Lee and colleagues examined acute type A dissection outcomes in the Society of Thoracic Surgeons (STS) adult cardiac surgery database from July 2011 to September 2012. Also, these data highlight the need for more expeditious surgical intervention. These data highlight the importance and challenge of timely diagnosis in AAD, which is often in the differential diagnosis of more common disorders such as acute coronary syndrome or pulmonary embolism. Moreover, while surgery for type A dissections increased, the time from admission to surgery remained unchanged at 6 hours in the most current time period. During the study period, the time from admission to diagnosis of AAD did not changed and remained at nearly 3 hours. The IRAD data also highlight areas that need continued improvement and further research over the next decade. These findings are likely secondary to improvements in peri-procedural and intra-operative surgical and medical management that have occurred over time. Importantly, the investigators demonstrate that outcomes with AAD are improving for both type A and B dissections. Eagle and colleagues at ACC.19 provide valuable insights into AAD trends. The IRAD investigators are to be congratulated for their dedication to creating and maintaining an international collaboration dedicated to AAD over the past 25 years. Significant risk factors for long-term survival included age ≥70, peri-procedural spinal cord ischemia, peri-procedural renal failure and a history of chronic obstructive pulmonary disease. Like type A dissections, there was a significant decline in the in-hospital mortality to 7.4%, however, there was also a decline in 5-year post-discharge survival to 83.7%. Using a similar analytic approach, the authors demonstrated that over the past 25 years there has been a shift in management trends for type B dissections to less surgical management (6.1%), less medical management (60.7%) and more endovascular management (31.2%). In addition to data on type A aortic dissections, IRAD maintains data on patients presenting with type B aortic dissections. Risk factors associated with long-term survival included age ≥70, post-procedural stroke and post-procedural tamponade. Despite an improvement in in-hospital mortality, 5-year post-discharge survival remained unchanged at 88.5% in the most current tertile. In-hospital mortality with medical management remained unchanged at 50.7%. This decrease was driven by a significant decline in the in-hospital mortality rate for surgically managed patients to 13.0%. Importantly, for type A dissection patients, the overall in-hospital mortality in the most current time period decreased significantly to 16.3%. Most type A dissections were diagnosed by CT scan and surgical management increased significantly to 88.6% in the past five years while the frequency of pre-operative stroke decreased to 3.9%. Hypertension, smoking and atherosclerosis were the three most common risk factors, with the frequency of hypertension increasing to 81.5% in the most recent tertile. To describe trends over time, patients were divided into three tertiles. Kim Eagle presented an overview of AAD over the past 25 years on behalf of the IRAD investigators. As such, the International Registry of Acute Aortic Dissection (IRAD) was developed in 1996 to better improve outcomes with AAD.Īs a consortium of over 55 large referral centers from 13 countries, IRAD maintains data on approximately 9,000 AAD patients. Quality improvement in AAD management has been limited by the emergent nature in which AADs present as well as the low incidence of AAD relative to conditions such as acute coronary syndrome. Effective management requires timely diagnosis and rapid treatment, yet even under ideal circumstances morbidity and mortality remain high. Please follow this link for the companion articles.Īcute aortic dissection (AAD) continues to be one of the most lethal cardiovascular conditions. Editor's Note: This Expert Analysis is part of a series presenting perspectives on major ACC.19 trials.
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