Optimal management strategy in patients with acute type A aortic dissection and pericardial tamponade_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

SHAO Jun , YAO Hao , ZHANG Xun , JIN Jing ,  LI Qingguo

Cardiovascular Center, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210011, P. R. China;

Corresponding author：

LI Qingguo, Email: lqg0235062@163.com

Keywords：

Acute type A aortic dissection; cardiac tamponade; management strategy

DOI：

10.7507/1007-4848.202103013

Video：

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Objective To explore the optimal preoperative management strategy in patients with acute type A aortic dissection and pericardial tamponade.Methods A total of 197 patients with acute type A aortic dissection were admitted to the Cardiovascular Center at the Second Affiliated Hospital of Nanjing Medical University from 2017 to 2019, among whom 26 patients suffered from cardiac tamponade, including 20 males and 6 females with an average age of 59.27±10.76 years. The clinical data of the patients were analyzed.Results All patients underwent surgical repair of the aorta. The median cardiopulmonary bypass time and aortic cross clamping time were 174.5 min and 121.5 min, respectively. Postoperative complications included kidney failure in 3 patients, respiratory failure in 2 patients and disturbance of consciousness in 3 patients. Postoperative death occurred in 5 (19.2%) patients. The other 21 patients were successfully followed up for 2 years, during which 1 patient died with a survival rate of 95.2%, and no re-intervention was indicated.Conclusion Adequate preoperative management is crucial in patients with acute type A aortic dissection complicated with cardiac tamponade. A cardiac surgery team with round-the-clock availability, an integrated cardiac surgery ward and a rational algorithm that can shorten the time from disease onset to surgery treatment are the keys to improve survival rate.

Citation： SHAO Jun, YAO Hao, ZHANG Xun, JIN Jing, LI Qingguo. Optimal management strategy in patients with acute type A aortic dissection and pericardial tamponade. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2022, 29(8): 997-1002. doi: 10.7507/1007-4848.202103013 Copy

1.	Aboyans V, Boukhris M. Dissecting the epidemiology of aortic dissection. Eur Heart J Acute Cardiovasc Care, 2021, 10(7): 710-711.
2.	Kuang J, Yang J, Wang Q, et al. A preoperative mortality risk assessment model for Stanford type A acute aortic dissection. BMC Cardiovasc Disord, 2020, 20(1): 508.
3.	Evangelista A, Isselbacher EM, Bossone E, et al. Insights from the International Registry of Acute Aortic Dissection: A 20-year experience of collaborative clinical research. Circulation, 2018, 137(17): 1846-1860.
4.	Gilon D, Mehta RH, Oh JK, et al. Characteristics and in-hospital outcomes of patients with cardiac tamponade complicating type A acute aortic dissection. Am J Cardiol, 2009, 103(7): 1029-1031.
5.	Nakai, C, Izumi S, Haraguchi T, et al. Acute type A aortic dissection with cardiopulmonary arrest at presentation. Ann Thorac Surg, 2021, 112(4): 1210-1216.
6.	Kitamura T, Miyaji K. Emergency pericardial drainage without aortic repair for type A intramural haematoma complicated by cardiac tamponade. Interact Cardiovasc Thorac Surg, 2021, 32(6): 953-955.
7.	Bossone E, Gorla R, Labounty TM et al. Presenting systolic blood pressure and outcomes in patients with acute aortic dissection. J Am Coll Cardiol, 2018, 71(13): 1432-1440.
8.	Ji D, Wu Z, Dai H, et al. Perioperative complications and postoperative mortality in patients of acute Stanford type A aortic dissection with cardiac tamponade. J Invest Surg, 2022, 35(7): 1536-1543.
9.	Une K, Hidaka Y, Maeda J, et al. Acute aortic dissection combined with cardiac tamponade in an elderly patient saved by pericardial drainage: A case report. Clin Case Rep, 2020, 9(1): 274-277.
10.	Alerhand S, Adrian RJ, Long B et al. Pericardial tamponade: A comprehensive emergency medicine and echocardiography review. Am J Emerg Med, 2022, 58: 159-174.
11.	Sobczyk D, Nycz K. Feasibility and accuracy of bedside transthoracic echocardiography in diagnosis of acute proximal aortic dissection. Cardiovasc Ultrasound, 2015, 13: 15.
12.	Uchida K, Imoto K, Takahashi M, et al. Pathologic characteristics and surgical indications of superacute type A intramural hematoma. Ann Thorac Surg, 2005, 79(5): 1518-1521.
13.	Song JK, Kim HS, Kang DH, et al. Different clinical features of aortic intramural hematoma versus dissection involving the ascending aorta. J Am Coll Cardiol, 2001, 37(6): 1604-1610.
14.	Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J, 2014, 35(41): 2873-2926.
15.	Isselbacher EM, Cigarroa JE, Eagle KA. Cardiac tamponade complicating proximal aortic dissection. Is pericardiocentesis harmful?. Circulation, 1994, 90(5): 2375-2378.
16.	Erbel R, Alfonso F, Boileau C, et al. Diagnosis and management of aortic dissection. Eur Heart J, 2001, 22(18): 1642-1681.
17.	Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation, 2010, 121(13): e266-e369.
18.	Hayashi T, Tsukube T, Yamashita T, et al. Impact of controlled pericardial drainage on critical cardiac tamponade with acute type A aortic dissection. Circulation, 2012, 126 (11 Suppl 1): S97-S101.
19.	Cruz I, Stuart B, Caldeira D, et al. Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: Experience of a centre without cardiothoracic surgery. Eur Heart J Acute Cardiovasc Care, 2015, 4(2): 124-128.
20.	Keiko T, Yanagawa Y, Isoda S. A successful treatment of cardiac tamponade due to an aortic dissection using open-chest massage. Am J Emerg Med, 2012, 30(4): 634.e1-2.
21.	Froehlich W, Tolenaar JL, Harris KM, et al. Delay from diagnosis to surgery in transferred type A aortic dissection. Am J Med, 2018, 131(3): 300-306.
22.	Nishida H, Tabata M, Fukui T, et al. A systematic approach to improve the outcomes of type A aortic dissection. J Thorac Cardiovasc Surg, 2017, 154(1): 89-96.

1. Aboyans V, Boukhris M. Dissecting the epidemiology of aortic dissection. Eur Heart J Acute Cardiovasc Care, 2021, 10(7): 710-711.
2. Kuang J, Yang J, Wang Q, et al. A preoperative mortality risk assessment model for Stanford type A acute aortic dissection. BMC Cardiovasc Disord, 2020, 20(1): 508.
3. Evangelista A, Isselbacher EM, Bossone E, et al. Insights from the International Registry of Acute Aortic Dissection: A 20-year experience of collaborative clinical research. Circulation, 2018, 137(17): 1846-1860.
4. Gilon D, Mehta RH, Oh JK, et al. Characteristics and in-hospital outcomes of patients with cardiac tamponade complicating type A acute aortic dissection. Am J Cardiol, 2009, 103(7): 1029-1031.
5. Nakai, C, Izumi S, Haraguchi T, et al. Acute type A aortic dissection with cardiopulmonary arrest at presentation. Ann Thorac Surg, 2021, 112(4): 1210-1216.
6. Kitamura T, Miyaji K. Emergency pericardial drainage without aortic repair for type A intramural haematoma complicated by cardiac tamponade. Interact Cardiovasc Thorac Surg, 2021, 32(6): 953-955.
7. Bossone E, Gorla R, Labounty TM et al. Presenting systolic blood pressure and outcomes in patients with acute aortic dissection. J Am Coll Cardiol, 2018, 71(13): 1432-1440.
8. Ji D, Wu Z, Dai H, et al. Perioperative complications and postoperative mortality in patients of acute Stanford type A aortic dissection with cardiac tamponade. J Invest Surg, 2022, 35(7): 1536-1543.
9. Une K, Hidaka Y, Maeda J, et al. Acute aortic dissection combined with cardiac tamponade in an elderly patient saved by pericardial drainage: A case report. Clin Case Rep, 2020, 9(1): 274-277.
10. Alerhand S, Adrian RJ, Long B et al. Pericardial tamponade: A comprehensive emergency medicine and echocardiography review. Am J Emerg Med, 2022, 58: 159-174.
11. Sobczyk D, Nycz K. Feasibility and accuracy of bedside transthoracic echocardiography in diagnosis of acute proximal aortic dissection. Cardiovasc Ultrasound, 2015, 13: 15.
12. Uchida K, Imoto K, Takahashi M, et al. Pathologic characteristics and surgical indications of superacute type A intramural hematoma. Ann Thorac Surg, 2005, 79(5): 1518-1521.
13. Song JK, Kim HS, Kang DH, et al. Different clinical features of aortic intramural hematoma versus dissection involving the ascending aorta. J Am Coll Cardiol, 2001, 37(6): 1604-1610.
14. Erbel R, Aboyans V, Boileau C, et al. 2014 ESC guidelines on the diagnosis and treatment of aortic diseases: Document covering acute and chronic aortic diseases of the thoracic and abdominal aorta of the adult. The Task Force for the Diagnosis and Treatment of Aortic Diseases of the European Society of Cardiology (ESC). Eur Heart J, 2014, 35(41): 2873-2926.
15. Isselbacher EM, Cigarroa JE, Eagle KA. Cardiac tamponade complicating proximal aortic dissection. Is pericardiocentesis harmful?. Circulation, 1994, 90(5): 2375-2378.
16. Erbel R, Alfonso F, Boileau C, et al. Diagnosis and management of aortic dissection. Eur Heart J, 2001, 22(18): 1642-1681.
17. Hiratzka LF, Bakris GL, Beckman JA, et al. 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, American Association for Thoracic Surgery, American College of Radiology, American Stroke Association, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Thoracic Surgeons, and Society for Vascular Medicine. Circulation, 2010, 121(13): e266-e369.
18. Hayashi T, Tsukube T, Yamashita T, et al. Impact of controlled pericardial drainage on critical cardiac tamponade with acute type A aortic dissection. Circulation, 2012, 126 (11 Suppl 1): S97-S101.
19. Cruz I, Stuart B, Caldeira D, et al. Controlled pericardiocentesis in patients with cardiac tamponade complicating aortic dissection: Experience of a centre without cardiothoracic surgery. Eur Heart J Acute Cardiovasc Care, 2015, 4(2): 124-128.
20. Keiko T, Yanagawa Y, Isoda S. A successful treatment of cardiac tamponade due to an aortic dissection using open-chest massage. Am J Emerg Med, 2012, 30(4): 634.e1-2.
21. Froehlich W, Tolenaar JL, Harris KM, et al. Delay from diagnosis to surgery in transferred type A aortic dissection. Am J Med, 2018, 131(3): 300-306.
22. Nishida H, Tabata M, Fukui T, et al. A systematic approach to improve the outcomes of type A aortic dissection. J Thorac Cardiovasc Surg, 2017, 154(1): 89-96.

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