Type A acute aortic dissection (TAAD) is a disease that has a catastrophic impact on a patient's life and emergent surgery represents a key goal of early treatment. Despite continuous improvements in imaging techniques, medical therapy and surgical management, early mortality in patients undergoing TAAD repair still remains high, ranging from 17% to 26%. In this setting, the International Registry of Acute Aortic Dissection (IRAD), the largest worldwide registry for acute aortic dissection, was established to assess clinical characteristics, management and outcomes of TAAD patients. The present review aimed to evaluate and comment on outcomes of TAAD surgery as reported from IRAD series.
Our findings showed that SURD-AVR is a safe and effective alternative to conventional aortic valve replacement and is associated with excellent clinical outcomes. Further adequately powered statistical analyses from the retrospective and prospective SURD-IR will allow for the development of high-quality evidence-based clinical guidelines for SURD-AVR.
The FET technique is a promising approach in patients with acute dissection. Solid long-term data are warranted to validate the assumed short- and long-term benefits, but we believe that thoughtful patient selection criteria remain crucial.
Patients presenting with type A acute aortic dissection (TAAD) complicated by malperfusion syndromes represent one of the highest surgical risk cohorts for cardiovascular surgeons. In the setting of aortic dissection, end-organ ischemia may involve any of the major arterial side branches resulting in myocardial, cerebral, spinal cord, visceral and/or limb ischemia. In TAAD patients with malperfusion, notwithstanding continuous improvement in diagnostic and management strategies, surgical and clinical outcomes remain poor and the optimal therapy is controversial. The present review aimed to assess current evidence on TAAD patients with the complication of malperfusion, as enunciated by the International Registry of Acute Aortic Dissection (IRAD) investigators.
Illicit fentanyl and its analogues are very dangerous synthetic opioids, with high abuse potential and severe adverse effects including coma and death. They are used as adulterants in street heroin, cocaine, and methamphetamine, or as heroin substitutes sold to unaware users with a high risk of overdoses. Fentanyl and its analogues have also been identified in counterfeit medicinal products, such as oxycodone, hydrocodone, and alprazolam tablets, or as components of speedball mixtures together with cocaine or other stimulants. In recent years, a number of epidemics involving acute intoxications and deaths related to illicit fentanyl or its analogues have occurred in the United States, Europe, Canada, Australia, and Japan. In several cases, fatalities involved polysubstance use. A review of the most recent case reports or case series of acute intoxications and fatalities involving illicit fentanyl and its newest analogues is herein provided, together with the available information on intoxication symptoms, eventual death cause, and metabolites detected in different biological fluids and reported concentrations.
The impact of sutureless and rapid deployment (SURD) valves on the clinical outcomes of patients undergoing minimally invasive aortic valve replacement (MI-AVR) has still to be defined. The aim of this study was to assess clinical characteristics and in-hospital results of patients receiving SURD-AVR through less invasive approaches in the large population of the Sutureless and Rapid Deployment International Registry (SURD-IR).
Of the 1935 patients who received primary isolated SURD-AVR between 2009 and 2018, a total of 1418 (73.3%) underwent MI interventions and were included in this analysis. SURD-AVR was performed using upper ministernotomy in 56.4% (n = 800) of cases and anterior right thoracotomy in 43.6% (n = 618). Perceval S was implanted in 1011 (71.3%) patients and Edwards Intuity or Intuity Elite in 407 (28.7%) patients.
Overall in-hospital mortality and stroke rates were 1.7% and 2%, respectively. A definitive pacemaker implantation was reported in 9% of cases and significantly decreased over the observational period, from 20.6% to 5.6% (P = 0.002). The Perceval valve was associated with shorter operative times and was more frequently implanted in patients receiving anterior right thoracotomy incision. The Intuity valve was preferred in younger patients and revealed superior postoperative haemodynamic results.
SURD-AVR was largely performed through less invasive approaches and can be considered as a primary indication in MI surgery. In the SURD-IR cohort, MI SURD-AVR using both Perceval and Intuity valves appeared a safe and reproducible procedure associated with promising early results.
Several studies have shown that after DeBakey type 1 acute aortic dissection (DB1-AAD) surgery, 70% of the surviving patients still present with a dissected distal aorta that can eventually dilate, rupture, lead to distal malperfusion or require secondary extensive interventions. In order to minimize these complications, different surgeons have advocated total thoracic aorta remodelling procedures during primary aortic repair to promote false-lumen obliteration and distal thrombosis. Such management, which includes arch replacement and antegrade stenting of the dissected descending thoracic aorta (DTA), remains controversial due to its perceived increased operative mortality. Furthermore, the desired long-term benefits remain to be confirmed. The present article aimed to evaluate results of antegrade stenting of DTA during surgery for DB1-AAD, focusing on in-hospital mortality and morbidity, and long-term survival, occurrence of distal aortic remodelling and freedom from aortic reinterventions. Early results from the identified studies suggested that hybrid repair of DB1-AAD with antegrade DTA stenting was associated with satisfactory in-hospital mortality (10.0%) and stroke (4.8%) rates, while the risk of spinal cord injury appeared to be higher (4.3%) than that reported from historical controls. Furthermore, antegrade stenting of DTA was associated with promising rates of partial/complete thrombosis of the peristent DTA false lumen (88.9%), suggesting that aortic remodelling is highly probable with this approach. Evidence on long-term results after proximal acute dissection repair is still sparse, and mostly jeopardized by limited data beyond 5 years. Further investigations with longer term follow-up and with specifically designed protocols to assess long-term clinical outcomes (late aortic mortality and freedom from distal aortic reinterventions) of total thoracic aortic remodelling procedures vs more conservative management are warranted to reach more definitive conclusions.
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