Rozwarstwienie aorty – Rokowania, prognozy i postęp choroby

Rozwarstwienie aorty
Rokowania, prognozy i postęp choroby

Rozwarstwienie aorty jest stanem o wysokiej śmiertelności, sięgającej 40% przed hospitalizacją, z dalszym wzrostem o 1% na godzinę bez leczenia. Śmiertelność wewnątrzszpitalna wynosi około 28% dla typu A i 11-15,7% dla typu B. Czynniki prognostyczne wczesnej śmiertelności obejmują niekontrolowane nadciśnienie (HR 20,69), średnicę aorty ≥4,75 cm (HR 6,30), bezbólowe rozwarstwienie (OR 4,30), podwyższony poziom troponiny T (OR 3,78) oraz małopłytkowość. Powikłania takie jak ostra niewydolność nerek, hipotensja, niedokrwienie trzewi i zajęcie odgałęzień aorty są kluczowymi predyktorami śmiertelności w ostrej fazie rozwarstwienia typu B. Skala ACEF (Age, Creatinine, Ejection Fraction) jest użytecznym narzędziem do oceny ryzyka u pacjentów z ostrym rozwarstwieniem typu A poddawanych wymianie łuku aorty, wykazując związek z 1-rocznym przeżyciem (HR 1,68; 95% CI 1,34-4,91).

Prognostyka rozwarstwienia aorty (outcome prediction)

Wczesna śmiertelność
Czynniki prognostyczne wczesnej śmiertelności
Skala ACEF jako narzędzie prognostyczne
Odległa śmiertelność
Predyktory degeneracji tętniakowatej
Analiza objętości jako predyktor rokowania
Metodyka badań prognostycznych
Przyszłość opieki nad pacjentami z rozwarstwieniem aorty
Kolejne rozdziały

Prognostyka rozwarstwienia aorty (outcome prediction)

Rozwarstwienie aorty (ang. Aortic dissection) stanowi poważne schorzenie naczyniowe, obarczone wysoką śmiertelnością, która wynosi 40% u pacjentów przed dotarciem do szpitala. Wśród pozostałych pacjentów śmiertelność wzrasta o 1% na każdą godzinę bez leczenia, a nawet po diagnozie 5-20% pacjentów umiera w okresie okołooperacyjnym. Bez leczenia około 50% pacjentów z rozwarstwieniem typu A umiera w ciągu pierwszych trzech dni, podczas gdy około 10% pacjentów z typem B umiera w ciągu miesiąca¹. Przy zastosowaniu agresywnego leczenia 30-dniowa przeżywalność dla rozwarstwienia aorty piersiowej może sięgać nawet 90%².

Wczesna śmiertelność

Śmiertelność wewnątrzszpitalna w ostrym rozwarstwieniu aorty typu B wynosi około 11-15,7%, natomiast w typie A sięga około 28%³⁴. Badania populacyjne wskazują, że liczba przypadków rozwarstwienia aorty wzrośnie w ciągu najbliższych 10 lat do ponad 5500 rocznie, co może prowadzić do około 3500 zgonów rocznie do 2050 roku. Warto jednak podkreślić, że przy odpowiednio wczesnej diagnozie i leczeniu współczynnik przeżywalności przekracza 80%⁵.

Czynniki prognostyczne wczesnej śmiertelności

Zidentyfikowano szereg czynników prognostycznych wczesnej śmiertelności u pacjentów z rozwarstwieniem aorty:

Niekontrolowane nadciśnienie (HR-20,69) i średnica rozwarstwionej aorty ≥4,75 cm (HR-6,30) stanowią niezależne predyktory wczesnej śmiertelności w rozwarstwieniu typu B⁶
Bezbólowe rozwarstwienie (OR 4,30, 95%CI 1,80-10,28) wiąże się ze wzrostem śmiertelności 30-dniowej z 17% do 52%⁷⁸
Podwyższony poziom troponiny T (OR 3,78, 95%CI 2,01-7,12) zwiększa śmiertelność 30-dniową z 12% do 35%⁹¹⁰
Małopłytkowość jest związana z wyższą wczesną śmiertelnością zarówno w rozwarstwieniu typu A ogółem, jak i u pacjentów poddawanych operacjom na otwartym sercu¹¹
Powikłania wewnątrzszpitalne takie jak ostra niewydolność nerek, hipotensja/wstrząs, niedokrwienie trzewi oraz zajęcie odgałęzień aorty przez rozwarstwienie są najważniejszym predyktorem śmiertelności wewnątrzszpitalnej w ostrej fazie rozwarstwienia typu B¹²
Nawracający ból, drożność fałszywego światła oraz omdlenie przy przyjęciu są ważnymi czynnikami związanymi z gorszym rokowaniem wewnątrzszpitalnym u pacjentów z rozwarstwieniem typu B¹³

Skala ACEF jako narzędzie prognostyczne

Wykazano, że skala ACEF (ang. Age, Creatinine, and Ejection Fraction) może być użytecznym narzędziem do oceny ryzyka u pacjentów z ostrym rozwarstwieniem aorty typu A (AAAD) poddawanych całkowitej wymianie łuku aorty. Analiza wieloczynnikowa wykazała, że wynik ACEF (skorygowany współczynnik ryzyka 1,68; 95% przedział ufności 1,34-4,91) oraz binarny wynik ACEF (skorygowany HR 2,26; 95% CI 1,82-6,20) były niezależnie związane z 1-rocznym przeżyciem¹⁴.

Główną zaletą skali ACEF jest jej prostota i szybkość obliczania – nie jest wymagane specjalistyczne oprogramowanie. Skala ta może być uznana za użyteczne narzędzie do stratyfikacji ryzyka u pacjentów z AAAD przed operacją w codziennej praktyce klinicznej¹⁵.

Odległa śmiertelność

W obserwacji długoterminowej śmiertelność 9-letnia u pacjentów z rozwarstwieniem aorty typu B osiąga 51,9%¹⁶. Niezależnymi predyktorami późnej śmiertelności są:

Nawracający ból (HR-7,93)¹⁷¹⁸
Niekontrolowane nadciśnienie (HR-7,25) w pierwszych 24 godzinach¹⁹²⁰
Patologiczna różnica ciśnienia tętniczego (>20 mmHg) (HR-5,33)²¹²²

Predyktory degeneracji tętniakowatej

Utworzenie tętniaka w fałszywym świetle (FL) jest długoterminowym powikłaniem u znacznego odsetka pacjentów z rozwarstwieniem aorty typu B. Zdolność przewidywania, u których pacjentów prawdopodobnie dojdzie do tworzenia tętniaka, jest kluczowa dla uzasadnienia ryzyka związanego z terapią interwencyjną²³.

Zgodnie z aktualnymi wytycznymi, utrzymująca się perfuzja fałszywego światła sprzyjająca jego drożności jest uważana za niezależny wskaźnik ryzyka późnych niekorzystnych wyników i degeneracji tętniakowatej, szczególnie w połączeniu z maksymalną średnicą aorty większą niż 40 mm²⁴.

Badania z wykorzystaniem dynamiki płynów obliczeniowej (CFD) wykazały, że szybki wzrost aorty wskazujący na degenerację tętniakowatą był związany z większym fałszywym światłem. Wysoki przepływ przez fałszywe światło i krętość aorty były związane z niekorzystnym rokowaniem (zgon podczas obserwacji) i pojawiły się jako wskaźniki ryzyka²⁵.

Analiza objętości jako predyktor rokowania

Długoterminowe rokowanie przy rozwarstwieniu aorty typu A jest bezpośrednio związane z ewolucją rezydualnego rozwarstwienia aorty (RAD). Badania potwierdzają, że początkowa średnica aorty przewiduje długoterminową niekorzystną ewolucję, ale sama średnica, choć potwierdzona w kilku badaniach, nie jest wystarczająca do optymalnego przesiewania pacjentów²⁶.

Wykazano, że ewolucja objętości fałszywego światła aorty po zaledwie 3 miesiącach przewidywała długoterminową niekorzystną ewolucję z czułością 88% i swoistością 75%, podczas gdy ewolucja średnicy aorty po 3 miesiącach nie była predyktorem długoterminowych zdarzeń związanych z rozwarstwieniem²⁷.

Analiza objętości, oprócz analizy średnicy, może być wykorzystana w przyszłości do przesiewania pacjentów zagrożonych ewolucją tętniakowatą, reinterwencjami i zgonem, oraz do zaproponowania bardziej agresywnego leczenia na wczesnym etapie w celu promowania przebudowy aorty i poprawy długoterminowego przeżycia bez reinterwencji²⁸.

Metodyka badań prognostycznych

Systematyczne przeglądy wykazały, że metody stosowane w badaniach prognostycznych dotyczących śmiertelności wśród pacjentów z ostrym rozwarstwieniem aorty, w tym modeli predykcyjnych lub badań czynników prognostycznych, były nieoptymalne, a wydajność modeli znacznie się różniła²⁹.

Skuteczność czynników prognostycznych wykazywała zróżnicowaną dyskryminację (AUC 0,58 do 0,95), a wydajność modeli predykcyjnych również znacznie się różniła (AUC 0,49 do 0,91). Tylko sześć badań opisało statystykę kalibracji³⁰.

Najczęściej wykorzystywanymi biomarkerami były D-dimery (DD), stosunek neutrofili do limfocytów (NLR) oraz białko C-reaktywne (CRP). Wiele z tych czynników prognostycznych lub modeli predykcyjnych jest metodologicznie słabych. Dla lepszego przewidywania śmiertelności w ostrym rozwarstwieniu aorty należy uwzględnić kilka ważnych kwestii, takich jak wielkość próby, metody postępowania z brakującymi danymi, odpowiednie metody analizy statystycznej oraz zgłaszanie zarówno kalibracji, jak i dyskryminacji dla modeli predykcyjnych³¹.

Przyszłość opieki nad pacjentami z rozwarstwieniem aorty

W ostatnich latach nastąpiła poprawa w zakresie usług i ekspertyzy; Liverpool i London Aortic Rotas wykazały zmniejszenie śmiertelności operacyjnej o połowę. Krajowa koordynacja i organizacja usług dla aorty obiecuje znaczną poprawę dla pacjentów z rozwarstwieniem aorty dzięki zestawowi narzędzi NHS Acute Aortic Dissection Toolkit (wdrożonemu w 2022 r.), dalszemu rozwojowi National Vascular Registry dla procedur dotyczących aorty oraz uwzględnieniu opinii pacjentów i rodzin przy wyborze opcji leczenia³².

NHS England, wraz ze wsparciem pacjentów z Aortic Dissection Charitable Trust, opracował zestaw narzędzi NHS Acute Aortic Dissection Toolkit, który znacznie poprawi ścieżkę dla pacjentów z rozwarstwieniem aorty i ma potencjał ratowania 500 życia rocznie oraz poprawy regionalnych różnic po wdrożeniu³³.

Przyszłość przyniesie łatwo dostępną bazę danych dla pracowników służby zdrowia w celu wsparcia leczenia pacjentów. Opcje leczenia będą oparte na wariancie genetycznym, umożliwiając specjalistom udzielanie dostosowanych zaleceń dotyczących leków i określanie różnych procedur kontrolnych, takich jak częstotliwość obrazowania aorty pacjenta, czy należy rozważyć tętniaki tętnicze lub czy należy przeprowadzić dalsze obrazowanie powiązanych stanów³⁴.

Aktualnym celem badawczym jest lepsze zrozumienie wariantów genetycznych i pełnej listy czynników środowiskowych, które na nie wpływają³⁵.

Kolejne rozdziały

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Materiały źródłowe

#1 Aortic dissection – Wikipedia
https://en.wikipedia.org/wiki/Aortic_dissection
Prognosis Mortality without treatment 10% (type B), 50% (type A)[3] […] Without treatment, about half of people with Stanford type A dissections die within three days and about 10% of people with Stanford type B dissections die within one month.[3] […] Of all people with aortic dissection, 40% die immediately and do not reach a hospital in time. Of the remainder, 1% die every hour, making prompt diagnosis and treatment a priority. Even after diagnosis, 5-20% die during surgery or in the immediate postoperative period.[26] In ascending aortic dissection, if surgery is decided to be not appropriate, 75% die within 2 weeks. With aggressive treatment, 30-day survival for thoracic dissections may be as high as 90%.[46]
#2 Aortic dissection – Wikipedia
https://en.wikipedia.org/wiki/Aortic_dissection
Prognosis Mortality without treatment 10% (type B), 50% (type A)[3] […] Without treatment, about half of people with Stanford type A dissections die within three days and about 10% of people with Stanford type B dissections die within one month.[3] […] Of all people with aortic dissection, 40% die immediately and do not reach a hospital in time. Of the remainder, 1% die every hour, making prompt diagnosis and treatment a priority. Even after diagnosis, 5-20% die during surgery or in the immediate postoperative period.[26] In ascending aortic dissection, if surgery is decided to be not appropriate, 75% die within 2 weeks. With aggressive treatment, 30-day survival for thoracic dissections may be as high as 90%.[46]
#3 Early and Late Mortality Predictors in Patients with Acute Aortic Dissection Type B
https://pmc.ncbi.nlm.nih.gov/articles/PMC9719417/
Despite technological advances in diagnosis and treatment, in-hospital mortality with acute aortic dissection type B is still about 11%. […] The in-hospital mortality rate was 15.7% and the 9-year mortality rate was 51.9%. […] Independent predictors of early mortality in patients with acute aortic dissection type B were uncontrolled hypertension (HR-20.69) and a dissecting aorta diameter 4.75cm (HR-6.30). Independent predictors of late mortality were relapsing pain (HR-7.93), uncontrolled hypertension (HR-7.25), and a pathologic difference in arterial blood pressure (20mmHg) (HR-5.33). […] Knowledge of key risk factors may help with a better choice of treatment and mortality reduction in acute aortic dissection type B patients. […] The presence of intrahospital complications (acute renal insufficiency, hypotension/shock, mesenteric ischemia, and aortic branches affected by dissection) in acute stage AADB is the most important predictor of intrahospital mortality in patients with AADB.
#4 Incidence, presentation and outcome of acute aortic dissection: results from a population-based study | Open Heart
https://openheart.bmj.com/content/11/1/e002595
A total of 344 patients were included. […] Overall, 30-day mortality was 28% in type A and 11% in type B (p0.001). […] Both painless dissection (OR 4.30, 95%CI 1.80 to 10.28, p=0.001) and elevated troponin T (OR 3.78, 95%CI 2.01 to 7.12, p0.001), respectively, were associated with increased 30-day mortality in all acute aortic dissection patients. […] Nearly two-thirds of acute aortic dissection patients had type A. Levels of troponin T and platelets, respectively, paired with presence or absence of typical symptoms may become useful adjuncts in risk stratification of patients with acute aortic dissection. […] Painless dissection was more frequent than previously described and it was associated with increased early mortality. Furthermore, elevation of plasma troponin T on admission was more common in patients with type A than type B acute AD and associated with higher early mortality in both patient groups.
#5 What does the future hold for aortic dissection patient care?
https://aorticdissectioncharitabletrust.org/future-of-aortic-care/
Population-based studies, such as the Oxford Vascular Study (1) predict that cases of aortic dissection are set to rise over the next 10 years to more than 5,500 annually. If this trajectory comes to fruition, almost 3,500 people will lose their lives every year by 2050. […] Itâs vitally important to remember that aortic dissection is a treatable condition and has a better than 80% survival rate when itâs diagnosed and treated on time. Yet today, in 2022, 50% of people who are struck by this condition, die. […] The service and expertise have improved in the past 10 years; the Liverpool and London Aortic Rotas have shown a halving in operative mortality. […] More recently, the national coordination and organisation of aortic services promises to make a vast improvement for aortic dissection patients thanks to the NHS Acute Aortic Dissection Toolkit (launched in 2022), further development of the National Vascular Registry for aortic procedures, and the inclusion of patient and family opinions when selecting treatment options.
#6 Early and Late Mortality Predictors in Patients with Acute Aortic Dissection Type B
https://pmc.ncbi.nlm.nih.gov/articles/PMC9719417/
Despite technological advances in diagnosis and treatment, in-hospital mortality with acute aortic dissection type B is still about 11%. […] The in-hospital mortality rate was 15.7% and the 9-year mortality rate was 51.9%. […] Independent predictors of early mortality in patients with acute aortic dissection type B were uncontrolled hypertension (HR-20.69) and a dissecting aorta diameter 4.75cm (HR-6.30). Independent predictors of late mortality were relapsing pain (HR-7.93), uncontrolled hypertension (HR-7.25), and a pathologic difference in arterial blood pressure (20mmHg) (HR-5.33). […] Knowledge of key risk factors may help with a better choice of treatment and mortality reduction in acute aortic dissection type B patients. […] The presence of intrahospital complications (acute renal insufficiency, hypotension/shock, mesenteric ischemia, and aortic branches affected by dissection) in acute stage AADB is the most important predictor of intrahospital mortality in patients with AADB.
#7 Incidence, presentation and outcome of acute aortic dissection: results from a population-based study | Open Heart
https://openheart.bmj.com/content/11/1/e002595
A total of 344 patients were included. […] Overall, 30-day mortality was 28% in type A and 11% in type B (p0.001). […] Both painless dissection (OR 4.30, 95%CI 1.80 to 10.28, p=0.001) and elevated troponin T (OR 3.78, 95%CI 2.01 to 7.12, p0.001), respectively, were associated with increased 30-day mortality in all acute aortic dissection patients. […] Nearly two-thirds of acute aortic dissection patients had type A. Levels of troponin T and platelets, respectively, paired with presence or absence of typical symptoms may become useful adjuncts in risk stratification of patients with acute aortic dissection. […] Painless dissection was more frequent than previously described and it was associated with increased early mortality. Furthermore, elevation of plasma troponin T on admission was more common in patients with type A than type B acute AD and associated with higher early mortality in both patient groups.
#8 Incidence, presentation and outcome of acute aortic dissection: results from a population-based study | Open Heart
https://openheart.bmj.com/content/11/1/e002595
As acute AD may present without pain and with elevation of troponin T, it should be considered as differential diagnosis in patients with atypical acute symptoms of severe disease or in acute onset chest pain without coronary ischaemia since early diagnosis of acute AD is of utmost importance to improve the outcome. […] An association to higher 30-day mortality was demonstrated in patients with painless dissection compared with painful dissection (52% mortality vs 17% mortality; OR 4.30, 95%CI 1.80 to 10.28, p=0.001) and in patients with elevated admission troponin T level compared with normal levels (35% mortality with elevated troponin T vs 12% mortality with normal troponin T; OR 3.78, 95%CI 2.01 to 7.12, p 0.001), respectively. […] Factors associated with higher early mortality both in TAD patients overall and in TAD patients undergoing OSR, respectively, were elevated troponin T and thrombocytopenia. […] Painless dissection as well as elevated troponin T level on admission was associated with higher 30-day mortality in patients with TBD.
#9 Incidence, presentation and outcome of acute aortic dissection: results from a population-based study | Open Heart
https://openheart.bmj.com/content/11/1/e002595
A total of 344 patients were included. […] Overall, 30-day mortality was 28% in type A and 11% in type B (p0.001). […] Both painless dissection (OR 4.30, 95%CI 1.80 to 10.28, p=0.001) and elevated troponin T (OR 3.78, 95%CI 2.01 to 7.12, p0.001), respectively, were associated with increased 30-day mortality in all acute aortic dissection patients. […] Nearly two-thirds of acute aortic dissection patients had type A. Levels of troponin T and platelets, respectively, paired with presence or absence of typical symptoms may become useful adjuncts in risk stratification of patients with acute aortic dissection. […] Painless dissection was more frequent than previously described and it was associated with increased early mortality. Furthermore, elevation of plasma troponin T on admission was more common in patients with type A than type B acute AD and associated with higher early mortality in both patient groups.
#10 Incidence, presentation and outcome of acute aortic dissection: results from a population-based study | Open Heart
https://openheart.bmj.com/content/11/1/e002595
As acute AD may present without pain and with elevation of troponin T, it should be considered as differential diagnosis in patients with atypical acute symptoms of severe disease or in acute onset chest pain without coronary ischaemia since early diagnosis of acute AD is of utmost importance to improve the outcome. […] An association to higher 30-day mortality was demonstrated in patients with painless dissection compared with painful dissection (52% mortality vs 17% mortality; OR 4.30, 95%CI 1.80 to 10.28, p=0.001) and in patients with elevated admission troponin T level compared with normal levels (35% mortality with elevated troponin T vs 12% mortality with normal troponin T; OR 3.78, 95%CI 2.01 to 7.12, p 0.001), respectively. […] Factors associated with higher early mortality both in TAD patients overall and in TAD patients undergoing OSR, respectively, were elevated troponin T and thrombocytopenia. […] Painless dissection as well as elevated troponin T level on admission was associated with higher 30-day mortality in patients with TBD.
#11 Incidence, presentation and outcome of acute aortic dissection: results from a population-based study | Open Heart
https://openheart.bmj.com/content/11/1/e002595
As acute AD may present without pain and with elevation of troponin T, it should be considered as differential diagnosis in patients with atypical acute symptoms of severe disease or in acute onset chest pain without coronary ischaemia since early diagnosis of acute AD is of utmost importance to improve the outcome. […] An association to higher 30-day mortality was demonstrated in patients with painless dissection compared with painful dissection (52% mortality vs 17% mortality; OR 4.30, 95%CI 1.80 to 10.28, p=0.001) and in patients with elevated admission troponin T level compared with normal levels (35% mortality with elevated troponin T vs 12% mortality with normal troponin T; OR 3.78, 95%CI 2.01 to 7.12, p 0.001), respectively. […] Factors associated with higher early mortality both in TAD patients overall and in TAD patients undergoing OSR, respectively, were elevated troponin T and thrombocytopenia. […] Painless dissection as well as elevated troponin T level on admission was associated with higher 30-day mortality in patients with TBD.
#12 Early and Late Mortality Predictors in Patients with Acute Aortic Dissection Type B
https://pmc.ncbi.nlm.nih.gov/articles/PMC9719417/
Despite technological advances in diagnosis and treatment, in-hospital mortality with acute aortic dissection type B is still about 11%. […] The in-hospital mortality rate was 15.7% and the 9-year mortality rate was 51.9%. […] Independent predictors of early mortality in patients with acute aortic dissection type B were uncontrolled hypertension (HR-20.69) and a dissecting aorta diameter 4.75cm (HR-6.30). Independent predictors of late mortality were relapsing pain (HR-7.93), uncontrolled hypertension (HR-7.25), and a pathologic difference in arterial blood pressure (20mmHg) (HR-5.33). […] Knowledge of key risk factors may help with a better choice of treatment and mortality reduction in acute aortic dissection type B patients. […] The presence of intrahospital complications (acute renal insufficiency, hypotension/shock, mesenteric ischemia, and aortic branches affected by dissection) in acute stage AADB is the most important predictor of intrahospital mortality in patients with AADB.
#13 Early and Late Mortality Predictors in Patients with Acute Aortic Dissection Type B
https://pmc.ncbi.nlm.nih.gov/articles/PMC9719417/
Our results showed the presence of relapsing pain, false lumen patency, and the existence of syncope on admission to be important for a poor intrahospital outcome in patients with AADB. […] The most important independent predictors of late mortality are the following clinical signs: relapsing pain and uncontrolled hypertension in the first 24 hours, and pathologic differences in arterial blood pressure over 20mmHg.
#14 Clinical predictive value of the age, creatinine, and ejection fraction score in patients in acute type A aortic dissection after total arch replacement | Scientific Reports
https://www.nature.com/articles/s41598-024-58608-4
The age, creatinine, and ejection fraction (ACEF) score has been accepted as a predictor of poor outcome in elective operations. This study aimed to investigate the predictive value of ACEF score in acute type A aortic dissection (AAAD) patients after total arch replacement. […] After IPTW, in the baseline characteristics reached an equilibrium, a higher ACEF score before operation still associated with higher in-hospital mortality. […] Multivariable analysis revealed that ACEF score (adjusted hazard ratio 1.68; 95% confidence interval 1.344.91; p=0.036) and binary ACEF score (adjusted HR 2.26; 95% CI 1.826.20; p0.001) was independently associated with 1-year survival. […] In conclusions, ACEF score could be considered as a useful tool to risk stratification in patients with AAAD before operation in daily clinical work.
#15 Clinical predictive value of the age, creatinine, and ejection fraction score in patients in acute type A aortic dissection after total arch replacement | Scientific Reports
https://www.nature.com/articles/s41598-024-58608-4
The current investigation showed that the predictive value of the ACEF score in early surgical outcome in AAAD patients underwent total arch replacement. […] The key advantage of ACEF score is its simplicity and rapidity, no specific software is necessary. The ACEF score could be considered as a useful tool to risk stratification in patients with AAAD before operation in daily clinical work. […] In this study, the ACEF score, was demonstrated to be associated with in-hospital mortality and 1-year survival of AAAD patients after total arch replacement. As a simple and reliable score, ACEF could be considered as a useful tool to risk stratification in patients with AAAD before operation in daily clinical work.
#16 Early and Late Mortality Predictors in Patients with Acute Aortic Dissection Type B
https://pmc.ncbi.nlm.nih.gov/articles/PMC9719417/
Despite technological advances in diagnosis and treatment, in-hospital mortality with acute aortic dissection type B is still about 11%. […] The in-hospital mortality rate was 15.7% and the 9-year mortality rate was 51.9%. […] Independent predictors of early mortality in patients with acute aortic dissection type B were uncontrolled hypertension (HR-20.69) and a dissecting aorta diameter 4.75cm (HR-6.30). Independent predictors of late mortality were relapsing pain (HR-7.93), uncontrolled hypertension (HR-7.25), and a pathologic difference in arterial blood pressure (20mmHg) (HR-5.33). […] Knowledge of key risk factors may help with a better choice of treatment and mortality reduction in acute aortic dissection type B patients. […] The presence of intrahospital complications (acute renal insufficiency, hypotension/shock, mesenteric ischemia, and aortic branches affected by dissection) in acute stage AADB is the most important predictor of intrahospital mortality in patients with AADB.
#17 Early and Late Mortality Predictors in Patients with Acute Aortic Dissection Type B
https://pmc.ncbi.nlm.nih.gov/articles/PMC9719417/
Despite technological advances in diagnosis and treatment, in-hospital mortality with acute aortic dissection type B is still about 11%. […] The in-hospital mortality rate was 15.7% and the 9-year mortality rate was 51.9%. […] Independent predictors of early mortality in patients with acute aortic dissection type B were uncontrolled hypertension (HR-20.69) and a dissecting aorta diameter 4.75cm (HR-6.30). Independent predictors of late mortality were relapsing pain (HR-7.93), uncontrolled hypertension (HR-7.25), and a pathologic difference in arterial blood pressure (20mmHg) (HR-5.33). […] Knowledge of key risk factors may help with a better choice of treatment and mortality reduction in acute aortic dissection type B patients. […] The presence of intrahospital complications (acute renal insufficiency, hypotension/shock, mesenteric ischemia, and aortic branches affected by dissection) in acute stage AADB is the most important predictor of intrahospital mortality in patients with AADB.
#18 Early and Late Mortality Predictors in Patients with Acute Aortic Dissection Type B
https://pmc.ncbi.nlm.nih.gov/articles/PMC9719417/
Our results showed the presence of relapsing pain, false lumen patency, and the existence of syncope on admission to be important for a poor intrahospital outcome in patients with AADB. […] The most important independent predictors of late mortality are the following clinical signs: relapsing pain and uncontrolled hypertension in the first 24 hours, and pathologic differences in arterial blood pressure over 20mmHg.
#19 Early and Late Mortality Predictors in Patients with Acute Aortic Dissection Type B
https://pmc.ncbi.nlm.nih.gov/articles/PMC9719417/
Despite technological advances in diagnosis and treatment, in-hospital mortality with acute aortic dissection type B is still about 11%. […] The in-hospital mortality rate was 15.7% and the 9-year mortality rate was 51.9%. […] Independent predictors of early mortality in patients with acute aortic dissection type B were uncontrolled hypertension (HR-20.69) and a dissecting aorta diameter 4.75cm (HR-6.30). Independent predictors of late mortality were relapsing pain (HR-7.93), uncontrolled hypertension (HR-7.25), and a pathologic difference in arterial blood pressure (20mmHg) (HR-5.33). […] Knowledge of key risk factors may help with a better choice of treatment and mortality reduction in acute aortic dissection type B patients. […] The presence of intrahospital complications (acute renal insufficiency, hypotension/shock, mesenteric ischemia, and aortic branches affected by dissection) in acute stage AADB is the most important predictor of intrahospital mortality in patients with AADB.
#20 Early and Late Mortality Predictors in Patients with Acute Aortic Dissection Type B
https://pmc.ncbi.nlm.nih.gov/articles/PMC9719417/
Our results showed the presence of relapsing pain, false lumen patency, and the existence of syncope on admission to be important for a poor intrahospital outcome in patients with AADB. […] The most important independent predictors of late mortality are the following clinical signs: relapsing pain and uncontrolled hypertension in the first 24 hours, and pathologic differences in arterial blood pressure over 20mmHg.
#21 Early and Late Mortality Predictors in Patients with Acute Aortic Dissection Type B
https://pmc.ncbi.nlm.nih.gov/articles/PMC9719417/
Despite technological advances in diagnosis and treatment, in-hospital mortality with acute aortic dissection type B is still about 11%. […] The in-hospital mortality rate was 15.7% and the 9-year mortality rate was 51.9%. […] Independent predictors of early mortality in patients with acute aortic dissection type B were uncontrolled hypertension (HR-20.69) and a dissecting aorta diameter 4.75cm (HR-6.30). Independent predictors of late mortality were relapsing pain (HR-7.93), uncontrolled hypertension (HR-7.25), and a pathologic difference in arterial blood pressure (20mmHg) (HR-5.33). […] Knowledge of key risk factors may help with a better choice of treatment and mortality reduction in acute aortic dissection type B patients. […] The presence of intrahospital complications (acute renal insufficiency, hypotension/shock, mesenteric ischemia, and aortic branches affected by dissection) in acute stage AADB is the most important predictor of intrahospital mortality in patients with AADB.
#22 Early and Late Mortality Predictors in Patients with Acute Aortic Dissection Type B
https://pmc.ncbi.nlm.nih.gov/articles/PMC9719417/
Our results showed the presence of relapsing pain, false lumen patency, and the existence of syncope on admission to be important for a poor intrahospital outcome in patients with AADB. […] The most important independent predictors of late mortality are the following clinical signs: relapsing pain and uncontrolled hypertension in the first 24 hours, and pathologic differences in arterial blood pressure over 20mmHg.
#23 Predicting Aneurysmal Degeneration in Uncomplicated Residual Type B Aortic Dissection
https://www.mdpi.com/2306-5354/11/7/690
The formation of an aneurysm in the false lumen (FL) is a long-term complication in a significant percentage of type B aortic dissection (AD) patients. […] The ability to predict which patients are likely to progress to aneurysm formation is key to justifying the risks of interventional therapy. […] The rapid aortic growth behind aneurysmal degeneration in the FL is not fully understood and is likely to be affected by local hemodynamics along with the presence of pre-existing conditions and comorbidities. […] According to current guidelines, a persistent FL perfusion favoring patency is regarded as an independent indicator of risk for late adverse outcomes and aneurysmal degeneration, especially when combined with a maximum aortic diameter greater than 40 mm. […] The investigation of patient-specific hemodynamics seems promising in the context of finding a patient-tailored approach to improve prognosis and disease management for uncomplicated type B AD patients.
#24 Predicting Aneurysmal Degeneration in Uncomplicated Residual Type B Aortic Dissection
https://www.mdpi.com/2306-5354/11/7/690
The formation of an aneurysm in the false lumen (FL) is a long-term complication in a significant percentage of type B aortic dissection (AD) patients. […] The ability to predict which patients are likely to progress to aneurysm formation is key to justifying the risks of interventional therapy. […] The rapid aortic growth behind aneurysmal degeneration in the FL is not fully understood and is likely to be affected by local hemodynamics along with the presence of pre-existing conditions and comorbidities. […] According to current guidelines, a persistent FL perfusion favoring patency is regarded as an independent indicator of risk for late adverse outcomes and aneurysmal degeneration, especially when combined with a maximum aortic diameter greater than 40 mm. […] The investigation of patient-specific hemodynamics seems promising in the context of finding a patient-tailored approach to improve prognosis and disease management for uncomplicated type B AD patients.
#25 Predicting Aneurysmal Degeneration in Uncomplicated Residual Type B Aortic Dissection
https://www.mdpi.com/2306-5354/11/7/690
The present study proposes the use of CFD-derived hemodynamic descriptors to retrospectively assess individual aortas for a population of type B ADs, and analyze potential correlations with known outcomes, such as rapid aortic growth indicating aneurysmal degeneration. […] Rapid aortic expansion was found to be associated with larger FL. […] High FL flow rate and tortuosity were associated with adverse outcome (reported death during follow-up) and emerged as indicators of risk. […] The reported findings emphasize the need for a patient-tailored approach when evaluating uncomplicated type B AD patients and show the potential of CFD-derived hemodynamics to complement anatomical assessment and help patient management.
#26 Volume Analysis to Predict the Long-Term Evolution of Residual Aortic Dissection after Type A Repair
https://www.mdpi.com/2308-3425/9/10/349
The long-term prognosis of a type A aortic dissection is directly related to the residual aortic dissection (RAD) evolution. […] The identified poor prognostic factors associated with a RAD are a matter of concern because patients with an increased risk of disease progression might be offered earlier endovascular treatment to increase the mid- and long-term survival. […] Our study confirms that the initial aortic diameter predicts a long-term unfavorable evolution, but the diameter alone, although confirmed in several studies, is not enough to screen patients in an optimal way. […] Indeed, we showed that the aortic FL volume evolution at just 3 months predicted a long-term unfavorable evolution with a sensitivity of 88% and specificity of 75%, whereas the evolution of the aortic diameter at 3 months was not predictive of long-term dissection-related events.
#27 Volume Analysis to Predict the Long-Term Evolution of Residual Aortic Dissection after Type A Repair
https://www.mdpi.com/2308-3425/9/10/349
The long-term prognosis of a type A aortic dissection is directly related to the residual aortic dissection (RAD) evolution. […] The identified poor prognostic factors associated with a RAD are a matter of concern because patients with an increased risk of disease progression might be offered earlier endovascular treatment to increase the mid- and long-term survival. […] Our study confirms that the initial aortic diameter predicts a long-term unfavorable evolution, but the diameter alone, although confirmed in several studies, is not enough to screen patients in an optimal way. […] Indeed, we showed that the aortic FL volume evolution at just 3 months predicted a long-term unfavorable evolution with a sensitivity of 88% and specificity of 75%, whereas the evolution of the aortic diameter at 3 months was not predictive of long-term dissection-related events.
#28 Volume Analysis to Predict the Long-Term Evolution of Residual Aortic Dissection after Type A Repair
https://www.mdpi.com/2308-3425/9/10/349
The volume analysis in addition to the diameter analysis could be used in the future to screen patients at risk of an aneurysmal evolution, reinterventions and death, and propose a more aggressive treatment at an early stage to promote the aortic remodeling and improve long-term survival without reintervention.
#29 Prognostic factors and prediction models for acute aortic dissection: a systematic review
https://pmc.ncbi.nlm.nih.gov/articles/PMC7925868/
Our study aimed to systematically review the methodological characteristics of studies that identified prognostic factors or developed or validated models for predicting mortalities among patients with acute aortic dissection (AAD), which would inform future work. […] The performance of prognostic factors showed varying discrimination (AUC 0.58 to 0.95), and the performance of prediction models also varied substantially (AUC 0.49 to 0.91). Only six studies reported calibration statistic. […] The methods used for prognostic studies on mortality among patients with AAD including prediction models or prognostic factor studies were suboptimal, and the model performance highly varied. Substantial efforts are warranted to improve the use of the methods in this population. […] In conclusion, DD, NLR and CRP predictors were the most commonly used biomarkers, the performance of prognostic factors showed a poor to strong discrimination, the prediction models varied substantially, only six studies reported the calibration, and of which five reported good calibration. Meanwhile, many of these prognostic factors or predictive models are weak methodologically, several important issues are needed to consider for strengthening for predicting mortality in AAD, such as the sample size, the methods for handling missing data, appropriate statistical analysis methods and reporting both calibration and discrimination for prediction models. Substantial efforts are warranted to improve the use of the methods for better care of this population.
#30 Prognostic factors and prediction models for acute aortic dissection: a systematic review
https://pmc.ncbi.nlm.nih.gov/articles/PMC7925868/
Our study aimed to systematically review the methodological characteristics of studies that identified prognostic factors or developed or validated models for predicting mortalities among patients with acute aortic dissection (AAD), which would inform future work. […] The performance of prognostic factors showed varying discrimination (AUC 0.58 to 0.95), and the performance of prediction models also varied substantially (AUC 0.49 to 0.91). Only six studies reported calibration statistic. […] The methods used for prognostic studies on mortality among patients with AAD including prediction models or prognostic factor studies were suboptimal, and the model performance highly varied. Substantial efforts are warranted to improve the use of the methods in this population. […] In conclusion, DD, NLR and CRP predictors were the most commonly used biomarkers, the performance of prognostic factors showed a poor to strong discrimination, the prediction models varied substantially, only six studies reported the calibration, and of which five reported good calibration. Meanwhile, many of these prognostic factors or predictive models are weak methodologically, several important issues are needed to consider for strengthening for predicting mortality in AAD, such as the sample size, the methods for handling missing data, appropriate statistical analysis methods and reporting both calibration and discrimination for prediction models. Substantial efforts are warranted to improve the use of the methods for better care of this population.
#31 Prognostic factors and prediction models for acute aortic dissection: a systematic review
https://pmc.ncbi.nlm.nih.gov/articles/PMC7925868/
Our study aimed to systematically review the methodological characteristics of studies that identified prognostic factors or developed or validated models for predicting mortalities among patients with acute aortic dissection (AAD), which would inform future work. […] The performance of prognostic factors showed varying discrimination (AUC 0.58 to 0.95), and the performance of prediction models also varied substantially (AUC 0.49 to 0.91). Only six studies reported calibration statistic. […] The methods used for prognostic studies on mortality among patients with AAD including prediction models or prognostic factor studies were suboptimal, and the model performance highly varied. Substantial efforts are warranted to improve the use of the methods in this population. […] In conclusion, DD, NLR and CRP predictors were the most commonly used biomarkers, the performance of prognostic factors showed a poor to strong discrimination, the prediction models varied substantially, only six studies reported the calibration, and of which five reported good calibration. Meanwhile, many of these prognostic factors or predictive models are weak methodologically, several important issues are needed to consider for strengthening for predicting mortality in AAD, such as the sample size, the methods for handling missing data, appropriate statistical analysis methods and reporting both calibration and discrimination for prediction models. Substantial efforts are warranted to improve the use of the methods for better care of this population.
#32 What does the future hold for aortic dissection patient care?
https://aorticdissectioncharitabletrust.org/future-of-aortic-care/
Population-based studies, such as the Oxford Vascular Study (1) predict that cases of aortic dissection are set to rise over the next 10 years to more than 5,500 annually. If this trajectory comes to fruition, almost 3,500 people will lose their lives every year by 2050. […] Itâs vitally important to remember that aortic dissection is a treatable condition and has a better than 80% survival rate when itâs diagnosed and treated on time. Yet today, in 2022, 50% of people who are struck by this condition, die. […] The service and expertise have improved in the past 10 years; the Liverpool and London Aortic Rotas have shown a halving in operative mortality. […] More recently, the national coordination and organisation of aortic services promises to make a vast improvement for aortic dissection patients thanks to the NHS Acute Aortic Dissection Toolkit (launched in 2022), further development of the National Vascular Registry for aortic procedures, and the inclusion of patient and family opinions when selecting treatment options.
#33 What does the future hold for aortic dissection patient care?
https://aorticdissectioncharitabletrust.org/future-of-aortic-care/
NHS England, along with patient support from The Aortic Dissection Charitable Trust, has produced the NHS Acute Aortic Dissection Toolkit which will significantly improve the pathway for AD patients and has the potential to save 500 lives annually and improve regional variation once implemented. […] The next step is for units to form regional acute dissection rotas, with a single point of contact to dramatically streamline aortic care across the UK and Ireland. […] There is unwarranted variation in terms of the treatment of aortic disease around the country, too. There is variation in treatment rates per head of population and studies show that high-volume centres do have better outcomes. […] The future will see an easily accessible database available to healthcare professionals to support patient treatment. Treatment options will be based on the gene variant, enabling specialists to give tailored recommendations on medication and determine a variety of follow-up procedures such as how often they should image the patientâs aorta, whether arterial aneurysms need to be considered or further imaging for related conditions need to be carried out. […] The current research objective is to better understand what the genetic variants are, and the complete list of environmental factors that affect them.
#34 What does the future hold for aortic dissection patient care?
https://aorticdissectioncharitabletrust.org/future-of-aortic-care/
NHS England, along with patient support from The Aortic Dissection Charitable Trust, has produced the NHS Acute Aortic Dissection Toolkit which will significantly improve the pathway for AD patients and has the potential to save 500 lives annually and improve regional variation once implemented. […] The next step is for units to form regional acute dissection rotas, with a single point of contact to dramatically streamline aortic care across the UK and Ireland. […] There is unwarranted variation in terms of the treatment of aortic disease around the country, too. There is variation in treatment rates per head of population and studies show that high-volume centres do have better outcomes. […] The future will see an easily accessible database available to healthcare professionals to support patient treatment. Treatment options will be based on the gene variant, enabling specialists to give tailored recommendations on medication and determine a variety of follow-up procedures such as how often they should image the patientâs aorta, whether arterial aneurysms need to be considered or further imaging for related conditions need to be carried out. […] The current research objective is to better understand what the genetic variants are, and the complete list of environmental factors that affect them.
#35 What does the future hold for aortic dissection patient care?
https://aorticdissectioncharitabletrust.org/future-of-aortic-care/
NHS England, along with patient support from The Aortic Dissection Charitable Trust, has produced the NHS Acute Aortic Dissection Toolkit which will significantly improve the pathway for AD patients and has the potential to save 500 lives annually and improve regional variation once implemented. […] The next step is for units to form regional acute dissection rotas, with a single point of contact to dramatically streamline aortic care across the UK and Ireland. […] There is unwarranted variation in terms of the treatment of aortic disease around the country, too. There is variation in treatment rates per head of population and studies show that high-volume centres do have better outcomes. […] The future will see an easily accessible database available to healthcare professionals to support patient treatment. Treatment options will be based on the gene variant, enabling specialists to give tailored recommendations on medication and determine a variety of follow-up procedures such as how often they should image the patientâs aorta, whether arterial aneurysms need to be considered or further imaging for related conditions need to be carried out. […] The current research objective is to better understand what the genetic variants are, and the complete list of environmental factors that affect them.