Delay from Diagnosis to Surgery in Transferred Type A Aortic Dissection - 30/12/17

Doi : 10.1016/j.amjmed.2017.11.009

William Froehlich, BS ^a, Jip L. Tolenaar, MD, PhD ^b, Kevin M. Harris, MD ^c, Craig Strauss, MD, MPH ^c, Thoralf M. Sundt, MD ^d, Thomas T. Tsai, MD, MSc ^e, Mark D. Peterson, MD, PhD ^f, Arturo Evangelista, MD ^g, Daniel G. Montgomery, BS ^a, Eva Kline-Rogers, MS, NP ^a, Christoph A. Nienaber, MD ^h, James B. Froehlich, MD, MPH ^a, Eric M. Isselbacher, MD ^d, Kim A. Eagle, MD ^a, Santi Trimarchi, MD, PhD ^b,^*
^a Cardiovascular Center, University of Michigan, Ann Arbor
^b Thoracic Aortic Research Center, IRCCS Policlinico San Donato, Milan, Italy
^c Cardiovascular Division, Minneapolis Heart Institute, Minn
^d Thoracic Aortic Center, Massachusetts General Hospital, Boston
^e Cardiology Department, University of Colorado Hospital, Denver
^f Division of Cardiac Surgery, St. Michael's Hospital, Toronto, ON, Canada
^g Servei de Cardiologia, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
^h Cardiology and Aortic Centre, The Royal Brompton & Harefield NHS Trust, London, UK

^*Requests for reprints should be addressed to Santi Trimarchi, MD, PhD, Thoracic Aortic Research Center, Policlinico San Donato IRCCS, University of Milan, Piazza Malan 2, San Donato Milanese, 20097, Italy.Thoracic Aortic Research CenterPoliclinico San Donato IRCCSUniversity of MilanPiazza Malan 2San Donato Milanese20097Italy

Sous presse. Épreuves corrigées par l'auteur. Disponible en ligne depuis le Saturday 30 December 2017

Abstract

Objectives

The purpose of this research is to analyze factors associated with delays to surgical management of Type A acute aortic dissection patients.

Methods

Time from diagnosis to surgery and associated factors were evaluated in 1880 surgically managed Type A dissection patients enrolled in the International Registry of Acute Aortic Dissection.

Results

The majority of patients were transferred (75.7% vs 24.3%). Patients who were transferred had a median delay from diagnosis to surgery of 4.0 hours (interquartile range 2.5-7.2 hours), compared with 2.3 hours (interquartile range 1.1-4.2 hours; P < .001) in nontransferred patients. Among patients who were transferred, those with worst-ever, posterior, or tearing chest pain those with severe complications, and those receiving transthoracic echocardiogram prior to a transesophageal echocardiogram or as the only echocardiogram were treated more quickly. Those undergoing magnetic resonance imaging, or who had prior cardiac surgery, had longer delays to surgery. Among nontransferred patients, those with coma were treated more quickly. In both groups, patients presenting with emergent conditions such as cardiac tamponade, hypotension, or shock had more rapid treatment. Among transferred patients, surviving patients had longer delays (4.1 [2.6-7.8] hours vs 3.3 [2.0-6.0] hours, P = .001). Overall mortality did not differ between patients who were transferred vs not (19.3% vs 21.1%, P = .416).

Conclusion

Simply being transferred added significantly to the delay to surgery for Type A acute aortic dissection patients, but a number of factors affected its extent. Overall, signs and symptoms leading to a definitive diagnosis or indicating immediate life threat reduced time to surgery, while factors suggesting other diagnoses correlated with delays.

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Keywords : Aortic dissection, Cardiothoracic surgery, Treatment delay

Plan

	Conflicts of Interest: TS serves on the advisory board of Thrasos. KE has received research grants from W.L. Gore & Associates and Medtronic, Inc. ST has received research grants and nonfinancial support from W.L. Gore & Associates and has served as a speaker and consultant for W.L. Gore & Associates and Medtronic, Inc. The other authors declare no conflicts of interest.
	Authorship: All authors had access to the data and a role in writing the manuscript.