The Coagulopathy of Acute Type A Aortic Dissection: A Prospective, Observational Study

Zindovic, Igor; Sjögren, Johan; Bjursten, Henrik; Ingemansson, Richard; Ingimarsson, Jónas; Larsson, Mårten; Svensson, Peter; Strandberg, Karin; Wierup, Per; Nozohoor, Shahab

doi:10.1053/j.jvca.2019.02.013

Cited by 32 publications

(37 citation statements)

References 23 publications

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“…Ehlers-Danlos syndrome has been reported in 0.6% of patients with ATAAD in the GERAADA registry [40]. It includes various genetic defects affecting the biosynthesis or structure of collagen type I, II, and V. Among the six major different Ehlers-Danlos subtypes, the vascular subtypetogether with the vascular-like subtype-are of special interest in the context of aortic disease as these impact Procollagen type III and Procollagen type I, respectively.…”

Section: Risk Factorsmentioning

confidence: 99%

Acute type A aortic dissection – a review

Guðbjartsson

Ahlsson

Geirsson

et al. 2019

Scandinavian Cardiovascular Journal

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Acute type A aortic dissection (ATAAD) is still one of the most challenging diseases that cardiac surgeons encounter. This review is based on the current literature and includes the results from the Nordic Consortium for Acute Type-A Aortic Dissection (NORCAAD) database. It covers different aspects of ATAAD and concentrates on the outcome of surgical repair. The diagnosis is occasionally delayed, and ATAAD is usually lethal if prompt repair is not performed. The dynamic nature of the disease, the variation in presentation and clinical course, and the urgency of treatment require significant attentiveness. Many surgical techniques and perfusion strategies of varying complexity have been described, ranging from simple interposition graft to total arch replacement with frozen elephant trunk and valve-sparing root reconstruction. Although more complex techniques may provide long-term benefit in selected patients, they require significant surgical expertise and experience. Short-term survival is first priority so an expedited operation that fits in with the surgeon's level of expertise is in most cases appropriate. ARTICLE HISTORY Definitions and classification systemsDissection of the aorta occurs when the aortic media is separated, usually by pulsatile flow that penetrates the intimal layer of the aortic wall [14] (Figure 1(b)). This allows blood to flow between the layers of the aortic wall, forcing the layers apart, creating a false lumen parallel to the native (i.e. true) aortic lumen (Figure 1(b)). Consequently, the false lumen can propagate in both directions from the tear of intima and affect most of its distal branches, including the coronary, cerebral, and mesenteric arteries [15]. Another-but less common-CONTACT Tomas Gudbjartsson

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Section: Risk Factorsmentioning

confidence: 99%

Acute type A aortic dissection – a review

Guðbjartsson

Ahlsson

Geirsson

et al. 2019

Scandinavian Cardiovascular Journal

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“…The repair of a dissected aorta involves significant intraoperative blood loss and associated coagulopathy. 46 The authors' hemostasis management was guided by thromboelastometry and included multiple allogeneic component therapy and intraoperative AWB collection. Use of AWB after ticagrelor ingestion remains controversial owing to the concern of reinfusing ticagrelor into the circulation.…”

Section: Discussionmentioning

confidence: 99%

“…Use of procoagulant factor concentrates, such as recombinant activated factor VII (rFVIIa), and activated or nonactivated prothrombin complex concentrate (APCC and PCC, respectively) has been reported as adjunct hemostatic agents after CPB. 46,[50][51][52] None of these agents directly improves platelet P2Y 12 function, but these agents potentially can improve platelet aggregability via protease (thrombin)-activated receptors (PAR-1 and PAR-4) signaling. A combined abnormality in P2Y 12 and PAR responses appears to increase the risk of severe bleeding after cardiac surgery.…”

Section: Discussionmentioning

confidence: 99%

“…27 Reduced thrombin generation is not uncommon after prolonged CPB owing to hemorrhagic and dilutional loss of procoagulant factors. 53 Restoration of vitamin KÀdependent factors using APCC or PCC thus is considered important, 46,50,51 particularly in the setting of ticagrelor-related coagulopathy. Safety profiles on the use of these agents in cardiac surgery are limited, and there is a concern for increased risk of thromboembolic events.…”

Section: Discussionmentioning

confidence: 99%

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Hemostasis Management of Patients Undergoing Emergency Cardiac Surgery After Ticagrelor Loading

Williams

Henderson

Reformato

et al. 2020

Journal of Cardiothoracic and Vascular Anesthesia

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“…Patients with acute type A aortic dissection are commonly found to have coagulation disorder preoperatively, such as by low PLT and fibrinogen and high D-dimer and PT-INR [ 9 ]. However, it is impractical to conduct advanced coagulation tests in all cases prior to emergency surgery, because FXII deficiency is extremely infrequent (1 in 1 million individuals) [ 10 ].…”

Section: Discussionmentioning

confidence: 99%

Global cerebral infarction after aortic arch replacement surgery in a patient with postoperatively revealed factor XII deficiency: a case report

Yoshida

Tanaka²,

Sato³

et al. 2020

J Med Case Reports

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Background This case report presents a case of a patient with global cerebral infarction of uncertain etiology following an emergency surgery for acute type A aortic dissection. As a result, factor XII deficiency was revealed postoperatively. To date, there have been several reports of cardiovascular surgery in patients with factor XII deficiency. However, all previous reports were of patients whose factor XII deficiency had been detected preoperatively; therefore, before this, there had been no reports of complications associated with factor XII deficiency following cardiovascular surgery. Case presentation We report a case of emergency aortic arch replacement surgery for acute type A aortic dissection in a 57-year-old Japanese man. A blood test prior to the surgery showed coagulopathy, a platelet count of 117 × 109/L, a prothrombin time–international normalized ratio of 1.78, an activated partial thromboplastin time of 69.7 seconds, and fibrinogen < 50 mg/dl. A smaller-than-usual dose of heparin (8000 IU) was administered because the patient’s activated clotting time was extremely prolonged (> 999 seconds). After the heparin administration, the activated clotting time, measured every 30–60 minutes, remained unchanged (> 999 seconds); therefore, additional heparin was not administered during the surgery, and there was no clinical problem during cardiopulmonary bypass. However, a diagnosis of global cerebral infarction was made on the first postoperative day. An additional blood coagulation test performed on postoperative day 9 revealed factor XII deficiency (8.0%). Regarding the reason that global cerebral infarction occurred in the present case, two reasons were considered: One was factor XII deficiency itself, and the other was low-dose heparin administration during the cardiopulmonary bypass due to excessively prolonged activated clotting time caused by factor XII deficiency. Conclusions Factor XII deficiency should be considered in patients with prolonged activated clotting time and spontaneous thrombosis in vascular surgeries. Moreover, the present case emphasizes that management of heparin during cardiopulmonary bypass should not be performed on the basis of activated clotting time monitoring alone, especially in a case with prolonged activated clotting time.

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The Coagulopathy of Acute Type A Aortic Dissection: A Prospective, Observational Study

Cited by 32 publications

References 23 publications

Acute type A aortic dissection – a review

Acute type A aortic dissection – a review

Hemostasis Management of Patients Undergoing Emergency Cardiac Surgery After Ticagrelor Loading

Global cerebral infarction after aortic arch replacement surgery in a patient with postoperatively revealed factor XII deficiency: a case report

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