Download Online Appendix for the following JACC article TITLE: Evidence

Online Appendix for the following JACC article
TITLE: Evidence, Lack of Evidence, Controversy, and Debate in the Provision and
Performance of the Surgery of Acute Type A Aortic Dissection
AUTHORS: Robert S. Bonser, A. M, Ranasinghe, M. Loubani, J. W. Evans, N. M. A.
Thalji, J. Bachet, T. Carrel, M. Czerny, R. <Di Bartolomeo, M. Grabenwöger, L. Lonn,
C.-A. Mestres, M. Schepens, E. Weigang
APPENDIX
Supplementary eFigures
eFigure 1: The time dependency of mortality risk of patients admitted to hospital
(alive) with acute aortic dissection according to dissection sub-type and treatment
allocation (A= type A dissection and B= type B dissection). Reproduced, with
permission, from Hagan et al. (1).
eFigure 2: Resuspension of the aortic valve after acute dissection of the ascending
aorta. Each commissure is anchored by a Teflon felt pledgeted horizontal mattress
suture, suturing from the inside to the outside of the aorta. This technique can be
supplemented with fabric inserts or adhesives to re-affix the dissected layers.
Reproduced with permission from Arom et al. (2).
eFigure 3: Cumulative probability bar charts for Group A (supracoronary
anastomosis) and Group B (composite aortic root replacement for outcomes with
respect to (a) proximal reoperation and (b) distal reoperation. There is a trend
towards lower proximal reoperation rates in Group B patients. Thirteen distal aortic
procedures were performed in 10 group A patients and 10 procedures in five group B
patients. Reproduced with permission from Halstead et al. (3).
eFigure 4: Actuarial survival curves demonstrating survival in patients undergoing
repair of type A aortic dissection with profound hypothermic circulatory arrest
(PHCA) and without (non-PHCA) for (A) the entire study group (n= 307) and (B) a
propensity score matched subset (n= 152). There was no statistically significant
difference in outcomes noted between the two techniques. Reproduced with
permission from Lai et al. (4).
Supplementary eTables
ECG finding
Percentage incidence
Normal
19%
Sinus rhythm
91%
Atrial fibrillation
5%
Other rhythm
4%
Left ventricular hypertrophy
29%
Right bundle branch block
7%
Left bundle branch block
2%
Left anterior hemiblock
8%
Low voltage
5%
Old Q waves
5%
Nonspecific ST-T abnormalities
59%
ACS-like profile
26%
STEMI
4%
Non-STEMI
21%
ST depression
1%
ST elevation and T wave
7%
abnormalities
13%
T wave ≥2mm in ≥2 contiguous
leads
eTable 1: ECG findings in acute Type A aortic dissection. Over 25% of presenting
patients have an ECG compatible with an acute coronary syndrome, most often
compatible with a non-ST elevation myocardial infarction (NSTEMI). Modified and
reproduced with permission from Biagini et al. (5).
Immer
Geirsson
Girdauskas
Cumulative
Number of patients
227
221
276
724
Overall incidence MPS (%)
33
27
34
31
Cardiac (%)
4
7
15
9
CNS (%)
14
9
14
13
Limb (%)
15
13
12
13
Visceral (%)
2
1
3
2
Renal (%)
4
4
Not reported
4
Number of MPS(%)
Not reported
Single
64
81
73
Double
27
13
20
Triple
5
5
5
Quadruple
3
4
4
eTable 2: The incidence of malperfusion syndrome (MPS) in patients presenting with acute type A aortic dissection. Data adapted
from studies by Immer, Geirsson and Girdauskas(6–8).
Cannulation site
Advantages
Disadvantages
Femoral artery
Ease of access
Retrograde flow
Size
Pressurization of false
lumen
Adequate flow rates
Proximal embolization
Axillary/subclavian artery
Reports of reduced
More time consuming
mortality and stroke rates
Brachial plexus injury
Aortic cannulation
Speed of cannulation
Identification of true
lumen
Ventricular apex
Adequacy of flow
Direct
Antegrade flow
Ventricular injury
Direct cannulation of true
lumen
eTable 3: The potential advantages and disadvantages of the different cannulation sites
utilized in acute type A aortic dissection
REFERENCES
1 Hagan PG, Nienaber CA, Isselbacher EM, et al. The International Registry of Acute
Aortic Dissection (IRAD): new insights into an old disease. JAMA 2000;283:897–903.
2. Arom KV, Grover FL. Adult cardiac surgery during the first 50 years of the Southern
Thoracic Surgical Association. Ann Thorac Surg 2003;76:S17–46.
3. Halstead JC, Spielvogel D, Meier DM, et al. Composite aortic root replacement in
acute type A dissection: time to rethink the indications? Eur J Cardiothorac Surg
2005;27:626–32.
4. Lai DT, Robbins RC, Mitchell RS, et al. Does profound hypothermic circulatory arrest
improve survival in patients with acute type A aortic dissection? Circulation 2002;106
Suppl 1:I218–28.
5. Biagini E, Lofegio C, Ferlito M, et al. Frequency, determinants and clinical relevance
of acute coronary syndrome-like electrocardiographic changes in patients with acute
aortic syndrome. Am J Cardiol 2007;100:1013–9.
6. Immer FF, Grobety V, Lauten A, Carrel TP. Does malperfusion
syndrome affect early and mid-term outcome in patients suffering
from acute type A aortic dissection? Interact CardioVasc Thorac Surg
2006;5:187–90.
7. Girdauskas E, Kuntze T, Borger MA, Falk V, Mohr F-W. Surgical risk of preoperative
malperfusion in acute type A aortic dissection. J Thorac Cardiovasc Surg
2009;138:1363–9.
8. Geirsson A, Szeto WY, Pochettino A, et al. Significance of malperfusion syndromes
prior to contemporary surgical repair for acute type A dissection: outcomes and need for
additional revascularizations. Eur J Cardiothorac Surg 2007;32:255–62.