Shuichi Kozawa

Neurological Outcomes After Immediate Aortic Repair for Acute Type A Aortic Dissection Complicated by Coma

Background— Management of acute type A aortic dissection (AADA) complicated by coma remains controversial. We analyzed our experience in managing AADA complicated by coma to determine the relationship of duration of preoperative coma to postoperative neurological recovery. Methods and Results— Between September 2003 and October 2010, 181 patients with AADA were treated, including 27 presenting with coma (Glasgow Coma Scale <11) on arrival. Twenty-one patients were repaired immediately (immediate group); time from onset of symptoms to operating room was <5 hours. For brain protection, deep hypothermia with antegrade cerebral perfusion was used, and postoperative therapeutic hypothermia with magnesium treatment was performed. Six patients initially were managed medically, and 3 of them were followed by eventual repair because time from onset was >5 hours (delayed group). The preoperative National Institutes of Health Stroke Scale score was 31.4±6.6 in the immediate group and 28.3±9.5 in the delayed group. Hospital mortality was 14% in the immediate group and 67% in the delayed group. Full recovery of consciousness was achieved in 86% of patients in the immediate group and in 17% in the delayed group. In immediate group, the postoperative National Institutes of Health Stroke Scale score significantly improved to 6.4±8.4, cumulative survival rate was 71.8% in 3 years, and independence in daily activities was achieved in 52% (11/21). Conclusions— Aortic repair, if performed immediately from the onset of symptoms, showed satisfactory recovery of consciousness and neurological function in patients with AADA complicated by coma. In this patient population, immediate aortic repair is warranted.

Impact of Controlled Pericardial Drainage on Critical Cardiac Tamponade With Acute Type A Aortic Dissection

Background— Cardiac tamponade is associated with fatal outcomes for patients with acute type A aortic dissection, and the presence of cardiac tamponade should prompt urgent aortic repair. However, treatment of the patient with critical cardiac tamponade who cannot survive until surgery remains unclear. We analyzed our experience of controlled pericardial drainage (CPD) managing critical cardiac tamponade. Methods and Results— Between September 2003 and May 2011, 175 patients with acute type A aortic dissection were treated surgically, including 43 (24.6%) who presented with cardiac tamponade on arrival. Eighteen patients, who did not respond to intravenous volume resuscitation, underwent CPD in the emergency department. An 8F pigtail drainage catheter was inserted percutaneously, and drainage volume was controlled by means of several cycles of intermittent drainage to maintain blood pressure at ≈90 mm Hg. After CPD, all of the patients were transferred to the operating room, and immediate aortic repair was performed. Systolic blood pressure before CPD was 64.3±8.2 mm Hg and elevated significantly in all of the cases after CPD. Systolic blood pressure after CPD was 94.8±10.5 mm Hg, and increase in systolic pressure was 30.5±11.7 mm Hg. Total volume of aspirated pericardial effusion was 40.1±30.6 mL, and 10 patients required only ⩽30-mL aspiration volume. All of the patients underwent aortic repair successfully. In-hospital mortality was 16.7%; however, there was no complications or mortality related to CPD. Conclusions— Preoperative pericardial drainage with control of volume is a safe and effective procedure for acute type A aortic dissection complicated by critical cardiac tamponade. In our patient population, timely controlled pericardial drainage is warranted.

Long-term outcomes after immediate aortic repair for acute type A aortic dissection complicated by coma

OBJECTIVES The management of acute type A aortic dissection complicated by coma remains controversial. We previously reported an excellent rate of recovery of consciousness provided aortic repair was performed within 5 hours of the onset of symptoms. This study evaluates the early and long-term outcomes using this approach. METHODS Between August 2003 and July 2013, of the 241 patients with acute type A aortic dissection brought to the Japanese Red Cross Kobe Hospital and Hyogo Emergency Medical Center, 30 (12.4%) presented with coma; Glasgow Coma Scale was less than 11 on arrival. Surgery was performed in 186 patients, including 27 (14.5%) who were comatose. Twenty-four comatose patients underwent successful aortic repair immediately (immediate group). Their mean age was 71.0 ± 11.1 years, Glasgow Coma Scale was 6.5 ± 2.4, and prevalence of carotid dissection was 79%. For brain protection, deep hypothermia with antegrade cerebral perfusion was used, and postoperative induced hypothermia was performed. Neurologic evaluations were performed using the Glasgow Coma Scale, National Institutes of Health Stroke Scale, and modified Rankin Scale. RESULTS In the immediate group, the time from the onset of symptoms to arrival in the operating theater was 222 ± 86 minutes. Hospital mortality was 12.5%. Full recovery of consciousness was achieved in 79% of patients in up to 30 days. Postoperative Glasgow Coma Scale and National Institutes of Health Stroke Scale improved significantly when compared with the preoperative score (P < .05), and postoperative activities of daily living independence (modified Rankin Scale <3) was achieved in 50% of patients. The mean follow-up period was 56.5 months, and the cumulative survival was 48.2% after 10 years. Cox proportional hazards regression analysis indicated that immediate repair (hazard ratio, 4.3; P = .007) was the only significant predictor of postoperative survival over a 5-year period. CONCLUSIONS The early and long-term outcomes as a result of immediate aortic repair for acute type A aortic dissection complicated by coma were satisfactory.

Successful surgical treatment of aortocaval fistula using cardiopulmonary bypass

Aortocaval fistula caused by rupture of an abdominal aneurysm was diagnosed before surgery and treated successfully using cardiopulmonary bypass, which effectively controlled the massive bleeding. Rupture of the false lumen of a dissecting aneurysm limited to the abdominal aorta was responsible for the aortocaval fistula. The defect of the inferior vena cava was closed with a running suture and the aneurysm replaced with a collagen-coated Y graft.

Successful emergency aortic valve replacement following percutaneous cardiopulmonary support for the patient with aortic stenosis and cardiac arrest

We present a 57-year-old woman with severe aortic stenosis. She was diagnosed with acute myocardial infarction by electrocardiography and the detection of elevated creatine phosphokinase in another hospital. Soon after transfer to our hospital, this patient developed cardiac arrest. Percutaneous cardiopulmonary support (PCPS) was established, and subsequently performed coronary angiography revealed normal coronary arteries. However echocardiography revealed severe aortic stenosis. Emergency aortic valve replacement (AVR) was performed, and the patient was discharged from hospital 30 days after surgery in good health. Prompt establishment of PCPS maintained her systemic circulation, and allowed us to conduct investigations for diagnosis. In patients with critical aortic stenosis, emergency AVR should be performed as early as possible following diagnosis.