Biancari Fausto, Demal Till, Nappi Francesco, Onorati Francesco, Francica Alessandra, Peterss Sven, Buech Joscha, Fiore Antonio, Folliguet Thierry, Perrotti Andrea, Hervé Amélie, Conradi Lenard, Rukosujew Andreas, Pinto Angel G, Lega Javier Rodriguez, Pol Marek, Rocek Jan, Kacer Petr, Wisniewski Konrad, Mazzaro Enzo, Vendramin Igor, Piani Daniela, Ferrante Luisa, Rinaldi Mauro, Quintana Eduard, Pruna-Guillen Robert, Gerelli Sebastien, Di Perna Dario, Acharya Metesh, Mariscalco Giovanni, Field Mark, Kuduvalli Manoj, Pettinari Matteo, Rosato Stefano, D'Errigo Paola, Jormalainen Mikko, Mustonen Caius, Mäkikallio Timo, Dell'Aquila Angelo M, Juvonen Tatu, Gatti Giuseppe
Department of Medicine, South-Karelia Central Hospital, University of Helsinki, Lappeenranta, Finland.
Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.
Front Cardiovasc Med. 2024 Jan 15;10:1307935. doi: 10.3389/fcvm.2023.1307935. eCollection 2023.
Surgery for type A aortic dissection (TAAD) is associated with high risk of mortality. Current risk scoring methods have a limited predictive accuracy.
Subjects were patients who underwent surgery for acute TAAD at 18 European centers of cardiac surgery from the European Registry of Type A Aortic Dissection (ERTAAD).
Out of 3,902 patients included in the ERTAAD, 2,477 fulfilled the inclusion criteria. In the validation dataset (2,229 patients), the rate of in-hospital mortality was 18.4%. The rate of composite outcome (in-hospital death, stroke/global ischemia, dialysis, and/or acute heart failure) was 41.2%, and 10-year mortality rate was 47.0%. Logistic regression identified the following patient-related variables associated with an increased risk of in-hospital mortality [area under the curve (AUC), 0.755, 95% confidence interval (CI), 0.729-0.780; Brier score 0.128]: age; estimated glomerular filtration rate; arterial lactate; iatrogenic dissection; left ventricular ejection fraction ≤50%; invasive mechanical ventilation; cardiopulmonary resuscitation immediately before surgery; and cerebral, mesenteric, and peripheral malperfusion. The estimated risk score was associated with an increased risk of composite outcome (AUC, 0.689, 95% CI, 0.667-0.711) and of late mortality [hazard ratio (HR), 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403]. In the validation dataset (248 patients), the in-hospital mortality rate was 16.1%, the composite outcome rate was 41.5%, and the 10-year mortality rate was 49.1%. The estimated risk score was predictive of in-hospital mortality (AUC, 0.703, 95% CI, 0.613-0.793; Brier score 0.121; slope 0.905) and of composite outcome (AUC, 0.682, 95% CI, 0.614-0.749). The estimated risk score was predictive of late mortality (HR, 1.035, 95% CI, 1.031-1.038; Harrell's C 0.702; Somer's D 0.403), also when hospital deaths were excluded from the analysis (HR, 1.024, 95% CI, 1.018-1.031; Harrell's C 0.630; Somer's D 0.261).
The present analysis identified several baseline clinical risk factors, along with preoperative estimated glomerular filtration rate and arterial lactate, which are predictive of in-hospital mortality and major postoperative adverse events after surgical repair of acute TAAD. These risk factors may be valuable components for risk adjustment in the evaluation of surgical and anesthesiological strategies aiming to improve the results of surgery for TAAD.
https://clinicaltrials.gov, identifier NCT04831073.
A型主动脉夹层（TAAD）手术死亡率高。目前的风险评分方法预测准确性有限。
研究对象为欧洲A型主动脉夹层注册研究（ERTAAD）中18个欧洲心脏外科中心接受急性TAAD手术的患者。
在ERTAAD纳入的3902例患者中，2477例符合纳入标准。在验证数据集（2229例患者）中，住院死亡率为18.4%。复合结局（住院死亡、中风/全脑缺血、透析和/或急性心力衰竭）发生率为41.2%，10年死亡率为47.0%。逻辑回归确定了以下与住院死亡率增加相关的患者相关变量[曲线下面积（AUC），0.755，95%置信区间（CI），0.729 - 0.780；Brier评分0.128]：年龄；估计肾小球滤过率；动脉血乳酸；医源性夹层；左心室射血分数≤50%；有创机械通气；术前即刻心肺复苏；以及脑、肠系膜和外周灌注不良。估计的风险评分与复合结局风险增加相关（AUC，0.689，95% CI，0.667 - 0.711）以及晚期死亡率相关[风险比（HR），1.035，95% CI，1.031 - 1.038；Harrell's C 0.702；Somer's D 0.403]。在验证数据集（248例患者）中，住院死亡率为16.1%，复合结局发生率为41.5%，10年死亡率为49.1%。估计的风险评分可预测住院死亡率（AUC，0.703，95% CI，0.613 - 0.793；Brier评分0.121；斜率0.905）和复合结局（AUC，0.682，95% CI，0.614 - 0.749）。估计的风险评分可预测晚期死亡率（HR，1.035，95% CI，1.031 - 1.038；Harrell's C 0.702；Somer's D 0.403）；当分析中排除医院死亡时也是如此（HR，1.024，95% CI，1.018 - 1.031；Harrell's C 0.630；Somer's D 0.261）。
本分析确定了几个基线临床风险因素，以及术前估计肾小球滤过率和动脉血乳酸，这些因素可预测急性TAAD手术修复后的住院死亡率和主要术后不良事件。这些风险因素可能是评估旨在改善TAAD手术结果之手术和麻醉策略时进行风险调整的重要组成部分。
