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      Veno-Arterial Extracorporeal Membrane Oxygenation for Patients Undergoing Acute Type A Aortic Dissection Surgery: A Six-Year Experience

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          Abstract

          Objectives: Acute type A aortic dissection (aTAAD) is usually lethal without emergency surgery. Although veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is widely used in patients with cardiogenic shock following cardiac surgery, VA-ECMO support following aTAAD surgery has not been well-described. Based on our 6-year experience, we aimed to retrospectively analyze risk factors, application and timing of VA-ECMO, and outcomes in aTAAD patients.

          Methods: In this retrospective, single-center study, we enrolled adult patients who underwent aTAAD surgery from January 2014 to December 2019 and were supported with VA-ECMO. Patients were divided into two groups according to whether or not they were successfully weaned from VA-ECMO. Preoperative, intraoperative and postoperative variables were assessed and analyzed. Outcomes of the patients were followed up until discharge.

          Results: Twenty-seven patients who received aTAAD surgery with VA-ECMO support were included in the study. Nine patients (33.3%) were successfully weaned from VA-ECMO. The median VA-ECMO support time and length of hospital stay in the successfully weaned group were significantly longer than in the group could not be successfully weaned (192 [111–327] vs. 55 [23–95] h, p < 0.01; 29 [18–40] vs. 4 [3–8] days, p < 0.01). Overall in-hospital mortality was 81.5%. The main causes of death were bleeding (37%), neurological complications (15%), and multiple organ dysfunction syndrome (15%). Preoperative levels of creatine kinase-MB (CK-MB) were lower in patients who were successfully weaned from VA-ECMO than in the failed group (14 [6–30] vs. 55 [28–138] U/L, p < 0.01). Postoperative peak levels of CK-MB, cardiac troponin T, lactate dehydrogenase, and lactate were significantly lower in the successful group than in the failed group.

          Conclusion: Postoperative VA-ECMO support was rarely used in aTAAD patients. Our study showed that VA-ECMO can be considered as a salvage treatment in aTAAD patients, despite the high rate of complications and mortality.

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          Insights From the International Registry of Acute Aortic Dissection: A 20-Year Experience of Collaborative Clinical Research.

          Arturo Evangelista, Eric Isselbacher, Eduardo Bossone … (2018)
          Acute aortic dissection (AAD) is a life-threatening condition associated with high morbidity and mortality rates, and it remains a challenge to diagnose and treat. The International Registry of Acute Aortic Dissection was established in 1996 with the mission to raise awareness of this condition and provide insights to guide diagnosis and treatment. Since then, >7300 cases have been included from >51 sites in 12 countries. Although presenting symptoms and physical findings have not changed significantly over this period, the use of computed tomography in the diagnosis has increased, and more patients are managed with interventional procedures: surgery in type A AAD and endovascular therapy in type B AAD; with these changes in care, there has been a significant decrease in overall in-hospital mortality in type A AAD but not in type B AAD. Herein, we summarized the key lessons learned from this international registry of patients with AAD over the past 20 years.
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            Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock and Cardiac Arrest

            Prashant A. Rao, Zain Khalpey, Richard Smith … (2018)
            Venoarterial extracorporeal membrane oxygenation (VA-ECMO)-also referred to as extracorporeal life support-is a form of temporary mechanical circulatory support and simultaneous extracorporeal gas exchange. The initiation of VA-ECMO has emerged as a salvage intervention in patients with cardiogenic shock, even cardiac arrest refractory to standard therapies. Analogous to veno-venous ECMO for acute respiratory failure, VA-ECMO provides circulatory support and allows time for other treatments to promote recovery or may be a bridge to a more durable mechanical solution in the setting of acute or acute on chronic cardiopulmonary failure. In this review, we provide a brief overview of VA-ECMO, the attendant physiological considerations of peripheral VA-ECMO, and its complications, namely that of left ventricular distention, bleeding, heightened systemic inflammatory response syndrome, thrombosis and thromboembolism, and extremity ischemia or necrosis.
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              Acute aortic syndromes: diagnosis and management, an update

              Eduardo Bossone, Troy M LaBounty, Kim Eagle (2018)
              Acute aortic syndromes (AAS) encompass a constellation of life-threatening medical conditions including classic acute aortic dissection (AAD), intramural haematoma, and penetrating atherosclerotic aortic ulcer. Given the non-specific symptoms and physical signs, a high clinical index of suspicion is necessary to detect the disease before irreversible lethal complications occur. In order to reduce the diagnostic time delay, a comprehensive flowchart for decision-making based on pre-test sensitivity of AAS has been designed by the European Society of Cardiology guidelines on aortic diseases and should be thus applied in the emergency scenario. When the definitive diagnosis is made, prompt and appropriate therapeutic interventions should be undertaken if indicated by a highly specialized aortic team. Urgent surgery for AAD involving the ascending aorta (Type A) and medical therapy alone for AAD not involving the ascending aorta (Type B) are typically recommended. In complicated Type B AAD, thoracic endovascular aortic repair (TEVAR) is generally indicated. On the other hand, in uncomplicated Type B AAD, pre-emptive TEVAR rather than medical therapy alone to prevent late complications, while intuitive, requires further study in randomized cohorts. Finally, it should be highlighted that there is an urgent need to increase awareness of AAS worldwide, including dedicated education/prevention programmes, and to improve diagnostic and therapeutic strategies, outcomes, and lifelong surveillance.
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                Author and article information

                Contributors
                Journal
                Journal ID (nlm-ta): Front Cardiovasc Med
                Journal ID (iso-abbrev): Front Cardiovasc Med
                Journal ID (publisher-id): Front. Cardiovasc. Med.
                Title: Frontiers in Cardiovascular Medicine
                Publisher: Frontiers Media S.A.
                ISSN (Electronic): 2297-055X
                Publication date (Electronic): 17 May 2021
                Publication date Collection: 2021
                Volume: 8
                Electronic Location Identifier: 652527
                Affiliations
                [1] 1Department of Critical Care Medicine, Zhongshan Hospital, Fudan University , Shanghai, China
                [2] 2Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University , Shanghai, China
                [3] 3Department of Nursing, Zhongshan Hospital, Fudan University , Shanghai, China
                [4] 4Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University , Xiamen, China
                Author notes

                Edited by: Karl Kern, University of Arizona, United States

                Reviewed by: Jianqing She, The First Affiliated Hospital of Xi'an Jiaotong University, China; Harry Staines, Independent Researcher, Balmullo, United Kingdom

                *Correspondence: Guo-wei Tu tu.guowei@ 123456zs-hospital.sh.cn

                This article was submitted to General Cardiovascular Medicine, a section of the journal Frontiers in Cardiovascular Medicine

                †These authors have contributed equally to this work

                Article
                DOI: 10.3389/fcvm.2021.652527
                PMC ID: 8165157
                PubMed ID: 34079828
                SO-VID: 4b67d297-3fee-416b-b032-8a95dc100937
                Copyright © Copyright © 2021 Hou, Wang, Lai, Sun, Li, Zheng, Wang, Luo, Tu and Luo.
                License:

                This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

                History
                Date received : 12 January 2021
                Date accepted : 16 April 2021
                Page count
                Figures: 2, Tables: 4, Equations: 0, References: 26, Pages: 9, Words: 5382
                Categories
                Subject: Cardiovascular Medicine
                Subject: Original Research

                Keywords: acute type a aortic dissection,veno-arterial extracorporeal membrane oxygenation,cardiogenic shock,aortic surgery,acute
                Data availability:
                Keywords: acute type a aortic dissection, veno-arterial extracorporeal membrane oxygenation, cardiogenic shock, aortic surgery, acute

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