J. B. Grau1,2, C. E. Kuschner1, G. Ferrari1,2, R. E. Shaw1, J. Romeo1, M. E. Brizzio1, J. Yallowitz3, A. Zapolanski1 1The Valley Columbia Heart Center, Columbia University College Of Physicians And Surgeons,Ridgewood, NJ, USA 2University Of Pennsylvania School Of Medicine,Philadelphia, PA, USA 3The Valley Columbia Hospital,Emergency Department,Ridgewood, NJ, USA
Introduction:
Patients with Ascending Aortic Dissections (AAD) are at high risk of mortality unless they are diagnosed early and critical treatment is initiated quickly. Achieving optimal clinical outcomes in these patients requires the collaboration of many practitioners and an enhanced awareness for AAD. We present the surgical results of 11 years of AAD treatment after the initiation of a program that incorporates the emergency, radiology, and cardiothoracic surgery departments with the goal of early identification leading to efficient and timely treatment of AAD.
Methods:
From January 2002 to December 2013, 55 patients with the diagnosis of AAD were treated at our institution. There were 38 males and 17 females with a mean age of 62.3 years. Early diagnosis was accomplished in the Emergency Department (ED) through staff education, implementation of standard protocols and knowledge about presenting signs and symptoms, which created a heightened level of awareness for the diagnosis of AAD during routine triage. The Department of Radiology was prepared to accept these cases immediately and perform emergency Computed Tomographic scans. The cardiothoracic surgery team was mobilized early in this process and became involved when the patient was in-route to the ED and the diagnosis was suspected. The surgical approaches performed were ascending and hemiarch replacements with or without Aortic Valve Repair (AVR), or valve replacement plus/minus coronary artery bypass (CABG). Cerebral protection was achieved using antegrade perfusion via axillary cannulation with moderate hypothermic circulatory arrest.
Results:
A majority of patients were male (69%), with 20% having undergone prior cardiac operations. Cardiac shock was present in 24.4%. A small proportion of patients experienced post-operative stroke (7.3%) or renal failure (9.1%). While the occurrence of cardiac shock was high in this group, the overall mortality was only 9.1%. Although the mortality seen in reoperative cases was 27.3%, the highest mortality was associated with the patients who required the most extensive procedures (AAD+AVR+CABG). Table 1 presents the demographics and surgical outcomes in the 3 different surgical approaches.
Conclusion:
The implementation of a multidisciplinary aortic program at our institution has allowed the development of protocols in the ED that expedite the management of patients with AAD. The data presented here supports the concept that community-based hospitals, if well-organized, can deliver excellent care to patients with acute aortic emergencies, including those that present in cardiogenic shock.
