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Publisher's version (útgefin grein) ; Objectives: To describe the relationship between the extent of primary aortic repair and the incidence of reoperations after surgery for type A aortic dissection. Methods: A retrospective cohort of 1159 patients treated for type A aortic dissection at eight Nordic low- to medium-sized cardiothoracic centers from 2005 to 2014. Data were gathered from patient records and national registries. Patients were separately divided into 3 groups according to the distal anastomoses technique (ascending aorta [n = 791], hemiarch [n = 247], and total arch [n = 66]), and into 2 groups for proximal repair (aortic root replacement [n = 285] and supracoronary repair [n = 832]). Freedom from reoperation was estimated with cumulative incidence survival and Fine-Gray competing risk regression model was used to identify independent risk factors for reoperation. Results: The median follow-up was 2.7 years (range, 0-10 years). Altogether 51 out of 911 patients underwent reoperation. Freedom from distal reoperation at 5 years was 96.9%, with no significant difference between the groups (P =.22). Freedom from proximal reoperation at 5 years was 97.8%, with no difference between the groups (P =.84). Neither DeBakey classification nor the extent of proximal or distal repair predicted freedom from a later reoperation. The only independent risk factor associated with a later proximal reoperation was a history of connective tissue disease. Conclusions: Type A aortic dissection repair in low- to medium-volume centers was associated with a low reoperation rate and satisfactory midterm survival. The extent of the primary repair had no significant influence on reoperation rate or midterm survival. ; Finnish governmental research funding ; Peer Reviewed

To access publisher's full text version of this article click on the hyperlink below ; To describe the relationship between the extent of primary aortic repair and the incidence of reoperations after surgery for type A aortic dissection. A retrospective cohort of 1159 patients treated for type A aortic dissection at eight Nordic low- to medium-sized cardiothoracic centers from 2005 to 2014. Data were gathered from patient records and national registries. Patients were separately divided into 3 groups according to the distal anastomoses technique (ascending aorta [n = 791], hemiarch [n = 247], and total arch [n = 66]), and into 2 groups for proximal repair (aortic root replacement [n = 285] and supracoronary repair [n = 832]). Freedom from reoperation was estimated with cumulative incidence survival and Fine-Gray competing risk regression model was used to identify independent risk factors for reoperation. The median follow-up was 2.7 years (range, 0-10 years). Altogether 51 out of 911 patients underwent reoperation. Freedom from distal reoperation at 5 years was 96.9%, with no significant difference between the groups (P = .22). Freedom from proximal reoperation at 5 years was 97.8%, with no difference between the groups (P = .84). Neither DeBakey classification nor the extent of proximal or distal repair predicted freedom from a later reoperation. The only independent risk factor associated with a later proximal reoperation was a history of connective tissue disease. Type A aortic dissection repair in low- to medium-volume centers was associated with a low reoperation rate and satisfactory midterm survival. The extent of the primary repair had no significant influence on reoperation rate or midterm survival. ; Finnish governmental research funding

Acute type A aortic dissection remains one of the most challenging conditions in aortic surgery. Despite the advancements in the field, the mortality rate still remains high. Though there is a general consensus that the ascending aorta should be replaced, the distal extension of the surgery still remains a controversy. Few surgeons argue for a conservative approach to reduce operative and postoperative morbidity while others considering the problems associated with "downstream problems" support an aggressive approach including a frozen elephant trunk. The cohort in the Indian subcontinent and APAC is far different from the western world. Many factors determine the decision for surgery apart from the pathology of the disease. Economy, availability of the suitable prosthesis, the experience of the surgeon, ease of access to the medical facility all contribute to the decision making to treat acute type A dissection.

Cardiovascular diseases (CVDs) are the leading cause of mortality in the European Union and accounted for about 36% of all deaths in 2019. Among these diseases, aortic dissection is relatively unknown and difficult to treat, with a survival rate for most severe cases not exceeding 10%. This pathology occurs when an injury leads to a localized tear of the innermost layer of the aorta, called the entry port. It allows blood to flow between the layers of the aortic wall, forcing the layers apart and creating a false lumen. The dissection of these layers may extend over a long portion of the thoracic and abdominal aorta. Endovascular treatment seeks to obliterate the entrances to the false lumen with a stent. The currently available surgical tools for endovascular procedures are selected only from information based on medical imaging techniques. The images are carried out before the intervention and therefore do not consider the deformation of the vascular structure by the implementation of the prosthesis. While many biomechanical studies have been done on the endovascular treatment of aneurysms of the abdominal aorta, there are, however, very few studies on aortic dissections. However,there are few studies as well on the postoperative demonstration of blood flow phenomena in the aortic dissection endovascular treatment. It is crucial to study the hemodynamic of blood in the aorta after an intervention, because the deployment of a stent leads to modifications in the blood flow. For the surgeons, the procedure can only be performed empirically, using MRI-4D images to view the post-operative flow of the patient's blood in the aorta with the stent. The numerical simulation method, instead allows us to simulate the complete endovascular procedure for an adapted recommendation during surgical planning. This thesis aims to present a numerical tool, from the open-source software FOAM-Extend, allowing for Multiphysics numerical simulations, performing the fluid-structure coupling between the hemodynamics and the arterial ...

Cardiovascular diseases (CVDs) are the leading cause of mortality in the European Union and accounted for about 36% of all deaths in 2019. Among these diseases, aortic dissection is relatively unknown and difficult to treat, with a survival rate for most severe cases not exceeding 10%. This pathology occurs when an injury leads to a localized tear of the innermost layer of the aorta, called the entry port. It allows blood to flow between the layers of the aortic wall, forcing the layers apart and creating a false lumen. The dissection of these layers may extend over a long portion of the thoracic and abdominal aorta. Endovascular treatment seeks to obliterate the entrances to the false lumen with a stent. The currently available surgical tools for endovascular procedures are selected only from information based on medical imaging techniques. The images are carried out before the intervention and therefore do not consider the deformation of the vascular structure by the implementation of the prosthesis. While many biomechanical studies have been done on the endovascular treatment of aneurysms of the abdominal aorta, there are, however, very few studies on aortic dissections. However,there are few studies as well on the postoperative demonstration of blood flow phenomena in the aortic dissection endovascular treatment. It is crucial to study the hemodynamic of blood in the aorta after an intervention, because the deployment of a stent leads to modifications in the blood flow. For the surgeons, the procedure can only be performed empirically, using MRI-4D images to view the post-operative flow of the patient's blood in the aorta with the stent. The numerical simulation method, instead allows us to simulate the complete endovascular procedure for an adapted recommendation during surgical planning. This thesis aims to present a numerical tool, from the open-source software FOAM-Extend, allowing for Multiphysics numerical simulations, performing the fluid-structure coupling between the hemodynamics and the arterial deformation to assist in the planning process. In addition, using Abaqus software, we realized the placement of the surgical tools in a "biomechano-faithful" aortic dissection model. This model will be able to predict the deformation of the flap and the artery wall during the implementation of the tools. Also, with the numerical simulation, we could obtain the postoperative hemodynamic in the aorta, to predict the modification of flow. Finally, the numerical simulation results are compared with the MRI data to have a validation of the numerical models. There is a parallel thesis that focuses on flows in aorta phantoms PIV applied in AD (same geometry) and enables the confrontation and inter-validation of both model methods at the time of the study. ; Les maladies cardiovasculaires sont la principale cause de mortalité dans le monde. Parmi ces maladies, la dissection aortique constitue une pathologie méconnue et difficile à traiter, avec un taux de survie, pour les cas les plus graves ne dépassant pas les 10%. Cette pathologie survient dans l'aorte et se caractérise par l'irruption de sang à l'intérieur de la paroi de l'aorte. Elle correspond à une déchirure localisée des couches internes de la paroi aortique, appelée porte d'entrée, par laquelle le sang sous pression pénètre et décolle les différentes couches qui constituent la paroi de l'aorte. Le traitement endovasculaire vise à obturer la fausse lumière à l'aide d'un stent. Les outils actuels de la chirurgie endovasculaire reposent uniquement sur les techniques d'imagerie médicale. Comme les images sont prises avant l'intervention, elles ne tiennent pas compte de la déformation de la structure vasculaire par la prothèse. Les phénomènes de flux sanguin postopératoire dans le traitement endovasculaire des dissections aortiques sont rares. L'hémodynamique du sang dans l'aorte après une intervention est critique car le déploiement du stent modifie le flux sanguin. Cette thèse a pour but de présenter un outil numérique, issu du logiciel open-source FOAM-Extend®, permettant des simulations numériques multiphysiques réalisant le couplage fluide-structure entre l'hémodynamique et la déformation artérielle pour aider au processus de planification. En outre, à l'aide du logiciel Abaqus, nous réalisons le placement des outils chirurgicaux dans un AD "bio-fidèle" modèle. Cela permettra de prédire la déformation du lambeau et de la paroi de l'artère lors de la mise en place des outils. Et aussi, avec la simulation numérique, nous pourrons réaliser l'hémodynamique dans l'aorte du postopératoire pour prédire la modification du flux. Enfin, les résultats de la simulation numérique sont comparés aux données de l'IRM pour avoir une validation des modèles numériques.

Background: Acute type A aortic dissection (ATAAD) is a life-threatening disease requiring urgent surgery. It is regionally managed by an emergency network (REseau Nord Alpin des Urgences-RENAU) in which our centre participates. Objectives: 1) To assess the local management of patients operated for ATAAD over the last decade, and the hospital morbi-mortality. 2) To analyse the risk factors of operative mortality. Method: Observational retrospective single-centre study including the patients operated for ATAAD from 01/01/2010 to 12/31/2019. Multivariate analysis of the risk factors of operative mortality, summarized by their adjusted odds ratio (OR). Results: Two hundred and twenty patients were included. The computed tomography scan was the diagnostic examination in 70.2% of the cases. The direct transfer to the operating room was achieved in 74.0% of the cases. A malperfusion was present in 43.2% of patients, 29.2% were in shock. A procedure on the aortic root or the arch was performed in 29.0% and 39.2% of the cases, respectively. Operative mortality was 19.1% and the risk factors were: an age over 70 years (OR 2.2, p=0.034), a preoperative cardiac arrest (OR 15.8, p=0.025), a femoro-femoral cannulation (OR 2.8, p=0.048), a postoperative low flow (OR 4.1, p=0.0057), stroke or coma (OR 4.2, p=0.0056), or digestive ischemia (OR 11.1, p=0.0017). Conclusion: The RENAU permits the rapid transfer to the operating room of ATAAD, whose diagnosis was facilitated by the democratization of the scan. Operative mortality was still high but acceptable considering the important part of patients admitted to the operating room with critical clinical condition. ; Introduction : La dissection aortique aiguë de type A (DAAA) est une maladie grave nécessitant une chirurgie urgente. Sa prise en charge régionale est encadrée par un réseau d'urgence (REseau Nord Alpin des Urgences-RENAU) auquel participe notre centre. Objectifs : 1) Décrire la prise en charge locale des patients opérés de DAAA sur la dernière décennie et la morbi-mortalité hospitalière. 2) Analyser les facteurs de risque de mortalité opératoire. Méthode : Etude rétrospective mono-centrique observationnelle concernant les patients opérés de DAAA du 01/01/2010 au 31/12/2019. Analyse multivariée des facteurs de risque de mortalité opératoire, résumés par leur odds ratio ajusté (OR). Résultats : Deux cent vingt patients étaient inclus. Le scanner était l'examen diagnostique dans 70,2% des cas. Le transfert direct au bloc opératoire était réalisé dans 74,0% des cas. Une malperfusion était constatée chez 43,2% des patients, 29,2% étaient en choc. Un geste sur la racine aortique ou la crosse était réalisé dans 29,0% et 39,2% des cas respectivement. La mortalité opératoire était de 19,1% et les facteurs de risque étaient : un âge supérieur à 70 ans (OR 2,2, p=0,034), un arrêt cardiaque préopératoire (OR 15,8, p=0,025), une canulation fémoro-fémorale (OR 2,8, p=0,048), un bas débit (OR 4,1, p=0,0057), un accident vasculaire cérébral ou coma (OR 4,2, p=0,0056) ou une ischémie digestive (OR 11,1, p=0,0017) postopératoire. Conclusion : Le RENAU permet le transfert rapide au bloc des DAAA, dont le diagnostic a été facilité par la démocratisation du scanner. La mortalité opératoire y reste élevée mais acceptable compte tenu d'une part importante de patients admis au bloc en état grave.

Background: Acute type A aortic dissection (ATAAD) is a life-threatening disease requiring urgent surgery. It is regionally managed by an emergency network (REseau Nord Alpin des Urgences-RENAU) in which our centre participates. Objectives: 1) To assess the local management of patients operated for ATAAD over the last decade, and the hospital morbi-mortality. 2) To analyse the risk factors of operative mortality. Method: Observational retrospective single-centre study including the patients operated for ATAAD from 01/01/2010 to 12/31/2019. Multivariate analysis of the risk factors of operative mortality, summarized by their adjusted odds ratio (OR). Results: Two hundred and twenty patients were included. The computed tomography scan was the diagnostic examination in 70.2% of the cases. The direct transfer to the operating room was achieved in 74.0% of the cases. A malperfusion was present in 43.2% of patients, 29.2% were in shock. A procedure on the aortic root or the arch was performed in 29.0% and 39.2% of the cases, respectively. Operative mortality was 19.1% and the risk factors were: an age over 70 years (OR 2.2, p=0.034), a preoperative cardiac arrest (OR 15.8, p=0.025), a femoro-femoral cannulation (OR 2.8, p=0.048), a postoperative low flow (OR 4.1, p=0.0057), stroke or coma (OR 4.2, p=0.0056), or digestive ischemia (OR 11.1, p=0.0017). Conclusion: The RENAU permits the rapid transfer to the operating room of ATAAD, whose diagnosis was facilitated by the democratization of the scan. Operative mortality was still high but acceptable considering the important part of patients admitted to the operating room with critical clinical condition. ; Introduction : La dissection aortique aiguë de type A (DAAA) est une maladie grave nécessitant une chirurgie urgente. Sa prise en charge régionale est encadrée par un réseau d'urgence (REseau Nord Alpin des Urgences-RENAU) auquel participe notre centre. Objectifs : 1) Décrire la prise en charge locale des patients opérés de DAAA sur la dernière décennie et la morbi-mortalité hospitalière. 2) Analyser les facteurs de risque de mortalité opératoire. Méthode : Etude rétrospective mono-centrique observationnelle concernant les patients opérés de DAAA du 01/01/2010 au 31/12/2019. Analyse multivariée des facteurs de risque de mortalité opératoire, résumés par leur odds ratio ajusté (OR). Résultats : Deux cent vingt patients étaient inclus. Le scanner était l'examen diagnostique dans 70,2% des cas. Le transfert direct au bloc opératoire était réalisé dans 74,0% des cas. Une malperfusion était constatée chez 43,2% des patients, 29,2% étaient en choc. Un geste sur la racine aortique ou la crosse était réalisé dans 29,0% et 39,2% des cas respectivement. La mortalité opératoire était de 19,1% et les facteurs de risque étaient : un âge supérieur à 70 ans (OR 2,2, p=0,034), un arrêt cardiaque préopératoire (OR 15,8, p=0,025), une canulation fémoro-fémorale (OR 2,8, p=0,048), un bas débit (OR 4,1, p=0,0057), un accident vasculaire cérébral ou coma (OR 4,2, p=0,0056) ou une ischémie digestive (OR 11,1, p=0,0017) postopératoire. Conclusion : Le RENAU permet le transfert rapide au bloc des DAAA, dont le diagnostic a été facilité par la démocratisation du scanner. La mortalité opératoire y reste élevée mais acceptable compte tenu d'une part importante de patients admis au bloc en état grave.

<p><strong>Objective: </strong>To evaluate racial differences in the burden of aortic dissection. </p><p><strong>Design: </strong>Retrospective analysis of a comprehensive state-wide inpatient database. <strong></strong></p><p><strong>Setting: </strong>Acute care hospitals in the state of Maryland, 2009 – 2014. </p><p><strong>Participants: </strong>All hospitalized adults with aortic dissection (AD), stratified by race. </p><p><strong>Main Outcome Measures: </strong>Statewide and county-level population adjusted hospitalization rates, access to specialty aortic care, and mortality. <strong></strong></p><p><strong>Results: </strong>Of 3,719,412 admissions to Maryland hospitals during the study period, 3,190 had AD (.09%; 1665 White, 1525 non- White). Non-White race was more common in patients with AD than without (48% vs. 41%, P&lt;.0001). Adjusted for statewide demographics, admission for AD was 1.4 times more common among non-Whites (11 vs. 8 per 100,000, P&lt;.0001). Non-White race was an independent risk factor for AD admission (OR 1.5, 95% CI 1.4 – 1.7). Among patients with AD, non-Whites were younger and more often female, but had similar or lower rates of cardiovascular comorbidities. Non-White race was not associated with decreased access to care or increased mortality. <strong></strong></p><p><strong>Conclusion: </strong>Hospitalization for AD is more common among non-Whites, who develop AD at younger ages despite fewer comorbidities. While clinical correlates are limited from this dataset, this may reflect more severe pathophysiology related to clinical or socioeconomic factors among non-Whites. Further study is warranted to better define this disparity and identify high-risk subgroups who may benefit from aggressive primary prevention. <em>Ethn Dis. </em>2016;26(3):363-368; doi:10.18865/ed.26.3.363 </p>