Research On Surgical Outcome Of Acute Type A Aortic Dissection

Part ?.Surgical outcome of Acute type A aortic dissection with preoperative renal dysfunctionObjective:The present study evaluated the impact of preoperative renal dysfunction on early mortality and postoperative complications after surgery for Acute type A aortic dissection(AAAD),and analyzed the independent risk factors for early mortality and postoperative complications.Furthermore,early and late prognosis between total arch replacement and ascending aortic replacement were compared in patients with preoperative renal dysfunction.Methods:From January 2007 to July 2016,150 consecutive patients with AAAD who underwent thoracic aortic surgery in the First Affiliated Hospital of Zhejiang University were retrospectively studied.Patients were grouped into two categories according to their preoperative estimated glomerular filtration rate(eGFR):those with normal renal function(eGFR>90 mL/min/1.73 m2;n=76)and those with renal dysfunction(eGFR<90 mL/min/1.73 m2;n=74).Study endpoints included:in-hospital mortality,postoperative permanent neurological dysfunction(PND),postoperative acute kidney injury(AKI),postoperative continuous renal replacement therapy(CRRT),postoperative acute lung injury(ALI),postoperative myocardial infarction(MI),duration of ICU stay and hospital stay.Multivariate logistic regression was used to identify independent risk factors for early mortality and postoperative complications.ROC curve was used to evaluate the predictive value of preoperative eGFR on early mortality and postoperative complications.In patients with preoperative renal dysfunction,the data of 9 patients with Debakey II aortic dissection and 4 patients received hemiarch replacement were removed,and the remaining 61 patients were grouped into two categories:those received ascending aortic replacement(n=26),and those received total arch replacement(n=35).The early and late prognosis between total arch replacement and ascending aortic replacement were compared.Results:Patients in the renal dysfunction group had significantly higher incidence ofin-hospital mortality(21.6%vs 7.9%,p=0.018),postoperative PND(25.7%vs 11.8%,p=0.03),AKI(54.1%vs 25.0%,p<0.001),CRRT(18.9%vs 6.6%,p=0.023),ALI(54.1%vs 28.9%,p=0.002),MI(8%vs 0%,p=0.034),and longer median duration of ICU stay(6 days vs 5 days,p=0.036).Multivariate logistic regression analysis further identified preoperative renal dysfunction as independent risk factor for in-hospital mortality(OR = 2.931,95%CI 1.068-8.043,p = 0.037),postoperative PND(OR =2.590,95%CI 1.010-6.645,p = 0.048),postoperative AKI(OR = 3.079,95%CI 1.391-6.817,p = 0.006)and postoperative ALI(OR=2.419,95%CI 1.180-4.958,p =0.016).ROC curve showed that preoperative eGFR had significant predictive value on early mortality(AUC=0.641,p=0.035,cut-off value=90.1 ml/min/1.73 m2),postoperative PND(AUCq=0.631,p=0.031,cut-off value=90.8 ml/min/1.73 m2),postoperative AKI(AUC=0.659,p=0.001,cut-off value=90.1 ml/min/1.73 m2)and postoperative ALI(AUC=0.645,p=0.003,cut-off value=90.1 ml/min/1.73 m2).In AAAD patients with preoperative renal dysfunction,the total arch replacement group had a significantly higher incidence of postoperative AKI compared to the ascending aortic replacement group(69%vs 39%,p=0.019).There was no significant difference in long term prognosis between the two groups.Conclusion:Preoperative renal dysfunction(eGFR<90 mL/nin/1.73 m2)was the independent risk factor for in-hospital mortality and postoperative complications of AAAD.In AAAD patients with preoperative renal dysfunction,the operation risk of ascending aortic replacement was lower than total arch replacement.Part II.Moderate hypothermic circulatory arrest versus deep hypothermic circulatory arrest for surgery of acute type A aortic dissection:A Meta-AnalysisObjective:Whether moderate hypothermic circulatory arrest(MHCA)better than deep hypothermic circulatory arrest(DHCA)for surgery of AAAD is still uncertain.This meta-analysis compared the surgical outcome between MHCA and DHCA for AAAD.Methods:We searched Pubmed and Web of science for study that compared the surgical outcome of MHCA with DHCA.Seven studies that included 780 patients met the eligibility criteria.Results:MHCA significantly decreased the risk of early mortality(OR = 0.58,95%CI 0.39-0.87,p = 0.009)and duration of ICU stay(SMD =-0.48,95%CI-0.71--0.24,p<0.0001)compared with DHCA.After removing a study with average circulation arrest temperature below 20? in the MHCA group,MHCA significantly decreased the risk of postoperative renal failure/dialysis(OR = 0.54,95%CI 0.30-0.95,p = 0.03)and postoperative temporary neurological dysfunction(OR = 0.51,95%CI 0.28-0.93,p =0.03)compared with DHCA.There was no significant difference in incidence of postoperative permanent neurological dysfunction between the MHCA group and DHCA group(OR = 0.66,95%CI 0.39-1.12,p = 0.13).Besides,prolonged cardiopulmonary bypass(CPB)time and circulatory arrest(CA)time of DHCA significantly associated with the higher incidence of postoperative temporary neurological dysfunction.Conclusion:MHCA significantly decreased the risk of early mortality,postoperative renal failure/dialysis and postoperative temporary neurological dysfunction compared with DHCA.There was no significant difference in risk of postoperative permanent neurological dysfunction between MHCA and DHCA.