DOI: 10.1016/j.athoracsur.2006.08.007 2007;83:55-61 Ann Thorac Surg
International Registry of Acute Aortic Dissection (IRAD) Investigators Fattori, Udo Sechtem, Michael G. Deeb, Thoralf M. Sundt, III, Eric M. Isselbacher and
V. Cooper, Jianming Fang, Dean Smith, Thomas Tsai, Arun Raghupathy, RossellaEduardo Bossone, Truls Myrmel, Giuseppe M. Sangiorgi, Carlo De Vincentiis, Jeanna
Vincenzo Rampoldi, Santi Trimarchi, Kim A. Eagle, Christoph A. Nienaber, Jae K. Oh, Dissection: The International Registry of Acute Aortic Dissection Score
Simple Risk Models to Predict Surgical Mortality in Acute Type A Aortic
http://ats.ctsnetjournals.org/cgi/content/full/83/1/55located on the World Wide Web at:
The online version of this article, along with updated information and services, is
imple Risk Models to Predict Surgical Mortalityn Acute Type A Aortic Dissection: The Internationalegistry of Acute Aortic Dissection Score
incenzo Rampoldi, MD, Santi Trimarchi, MD, Kim A. Eagle, MD,hristoph A. Nienaber, MD, Jae K. Oh, MD, Eduardo Bossone, MD, Truls Myrmel, MD,iuseppe M. Sangiorgi, MD, Carlo De Vincentiis, MD, Jeanna V. Cooper, MS,
ianming Fang, MD, MS, Dean Smith, PhD, Thomas Tsai, MD, Arun Raghupathy, MD,ossella Fattori, MD, Udo Sechtem, MD, Michael G. Deeb, MD,horalf M. Sundt III, MD, and Eric M. Isselbacher, MD, on behalf of the Internationalegistry of Acute Aortic Dissection (IRAD) Investigators
ardiovascular Center “E. Malan,” Policlinico S. Donato, S. Donato Milanese, Italy; University of Michigan, Coordinating Centeror IRAD, Ann Arbor, Michigan; University of Rostock, Rostock, Germany; Mayo Clinic, Rochester, Minnesota; National Research
ouncil, Lecce, Italy; Tromsø University Hospital, Tromsø, Norway; University Hospital S. Orsola, Bologna, Italy; Robert-Boschrankenhaus, Stuttgart, Germany; Massachusetts General Hospital, Boston, Massachusetts
s1cgIialc
tImaao
Background. Surgical mortality for acute type A aorticissection is frequently related to preoperative clinicalonditions. We report a predictive score to identify riskf death that may be helpful to assist surgeons who areonsidering whether to proceed with surgical correctionn the case of patients in extreme clinical risk.
Methods. Surgical outcome of 682 patients enrolled inhe International Registry of Acute Aortic Dissectionrom 1996 to 2003 was analyzed. Two different modelsere used. The initial model included only preopera-
ive variables such as demographics, history, symp-oms, signs, and diagnostic methods (model 1). Theecond model also tested intraoperative hemodynamicnd surgical variables (model 2). A bedside risk predic-ion tool to predict operative mortality in individualatients was developed.Results. The overall in-hospital surgical mortality was
3.9%. Independent preoperative predictors of mortality
n model 1 were age greater than 70 years, prior cardiac
d2cpscacdpsmbma
E. Malan,” Policlinico S. Donato, via Morandi 30, 20097 S. Donato Milanese,taly; e-mail: [email protected].
2007 by The Society of Thoracic Surgeonsublished by Elsevier Inc
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urgery, hypotension (systolic blood pressure less than00 mm Hg) or shock at presentation, migrating pain,ardiac tamponade, any pulse deficit, and electrocardio-ram with findings of myocardial ischemia or infarction.n model 2, other predictors of surgical death werentraoperative hypotension, a right ventricle dysfunctiont surgery, and a necessity to perform coronary revascu-arization. An independent predictor for favorable surgi-al outcome was right hemiarch replacement.
Conclusions. Surgery in unstable patients with acuteype A aortic dissection can be highly unsuccessful. Thenternational Registry of Acute Aortic Dissection riskodels predict in-hospital mortality using a multivari-
ble risk prediction tool, useful for surgeons and patientss they consider their surgical risk and the pros and consf embarking on high-risk surgery.
cute type A aortic dissection (AAAD) is a cardiovas-cular emergency with a high potential for death.
apid surgical treatment is indicated to prevent fatalomplications. Despite improved surgical techniquesnd perioperative care, mortality remains high, be-ween 15% and 30% [1– 6]. Predictors of surgical mor-ality have been variously reported [2, 7–9]; however, aimple risk model developed from a large patient cohorto predict surgical death has not been reported.
The International Registry of Acute Aortic DissectionIRAD) represents an opportunity to study acute aortic
ccepted for publication Aug 2, 2006.
ddress correspondence to Dr Trimarchi, Cardiovascular Center
issections. We completed a comprehensive analysis of90 clinical variables and their relation to surgical out-omes. The aim of this analysis was to identify independentredictors for surgical outcomes in the largest reportederies of consecutive patients affected by AAAD, and toreate a simple bedside tool helpful to assist surgeons whore considering whether or not to proceed with surgicalorrection in patients presenting with extreme clinical con-itions. Although the risk analysis is not beneficial in youngatients, who generally all go to surgery, in other circum-tances in which surgery may be deferred, such as age orajor comorbidities, this could be useful. Decision-making
y family members may also benefit. Ultimately, these riskodels may be useful for evaluation of quality of risk
CG normal with no abnormalities noted 188CG with findings of left ventricular hypertrophy 139CG with findings of myocardial ischemia 114CG with findings of myocardial infarction,
onsecutive patients with acute aortic dissection were en-olled at 18 large tertiary centers in six countries betweenanuary 1, 1996, and December 31, 2003 (Appendix 1). Theim of the IRAD has been to assess patterns of clinical signsnd presentation, diagnostic and therapeutic manage-
57Ann Thorac Surg RAMPOLDI ET AL2007;83:55–61 RISK MODELS IN TYPE A DISSECTION
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ent, and outcomes of patients with acute aortic dissec-ion, prospectively followed from presentation or retro-pectively from hospital records. Data were collectedsing a standardized data form including patient demo-raphics, history, clinical presentation, physical findings,
maging studies, medical and surgical management, in-ospital mortality, and adverse events. Completed data
orms were forwarded to the coordinating center at theniversity of Michigan. Data forms were reviewed for
nalytical internal validity and scanned electronicallynto an Access database. For this analysis, 682 patientsndergoing surgery for proximal aortic dissection withere analyzed. The institutional review boards for re-
earch at all IRAD centers approved the study protocol.ndividual patient consent was adopted for the study.
ata Analysisummary statistics are presented as frequencies andercentages, mean � standard deviation, or as a median
able 3. Preoperative Hemodynamic Status of Surgical Acute
ariable
lood pressure at presentationHypertension (SBP � 150 mm Hg)Normotension (SBP 100–149 mm Hg)Hypotension (SBP � 100 mm Hg)Shock or tamponade (SBP � 80 mm Hg)
lood pressure after hospitalizationIn-hospital preoperative hypotension (SBP � 100 mm Hg)Hypotension from admission to surgeryemodynamics at surgeryHypotension or shock at surgeryNormotension at surgeryLV dysfunction at surgeryRV dysfunction at surgery
V � left ventricle; RV � right ventricle; SBP � systolic blood pr
able 4. Surgical Techniques of Acute Type A Aortic Dissecti
nd interquartile range. Missing data were not defaultedo negative, and denominators reflect only cases re-orted. Associations of death among nominal variablesere compared using the �2 test or two-sided Fisher’s
xact test. Bivariate comparisons of continuous variablesere compared by use of Student’s t test or Wilcoxon
ank-sum test. Iterative logistic modeling was performedor in-hospital mortality using the likelihood ratio test for
odel selection. Initial modeling implemented elementsarginally suggestive of an unadjusted association of
n-hospital mortality (p � 0.20). Variables were reviewedor clinical significance before testing. Diagnostic rou-ines (Hosmer-Lemeshow test for lack of fit, change ineviance and residuals, and leverage indicators) weresed in model selection. Two different models werereated, first evaluating demographics, history, andreoperative variables as symptoms, signs, and diag-ostic methods (model 1). The second model also in-luded intraoperative hemodynamic and surgical vari-
A Aortic Dissection Patients
all (n � 682) Survived (n � 519) Dead (n � 163) p Value
ty in the best regression model were assigned a score equalo their coefficients in the fitted model (natural logarithm ofheir odds ratios rounded to the nearest decimal). The sumf this numerical score could then be used to predict theperative mortality in individual patients. A risk predictionool that plotted the risk score against the correspondingredicted death rate was developed to assist surgeons whore considering whether or not to proceed with surgicalorrection in high-risk patients.
esults
atient Populationf 1,334 consecutive patients with acute aortic dissection
nrolled between January 1, 1996, and December 31, 2003,34 (62.5%) patients had type A dissection. Of these, 148atients (17.7%) were treated medically for a variety ofeasons such as advanced age, severe comorbid illness,ntramural hematoma, or refusal of surgical intervention;
had a percutaneous approach. A total of 682 patientsnderwent surgery for AAAD and were included in this
able 5. Preoperative Prediction Model
ariableOverall
Type A (%)% AmongSurvivors
ge � 70 y 27.3 24.1istory aortic valve replacement 4.5 3.8resenting hypotension, shock,or tamponade
28.8 22.4
igrating chest pain 13.8 12.1reoperative cardiac tamponade 15.5 11.7ny pulse deficit 28.6 25.7CG infarct, new Q waves,ST elevation, or ischemia
21.1 18.7
I � confidence interval; ECG � electrocardiogram; OR � odds
able 6. Prediction Model With Variables During Operation
ariableOverall
Type A (%)% AmongSurvivors
ge � 70 y 27.3 24.1istory aortic valve replacement 4.5 3.8resenting hypotension, shock, or
n operationHypotension or shock 30.7 21.1RV dysfunction 7.0 3.6Partial arch 27.3 28.9
ABG � coronary artery bypass graft; CI � confidence interval; OR �
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nalysis (Tables 1–3). Their mean age was 59.9 � 13.8ears, with male predominance (70.3%). Three fourths ofhe patients had been transferred to an IRAD center fromreferral hospital for definitive treatment. The diagnosisf AAAD was made using transesophageal echocardiog-aphy in 77.4% and computed tomography in 70.7%. Aroximal intimal tear was identified in the aortic root in8.4%, the ascending aorta in 56.4%, and the aortic arch in.1%. The mean diameter of the aortic annulus was 29 �.8 mm, the aortic root 45 � 1.1 mm, the sinotubularunction 43 � 1.1 mm, the ascending aorta 53 � 1.3 mm,nd the aortic arch 37 � 0.7 mm.
urgical Strategyupracoronary aortic replacement was performed in 399atients (58.5%); aortic valve-sparing operations, defineds any operation with replacement of the aortic root andortic valve sparing, were adopted in 58 patients (8.5%).n aortic valve, root, and ascending aorta replacementith coronary artery reimplant was performed in 101atients (16.2%) by use of a composite aortic-valve graft.he hemiarch was replaced in 168 (27.3%), complete arch
n 72 (11.5%). An open procedure with hypothermicirculatory arrest was used in 597 patients (92%), witherebral perfusion in 322 patients (51.4%). Overall, theortic valve was replaced in 152 patients (24.2%), and
59Ann Thorac Surg RAMPOLDI ET AL2007;83:55–61 RISK MODELS IN TYPE A DISSECTION
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imultaneous coronary artery bypass grafting was pro-ided in 93 patients (14.6%; Table 4).
ospital Outcomeshe overall surgical in-hospital mortality was 23.9%;edically treated patients had an in-hospital mortality of
8.1% (p � 0.0001). With further stratification in theurgical patients, those who were unstable (patients withardiac tamponade, shock, congestive heart failure, cere-rovascular accident, stroke, coma, myocardial ischemiar infarction, electrocardiograms with new Q waves or STlevation, acute renal failure, or mesenteric ischemia ornfarction at surgery) had nearly two times the mortalityf stable patients (30.0% versus 15.5%; p � 0.0001).auses of death were neurologic (14.2%), visceral isch-mia (12.1%), aortic rupture (32.6%), tamponade (4.3%),nd unspecified (36.8%).
nivariate Predictors of Surgical Mortalitylinical characteristics associated with death after sur-ery (p � 0.05) were age older than 70 years, female sex,resence of atherosclerosis, prior cardiac surgery, pre-entation with severe or worst-ever pain, migrating pain,widened mediastinum on chest roentgenograph, hypo-
ension (systolic blood pressure �100 mm Hg) or shocksystolic blood pressure �80 mm Hg) before surgery,
yocardial ischemia or infarction with new Q waves,reoperative myocardial infarction, presence of a neweurologic deficit, any pulse deficit, cardiac tamponade,eriaortic hematoma, limb ischemia, left or right ventri-le dysfunction at surgery, a composite aortic-valve graftmplant procedure, and the necessity to perform a coro-ary revascularization. Predictors of survival after sur-
ig 1. Model 1: observed versus predicted death by score. Model 1ncluded only preoperative variables from demographics, history,ymptoms, signs, and diagnostic methods. Logarithmic odds of deathere calculated as �3.20 � 0.68 � age � 70 � 1.44 � history ofortic valve replacement � 1.17 � hypotension (systolic blood pres-ure � 100 mm Hg) or shock at presentation � 0.88 � migratinghest pain � 0.97 � preoperative cardiac tamponade � 0.56 � anyulse deficit � 0.57 � electrocardiogram with findings of myocar-ial ischemia or infarction. Hosmer-Lemeshow �2 (6 degrees of
areedom) � 8.16. Probability by �2 � 0.23.
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ery were radiating pain, electrocardiogram without ab-ormalities, normotension at presentation and aturgery, preoperative aortography, site of origin of dis-ection evidenced in the ascending aorta, and supracoro-ary aortic graft replacement.
imple Model for Surgical In-Hospital Deathndependent predictors are summarized in a risk-djusted model (Tables 5, 6). The C statistics were 0.76 forodel 1 and 0.81 for model 2, giving good model discrim-
nation. For model 1, the deviance probability value was.28 and the Hosmer-Lemeshow statistic was not signif-cant, indicating little departure from perfect fit (�2 �.16; degrees of freedom, 6; p � 0.23). Figures 1 and 2 plotxpected deaths versus observed deaths. There was goodgreement between observed and predicted death forcore categories (Figs 3, 4). For model 2, the deviancerobability value was 0.04 and the Hosmer-Lemeshowtatistic was not significant, indicating little departurerom perfect fit (�2 � 8.59; degrees of freedom, 8; p � 0.38).
omment
here is a consensus that AAAD is an urgent surgicalisease, given the high mortality in patients who receiveedical treatment [11, 12]. The IRAD data have further
onfirmed this statement: in this registry, which includesortic centers around the world using different policiesegarding diagnosis and management, the overall surgi-al mortality was 23.9%, whereas patients treated medi-ally had an in-hospital mortality of 58.1%. Others have
ig 2. Model 2: observed versus predicted death by score. Model 2 alsoncluded intraoperative hemodynamic and surgical variables. Logarith-ic odds of death were calculated as �3.35 � 0.58 � age � 70 �
.78 � history of aortic valve replacement � 0.92 � hypotensionsystolic blood pressure � 100 mm Hg) or shock at presentation �.70 � migrating chest pain � 0.64 � any pulse deficit � 1.34 �ntraoperative hypotension � 1.59 � right ventricle dysfunction aturgery � 0.93 � a necessity to perform a coronary artery bypassraft. An independent predictor for favorable surgical outcomeas �0.65 � partial arch replacement. Hosmer-Lemeshow �2
8 degrees of freedom) � 8.59. Probability by �2 � 0.38.
lso confirmed that surgical results remain suboptimal,
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howing a mortality rate of 15% to 30% [13–17]. It haseen reported that the major determinants of surgicalutcome in AAAD patients are preoperative complicationsnd comorbidities such as shock, aortic rupture, severeeurologic damage, and visceral ischemia [7–9, 15, 18].ach of these may justify a decision not to operate on anAAD patient. Recently, dividing this cohort into stablend unstable patients, we showed that unstable patientsave almost double the surgical mortality rate (31.4%ersus 16.7%) compared with stable patients regardlessf the type of surgical procedure [2]. We have confirmed
t in this larger cohort (mortality rate in unstable patients0.0% versus 15.5% in stable patients; p � 0.0001). In thisge of increasing pressure to practice evidence-basededicine, difficult decisions about whether to forego
urgery in extremely ill patients are often based onurgeons’ anecdotal experience and intuitive belief. Ourtudy identifies important preoperative and intraoper-tive predictors of surgical death in AAAD patientsTables 5, 6), which are similar to those reported in otherxperiences [1, 7, 13, 14, 19, 20]. These include age olderhan 70 years, aortic rupture with preoperative hypoten-ion, shock or cardiac tamponade, signs of acute myocar-ial ischemia or infarction, and intraoperative cardiacysfunction. These similarities with other published re-orts support the clinical relevancy of this risk predictionodel. In addition, we showed that prolonged hypoten-
ion, from admission to intraoperatively, often a sign ofrank rupture, is associated with a fatal outcome inreater than 40% of patients (p � 0.001). Clearly the
nclusion of these patients in whom the surgery is aeroic attempt at salvage may explain why the reportedurgical results for AAAD have not improved consis-ently in the last decades. On the other hand, in theresence of such complicated clinical status, immediateurgery remains the option for survival. Although theisk analysis is not beneficial in young patients, whoenerally all go to surgery, in other circumstances in
ig 3. Model 1: observed versus model probabilities of death bycore. Example: 77-year-old woman with migrating chest pain, pre-perative cardiac tamponade, a pulse deficit, and ST elevation. Herodel score is 0.7 (age � 70) � 0.9 (migrating chest pain) � 1.0
preoperative cardiac tamponade) � 0.6 (pulse deficit) � 0.6 (STlevation). Total score � 3.8. Drawing a line straight up from herisk score, the estimate of her surgical mortality risk is 61%.
hich surgery may be deferred, such as age or major m
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omorbidities, this could be useful. Decision-making byamily members may also benefit. In addition, these risk
odels may be useful for evaluation of quality of riskssessment and improvement tools.The International Registry of Acute Aortic Dissection
lso demonstrates that prior aortic valve replacement isepresented in both models as a predictor of surgicalortality. In such patients, greater technical difficulties
an be present, often requiring total replacement of theinotubular junction or coronary artery bypass grafts.oth conditions in this experience were associated withigher risk (p � 0.05 and p � 0.004, respectively), as waspreoperative aortic root diameter greater than 44 mm,hich led to more complex interventions (p � 0.03). On
he other hand, hemiarch replacement were a predictorf favorable surgical results. This technique, which wassed in 25% of surgical interventions, is directly related
o the open procedure, which is widely accepted as thetandard method to perform a safe distal anastomosissing hypothermic circulatory arrest with or withouterebral perfusion. In the IRAD, open distal anastomosisas performed in 92% of patients, using cerebral perfu-
ion in more than 50% of cases (not significant for both).or accurate risk prediction, simple bedside tools forstimating surgical risk in acute aortic dissection canssist surgeons in advising patients and their familiesbout the realistic chances of the operation, both preop-ratively (model 1) and postoperatively (model 2). TheRAD prediction tools provide an accurate method toredict operative results in AAAD patients (Figs 1–4). Inarticular, model 1 is applicable to all potential surgicalandidates affected by AAAD. The model is likely gen-ralizable to most patients, given the number of patientsnrolled in different institutions across six countries andhe broad spectrum of clinical presentations observed.
ig 4. Model 2: observed versus model probabilities of death bycore. Example: 54-year-old man presenting with shock, both atymptom presentation and at his arrival in the operating room, whoeeded a coronary artery bypass graft and right hemiarch replace-ent. His model score is 0.9 (shock at presentation) � 1.3 (shock atis arrival in the operating room) � 0.9 (needing coronary arteryypass graft) � 0.7 (partial arch replacement). Total score � 2.4.rawing a line straight up from his risk score, the estimate of his
61Ann Thorac Surg RAMPOLDI ET AL2007;83:55–61 RISK MODELS IN TYPE A DISSECTION
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tudy Limitationshe International Registry of Acute Aortic Dissection isn observational study, reflecting care at a number ofortic centers, and the results cannot be generalized toll patients who undergo surgery in a given institution.n-hospital death was the only outcome that was as-essed in this analysis, and, although important, it is notufficient for full evaluation of patients with type A aorticissection. Further studies are needed to address theptimal surgical approach for evaluating the predictorsf short-term and long-term survival.
onclusionscute type A aortic dissection is a highly lethal disease inhich prompt identification and surgery is the best hope
or survival. The present study confirms that principaleterminants of surgical mortality in AAAD patients arereoperative complications and comorbidities. The IRADisk prediction tool can provide an accurate prediction ofortality risk and can assist with a decision of whether or
ot to proceed with surgery. In particular, the tool may beseful in managing the truly moribund patient in whom,egardless of surgery, the likelihood of survival is small.
e acknowledge the University of Michigan Faculty Group Prac-ice and the Varbedian Fund for Aortic Research for support. Theollowing companies have provided research funding for the cur-ent and past calendar year: St. Jude Medical; W.L. Gore andssociates, Inc; Cryolife, Inc; Medtronic, Inc; Atricure, Inc; Thoratecorp; Carbomedics/Sorin Group; Jarvik Heart, Inc; Baxter; Ed-ards Lifesciences; Boston Scientific Corp; Avant Immunothera-eutics, Inc; AstraZeneca; and TransTech Pharma, Inc.
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ppendix
he International Registry of Acute Aortic DissectionIRAD) Investigators
Co-Principal Investigators: Kim A. Eagle, MD, University ofichigan, Ann Arbor, Michigan USA; Eric M. Isselbacher, MD,assachusetts General Hospital, Boston, Massachusetts, USA;
nd Christoph A. Nienaber, MD, University of Rostock, Rostock,ermany.Co-Investigators: Eduardo Bossone, MD, National Research
ouncil, Lecce, Italy; Arturo Evangelista, MD, Hospital Generalniversitari Vall d’Hebron, Barcelona, Spain; Rosella Fattori,D, University Hospital S. Orsola, Bologna, Italy; Dan Gilon,D, Hadassah University Hospital, Jerusalem, Israel; Stuartutchison, MD, St. Michael’s Hospital, Toronto, Ontario, Canada;lfredo Llovet, MD, Hospital Universitario “12 de Octubre,”adrid, Spain; Truls Myrmel, MD, Tromsø University Hospital,
romsø, Norway; Patrick O’Gara, MD, Brigham and Women’sospital, Boston, Massachusetts, USA; Jae K. Oh, MD, Mayolinic, Rochester, Minnesota, USA; Linda A. Pape, MD, Univer-
ity of Massachusetts Hospital, Worcester, Massachusetts, USA;do Sechtem, MD, Robert-Bosch Krankenhaus, Stuttgart, Ger-any; Toru Suzuki, MD, University of Tokyo, Tokyo, Japan; and
anti Trimarchi, MD, Policlinico San Donato, San Donato
DOI: 10.1016/j.athoracsur.2006.08.007 2007;83:55-61 Ann Thorac Surg
International Registry of Acute Aortic Dissection (IRAD) Investigators Fattori, Udo Sechtem, Michael G. Deeb, Thoralf M. Sundt, III, Eric M. Isselbacher and
V. Cooper, Jianming Fang, Dean Smith, Thomas Tsai, Arun Raghupathy, RossellaEduardo Bossone, Truls Myrmel, Giuseppe M. Sangiorgi, Carlo De Vincentiis, Jeanna
Vincenzo Rampoldi, Santi Trimarchi, Kim A. Eagle, Christoph A. Nienaber, Jae K. Oh, Dissection: The International Registry of Acute Aortic Dissection Score
Simple Risk Models to Predict Surgical Mortality in Acute Type A Aortic
& ServicesUpdated Information
http://ats.ctsnetjournals.org/cgi/content/full/83/1/55including high-resolution figures, can be found at:
