Journal and News Scan

Objective: The aim of the study was to determine cause-specific mortality in TBAD and to evaluate the clinical characteristics associated with aorta-related and non aorta-related mortality.
Methods: Clinical and administrative records were reviewed for patients with acute TBAD between 1995 and 2017. Demographics, comorbidities, presentation, and initial imaging findings were abstracted. Cause of death was ascertained through a multimodality approach using electronic health records, obituaries, social media, Social Security Death Index, and state mortality records. Causes of death were classified as aorta related, nonaorta related, or unknown. A Fine-Gray multivariate competing risk regression model for sub distribution hazard ratio was employed to analyze the association of clinical characteristics with aorta-related and non aorta-related mortality.

Results: A total of 275 individuals met inclusion criteria (61.1 6 13.7 years, 70.9% male, 68% white). Mean survival after discharge was 6.3 6 4.7 years. Completeness of follow-up Clark C index was 0.87. All-cause mortality was 50.2% (n . 138; mean age, 70.1 6 14.6 years) including an in-hospital mortality of 8.4%. Cause-specific mortality was aorta related, non aorta related, and unknown in 51%, 43%, and 6%, respectively. Compared with patients with non aorta-related mortality, patients with aorta-related mortality were younger at acute TBAD (69.5 6 11.2 years vs 61.6 6 15.5 years; P .001), underwent more descending thoracic aortic repairs (19.4% vs 45.8%; P . .002), and had a shorter survival duration(5.7 6 3.9 vs 3.4 6 4.5 years; P . .002). There was clear variation in cause of death by each decade of life, with higher aorta related mortality among those younger than 50 years and older than 70 years and a stepwise increase in non aorta related mortality with each increasing decade (P < .001). All-cause mortality at 1 year, 3 years, and 10 years was 15%, 24%, and 57%, respectively. After accounting for competing risks, the cumulative incidence of aorta-related mortality at
1 year, 3 years, and 10 years was 8.9%, 16.5%, and 27.2%, respectively, and that of non aorta-related mortality was 2.7%, 7.2%,and 29%, respectively. A maximum descending thoracic aortic diameter >4 cm was associated with an increase in hazard of aorta-related mortality by 84% (sub distribution hazard ratio, 1.84; 95% confidence interval, 1.03-3.28) on multivariate competing risk regression analysis.

Conclusions: TBAD is associated with high 10-year mortality. Those at risk for aorta-related mortality have a clinical phenotype different from that of individuals at risk for non aorta-related mortality. This information is important for building risk prediction models that account for competing mortality risks and to direct optimal and individualized surgical and medical management of TBAD.

The authors review existing literature and propose recommendations to improve physical preparedness for surgery both in and outside the operating room. Cardiothoracic surgeons suffer from MSK pain, most commonly in the neck and back due to a lack of proper ergonomics during surgery. A lack of dedicated ergonomics curriculum during training may leave surgeons at a high predisposition for work-related MSK disorders. The authors reviewed relevant surgical ergonomics studies and prevalence of MSK disease among surgeons and interventionalists. Whenever possible, data from quantitative studies and meta-analyses were presented. They report high rates of work-related pain in surgeons - as high as 87% in minimally-invasive surgeons. Several optimizations regarding correct table height, monitor positioning, and loupe angles are discussed. The authors share factors, including smaller incisions and technological advancements, that led to this plight. They make a case that work-related injuries are underreported and understudied and the field of surgical ergonomics remains open for investigative study. The authors also recommend exercises that can be performed to improve MSK pain and outcomes.

Patient prosthesis mismatch is linked with significant long-term morbidity and mortality after aortic valve replacement, but the roles and conclusion of annular enlargement (AE) remain poorly defined. We hypothesized that increasing rates of AE may lead to improved outcomes for patients at risk for severe patient prosthesis mismatch.

A comprehensive update on the evidence on the management of acute aortic syndromes, including IMH. Of particular interest is the robust recommendation to bypass non-dedicated aortic centers even to the expense of increased transit time in order to offer management in a Comprehensive Aortic Center (CAC). The femoral cannulation appears to come gradually out of favour. The cerebral perfusion for arch work is proposed to be either ante-or retrograde. Figure 3 is particularly germane to the technical aspects. Visceral malperfusion is again heralded as a poor-outcome situation.