Cardiac rehabilitation and acute aortic dissection: understanding and addressing the evidence GAP a systematic review.

Despite guideline recommendations, strategies for implementing cardiac rehabilitation (CR) in patients with acute aortic dissection (AAD) are not well established with little evidence to risk stratify prudent and effective guidelines for the many required variables. We conducted a systematic review of studies (2004-2023) reporting CR following type A (TA) and type B (TB) AAD. Our review is limited to open surgical repair for TA and medical treatment for TB. A total of 5 studies were included (4 TA-AAD and 1 TB-AAD) in the qualitative analysis. In general, observational data included 311 patients who had an overall favorable effect of CR in AAD consisting of a modestly improved exercise capacity and work load during cycle cardiopulmonary exercise test (TB-AAD), and improved quality of life (QoL). No adverse events were reported during symptom limited pre-CR treadmill or cycle exercise VO2 max or CR. Given the overall potential in this high risk population without adequate evidence for important variables such as safe time from post-op to CR, intensity of training, duration and frequency of sessions and followup it is time for a moderate sized well designed safe trial for patients' post-op surgery for TA-AAD and medically treated TB-AAD who are treated with standardized evidence based medical therapy and physical therapy from discharge randomized to CR versus usual care. PROSPERO registry ID: CRD42023392896.

Long-term outcome and quality of life following emergency surgery for acute aortic dissection type A: a comparison between young and elderly adults.

Objectives: Innovations in surgical techniques and perioperative management have continuously improved survival rates for acute aortic dissection type A (AADA). The aim of our study was to evaluate long-term outcome and quality of life (QoL) after surgery for AADA in elderly patients compared with younger patients. Methods: We retrospectively evaluated 242 consecutive patients, who underwent surgery for AADA between January 2004 and April 2014. Patients were divided into two groups: those aged 70 years and older (elderly group; n = 78, mean age, 76 ± 4 years) and those younger than 70 years (younger group; n = 164, mean age, 56 ± 10 years). QoL was assessed with the Short Form Health Survey Questionnaire (SF-36) 1 year after surgery. Results: The questionnaire return rate was 91.0%. There were already significant differences noted between the two groups with regard to preoperative risk factors on admission. The clinical presentation with a cardiac tamponade was higher in the elderly group (62.8% vs 47.6%; P = 0.03). Intraoperatively, complex procedures were more common in the younger group (21.3% vs 5.2%; P = 0.001). Accordingly, cardiopulmonary bypass and cross-clamping times were significantly longer in the younger group. The operative mortality was similar in both groups (3.8% vs 1.2%; P = 0.33). In the elderly population, 30-day mortality was higher (21.8% vs 7.9%; P = 0.003). One-year (72% vs 85%), 3-year (68% vs 84%) and 5-year (63% vs 79%) survival rates were satisfactory for the elderly group, but significantly lower compared with the younger group ( P = 0.008). The physical component summary score also was similar between the groups (39.14 ± 11.12 vs 39.12 ± 12.02; P = 0.99). However, the mental component summary score might be slightly higher in the elderly group but not statistically significant (51.61 ± 10.73 vs 48.63 ± 11.25; P = 0.12). Conclusions: Satisfactory long-term outcome and the general perception of well-being encourage surgery in selected elderly patients with AADA.

French registry of cases of type I acute aortic dissection admitted to a cardiac rehabilitation center after surgery.

BACKGROUND: After surgery for type I acute aortic dissection, the aorta remains partly dissected. This new population of patients is now referred to cardiac rehabilitation centers (CRCs). The feasibility of subsequent physical exercise is unknown. METHODS: Thirty-three consecutive patients (aged 55.1+/-9.3 years) were included in a prospective registry with clinical and radiological follow-up for 1 year after admission to a CRC. Twenty-six patients had undergone standard training sessions with exercise on a bicycle ergometer. Physical training programs included calisthenics, respiratory physiotherapy, walking, and cycling. Seven patients did not perform standard exercise training sessions but only walking and respiratory physiotherapy. RESULTS: For trained patients, the sessions (18+/-10) were carried out at 11.3+/-1.5 on the Borg scale ('light'), with blood pressure monitoring on exercise (<160 mmHg in 75% of patients). Maximum workload during exercise test (bicycle ergometer, 10 watts/min) increased from 62.7+/-11.8 to 91.6+/-16.5 watts (P=0.002). We identified three complications in two patients requiring further thoracic aorta surgery during follow-up. There was also one case of aortic valve replacement after 5 months and three cases of peripheral ischemia. No deaths, cerebral vascular accidents, or myocardial infarctions were recorded. Ten of the 19 patients of working age were able to return to work. CONCLUSION: Physical training of moderate intensity seems feasible and beneficial in postsurgical type I aortic dissection patients.

Survival and quality of life after repair of acute type A aortic dissection in patients aged 75 years and older justify intervention.

OBJECTIVE: Controversy still exists about averting expenditure of health care resources on the growing elderly population. This study evaluates clinical outcome of patients aged 75 years and older operated upon for acute type A aortic dissection. METHODS: Between January 1990 and April 2004, of 247 patients undergoing emergency operation for acute type A aortic dissection at our Institution, 40 patients (16%) were aged 75 years and older (mean 78+/-3 years, range 75-88 years) and represent the study population. On admission, 9 (22.5%) had cardiogenic shock/hypotension, 20 (50%) cardiac tamponade, 14 (35%) kidney failure, 11 (27.5%) limb ischemia, 3 (7.5%) neurologic deficit, and 1 (2.5%) myocardial ischemia. Surgical procedures included isolated replacement of the ascending aorta in 34 patients (85%), associated with total root replacement in 5 (12.5%), and with aortic valve replacement in 1 (2.5%). Eleven patients (27.5%) underwent aortic arch replacement (hemiarch: n=8, 20%; total arch: n=3, 7.5%). RESULTS: In-hospital mortality was 30% (12 patients). Mortality tended to be higher (8/21, 38% vs 4/19, 21%; p=NS) for patients presenting with any one of the following complications: tamponade, shock, brain and/or myocardial, renal, limb malperfusion. Actuarial survival at 1, 5, and 7 years was 93+/-5%, 80+/-8%, and 80+/-8%, respectively, and freedom from reoperation 97+/-2%, 97+/-2%, and 97+/-2%, respectively. Actuarial event-free rates were 94+/-3%, 90+/-5%, and 90+/-5%. Seventy-four percent of survivors are in NYHA FC I, and quality of life test (RAND SF-36) revealed a generalized perception of independency and well-being, comparable to an age-matched population. CONCLUSIONS: Overall results for emergency repair of acute type A aortic dissection in the elderly justify intervention, particularly in uncomplicated cases. Expeditious referral and intervention by lowering pre-operative dissection-related complications and comorbidities might help to improve results. Survivors show functional status and quality of life similar to contemporary individuals.

[Return to work after reconstructive arterial surgery (author's transl)]. / Etude de la reprise de l'activité professionnelle des sujets ayant subi une restauration artérielle.

The authors studied the conditions of the return to work of 65 patients, with a maximum age of 55 years, after reconstructive arterial surgery. Of the 51 patients who were working at the time of the operation, 46 (90.2%) had started working after an average period of 97 days, but only one of the patients who were no longer working started work after the operation. If the nature and more especially the site of the operation is analyzed, the highest level of return to work was after aorto-iliac surgery (96,4%), with a lower level (81%) after femorotibial operations. In a small group of 6 patients operated upon for aneurysms (of which 5 were aneuryms of the abdominal aorta), 4 had started work again, but after a longer period of 4 months on average. These results are compared with those obtained by a British team in Newcastle (Waters, Proud, and Chamberlain) who conducted a similar study in 1977. These overall results prove that reconstructive arterial surgery is favourable from the social and occupational point of view, as very large proportion of the operated patients continue working, and some of them start work again after having stopped their occupation before the operation.