaner hepatischer Melphalanperfusion (Chemosaturation).

Percutaneous hepatic melphalan perfusion (PHMP) is a last-line treatment of inoperable primary or secondary liver tumors. Selective perfusion and saturation (chemosaturation) of the liver with the chemotherapeutic agent melphalan is performed via catheterization of the hepatic artery without affecting the rest of the body with its cytotoxic properties. Using an extracorporeal circulation and balloon occlusion of the inferior vena cava, the venous hepatic blood is filtered and returned using a bypass procedure. During the procedure, considerable circulatory depression and coagulopathy are frequent. The purpose of this article is to review the anesthesiological and postprocedural management of patients undergoing PHMP with consideration of the pitfalls and special circumstances.

Chest Tube Placement in Mechanically Ventilated Trauma Patients: Differences between Computed Tomography-Based Indication and Clinical Decision.

The rate of occult pneumothorax in intubated and mechanically ventilated trauma patients until initial computed tomography (CT) remains undetermined. The primary aims of this study were to analyze initial chest CTs with respect to the thoracic pathology of trauma, the clinical injury severity, and chest tube placement (CTP) before and after CT. In a single-center retrospective analysis of 616 intubated and mechanically ventilated adult patients admitted directly from the scene to the emergency department (ED), 224 underwent CTP (36%). Of these, 142 patients (62%) underwent CTP before CT, of which, 125 (88%) had significant chest injury on CT. Seventeen patients had minor or absent chest injuries, most of which were associated with transient or unrecognized tracheal tube malposition. After CT, CTP was performed in another 82 patients, of which, 56 (68.3%) had relevant pneumothorax and 26 had minor findings on CT. Sixty patients who had already undergone CTP before CT received another CTP after CT, of which, 15 (25%) had relevant pneumothorax and 45 (75%) had functionality issues or malposition requiring replacement. Nine patients showed small pneumothorax on CT, and did not undergo CTP (including four patients with CTP before CT). The physiological variables were unspecific, and the trauma scores were dependent on the CT findings for identifying patients at risk for CTP. In conclusion, the clinical decisions for CTP before CT are associated with relevant false-negative and false-positive cases. Clinical assessment and CT imaging, together, are important indicators for CTP decisions that cannot be achieved by using clinical assessment or CT alone.

Methods for Determination of Individual PEEP for Intraoperative Mechanical Ventilation Using a Decremental PEEP Trial.

(1) Background: Individual PEEP settings (PEEPIND) may improve intraoperative oxygenation and optimize lung mechanics. However, there is uncertainty concerning the optimal procedure to determine PEEPIND. In this secondary analysis of a randomized controlled clinical trial, we compared different methods for PEEPIND determination. (2) Methods: Offline analysis of decremental PEEP trials was performed and PEEPIND was retrospectively determined according to five different methods (EIT-based: RVDI method, Global Inhomogeneity Index [GI], distribution of tidal ventilation [EIT VT]; global dynamic and quasi-static compliance). (3) Results: In the 45 obese and non-obese patients included, PEEPIND using the RVDI method (PEEPRVD) was 16.3 ± 4.5 cm H2O. Determination of PEEPIND using the GI and EIT VT resulted in a mean difference of −2.4 cm H2O (95%CI: −1.2;−3.6 cm H2O, p = 0.01) and −2.3 cm H2O (95% CI: −0.9;3.7 cm H2O, p = 0.01) to PEEPRVD, respectively. PEEPIND selection according to quasi-static compliance showed the highest agreement with PEEPRVD (p = 0.67), with deviations > 4 cm H2O in 3/42 patients. PEEPRVD and PEEPIND according to dynamic compliance also showed a high level of agreement, with deviations > 4 cm H2O in 5/42 patients (p = 0.57). (4) Conclusions: High agreement of PEEPIND determined by the RVDI method and compliance-based methods suggests that, for routine clinical practice, PEEP selection based on best quasi-static or dynamic compliance is favorable.

Central COVID-19 Coordination Centers in Germany: Description, Economic Evaluation, and Systematic Review.

BACKGROUND: During the COVID-19 pandemic, Central COVID-19 Coordination Centers (CCCCs) have been established at several hospitals across Germany with the intention to assist local health care professionals in efficiently referring patients with suspected or confirmed SARS-CoV-2 infection to regional hospitals and therefore to prevent the collapse of local health system structures. In addition, these centers coordinate interhospital transfers of patients with COVID-19 and provide or arrange specialized telemedical consultations. OBJECTIVE: This study describes the establishment and management of a CCCC at a German university hospital. METHODS: We performed economic analyses (cost, cost-effectiveness, use, and utility) according to the CHEERS (Consolidated Health Economic Evaluation Reporting Standards) criteria. Additionally, we conducted a systematic review to identify publications on similar institutions worldwide. The 2 months with the highest local incidence of COVID-19 cases (December 2020 and January 2021) were considered. RESULTS: During this time, 17.3 requests per day were made to the CCCC regarding admission or transfer of patients with COVID-19. The majority of requests were made by emergency medical services (601/1068, 56.3%), patients with an average age of 71.8 (SD 17.2) years were involved, and for 737 of 1068 cases (69%), SARS-CoV-2 had already been detected by a positive polymerase chain reaction test. In 59.8% (639/1068) of the concerned patients, further treatment by a general practitioner or outpatient presentation in a hospital could be initiated after appropriate advice, 27.2% (291/1068) of patients were admitted to normal wards, and 12.9% (138/1068) were directly transmitted to an intensive care unit. The operating costs of the CCCC amounted to more than €52,000 (US $60,031) per month. Of the 334 patients with detected SARS-CoV-2 who were referred via EMS or outpatient physicians, 302 (90.4%) were triaged and announced in advance by the CCCC. No other published economic analysis of COVID-19 coordination or management institutions at hospitals could be found. CONCLUSIONS: Despite the high cost of the CCCC, we were able to show that it is a beneficial concept to both the providing hospital and the public health system. However, the most important benefits of the CCCC are that it prevents hospitals from being overrun by patients and that it avoids situations in which physicians must weigh one patient's life against another's.

Percutaneous hepatic melphalan perfusion: Single center experience of procedural characteristics, hemodynamic response, complications, and postoperative recovery.

BACKGROUND: Percutaneous hepatic melphalan perfusion (PHMP) for the selective treatment of hepatic metastases is known to be associated with procedural hypotension and coagulation disorders. Studies on anesthetic management, perioperative course, complications, and postoperative recovery in the intensive care unit (ICU) have not been published. METHODS: In a retrospective observational study, we analyzed consecutive patients who were admitted for PHMP over a 6-year period (2016-2021). Analyses included demographic, treatment, and outcome data with regard to short-term complications until ICU discharge. RESULTS: Fifty-three PHMP procedures of 16 patients were analyzed. In all of the cases, procedure-related hypotension required the median (range) highest noradrenaline infusion rate of 0.5 (0.17-2.1) µg kg min-1 and fluid resuscitation volume of 5 (3-14) liters. Eighty-four PHMP-related complications were observed in 33 cases (62%), of which 9 cases (27%) involved grade III and IV complications. Complications included airway constriction (requiring difficult airway management), vascular catheterization issues (which resulted in the premature termination of PHMP, as well as to the postponement of PHMP and to the performance of endovascular bleeding control after PHMP), and renal failure that required hemodialysis. Discharge from the ICU was possible after one day in most cases (n = 45; 85%); however, in 12 cases (23%), prolonged mechanical ventilation was required. There were no procedure-related fatalities. CONCLUSIONS: PHMP is frequently associated with challenging cardiovascular conditions and complications that require profound anesthetic skills. For safety reasons, PHMP should only be performed in specialized centers that provide high-level hospital infrastructures and interdisciplinary expertise.

Individualized versus Fixed Positive End-expiratory Pressure for Intraoperative Mechanical Ventilation in Obese Patients: A Secondary Analysis.

BACKGROUND: General anesthesia may cause atelectasis and deterioration in oxygenation in obese patients. The authors hypothesized that individualized positive end-expiratory pressure (PEEP) improves intraoperative oxygenation and ventilation distribution compared to fixed PEEP. METHODS: This secondary analysis included all obese patients recruited at University Hospital of Leipzig from the multicenter Protective Intraoperative Ventilation with Higher versus Lower Levels of Positive End-Expiratory Pressure in Obese Patients (PROBESE) trial (n = 42) and likewise all obese patients from a local single-center trial (n = 54). Inclusion criteria for both trials were elective laparoscopic abdominal surgery, body mass index greater than or equal to 35 kg/m2, and Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score greater than or equal to 26. Patients were randomized to PEEP of 4 cm H2O (n = 19) or a recruitment maneuver followed by PEEP of 12 cm H2O (n = 21) in the PROBESE study. In the single-center study, they were randomized to PEEP of 5 cm H2O (n = 25) or a recruitment maneuver followed by individualized PEEP (n = 25) determined by electrical impedance tomography. Primary endpoint was Pao2/inspiratory oxygen fraction before extubation and secondary endpoints included intraoperative tidal volume distribution to dependent lung and driving pressure. RESULTS: Ninety patients were evaluated in three groups after combining the two lower PEEP groups. Median individualized PEEP was 18 (interquartile range, 16 to 22; range, 10 to 26) cm H2O. Pao2/inspiratory oxygen fraction before extubation was 515 (individual PEEP), 370 (fixed PEEP of 12 cm H2O), and 305 (fixed PEEP of 4 to 5 cm H2O) mmHg (difference to individualized PEEP, 145; 95% CI, 91 to 200; P < 0.001 for fixed PEEP of 12 cm H2O and 210; 95% CI, 164 to 257; P < 0.001 for fixed PEEP of 4 to 5 cm H2O). Intraoperative tidal volume in the dependent lung areas was 43.9% (individualized PEEP), 25.9% (fixed PEEP of 12 cm H2O) and 26.8% (fixed PEEP of 4 to 5 cm H2O) (difference to individualized PEEP: 18.0%; 95% CI, 8.0 to 20.7; P < 0.001 for fixed PEEP of 12 cm H2O and 17.1%; 95% CI, 10.0 to 20.6; P < 0.001 for fixed PEEP of 4 to 5 cm H2O). Mean intraoperative driving pressure was 9.8 cm H2O (individualized PEEP), 14.4 cm H2O (fixed PEEP of 12 cm H2O), and 18.8 cm H2O (fixed PEEP of 4 to 5 cm H2O), P < 0.001. CONCLUSIONS: This secondary analysis of obese patients undergoing laparoscopic surgery found better oxygenation, lower driving pressures, and redistribution of ventilation toward dependent lung areas measured by electrical impedance tomography using individualized PEEP. The impact on patient outcome remains unclear.

Meropenem Plasma and Interstitial Soft Tissue Concentrations in Obese and Nonobese Patients-A Controlled Clinical Trial.

BACKGROUND: This controlled clinical study aimed to investigate the impact of obesity on plasma and tissue pharmacokinetics of meropenem. METHODS: Obese (body mass index (BMI) ≥ 35 kg/m2) and age-/sex-matched nonobese (18.5 kg/m2 ≥ BMI ≤ 30 kg/m2) surgical patients received a short-term infusion of 1000-mg meropenem. Concentrations were determined via high performance liquid chromatography-ultraviolet (HPLC-UV) in the plasma and microdialysate from the interstitial fluid (ISF) of subcutaneous tissue up to eight h after dosing. An analysis was performed in the plasma and ISF by noncompartmental methods. RESULTS: The maximum plasma concentrations in 15 obese (BMI 49 ± 11 kg/m2) and 15 nonobese (BMI 24 ± 2 kg/m2) patients were 54.0 vs. 63.9 mg/L (95% CI for difference: -18.3 to -3.5). The volume of distribution was 22.4 vs. 17.6 L, (2.6-9.1), but the clearance was comparable (12.5 vs. 11.1 L/h, -1.4 to 3.1), leading to a longer half-life (1.52 vs. 1.31 h, 0.05-0.37) and fairly similar area under the curve (AUC)8h (78.7 vs. 89.2 mg*h/L, -21.4 to 8.6). In the ISF, the maximum concentrations differed significantly (12.6 vs. 18.6 L, -16.8 to -0.8) but not the AUC8h (28.5 vs. 42.0 mg*h/L, -33.9 to 5.4). Time above the MIC (T > MIC) in the plasma and ISF did not differ significantly for MICs of 0.25-8 mg/L. CONCLUSIONS: In morbidly obese patients, meropenem has lower maximum concentrations and higher volumes of distribution. However, due to the slightly longer half-life, obesity has no influence on the T > MIC, so dose adjustments for obesity seem unnecessary.

Individualised positive end-expiratory pressure guided by electrical impedance tomography for robot-assisted laparoscopic radical prostatectomy: a prospective, randomised controlled clinical trial.

BACKGROUND: Robot-assisted laparoscopic radical prostatectomy requires general anaesthesia, extreme Trendelenburg positioning and capnoperitoneum. Together these promote impaired pulmonary gas exchange caused by atelectasis and may contribute to postoperative pulmonary complications. In morbidly obese patients, a recruitment manoeuvre (RM) followed by individualised PEEP improves intraoperative oxygenation and end-expiratory lung volume (EELV). We hypothesised that individualised PEEP with initial RM similarly improves intraoperative oxygenation and EELV in non-obese individuals undergoing robot-assisted prostatectomy. METHODS: Forty males (age, 49-76 yr; BMI <30 kg m-2) undergoing prostatectomy received volume-controlled ventilation (tidal volume 8 ml kg-1 predicted body weight). Participants were randomised to either (1) RM followed by individualised PEEP (RM/PEEPIND) optimised using electrical impedance tomography or (2) no RM with 5 cm H2O PEEP. The primary outcome was the ratio of arterial oxygen partial pressure to fractional inspired oxygen (Pao2/Fio2) before the last RM before extubation. Secondary outcomes included regional ventilation distribution and EELV which were measured before, during, and after anaesthesia. The cardiovascular effects of RM/PEEPIND were also assessed. RESULTS: In 20 males randomised to RM/PEEPIND, the median PEEPIND was 14 cm H2O [inter-quartile range, 8-20]. The Pao2/Fio2 was 10.0 kPa higher with RM/PEEPIND before extubation (95% confidence interval [CI], 2.6-17.3 kPa; P=0.001). RM/PEEPIND increased end-expiratory lung volume by 1.49 L (95% CI, 1.09-1.89 L; P<0.001). RM/PEEPIND also improved the regional ventilation of dependent lung regions. Vasopressor and fluid therapy was similar between groups, although 13 patients randomised to RM/PEEPIND required pharmacological therapy for bradycardia. CONCLUSION: In non-obese males, an individualised ventilation strategy improved intraoperative oxygenation, which was associated with higher end-expiratory lung volumes during robot-assisted laparoscopic prostatectomy. CLINICAL TRIAL REGISTRATION: DRKS00004199 (German clinical trials registry).

Linezolid Concentrations in Plasma and Subcutaneous Tissue are Reduced in Obese Patients, Resulting in a Higher Risk of Underdosing in Critically Ill Patients: A Controlled Clinical Pharmacokinetic Study.

Background: Linezolid is used for the treatment of soft tissue infections in critically ill patients. However, data for characterizing the pharmacokinetics (PK) and assessing whether effective concentrations are reached at the target site are lacking. We hypothesized that current dosing regimens do not lead to effective concentrations in the plasma and interstitial fluid (ISF) of subcutaneous tissue in obese patients. Methods: As a controlled clinical model, critically ill obese and non-obese patients undergoing intra-abdominal surgery received 600 mg linezolid as a single infusion. Concentrations in the plasma and microdialysate from the ISF of subcutaneous tissue were determined up to 8 h after dosing. Pharmacokinetic analysis was performed by non-compartmental methods. As a therapeutic target, we used fAUC/MIC > 80. Results: Fifteen obese (BMI: 48.7 ± 11.2 kg/m2) and 15 non-obese (23.9 ± 2.1 kg/m2) patients were analyzed. AUC0-8 in ISF decreased by -1.69 mg*h/L (95% CI: -2.59 to -0.79, p < 0.001) for every 10 kg increase in weight. PK in obese patients were characterized by lower maximal plasma concentrations (median 3.8 vs. 8.3 mg/L, p < 0.001) and a higher volume of distribution (41.0 vs. 30.8 L, p < 0.001), and the therapeutic target was not reached for MIC ≥ 1 mg/L in ISF and ≥ 2 mg/L in plasma. Conclusions: Increasing the weight led to a decrease of linezolid concentrations in the plasma and subcutaneous tissue. The current dosing regimen does not seem to produce sufficient concentrations to kill bacteria with MIC ≥ 2 mg/L, especially as empirical antimicrobial therapy in critically ill obese patients.

Detection of posttraumatic pneumothorax using electrical impedance tomography-An observer-blinded study in pigs with blunt chest trauma.

INTRODUCTION: Posttraumatic pneumothorax (PTX) is often overseen in anteroposterior chest X-ray. Chest sonography and Electrical Impedance Tomography (EIT) can both be used at the bedside and may provide complementary information. We evaluated the performance of EIT for diagnosing posttraumatic PTX in a pig model. METHODS: This study used images from an existing database of images acquired from 17 mechanically ventilated pigs, which had sustained standardized blunt chest trauma and had undergone repeated thoracic CT and EIT. 100 corresponding EIT/CT datasets were randomly chosen from the database and anonymized. Two independent and blinded observers analyzed the EIT data for presence and location of PTX. Analysis of the corresponding CTs by a radiologist served as reference. RESULTS: 87/100 cases had at least one PTX detected by CT. Fourty-two cases showed a PTX > 20% of the sternovertebral diameter (PTXtrans20), whereas 52/100 PTX showed a PTX>3 cm in the craniocaudal diameter (PTXcc3), with 20 cases showing both a PTXtranscc and a PTXcc3. We found a very low agreement between both EIT observers considering the classification overall PTX/noPTX (κ = 0.09, p = 0.183). For PTXtrans20, sensitivity was 59% for observer 1 and 17% for observer 2, with a specificity of 48% and 50%, respectively. For PTXcc3, observer 1 showed a sensitivity of 60% with a specificity of 51% while the sensitivity of observer 2 was 17%, with a specificity of 89%. By programming a semi-automatized detection algorithm, we significantly improved the detection rate of PTXcc3, with a sensitivity of 73% and a specificity of 70%. However, detection of PTXtranscc was not improved. CONCLUSION: In our analysis, visual interpretation of EIT without specific image processing or comparison with baseline data did not allow clinically useful diagnosis of posttraumatic PTX. Multimodal imaging approaches, technical improvements and image postprocessing algorithms might improve the performance of EIT for diagnosing PTX in the future.

A Modified Method to Assess Tidal Recruitment by Electrical Impedance Tomography.

Avoiding tidal recruitment and collapse during mechanical ventilation should reduce the risk of lung injury. Electrical impedance tomography (EIT) enables detection of tidal recruitment by measuring regional ventilation delay inhomogeneity (RVDI) during a slow inflation breath with a tidal volume (VT) of 12 mL/kg body weight (BW). Clinical applicability might be limited by such high VTs resulting in high end-inspiratory pressures (PEI) during positive end-expiratory pressure (PEEP) titration. We hypothesized that RVDI can be obtained with acceptable accuracy from reduced slow inflation VTs. In seven ventilated pigs with experimental lung injury, tidal recruitment was quantified by computed tomography at PEEP levels changed stepwise between 0 and 25 cmH2O. RVDI was measured by EIT during slow inflation VTs of 12, 9, 7.5, and 6 mL/kg BW. Linear correlation of tidal recruitment and RVDI was excellent for VTs of 12 (R2 = 0.83, p < 0.001) and 9 mL/kg BW (R2 = 0.83, p < 0.001) but decreased for VTs of 7.5 (R2 = 0.76, p < 0.001) and 6 mL/kg BW (R2 = 0.71, p < 0.001). With any reduction in slow inflation VT, PEI decreased at all PEEP levels. Receiver-Operator-Characteristic curve analyses revealed that RVDI-thresholds to predict distinct amounts of tidal recruitment differ when obtained from different slow inflation VTs. In conclusion, tidal recruitment can sufficiently be monitored by EIT-based RVDI-calculation with a slow inflation of 9 mL/kg BW.

[Mechanically circulatory support devices--management of typical emergencies]. / Patienten mit linksventrikulären Assist Devices--Typische Notfälle versorgen.

The use of mechanically circulatory support devices (MCS) will become increasingly important as a therapy option in patients with end-stage heart failure, and emergency physicians will more frequently encounter MCS patients in the next few years. However, emergency management in MCS patients has not yet been standardized. In the following article, common MCS devices are presented and typical emergencies associated with MCS devices are discussed. Furthermore, we try to give recommendations for the management of MCS patients in an emergency situation and present an algorithm in order to facilitate a structured and timely efficient evaluation of the MCS patient.

Acute type A aortic dissection: characteristics and outcomes comparing patients with bicuspid versus tricuspid aortic valve.

OBJECTIVES: The aim of this study is to investigate the clinical characteristics and postoperative outcome of patients with a bicuspid aortic valve (BAV) suffering acute dissection in comparison with their tricuspid peers. METHODS: Between 1995 and 2011, 460 consecutive patients underwent emergency repair for acute type A aortic dissection. In 379 patients without connective tissue disease, the aortic valve morphology could clearly be specified (91.6% tricuspid and 8.4% bicuspid). RESULTS: At the time of dissection, patients with a bicuspid valve were younger (46.7 ± 13 vs 61.6 ± 12 years, P < 0.001) with the entry tear more often located in the root compared with those with a tricuspid valve (bicuspid: 31.3% vs tricuspid: 6.3%, P < 0.001). Consequently, surgical repair warranted root replacement in 93.8% of bicuspid vs 28.8% of tricuspid valve patients (P < 0.001). The leading pathology was medial necrosis/degeneration in bicuspid and atherosclerosis in tricuspid patients (P = 0.166). Hospital mortality was 20.3% and not significantly different between the two valve morphologies, even despite the younger age of bicuspid patients: 28.1% among bicuspids vs 19.6% among tricuspids (P = 0.255). Survival after discharge was 63.3% at 10 years for all patients. BAV patients had a significantly better survival with 100% at 10 years compared with 60.2% in tricuspid valve patients (P = 0.011). Mean follow-up among survivors was comparable for bicuspid and tricuspid patients (3.7 and 4.1 years, respectively). CONCLUSIONS: Patients with BAV have a distinctive dissection pattern with the entry tear frequently located in the aortic root and-despite their younger age-are subject to substantial hospital mortality. For bicuspid patients suffering from dissection, composite root replacement yields an excellent outcome equal to an age- and gender-matched normal population.