Death rate for ruptured aortic drip still 5 times deadlier without surgery, study finds

Newswise – A patient’s chance of survival after an aortic rupture has improved significantly, but the condition remains fatal if not caught early and treated surgically, according to a study.

A team of researchers examined the early mortality rates of over 5,600 patients hospitalized and assessed hourly between 1996 and 2018 with acute type A aortic dissection from the International Acute Aortic Dissection Registry. The often-fatal dissection occurs when blood rushes through a tear in the ascending aorta, causing its layers to separate.

Results published in JAMA Cardiology show that 5.8% of patients with acute type A aortic dissection died within the first two days of arrival at the hospital, corresponding to a mortality rate of 0.12% per hour. The rate is significantly lower than that reported in the 1950s, which estimated that 37% of patients died within the first 48 hours, with an increasing mortality rate of 1-2% per hour.

“We believe that advances in diagnosis and treatment, particularly a focus on early surgical repairs, may have contributed in part to these improvements in mortality from acute aortic dissection,” said Kim Eagle, MD, MACC, the paper’s senior author and director of the Frankel University of Michigan Cardiovascular Center.

Of all patients, 91% either underwent surgery or were scheduled for surgery, with the remainder receiving medical treatment for advanced age and complications such as stroke and kidney failure. Nearly 24% of patients treated medically alone died within two days, compared to 4.4% of patients treated with surgical repair — a mortality rate more than five times higher.

“Patients treated medically were probably not candidates for surgery because of their comorbidities,” said Dr. Bo Yang, a professor of cardiothoracic surgery at the University of Michigan Medical School, who was not involved in the study. “The patients treated medically could die from complications associated with aortic dissection—such as malperfusion, cardiac tamponade, aortic rupture, and acute aortic regurgitation, which can be treated surgically—or from their existing medical conditions, which could be aggravated by the aortic dissection. ”

Only 1% of patients who were eligible for surgery died before the procedure. These patients died an average of nearly nine hours after hospital admission, exceeding the median time to surgery of six hours for all patients.

In more than 70% of aortic dissection cases, transfers between hospitals are required, resulting in inherent delays. Prior to this study, Eagle says, it was thought that early death from this condition was so prohibitively expensive that urgent surgery was the preferred strategy even in hospitals with limited volume of aortic dissection surgeries and resources.

However, there is evidence that surgery at a low-volume hospital can double the risk of dying during repair compared to the highest-volume providers. In addition, mortality rates for open repair of an acute type A aortic dissection are almost three times higher when the surgery is not performed by a specialized aortic surgeon.

“The in-hospital mortality in a high volume center like UM, where aortic dissection patients are cared for only by highly experienced aortic surgeons, can be as low as 5%, while the same patient operated on in a low volume center can be as high as 20%. or higher,” Eagle said. “With this new information, it is clear that the ‘cost’ or risk of a four to six hour delay due to transfers is more than offset by the reduced risk of surgery at experienced hospitals.”

cases are rare. About three out of every 100,000 people suffer an aortic dissection each year. The condition most commonly affects older men, and a person who develops the tear may experience a “knife-like, tearing pain in the back,” according to the IRAD.

It is estimated that up to 50% of patients die before even reaching the hospital, making the all-cause mortality for aortic dissection much higher.

“There is a need to identify the high-risk population of an aortic dissection, e.g. B. those with a family history of aortic aneurysms and dissections, particularly at a younger age, or known pathogenic genetic variants, so that we can electively replace the proximal aorta to prevent acute type A aortic dissection,” Yang said. “For young people under the age of 55 with severe chest pain, we need to establish whether the patients have an aortic dissection or something else.”

The International Registry of Aortic Dissection was established in 1996 at the University of Michigan. Currently, 58 aortic centers worldwide participate in this ongoing collaboration.

Additional authors include Elise M. Woznicki, BS, Daniel G. Montgomery, BS, both of Michigan Medicine, Kevin M. Harris, MD, Craig Strauss, MD, both of the Minneapolis Heart Institute Foundation, Christoph A. Nienaber, MD, The Royal Brompton & Harefield NHS Foundation Trust, Mark D. Peterson, MD, University of Toronto, Alan C. Braverman, MD, Washington University School of Medicine, Santi Trimarchi, MD, Ph.D., Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico , Truls Myrmel, MD, Ph.D., Tromsø University Hospital, Reed Pyeritz, MD, Perelman School of Medicine, Stuart Hutchison, MD, University of Calgary, Marek P. Ehrlich, MD, Medical University of Vienna, Thomas G. Gleason , MS, MD, Brigham and Women’s Hospital, Amit Korach, MD, Hadassah Hebrew University Medical Center, Eric M. Isselbacher, MD, Massachusetts General Hospital

dr Eagle reported grants from WL Gore & Associates, Medtronic and Terumo during the conduct of the study.

Article cited: “Early Mortality in Type A Acute Aortic Dissection: Insights from the International Registry of Acute Aortic Dissection”, JAMA Cardiology. DOI: 10.1001/jamacardio.2022.2718