A simple bedside model to predict the risk of in-hospital mortality in Stanford type A acute aortic dissection_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

WANG De , QIU Juntao , YU Cuntao ,  ZHANG Liang , YANG Yang , CHANG Qian , SHU Chang , SUN Xiaogang , QIAN Xiangyang

State Key Laboratory of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, P.R.China;

Corresponding author：

ZHANG Liang, Email: bjkmy2013@163.com

Keywords：

Type A aortic dissection; in-hospital mortality; scoring model

DOI：

10.7507/1007-4848.201802010

Video：

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Objective To investigate predictors for mortality among patients with Stanford type A acute aortic dissection (AAD) and to establish a predictive model to estimate risk of in-hospital mortality. Methods A total of 999 patients with Stanford type A AAD enrolled between 2010 and 2015 in our hospital were included for analysis. There were 745 males and 254 females with a mean age of 49.8±12.0 years. There were 837 patients with acute dissection and 182 patients (18.22%) were preoperatively treated or waiting for surgery in the emergency department and 817 (81.78%) were surgically treated. Multivariable logistic regression analysis was used to investigate predictors of in-hospital mortality. Significant risk factors for in-hospital death were used to develop a prediction model. Results The overall in-hospital mortality was 25.93%. In the multivariable analysis, the following variables were associated with increased in-hospital mortality: increased age (OR=1.04, 95% CI 1.02 to 1.05, P<0.000 1), acute aortic dissection (OR=2.49, 95% CI 1.30 to 4.77, P=0.006 1), syncope (OR=2.76, 95% CI 1.15 to 6.60, P=0.022 8), lower limbs numbness/pain (OR=7.99, 95% CI 2.71 to 23.52, P=0.000 2), type Ⅰ DeBakey dissection (OR=1.72, 95% CI 1.05 to 2.80, P=0.030 5), brachiocephalic vessels involvement (OR=2.25, 95% CI 1.20 to 4.24, P=0.011 7), acute liver insufficiency (OR=2.60, 95% CI 1.46 to 4.64, P=0.001 2), white blood cell count (WBC)>15×10⁹ cells/L (OR=1.87, 95% CI 1.21 to 2.89, P=0.004 9) and massive pericardial effusion (OR=4.34, 95% CI 2.45 to 7.69, P<0.000 1). Based on these multivariable results, a reliable and simple bedside risk prediction tool was developed. Conclusion Different clinical manifestations and imaging features of patients with Stanford type A AAD predict the risk of in-hospital mortality. This model can be used to assist physicians to quickly identify high risk patients and to make reasonable treatment decisions.

Citation： WANG De, QIU Juntao, YU Cuntao, ZHANG Liang, YANG Yang, CHANG Qian, SHU Chang, SUN Xiaogang, QIAN Xiangyang. A simple bedside model to predict the risk of in-hospital mortality in Stanford type A acute aortic dissection. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2018, 25(6): 500-506. doi: 10.7507/1007-4848.201802010 Copy

1.	Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA, 2000, 283(7): 897-903.
2.	楚军民, 卫金花, 常谦, 等. Stanford A 型主动脉夹层术后死亡和严重并发症的危险因素. 中国胸心血管外科临床杂志, 2017, 24(3), 211-216.
3.	Pape LA, Awais M, Woznicki EM, et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the international registry of acute aortic dissection. J Am Coll Cardiol, 2015, 66(4): 350-358.
4.	Lee TC, Kon Z, Cheema FH, et al. Contemporary management and outcomes of acute type A aortic dissection: An analysis of the STS adult cardiac surgery database. J Card Surg, 2018, 33(1): 7-18.
5.	Trimarchi S, Eagle KA, Nienaber CA, et al. Role of age in acute type A aortic dissection outcome: report from the International Registry of Acute Aortic Dissection (IRAD). J Thorac Cardiovasc Surg, 2010, 140(4): 784-789.
6.	Geirsson A, Szeto WY, Pochettino A, et al. Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations. Eur J Cardiothorac Surg, 2007, 32(2): 255-262.
7.	Conzelmann LO, Weigang E, Mehlhorn U, et al. Mortality in patients with acute aortic dissection type A: analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac Surg, 2016, 49(2): e44-e52.
8.	Lio A, Nicolò F, Bovio E, et al. Total arch versus hemiarch replacement for type a acute aortic dissection: a single-center experience. Tex Heart Inst J, 2016, 43(6): 488-495.
9.	Tolenaar JL, Froehlich W, Jonker FH, et al. Predicting in-hospital mortality in acute type B aortic dissection: evidence from International Registry of Acute Aortic Dissection. Circulation, 2014, 130(11 Suppl 1): S45-S50.
10.	Trimarchi S, Nienaber CA, Rampoldi V, et al. Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience. J Thorac Cardiovasc Surg, 2005, 129(1): 112-122.
11.	Rylski B, Hoffmann I, Beyersdorf F, et al. Acute aortic dissection type A: age-related management and outcomes reported in the German Registry for Acute Aortic Dissection Type A (GERAADA) of over 2000 patients. Ann Surg, 2014, 259(3): 598-604.
12.	Di Eusanio M, Patel HJ, Nienaber CA, et al. Patients with type A acute aortic dissection presenting with major brain injury: Should we operate on them? J Thorac Cardiovasc Surg, 2013, 145(3 Suppl): S213-S221.
13.	Rampoldi V, Trimarchi S, Eagle KA, et al. Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score. Ann Thorac Surg, 2007, 83(1): 55-61.
14.	Mussa FF, Horton JD, Moridzadeh R, et al. Acute aortic dissection and intramural hematoma: a systematic review. JAMA, 2016, 316(7): 754-763.
15.	Sun L, Qi R, Zhu J, et al. Total arch replacement combined with stented elephant trunk implantation: a new "standard" therapy for type a dissection involving repair of the aortic arch? Circulation, 2011, 123(9): 971-978.
16.	Rylski B, Milewski RK, Bavaria JE, et al. Long-term results of aggressive hemiarch replacement in 534 patients with type A aortic dissection. J Thorac Cardiovasc Surg, 2014, 148(6): 2981-2985.
17.	Pape LA, Tsai TT, Isselbacher EM, et al. Aortic diameter>5.5 cm is not a good predictor of type A aortic dissection observations from the International Registry of Acute Aortic Dissection (IRAD). Circulation, 2007, 116:1120-1127.
18.	Tieu BC, Lee C, Sun H, et al. An adventitial IL-6/MCP1 amplification loop accelerates macrophage-mediated vascular inflammation leading to aortic dissection in mice. J Clin Invest, 2009, 119(12): 3637-3651.
19.	Kurihara T, Shimizu-Hirota R, Shimoda M, et al. Neutrophil-derived matrix metalloproteinase 9 triggers acute aortic dissection. Circulation, 2012, 126(25): 3070-3080.

1. Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA, 2000, 283(7): 897-903.
2. 楚军民, 卫金花, 常谦, 等. Stanford A 型主动脉夹层术后死亡和严重并发症的危险因素. 中国胸心血管外科临床杂志, 2017, 24(3), 211-216.
3. Pape LA, Awais M, Woznicki EM, et al. Presentation, diagnosis, and outcomes of acute aortic dissection: 17-year trends from the international registry of acute aortic dissection. J Am Coll Cardiol, 2015, 66(4): 350-358.
4. Lee TC, Kon Z, Cheema FH, et al. Contemporary management and outcomes of acute type A aortic dissection: An analysis of the STS adult cardiac surgery database. J Card Surg, 2018, 33(1): 7-18.
5. Trimarchi S, Eagle KA, Nienaber CA, et al. Role of age in acute type A aortic dissection outcome: report from the International Registry of Acute Aortic Dissection (IRAD). J Thorac Cardiovasc Surg, 2010, 140(4): 784-789.
6. Geirsson A, Szeto WY, Pochettino A, et al. Significance of malperfusion syndromes prior to contemporary surgical repair for acute type A dissection: outcomes and need for additional revascularizations. Eur J Cardiothorac Surg, 2007, 32(2): 255-262.
7. Conzelmann LO, Weigang E, Mehlhorn U, et al. Mortality in patients with acute aortic dissection type A: analysis of pre- and intraoperative risk factors from the German Registry for Acute Aortic Dissection Type A (GERAADA). Eur J Cardiothorac Surg, 2016, 49(2): e44-e52.
8. Lio A, Nicolò F, Bovio E, et al. Total arch versus hemiarch replacement for type a acute aortic dissection: a single-center experience. Tex Heart Inst J, 2016, 43(6): 488-495.
9. Tolenaar JL, Froehlich W, Jonker FH, et al. Predicting in-hospital mortality in acute type B aortic dissection: evidence from International Registry of Acute Aortic Dissection. Circulation, 2014, 130(11 Suppl 1): S45-S50.
10. Trimarchi S, Nienaber CA, Rampoldi V, et al. Contemporary results of surgery in acute type A aortic dissection: The International Registry of Acute Aortic Dissection experience. J Thorac Cardiovasc Surg, 2005, 129(1): 112-122.
11. Rylski B, Hoffmann I, Beyersdorf F, et al. Acute aortic dissection type A: age-related management and outcomes reported in the German Registry for Acute Aortic Dissection Type A (GERAADA) of over 2000 patients. Ann Surg, 2014, 259(3): 598-604.
12. Di Eusanio M, Patel HJ, Nienaber CA, et al. Patients with type A acute aortic dissection presenting with major brain injury: Should we operate on them? J Thorac Cardiovasc Surg, 2013, 145(3 Suppl): S213-S221.
13. Rampoldi V, Trimarchi S, Eagle KA, et al. Simple risk models to predict surgical mortality in acute type A aortic dissection: the International Registry of Acute Aortic Dissection score. Ann Thorac Surg, 2007, 83(1): 55-61.
14. Mussa FF, Horton JD, Moridzadeh R, et al. Acute aortic dissection and intramural hematoma: a systematic review. JAMA, 2016, 316(7): 754-763.
15. Sun L, Qi R, Zhu J, et al. Total arch replacement combined with stented elephant trunk implantation: a new "standard" therapy for type a dissection involving repair of the aortic arch? Circulation, 2011, 123(9): 971-978.
16. Rylski B, Milewski RK, Bavaria JE, et al. Long-term results of aggressive hemiarch replacement in 534 patients with type A aortic dissection. J Thorac Cardiovasc Surg, 2014, 148(6): 2981-2985.
17. Pape LA, Tsai TT, Isselbacher EM, et al. Aortic diameter>5.5 cm is not a good predictor of type A aortic dissection observations from the International Registry of Acute Aortic Dissection (IRAD). Circulation, 2007, 116:1120-1127.
18. Tieu BC, Lee C, Sun H, et al. An adventitial IL-6/MCP1 amplification loop accelerates macrophage-mediated vascular inflammation leading to aortic dissection in mice. J Clin Invest, 2009, 119(12): 3637-3651.
19. Kurihara T, Shimizu-Hirota R, Shimoda M, et al. Neutrophil-derived matrix metalloproteinase 9 triggers acute aortic dissection. Circulation, 2012, 126(25): 3070-3080.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

A simple bedside model to predict the risk of in-hospital mortality in Stanford type A acute aortic dissection

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