Predictors of in-hospital mortality in patients with acute aortic dissection

BACKGROUND: If acute aortic dissection is a highly lethal disease. There were few reports addressing predictors of in-hospital mortality of this disease in southern Taiwan. METHODS: If from January 1, 1989, to December 31, 2001, patients with acute aortic dissection were enrolled. Patient demographics, history, clinical characteristics, and laboratory examinations were reviewed. Univariate testing followed by logistic regression analysis was performed to identify the predictors of in-hospital mortality. RESULTS: If in total, 198 (146 male) patients with mean age of 60.7+/-11.6 years were enrolled. The in-hospital mortality rate was 34.8% in overall patients, 58.8% for type A dissection, and 14.8% for type B dissection. There were five independent predictors of in-hospital mortality: presence of hypertension [odds ratio (OR)=0.09, 95% confidence interval (CI)=0.02-0.36, p<0.001], type A dissection (OR=8.26, 95% CI=3.44-19.60, p<0.001), probable extravasation (pericardial effusion in type A dissection or left side pleural effusion in patients with involvement of descending thoracic aorta) (OR=2.70, 95% CI=1.14-6.41, p=0.024), visible intimal flap in ascending aorta in trans-thoracic echocardiography (OR=4.46, 95% CI=1.58-12.60, p=0.005), and acute renal deterioration (OR=3.85, 95% CI=1.36-10.87, p=0.011). CONCLUSIONS: If acute aortic dissection, especially type A, is with high mortality in southern Taiwan. There are five independent predictors of in-hospital mortality found in current analysis. Our result may remind doctors to find out their patients at high risk. Trans-thoracic echocardiography is a useful tool to find out patients at high risk because it is easily performed to check if there is pericardial effusion or visible intimal flap in ascending aorta.     

Usefulness of pulse deficit to predict in-hospital complications and mortality in patients with acute type A aortic dissection

Vascular compromise seen with pulse deficits is common in patients with type A dissection. However, patient characteristics and in-hospital outcomes associated with pulse deficits have not been evaluated. Accordingly, we studied 513 patients (mean age 62 +/- 14 years, 65% men) with acute type A aortic dissection enrolled in the International Registry of Acute Aortic Dissection. Pulse deficits, defined as decreased or absent carotid or peripheral pulses as noted by clinicians and later confirmed by diagnostic imaging, at surgery or at autopsy were noted in 154 patients (30%). Age <70 years, male gender, neurologic deficit(s), altered mental status, and hypotension, shock, or tamponade on admission were all significantly higher in patients with than without pulse deficits. The etiology of aortic dissection, clinical symptoms, and imaging findings were similar in the 2 groups. In-hospital complications (hypotension, coma, renal failure, and limb ischemia) and mortality (41% vs 25%, p = 0.0002) were significantly higher in patients with pulse deficit. Cox proportional-hazards regression analysis identified pulse deficit as an independent predictor of 5-day in-hospital mortality (risk ratio 2.73, 95% confidence interval 1.7 to 4.4; p <0.0001). Further, overall mortality rates increased with an increasing number of pulse deficits (p for trend <0.0001). Pulse deficits are common findings in patients with type A aortic dissection and identify those at high risk of in-hospital adverse events. This simple clinical sign should direct physicians to consider a diagnosis of aortic dissection in patients with acute chest pain, and should help identify a subgroup of patients who would benefit from more aggressive strategies.     

Predictors and in-hospital outcomes of preoperative acute kidney injury in patients with type A acute aortic dissection

Background Acute kidney injury (AKI) is common after surgery for acute aortic dissection (AAD) and increases in-hospital and long-term mortality. However, few data exist on the clinical and prognostic relevance of early preoperative AKI in patients with type A AAD. We aimed to determine the incidence and predictors of preoperative AKI and the impact of AKI on in-hospital outcomes in patients with type A AAD. Methods From May 2009 to June 2014, we retrospectively enrolled 178 patients admitted to our hospital within 48 h from symptom onset and receiving open surgery for type A AAD. The patients were divided into no AKI and AKI groups and staged with AKI severity according to the KDIGO criteria before surgery. Results AKI occurred in 41 patients (23.0%). The incidence of in-hospital complications was significantly higher in patients with preoperative AKI compared to no AKI (41.5% vs. 9.5%, P < 0.001), including renal infarction (7.3% vs. 0, P = 0.012), and it increased with AKI severity (P_trend < 0.001). Patients with AKI had higher in-hospital mortality compared with patients without AKI, although no significant difference was found (14.6% vs. 5.1%, P = 0.079). Multivariate analysis indicated that male gender, diastolic blood pressure on admission and bilateral renal artery involvement were independent predictors of preoperative AKI in patients with type A AAD. Conclusions Early AKI before surgery was common in patients with type A AAD, and was associated with increased in-hospital complications. Male gender, diastolic blood pressure on admission and bilateral renal artery involvement were major predictors for preoperative AKI.     

强离子间隙对急性Stanford A型主动脉夹层术后患者预后的预测价值

目的探讨强离子间隙(SIG)对于急性Stanford A型主动脉夹层患者术后病死率的预测价值。方法本研究为回顾性观察性研究,筛选2017年1月至2018年3月于南京市第一医院行外科手术治疗并收住重症医学科的急性Stanford A型主动脉夹层患者。收集患者术后的血气分析及生化指标来计算近似强离子差(SIDa)、有效SID(SIDe)和SIG等Stewart模型酸碱变量的数值,分析其与病死率之间的相关性。结果最终纳入急性Stanford A型主动脉夹层术后患者93例,包括存活组87例和死亡组6例。死亡组患者的术后SIG水平显著高于存活组[9.7(8.8,13.7)mEq/L比4.1(1.8,6.7)mEq/L,t=4.432,P<0.01]。单因素逻辑回归分析显示,术后动脉血pH值、PaCO_2、乳酸、SIDe、SIG和血清肌酐水平均与急性Stanford A型主动脉夹层患者的病死率显著相关(均为P<0.05)。进一步行多因素逻辑回归分析显示,pH(OR:4.83×10~(28),95%CI:0.00～1.46×10~(61),P=0.08)和SIG(OR:0.09,95%CI:0.01～1.23,P=0.07)与患者病死率显著相关。SIG的受试者工作特征曲线下面积为0.92(95%CI:0.85～0.99,P<0.01),大于pH的0.86(95%CI:0.74～0.98,P<0.01),提示SIG升高是急性Stanford A型主动脉夹层患者术后死亡的较好预测因子,敏感度100%,特异度84%。结论术后SIG水平升高可在一定程度上预测急性Stanford A型主动脉夹层患者术后死亡。     

Association between admission time and in-hospital mortality in acute aortic dissection patients: A retrospective cohort study

PurposeThis study aimed to evaluate the relationship between admission time and in-hospital mortality in acute aortic dissection (AAD) patients.MethodsThe risk factors of in-hospital clinical outcomes were retrospectively evaluated in patients with AAD. All the patients were enrolled from January to December 2017 and were divided into two groups depending on the time of admission: daytime admissions were conducted from 8: 00 to 17: 30 hours whereas, nighttime admissions were from 17: 30 to 8: 00 hours. The primary endpoints were in-hospital mortality. Univariate and multivariable cox analyses were used to test the association between admission time and in-hospital mortality.ResultsThe average age of the 363 participants in the present study was 52.25 ± 11.77 years, of which 81.6% were male. A total of 183 (50.4%) of these patients were admitted during nighttime. In-hospital mortality rate was higher in the nighttime admission group than in the daytime admission group (HR=1.86; 95%CI, 1.13 to 3.06, P=0.015). After adjusting for age, sex, and other risk factors, nighttime admission suggested as an independent risk factor for in-hospital mortality (HR=2.67, 95%CI, 1.30 to 5.46; P=0.007). Further subgroup analysis showed that none of the variables had a significant effect on the association between nighttime admission and in-hospital mortality.ConclusionNighttime admission for type A acute aortic dissection is associated with a higher risk of in-hospital mortality. Therefore, health care systems should focus on managing the increased risk of in-hospital mortality among patients admitted at night, regardless of the cause.     

术前急性肾损伤与急性主动脉夹层院内死亡率的相关性研究

目的：探讨术前急性肾损伤与急性主动脉夹层院内死亡率的关系。方法：回顾性分析北部战区总医2015年1月至2019年1月Debekay Ⅰ型主动脉夹层手术312例患者的临床资料,将其分为住院死亡组和生存组。分析两组术前基线特征以及围手术期、预后情况。结果：全组共有312名患者入选,住院总死亡率为6.73％（21/312）。术前有无AKI与院内死亡率之间无差异。进一步亚组分析显示,AKI3期显著增加院内死亡率（45.5％vs17.2％;P=0.022）。单因素分析显示：年龄65岁以上（42.9％vs20.3％;P=0.021）,术前心包填塞（46.7vs19.0％;P<0.001）,术前休克/低血压（57.1％vs10.9％;P <0.001）和3期AKI（16.7％vs4.8％;P=0.039）,4个因素显著影响住院死亡率。多变量分析显示：术前休克或低血压（OR=5.2;95％;CI=2.2-2.3）和术前3期AKI（OR=4.9;95％;CI=1.3-19.3）是影响AAD手术住院死亡率的独立预测因素。老年心血管疾病（22.5％vs8.6％;P=0.028）与术前AKI也存在显著相关性。多变量分析提示老年心血管疾病（OR=3.3;95％;CI=1.2-9.3）是AKI的独立术前因素。结论：术前3期AKI是影响AAD患者外科治疗预后的重要风险因素。心脏外科医生在处理AAD患者时应加以重视,对主动脉夹层患者更有意义。     

脉压差和急性主动脉夹层院内预后关系的研究

目的 探讨脉压差和急性主动脉夹层院内预后的关系。 方法 选取2013年1月至2015年12月于安徽医科大学第一附属医院住院的急性主动脉夹层患者270例,根据入院时脉压差分为四组：A组（脉压差低,PP≤39mmHg,1mmHg=0.133kPa）,B组（脉压差正常,PP:40-56mmHg）,C组（脉压差轻度增高,PP:57-75mmHg）,D组（脉压差明显增高,PP≥76mmHg）,分析四组间的临床资料及院内预后,并进一步Logistic回归分析影响院内预后的相关因素。 结果 与其他三组比较,A组患者在年龄、心率水平、Stanford A分型中差异具有统计学意义（P<0.05）;与其他三组比较,A组患者中晕厥/昏迷、低血压（SBP＜100mmHg）、腹腔干缺血、心包积液、夹层破裂等并发症及其院内死亡率差异具有统计学意义（P<0.05）;进一步对院内预后影响因素进行Logistic回归分析显示,肾功能不全、Stanford A型、心包积液、低脉压差（PP≤39mmHg）是院内预后的预测危险因素,手术治疗是院内预后的预测保护因素。结论 低脉压差（≤39mmHg）与急性主动脉夹层患者院内预后有一定相关性,是其院内预后的预测危险因素。     

Relationship between acute kidney injury before thoracic endovascular aneurysm repair and in-hospital outcomes in patients with type B acute aortic dissection

Objective Acute kidney injury (AKI) frequently occurs after catheter-based interventional procedures and increases mortality. However, the implications of AKI before thoracic endovascular aneurysm repair (TEVAR) of type B acute aortic dissection (AAD) remain unclear. This study evaluated the incidence, predictors, and in-hospital outcomes of AKI before TEVAR in patients with type B AAD. Methods Between 2009 and 2013, 76 patients were retrospectively evaluated who received TEVAR for type B AAD within 36 h from symptom onset. The patients were classified into no-AKI vs. AKI groups, and the severity of AKI was further staged according to kidney disease: improving global outcomes criteria before TEVAR. Results The incidence of preoperative AKI was 36.8%. In-hospital complications was significantly higher in patients with preoperative AKI compared with no-AKI (50.0% vs. 4.2%, respectively; P < 0.001), including acute renal failure (21.4% vs. 0, respectively; P < 0.001), and they increased with severity of AKI (P < 0.001). The maximum levels of body temperature and white blood cell count were significantly related to maximum serum creatinine level before TEVAR. Multivariate analysis showed that systolic blood pressure on admission (OR: 1.023; 95% CI: 1.003–1.044; P = 0.0238) and bilateral renal artery involvement (OR: 19.076; 95% CI: 1.914–190.164; P = 0.0120) were strong predictors of preoperative AKI. Conclusions Preoperative AKI frequently occurred in patients with type B AAD, and correlated with higher in-hospital complications and enhanced inflammatory reaction. Systolic blood pressure on admission and bilateral renal artery involvement were major risk factors for AKI before TEVAR.     

The impact of age and sex on in-hospital outcomes in acute type A aortic dissection surgery

BackgroundOlder age and female sex are thought to be risk factors for adverse outcomes after repair of acute type A aortic dissection (AAAD). The aim of this study is to analyze age- and sex-related outcomes in patients undergoing AAAD repair.MethodsRetrospective analysis of patients undergoing emergency AAAD repair. Patients were divided in Group A, patients aged ≥75 years and Group B <75. Intraoperative and postoperative data were compared between groups before and after propensity score matching. Sex differences were analyzed by age group.ResultsBetween January 2006 and December 2018, 638 patients underwent emergency AAAD repair. Group A included 143 patients (22.4%), Group B 495 (77.6%). More patients in Group A presented with circulatory collapse (Penn C 26.6% vs. 9.7%, P=0.001) while Group B presented with circulatory collapse-branch malperfusion (Penn BC 29.3% vs. 15.4% P=0.001). After propensity score matching, Group B patients received more complex aortic root (33.6% vs. 23.2%, P=0.019) and concomitant bypass surgery (12.3% vs. 6.3%, P=0.042). There was no significant difference in in-hospital mortality between age groups (18% vs. 12% P=0.12). In Group B, in-hospital mortality was significantly higher in females (22.2% vs. 8.2%, P=0.028). Differences in mortality disappeared after the age of 75 (18.3% vs. 19.4% P=0.87).ConclusionsMorbidity and mortality are comparable between patients under and over 75 years after AAAD repair. Female patients <75 had higher in-hospital mortality than their male counterparts.     

Risk factors analysis for in-hospital death of acute Stanford type B aortic dissection

Background Data is limited regarding the correlation between related factors and in-hospital death of Stanford type B acute aortic dissection (AAD). Methods We registered consecutive Stanford type B AAD patients, who were in the Guangdong Cardiovascular Institute of Guangdong General Hospital from October 2010 to August 2011, and the onset day to admission day were less than or equal to 2 weeks. We collected in-hospital mortality, history of disease, laboratory parameters, some biochemical markers tests, treatment and so on, analyzed the relationship between risk factors and mortality. Results One hundred and five Stanford B AAD patients were enrolled, 9 patients died, accounting for 8.6%. There are 24 patients treated with medicine, and 4 cases finally died. Endovascular aortic repair (EVAR) 62 cases, 2 cases died. EVAR combined carotid artery bypass (CAB) 19 cases, and 3 cases died. Among the three treatments, there was no significant difference in statistics (P = 0.063). Compared with the survivors, the death group had higher D-dimer (P = 0.016) and NT-proBNP (P = 0.014) level, and more patients with myocardial infarction (P = 0.007), hypotension or shock (P = 0.019), a- cute renal failure (P = 0.005), nervous system related events (P 0.001). After adjusting for other predictors of in-hospital death, logistic regression analysis shows that the nervous system related events (odds ratio: 21.648; 95% CI: 1.228-381.704, P = 0.036 is the independent risk factor for death. Conclusions D-dimer, hypotension or shock, acute renal failure, nervous system related events are associated with hospitalization death of Stanford type B AAD patients, while nervous system related events is an independent risk factor for in-hospital death.     

急性A型主动脉夹层术后急性呼吸功能不全的治疗

目的:探讨急性A型主动脉夹层患者在深低温停循环(DHCA)下行主动脉替换手术后,急性呼吸功能不全(ARD)发生的临床特点及治疗策略。方法:2009年2月至2011年1月,急性A型主动脉夹层患者202例,在DHCA(鼻温降至22℃)下行主动脉弓替换。ARD定义为术后72 h内发生的低氧血症(PaO2/FiO2<150),除外术后心源性肺水肿、肺部感染、血/气胸等因素引起的低氧血症。27例患者术后发生ARD,发生率13.4%(27/202)。所有患者分为两组:ARD组和非ARD组,比较两组的临床特点。ARD诊断后立即采取①肺保护性通气;②膨肺;③提高心排量等综合治疗。结果:ARD组体质量指数和DHCA时间明显高于非ARD组(P<0.05)。27例ARD患者经治疗后,26例成功拔除气管插管,仅1例因机械通气时间>7 d行气管切开,术后20 d拔除气切套管出院。ARD平均持续时间3.2 d,住ICU时间(4.5±2.1)d,ARD组无医院死亡。结论:急性主动脉夹层术后早期ARD发生率为13.4%,肺保护性通气结合综合治疗策略对于急性A型主动脉夹层术后ARD有很好的疗效。     

Heart rate on admission independently predicts in-hospital mortality in acute ischemic stroke patients

Background

Higher heart rate (HR) is associated with worse outcomes – in particular death – in long term follow-up of patients with vascular diseases. We investigated the association between HR measured on admission and early in-hospital mortality in acute ischemic stroke patients.

Methods

Over a period of 30 months all patients admitted to our hospital with acute ischemic stroke but without atrial fibrillation were prospectively enrolled. Univariate and multiple logistic regression analyses were conducted to estimate the impact of HR on in-hospital mortality. HR was analyzed as continuous and categorical variable (tertiles).

Results

A total of 1335 patients (median age 73 (IQR 65–81), median National Institutes of Health Stroke Scale score 4 (IQR 2–8), median length of stay 5 days (IQR 4–7), female sex 46%) were studied. In-hospital mortality was 2.6%. When analyzed as categorical variable, HR ≥ 83 bpm was independently associated with in-hospital mortality after adjustment for predictors of poor outcome compared to the reference tertile (HR ≤ 69 bpm) (adjusted odds ratio 4.42, 95% CI 1.36–14.42, p = 0.01). When HR was modeled as continuous variable, relative risk for in-hospital death was elevated by 40% for every additional 10-bpm (p = 0.003). These results were not changed by including beta-blockers as covariate into the multiple regression model.

Conclusions

HR on admission is independently associated with in-hospital mortality in acute ischemic stroke patients suggesting early negative effects of autonomic imbalance. HR may represent a therapeutic target to improve outcome after ischemic stroke.     

Prognostic value of left ventricular hypertrophy in postoperative outcomes in type A acute aortic dissection

BackgroundLeft ventricular hypertrophy (LVH) is common in hypertension patients. Hypertension is a recognized risk factor of acute aortic dissection. This study aimed to explore the prognostic value of LVH in predicting postoperative outcomes in acute type A aortic dissection (ATAAD) patients.MethodsThis was a single-central retrospectively designed study. One hundred and ninety-three ATAAD patients who underwent surgical repair at Renmin Hospital of Wuhan University from January 2018 to November 2021 were enrolled. Patients were divided based on their left ventricular mass index (LVMI). We compared their baseline characteristics, perioperative data, and in-hospital outcome. Then nomogram models were developed based on logistic regression to predict the postoperative outcomes.ResultsLVH presented in 28.5% (55 in 193) patients. LVH group had a higher proportion of female patients compared with the non-LVH group (32.7% vs. 17.4%, P=0.03). Decreased left ventricular ejection fraction and cardiac tamponade were more prevalent in patients with LVH. LVH group had a higher risk of postoperative composite major outcomes (CMO) and operative mortality. Based on multivariable logistic regression, LVH/LVMI, Penn classification, hyperlipidemia, emergency surgery and cardiopulmonary bypass duration were applied to develop nomogram models for predicting postoperative CMO. The area under curve was 0.825 (95% CI: 0.749–0.900) for Model LVH and 0.841 (95% CI: 0.776–0.905) for Model LVMI. Nomogram models for predicting postoperative cardiac were developed based on LVH/LVMI and cardiopulmonary bypass duration. The area under curves for the models involving LVH or LVMI were 0.782 (95% CI: 0.640–0.923) and 0.795 (95% CI: 0.643–0.947), respectively.ConclusionsLVH and increased LVMI was associated with increased risk of postoperative CMO and cardiac events in ATAAD patients. The nomogram models based on LVH or LVMI might help predict postoperative CMO. Future research would be necessary to investigate prognostic value of LVH for long-term outcomes in ATAAD patients.