Is surgery in acute aortic dissection type A still contraindicated in the presence of preoperative neurological symptoms?
- Most H Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland henriette.most@insel.ch.
- Reinhard B Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
- Gahl B Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
- Englberger L Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
- Kadner A Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
- Weber A Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
- Schmidli J Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
- Carrel TP Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
- Huber C Department of Cardiac and Vascular Surgery, Inselspital University Hospital Berne, Berne, Switzerland.
- 2015-01-22
Published in:
- European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery. - 2015
Aortic dissection type A
Coma
Malperfusion
Neurological deficit
Recovery
Aneurysm, Dissecting
Aortic Aneurysm
Female
Glasgow Coma Scale
Humans
Male
Middle Aged
Nervous System Diseases
Retrospective Studies
Treatment Outcome
English
OBJECTIVES
Severe neurological deficit (ND) due to acute aortic dissection type A (AADA) was considered a contraindication for surgery because of poor prognosis. Recently, more aggressive indication for surgery despite neurological symptoms has shown acceptable postoperative clinical results. The aim of this study was to evaluate early and mid-term outcomes of patients with AADA presenting with acute ND.
METHODS
Data from 53 patients with new-onset ND who received surgical repair for AADA between 2005 and 2012 at our institution were retrospectively reviewed. ND was defined as focal motor or sensory deficit, hemiplegia, paraplegia, convulsions or coma. Neurological symptoms were evaluated preoperatively using the Glasgow Coma Scale (GCS) and modified Rankin Scale (mRS), and at discharge as well as 3-6 months postoperatively using the mRS and National Institutes of Health Stroke Scale. Involvement of carotid arteries was assessed in the pre- and postoperative computed tomography. Logistic regression analysis was performed to detect predictive factors for recovery of ND.
RESULTS
Of the 53 patients, 29 (54.7%) showed complete recovery from focal ND at follow-up. Neurological symptoms persisted in 24 (45.3%) patients, of which 8 (33%) died without neurological assessment at follow-up. Between the two groups (patients with recovery and those with persisting ND), there was no significant difference regarding the duration of hypothermic circulatory arrest (28 ± 14 vs 36 ± 20 min) or severely reduced consciousness (GCS <8). Multivariate analysis showed significant differences for the preoperative mRS between the two groups (P < 0.007). A high preoperative mRS was associated with persistence of neurological symptoms (P < 0.02). Cardiovascular risk factors, age or involvement of supra-aortic branches were not predictive for persistence of ND.
CONCLUSION
More than half of our patients recovered completely from ND due to AADA after surgery. Severity of clinical symptoms had a predictive value. Patients suffering from AADA and presenting with ND before surgery should not be excluded from emergency surgery.
Severe neurological deficit (ND) due to acute aortic dissection type A (AADA) was considered a contraindication for surgery because of poor prognosis. Recently, more aggressive indication for surgery despite neurological symptoms has shown acceptable postoperative clinical results. The aim of this study was to evaluate early and mid-term outcomes of patients with AADA presenting with acute ND.
METHODS
Data from 53 patients with new-onset ND who received surgical repair for AADA between 2005 and 2012 at our institution were retrospectively reviewed. ND was defined as focal motor or sensory deficit, hemiplegia, paraplegia, convulsions or coma. Neurological symptoms were evaluated preoperatively using the Glasgow Coma Scale (GCS) and modified Rankin Scale (mRS), and at discharge as well as 3-6 months postoperatively using the mRS and National Institutes of Health Stroke Scale. Involvement of carotid arteries was assessed in the pre- and postoperative computed tomography. Logistic regression analysis was performed to detect predictive factors for recovery of ND.
RESULTS
Of the 53 patients, 29 (54.7%) showed complete recovery from focal ND at follow-up. Neurological symptoms persisted in 24 (45.3%) patients, of which 8 (33%) died without neurological assessment at follow-up. Between the two groups (patients with recovery and those with persisting ND), there was no significant difference regarding the duration of hypothermic circulatory arrest (28 ± 14 vs 36 ± 20 min) or severely reduced consciousness (GCS <8). Multivariate analysis showed significant differences for the preoperative mRS between the two groups (P < 0.007). A high preoperative mRS was associated with persistence of neurological symptoms (P < 0.02). Cardiovascular risk factors, age or involvement of supra-aortic branches were not predictive for persistence of ND.
CONCLUSION
More than half of our patients recovered completely from ND due to AADA after surgery. Severity of clinical symptoms had a predictive value. Patients suffering from AADA and presenting with ND before surgery should not be excluded from emergency surgery.
- Language
-
- English
- Open access status
- green
- Identifiers
-
- DOI 10.1093/ejcts/ezu538
- PMID 25605829
- Persistent URL
- https://sonar.ch/global/documents/278400
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