Transportation model for acute aortic dissection: implications for reduced treatment centres.

OBJECTIVES: The objective of the present study was to model the effects of a reduced number of treatment centres for acute type A aortic dissection on preclinical transportation distance and time. We examined whether treatment in selected centres in Germany would be implementable with respect to time to treatment. METHODS: For our transportation model, the number of aortic dissections and respective mean annual volume were collected from the annual quality reports (2015-2017) of all German cardiac surgery centres (n = 76). For each German postal code, the fastest and shortest routes to the nearest centre were calculated using Google Maps. Furthermore, we analysed data from the German Federal Statistical Office from January 2005 to December 2015 to identify all surgically treated patients with acute type A aortic dissection (n = 14 102) and examined the relationship between in-hospital mortality and mean annual volume of medical centres. RESULTS: Our simulation showed a median transportation distance of 27.13 km and transportation time of 35.78 min for 76 centres. Doubling the transportation time (70 min) would allow providing appropriate care with only 12 medical centres. Therefore, a mean annual volume of >25 should be obtained. High mean annual volume was associated with significantly lower in-hospital mortality rates (P < 0.001). A significantly lower mortality rate of 14% was observed (P < 0.001) if a mean annual volume of 30 was achieved. CONCLUSIONS: Operationalizing the volume-outcome relationship with fewer but larger medical centres results in lower mortality, which outweighs the disadvantage of longer transportation time.

Acute type A aortic dissection: Aortic Dissection Detection Risk Score in emergency care - surgical delay because of initial misdiagnosis.

BACKGROUND: Acute type A aortic dissection requires immediate surgical treatment, but the correct diagnosis is often delayed. This study aimed to analyse how initial misdiagnosis affected the time intervals before surgical treatment, symptoms associated with correct or incorrect initial diagnosis and the potential of the Aortic Dissection Detection Risk Score to improve the sensitivity of initial diagnosis. METHODS: We conducted a retrospective analysis of 350 patients with acute type A aortic dissection. Patients were divided into two groups: initial misdiagnosis (group 0) and correct initial diagnosis of acute type A aortic dissection (group 1). Symptoms were analysed as predictors for the correct or incorrect initial diagnosis by multivariate analysis. Based on these findings, the Aortic Dissection Detection Risk Score was calculated retrospectively; a result ⩾2 was defined as a positive score. RESULTS: The early suspicion of aortic dissection significantly shortened the median time from pain to surgical correction from 8.6 h in patients with an initial misdiagnosis to 5.5 h in patients with the correct initial diagnosis (p<0.001). Of all acute type A aortic dissection patients, 49% had a positive Aortic Dissection Detection Risk Score. Of all initial misdiagnosed patients, 41% had a positive score (⩾2). The presence of lumbar pain (p<0.001), any paresis (p=0.037) and sweating (p=0.042) was more likely to lead to the correct initial diagnosis. CONCLUSION: An early consideration of acute aortic dissection may reduce the delay of surgical care. The suggested Aortic Dissection Detection Risk Score may be a useful tool to improve the preclinical assessment.

Left Ventricular Systolic Dysfunction in Patients With Type-A Aortic Dissection Is Associated With 30-Day Mortality.

OBJECTIVE: The aim of this study was to analyze preoperative and postoperative echocardiographic parameters in patients with type-A acute aortic dissection (ATAAD) and to analyze whether impaired preoperative left ventricular function was associated with short- and long-term survival. To enable multivariable analysis, established risk factors of ATAAD were analyzed as well. DESIGN: Retrospective single-center study. SETTING: The German Heart Center Berlin. PARTICIPANTS: The retrospective data of 512 patients with ATAAD who were treated between 2006 and 2014 were analyzed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Preoperative versus postoperative left ventricular ejection fraction (LVEF), right ventricular ejection fraction, left ventricular end-diastolic diameter, and right ventricular end-diastolic diameter were not significantly different, and the mean values were within the reference ranges. Because of the surgical intervention, incidences and severities of aortic regurgitation and pericardial effusion decreased. In multivariable logistic analysis, the authors identified age (odds ratio [OR] 1.04, p < 0.001), preoperative LVEF ≤35% (OR 2.20, p = 0.003), any ischemia (Penn non-Aa) (OR 2.15, p < 0.001), and longer cardiopulmonary bypass time (OR 1.04, p < 0.001) as independent predictors of 30-day mortality. Cardiopulmonary resuscitation, tamponade, or shock, and pre-existing cardiac disease, were not predictors of death. CONCLUSION: After surgery, aortic insufficiency and pericardial effusion decreased, whereas cardiac functional parameters did not change. Severe LV dysfunction was identified as a new independent predictor of 30-day mortality.

How to prevent inadvertent emergency anticoagulation in acute type A aortic dissection: when in doubt, don't.

Inadvertent emergency anticoagulation in patients with acute type A aortic dissection (ATAAD) has been sparsely reported. There are case reports bringing this potential critical incident to attention, however, little is known about the number of undetected and unreported cases. We approach this issue based on a case report of inadvertent emergency anticoagulation in ATAAD and attempt to shed light on aspects that may have contributed to the critical incident: The challenge of distinguishing an ATAAD from an acute coronary syndrome (ACS) and the potential underestimation of incidents of ATAAD. We also discuss errors and biases in medical decision making, and provide suggestions that may help raise awareness of how ATAAD can be mimicking ACS in clinical practice.