The risk for early death after a procedure among patients with acute Stanford type A aortic dissection (ATAAD) is higher for men and patients with cardiac tamponade, malperfusion, shock, and older age, according to a systematic review and meta-analysis published in the International Journal of Cardiology.
Investigators sought to evaluate risk factors and assess evidence-based prevention strategies for early death after surgery in patients with ATAAD.
They conducted a systematic search of the Cochrane Library, Web of Science, Scopus, Ovid, and PubMed databases from inception to May 2021. They identified 23 articles that included 5510 patients and met the following inclusion criteria:
- Patients were at least 19 years of age
- Patients were diagnosed with Stanford type A or DeBakey type I or type II aortic dissection
- Patients had less than 15 days from initial symptom onset to diagnosis
- Patients died within 30 days after receiving a procedure
- Studies were cross-sectional/cohort/retrospective studies involving a case group and a control group and reporting between-group comparisons
- Study outcomes included risk factors for early death after receiving a procedure
Exclusion criteria included experimental studies, case reports or reviews, lack of original data or unable to transfer or combine data, and no clear phase of the perioperative period.
Patients’ mean age after receiving a procedure ranged from 42.7 years to 70.0 years, the percentage of patients who were men ranged from 49.74% to 87.5%, and study sizes ranged from 56 to 609 patients. Mortality after surgery ranged from 6.12% to 35.00%. There were 5 studies that defined early death after surgery as death within 30 days. Of the included studies, 10 were conducted in China, 3 in Japan, and 4 were conducted in European countries.
The investigators found the preoperative risk factors for early death after receiving a procedure in patients with ATAAD were cardiac tamponade (odds ratio [OR], 3.89; 95% CI, 1.17-12.98; P =.027), malperfusion (OR, 3.45; 95% CI, 2.24-5.31; P <.001), shock (OR, 1.91; 95% CI, 1.06-3.45; P =.032), male sex (OR, 1.43; 95% CI, 1.06-1.92; P =.020), and age (OR, 1.03; 95% CI, 1.01-1.06; P =.005). They found no evidence to suggest that creatinine level and time from symptom onset to operation effected the increased risk for early mortality.
Sensitivity analysis revealed that excluding 1 of the studies changed the conclusions for cardiac tamponade, malperfusion, shock, and male sex, but not for age. The investigators found no evidence suggesting that cardiopulmonary bypass time (CPB) (7 studies), cross-clamping time (4 studies), and operation time (3 studies) affected increased risk for early mortality after receiving a procedure in patients with ATAAD. Sensitivity analysis showed that if certain studies were excluded, CPB time was affected, as was operation time conclusions. Cross-clamping time conclusions were not changed by study exclusion.
Study limitations include using pooled effect sizes from retrospective studies only and the limited number of studies involving every risk factor.
“Patients of an older age, of male sex, and with shock, malperfusion and cardiac tamponade have a higher risk for early death after surgery,” the study authors wrote. “However, significant heterogeneity was found for some of the factors, and many intraoperative and postoperative risk factors were not included in this meta-analysis because of the limited number of included studies.”
Zhang Y, Yang Y, Guo J, et al. Risk factors for early death after surgery in patients with acute Stanford type A aortic dissection: a systematic review and meta-analysis. Int J Cardiol. Published online December 10, 2022. doi:10.1016/j.ijcard.2022.12.013