Does malperfusion syndrome affect early and mid-term outcome in patients suffering from acute type A aortic dissection
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《血管的通路杂志》
Department of Cardiovascular Surgery, University Hospital, 3010 Berne, Switzerland
Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.
Abstract
It is well known that malperfusion syndrome (MPS) increases early mortality of patients suffering from acute type A aortic dissection (AADA). The aim of the present study was to analyze the outcome of patients who survived after surgical treatment of AADA with or without MPS. Data of 227 consecutive patients, who underwent surgery for AADA, were analyzed. The impact of MPS on in-hospital data and outcome was analyzed. Quality of life (QoL), using the short form 36 health survey questionnaire (SF-36), and late mortality were analyzed. Seventy-five patients (33%) with AADA had preoperative MPS. In 31 patients (41.3%), central nervous system (CNS) was involved and in 33 patients (44%) MPS of the extremities was present. Coronary malperfusion was found in 9 patients, renal in 8 patients and visceral malperfusion in 5 patients. Mean age in the group with MPS was 61.9±9.1 compared to 61.6±12.7 years without MPS (P=ns). In-hospital mortality was 18.7% in patients with MPS, compared to 9.9% without MPS (P<0.05). Follow-up revealed a significant poorer outcome in patients with MPS, with a 3-year-survival of 73.3% in patients with MPS and 86.2% without MPS (P<0.05). Average SF-36 values were lower in patients with MPS (78.3±12.8 vs. 87.8±11.9; P=ns), which is mainly due to patients with CNS-MPS, who showed an average SF-36 of 65.8±17.9 (P<0.05). AADA associated to MPS carries a higher early- and mid-term mortality. Postoperative mid-term QoL, however, except in patients with CNS-MPS and persistent neurological deficits, is fairly good and similar to patients who underwent successful surgery for AADA without MPS.
Key Words: Aortic dissection; Malperfusion syndrome; Outcome; Quality of life
1. Introduction
In patients with acute type A aortic dissection (AADA) malperfusion syndrome (MPS) remains a life-threatening aspect. Recent studies have shown that the presence of MPS increases in-hospital mortality which ranges between 25% and 58% [1–3]. This observation leads to our recommendation that risk-stratification systems, such as the EuroSCORE, should include the presence of preoperative MPS in AADA as one major risk-factor for poor postoperative outcome [4]. Ideal management of these patients includes the rapid restoration of organ perfusion, while avoiding rupture and tamponade.
Besides early mortality, mid-term outcome and quality of life (QoL) is of increasing interest in these patients. The question whether or not MPS does influence mid-term outcome remains to be elucidated. Especially, patients suffering from central nervous MPS may be affected in their QoL by persistent neurological deficits.
The aim of the present study is to analyze the outcome and QoL of patients who survived after surgical treatment of AADA with and without MPS.
2. Methods
Data of 227 consecutive patients, who underwent surgery for AADA, were analyzed. Seventy-five patients (33.0%) suffered from MPS. MPS was diagnosed based on clinical symptoms and/or radiological evidence and/or angiographic demonstration and/or physical examination (absence of pulse, livid extremity). Thirty-eight percent presented with MPS of the extremities and 36% suffered from central nervous malperfusion with neurological symptoms (stroke). In the remaining patients with MPS coronary and renal malperfusion were found in 10% and visceral malperfusion was present in 6% (Fig. 1). Immediate surgery was refused in patients presenting with preoperative coma. A neurological evaluation of these patients was made at the intensive care unit (ICU) and the decision whether or not patients should undergo surgery depended on the neurological evaluation. Overall, 6 patients were evaluated in the ICU due to serious preoperative neurologic symptoms (e.g. coma), out of which 3 underwent delayed surgery (22 to 48 h after admission).
All pre-, intra- and postoperative data were assessed and displayed in Table 1. Mean follow-up was 36.1±18.2 months. QoL was assessed using the SF-36 questionnaire [10–12]. Details of this validated questionnaire have been published previously [1,2]. The SF-36 consists of 36 short questions reflecting QoL in eight different aspects: bodily pain (abbreviated BP, 2 items); mental health (MH, 5); vitality (VT, 4); social functioning (SF, 2); general health (GH, 5); physical functioning (PF, 10); and role functioning, both emotional (RE, 3) and physical (RP, 4). Role functioning reflects the impact of emotional and physical disability on work and regular activity (the individual's normal everyday role). Raw points were transformed, generating a score for each dimension ranging from 0 to 100, with 100 reflecting best functioning. Swedish normal population (n=8930) scores are used as a standard population for comparison (range 85–115). Results were compared according to the preoperative presence of MPS (with MPS vs. no MPS). A subgroup analyses was performed in patients suffering from central nervous MPS. As the primary language of the majority of our patients is German, we used the German version of the SF-36, although several languages are spoken in Switzerland. Consequently, among the cases in which the questionnaire was not answered, the majority was caused by language problems. However, follow-up was very complete with over 80% of the questionnaire filled-out correctly. If patients did not reply, the patient or the general practicioner were contacted by phone, which leads to a follow-up of 100%.
All aortic patients are followed at our outpatient clinic at regular intervals (6 to 12 months).
2.1. Statistical analysis
Data are presented as mean values±their first standard deviation. A Mann–Whitney U-test and 2 test were used for comparison between groups of continuous and nominal variables, respectively. Linear regression for the relationship between DHCA duration and averaged QoL score was analyzed. A P-value of less than 0.05 was considered significant.
The SF-36 questionnaire was analyzed in accordance to the SF-36 manual, replacing missing values using the described algorithm [5–7]. Scores were adjusted for gender and age in order to be comparable with the normal population. Data were analyzed using the StatView 4.1 statistical package (Abacus Concepts, Berkley, CA).
3. Results
Preoperative MPS was present in 75 patients (33.0%). Preoperative patients characteristics were quite similar in both groups (Table 1). A composite graft (implanted in the bentall button technique) was more frequent in the collective of patients with MPS (36 vs. 25.7%; P<0.05).
In-hospital 30-day mortality was significantly higher in MPS patients with 18.7%, compared to 9.9% in patients without MPS (P<0.05). Two-year survival was 84.2% in patients without MPS and 62.7% in patients with MPS (P<0.05). In patients suffering from central nervous MPS 2-year survival was 54.8% (Fig. 2). Mid-term mortality (without 30-day mortality) in the follow-up of 24 months was 5.9% in patients without MPS and 18.7% in patients with MPS (P<0.05) (Table 1). Looking at the subgroup of patients with CNS-MPS, mid-term mortality was 25.8% and for the others with other types of MPS 13.6% (P<0.05). Two-year freedom from aortic reinterventions in the discharged collective, if the diameter of the aortic arch and the descending aorta were smaller than 4.5 cm at primary admission, was 98.6% without MPS and 90.2% with MPS (P<0.05). The average age- and gender-matched SF-36 was 87.8±11.9 in patients without MPS, and 78.3±12.8 (P=ns) with MPS. In patients with central nervous MPS average QoL was significantly impaired, with an average SF-36 of 65.8±17.9 (Fig. 3). Despite the presence of MPS, length of stay (LOS) was not longer in the MPS-group, compared to patients without MPS (P=ns).
4. Discussion
The presence of MPS in patients suffering from AADA increases mortality. A recent study reported an early mortality of central nervous MPS of 43.7% in comparison to a mortality of 17.0% in patients without MPS [1]. Technical refinements, such as the open distal anastomosis technique, the use of gelatine-resorcin-formaldehyde (GRF) glue, subclavian artery cannulation for arterial return and antegrade cerebral perfusion, constantly lower hospital mortality. Recent studies from Japan reported an in-hospital mortality for AADA between 2.8% and 5.1% [9,10]. In patients suffering from MPS, immediate restoration of organ perfusion is crucial. However, technically we first proceed to the replacement of the ascending aorta in order to treat as fast as possible the life-threatening disease, to prevent aortic rupture and/or pericardial tamponade. In some cases coronary malperfusion syndrome can be resolved by removing the haematoma surrounding the dissected coronary ostia and readapting the tissue layers with GRF. If the tissue quality of the coronary ostia is poor CABG-surgery should resolve the problem. If intraoperative visceral malperfusion is suspected (high serum lactate, haemorrhagical diarrhoea), we are very liberal in performing median laparatomy to control bowel perfusion after ascending aortic replacement. In these patients very often a second look 6–12 h after surgery is performed. MPS of the extremities, acute renal insufficieny (clinically presenting with anuria postoperative) and visceral MPS, should be treated by interventional fenestration or by surgical fenestration combined with tube graft interposition in order to restore perfusion. If paraplegia is present, mostly encountered in patients with a false lumen dorsal at the thoraco-abdominal level, a peridural catheter is placed and spinal decompression is performed by removing spinal fluid. It is well known that immediate organ perfusion decreases mortality [10]. In these patients mid-term outcome and QoL is fairly good and similar to patients who underwent surgery for AADA without MPS. A poor outcome and limitation in QoL can be found in patients presenting with central nervous MPS – restoration of brain perfusion is feasible by excluding the dissection, however, in half of the patients presenting with central nervous MPS, neurological symptoms were present at discharge, 30% recovered and in-hospital mortality in central nervous MPS was close to 20%. The low mortality in this collective, in comparison to other studies, is due to the fact that in the present study 6 patients underwent in-depth neurological evaluation at the ICU (performed by a neurologist including EEG, CT-scan, etc.) – in 3 patients surgery was refused, due to severe brain damage, confirmed by neurological examination. All three patients died within 72 h after admission. In the remaining 3 patients focal neurological symptoms were present and delayed surgery was performed. One patient recovered totally and in 2 patients preoperative neurological symptoms persisted after surgery.
Two-year freedom from aortic reinterventions, due to secondary dilatation of the descending aorta, was significantly higher in the collective without MPS, which is consistent with the findings recently described by our group [11]. Of patients presenting with dilatation of the descending aorta at the time of AADA, 2-year freedom from reinterventions was 91.8% in patients without MPS and 86.7% in patients with MPS.
QoL after surgery for AADA was fairly good and similar to data reported in an age- and gender-matched standard population for patients without MPS. Limitations in QoL were mainly found in patients suffering from central nervous MPS, in which significant limitations in QoL could be observed. In the remaining patients with MPS QoL was equal to data reported in a standard population.
We therefore conclude that AADA associated to MPS carries a higher early and mid-term mortality. However, except in patients suffering from central nervous MPS, QoL is fairly good and freedom from aortic reintervention due to secondary dilatation is rather low. In patients with severe central nervous MPS, indication for surgery should be carefully evaluated.
References
Tanaka H, Okada K, Yamashita T, Morimoto Y, Kawanishi Y, Okita Y. Surgical results of acute aortic dissection complicated with cerebral malperfusion. Ann Thorac Surg 2005; 80:72–76.
Kawahito K, Adachi H, Murata S, Yamaguchi A, Ino T. Coronary malperfusion due to type A aortic dissection: mechanism and surgical management. Ann Thorac Surg 2003; 76:1471–1476.
Apaydin AZ, Buket S, Posacioglu H, Islamoglu F, Calkavur T, Yagdi T, Ozbaran M, Yuksel M. Perioperative risk factors for mortality in patients with acute type A aortic dissection. Ann Thorac Surg 2002; 74:2034–2039.
Barmettler H, Immer FF, Berdat PA, Eckstein FS, Kipfer B, Carrel TP. Risk-stratification in thoracic aortic surgery: should the EuroSCORE be modified Eur J Cardiothorac Surg May 2004; 25:691–694.
Ware JE, Snow KK, Kosinski M. SF-36 health survey manual and interpretation guide 1993;Boston MA: New England MedicalCenter The Health Institute.
Sullivan M, Karlsson J, Ware JE. SF-36 health questionnaire. Swedish manual and interpretation guide 1994;Gothenburg Sweden: Gothenburg University.
Bland JM, Altmann DG. Statistics notes. Cronbach's alpha. Br Med J 1997; 314:572.
Immer FF, Lippeck C, Barmettler H, Berdat PA, Eckstein FS, Kipfer B, Saner H, Schmidli J, Carrel TP. Improvement of quality of life after surgery on the thoracic aorta: effect of antegrade cerebral perfusion and short duration of deep hypothermic circulatory arrest. Circulation Sep 14, 2004; 110:11 Suppl 1II250–II255.
Shiono M, Hata M, Sezai A, Negishi N, Sezai Y. Surgical results in acute type A aortic dissection. Ann Thorac Surg 2005; 11:29–34.
Girardi LN, Krieger KH, Lee LY, Mack CA, Tortolani AJ, Isom OW. Management strategies for type A dissection complicated by peripheral vascular malperfusion. Ann Thorac Surg 2004; 77:1309–1314.
Immer FF, Hagen U, Berdat PA, Eckstein FS, Carrel TP. Risk factors for secondary dilatation of the aorta after acute type A aortic dissection. Eur J Cardiothorac Surg Apr 2005; 27:654–657.(Franz F. Immer, Veronique)
Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.
Abstract
It is well known that malperfusion syndrome (MPS) increases early mortality of patients suffering from acute type A aortic dissection (AADA). The aim of the present study was to analyze the outcome of patients who survived after surgical treatment of AADA with or without MPS. Data of 227 consecutive patients, who underwent surgery for AADA, were analyzed. The impact of MPS on in-hospital data and outcome was analyzed. Quality of life (QoL), using the short form 36 health survey questionnaire (SF-36), and late mortality were analyzed. Seventy-five patients (33%) with AADA had preoperative MPS. In 31 patients (41.3%), central nervous system (CNS) was involved and in 33 patients (44%) MPS of the extremities was present. Coronary malperfusion was found in 9 patients, renal in 8 patients and visceral malperfusion in 5 patients. Mean age in the group with MPS was 61.9±9.1 compared to 61.6±12.7 years without MPS (P=ns). In-hospital mortality was 18.7% in patients with MPS, compared to 9.9% without MPS (P<0.05). Follow-up revealed a significant poorer outcome in patients with MPS, with a 3-year-survival of 73.3% in patients with MPS and 86.2% without MPS (P<0.05). Average SF-36 values were lower in patients with MPS (78.3±12.8 vs. 87.8±11.9; P=ns), which is mainly due to patients with CNS-MPS, who showed an average SF-36 of 65.8±17.9 (P<0.05). AADA associated to MPS carries a higher early- and mid-term mortality. Postoperative mid-term QoL, however, except in patients with CNS-MPS and persistent neurological deficits, is fairly good and similar to patients who underwent successful surgery for AADA without MPS.
Key Words: Aortic dissection; Malperfusion syndrome; Outcome; Quality of life
1. Introduction
In patients with acute type A aortic dissection (AADA) malperfusion syndrome (MPS) remains a life-threatening aspect. Recent studies have shown that the presence of MPS increases in-hospital mortality which ranges between 25% and 58% [1–3]. This observation leads to our recommendation that risk-stratification systems, such as the EuroSCORE, should include the presence of preoperative MPS in AADA as one major risk-factor for poor postoperative outcome [4]. Ideal management of these patients includes the rapid restoration of organ perfusion, while avoiding rupture and tamponade.
Besides early mortality, mid-term outcome and quality of life (QoL) is of increasing interest in these patients. The question whether or not MPS does influence mid-term outcome remains to be elucidated. Especially, patients suffering from central nervous MPS may be affected in their QoL by persistent neurological deficits.
The aim of the present study is to analyze the outcome and QoL of patients who survived after surgical treatment of AADA with and without MPS.
2. Methods
Data of 227 consecutive patients, who underwent surgery for AADA, were analyzed. Seventy-five patients (33.0%) suffered from MPS. MPS was diagnosed based on clinical symptoms and/or radiological evidence and/or angiographic demonstration and/or physical examination (absence of pulse, livid extremity). Thirty-eight percent presented with MPS of the extremities and 36% suffered from central nervous malperfusion with neurological symptoms (stroke). In the remaining patients with MPS coronary and renal malperfusion were found in 10% and visceral malperfusion was present in 6% (Fig. 1). Immediate surgery was refused in patients presenting with preoperative coma. A neurological evaluation of these patients was made at the intensive care unit (ICU) and the decision whether or not patients should undergo surgery depended on the neurological evaluation. Overall, 6 patients were evaluated in the ICU due to serious preoperative neurologic symptoms (e.g. coma), out of which 3 underwent delayed surgery (22 to 48 h after admission).
All pre-, intra- and postoperative data were assessed and displayed in Table 1. Mean follow-up was 36.1±18.2 months. QoL was assessed using the SF-36 questionnaire [10–12]. Details of this validated questionnaire have been published previously [1,2]. The SF-36 consists of 36 short questions reflecting QoL in eight different aspects: bodily pain (abbreviated BP, 2 items); mental health (MH, 5); vitality (VT, 4); social functioning (SF, 2); general health (GH, 5); physical functioning (PF, 10); and role functioning, both emotional (RE, 3) and physical (RP, 4). Role functioning reflects the impact of emotional and physical disability on work and regular activity (the individual's normal everyday role). Raw points were transformed, generating a score for each dimension ranging from 0 to 100, with 100 reflecting best functioning. Swedish normal population (n=8930) scores are used as a standard population for comparison (range 85–115). Results were compared according to the preoperative presence of MPS (with MPS vs. no MPS). A subgroup analyses was performed in patients suffering from central nervous MPS. As the primary language of the majority of our patients is German, we used the German version of the SF-36, although several languages are spoken in Switzerland. Consequently, among the cases in which the questionnaire was not answered, the majority was caused by language problems. However, follow-up was very complete with over 80% of the questionnaire filled-out correctly. If patients did not reply, the patient or the general practicioner were contacted by phone, which leads to a follow-up of 100%.
All aortic patients are followed at our outpatient clinic at regular intervals (6 to 12 months).
2.1. Statistical analysis
Data are presented as mean values±their first standard deviation. A Mann–Whitney U-test and 2 test were used for comparison between groups of continuous and nominal variables, respectively. Linear regression for the relationship between DHCA duration and averaged QoL score was analyzed. A P-value of less than 0.05 was considered significant.
The SF-36 questionnaire was analyzed in accordance to the SF-36 manual, replacing missing values using the described algorithm [5–7]. Scores were adjusted for gender and age in order to be comparable with the normal population. Data were analyzed using the StatView 4.1 statistical package (Abacus Concepts, Berkley, CA).
3. Results
Preoperative MPS was present in 75 patients (33.0%). Preoperative patients characteristics were quite similar in both groups (Table 1). A composite graft (implanted in the bentall button technique) was more frequent in the collective of patients with MPS (36 vs. 25.7%; P<0.05).
In-hospital 30-day mortality was significantly higher in MPS patients with 18.7%, compared to 9.9% in patients without MPS (P<0.05). Two-year survival was 84.2% in patients without MPS and 62.7% in patients with MPS (P<0.05). In patients suffering from central nervous MPS 2-year survival was 54.8% (Fig. 2). Mid-term mortality (without 30-day mortality) in the follow-up of 24 months was 5.9% in patients without MPS and 18.7% in patients with MPS (P<0.05) (Table 1). Looking at the subgroup of patients with CNS-MPS, mid-term mortality was 25.8% and for the others with other types of MPS 13.6% (P<0.05). Two-year freedom from aortic reinterventions in the discharged collective, if the diameter of the aortic arch and the descending aorta were smaller than 4.5 cm at primary admission, was 98.6% without MPS and 90.2% with MPS (P<0.05). The average age- and gender-matched SF-36 was 87.8±11.9 in patients without MPS, and 78.3±12.8 (P=ns) with MPS. In patients with central nervous MPS average QoL was significantly impaired, with an average SF-36 of 65.8±17.9 (Fig. 3). Despite the presence of MPS, length of stay (LOS) was not longer in the MPS-group, compared to patients without MPS (P=ns).
4. Discussion
The presence of MPS in patients suffering from AADA increases mortality. A recent study reported an early mortality of central nervous MPS of 43.7% in comparison to a mortality of 17.0% in patients without MPS [1]. Technical refinements, such as the open distal anastomosis technique, the use of gelatine-resorcin-formaldehyde (GRF) glue, subclavian artery cannulation for arterial return and antegrade cerebral perfusion, constantly lower hospital mortality. Recent studies from Japan reported an in-hospital mortality for AADA between 2.8% and 5.1% [9,10]. In patients suffering from MPS, immediate restoration of organ perfusion is crucial. However, technically we first proceed to the replacement of the ascending aorta in order to treat as fast as possible the life-threatening disease, to prevent aortic rupture and/or pericardial tamponade. In some cases coronary malperfusion syndrome can be resolved by removing the haematoma surrounding the dissected coronary ostia and readapting the tissue layers with GRF. If the tissue quality of the coronary ostia is poor CABG-surgery should resolve the problem. If intraoperative visceral malperfusion is suspected (high serum lactate, haemorrhagical diarrhoea), we are very liberal in performing median laparatomy to control bowel perfusion after ascending aortic replacement. In these patients very often a second look 6–12 h after surgery is performed. MPS of the extremities, acute renal insufficieny (clinically presenting with anuria postoperative) and visceral MPS, should be treated by interventional fenestration or by surgical fenestration combined with tube graft interposition in order to restore perfusion. If paraplegia is present, mostly encountered in patients with a false lumen dorsal at the thoraco-abdominal level, a peridural catheter is placed and spinal decompression is performed by removing spinal fluid. It is well known that immediate organ perfusion decreases mortality [10]. In these patients mid-term outcome and QoL is fairly good and similar to patients who underwent surgery for AADA without MPS. A poor outcome and limitation in QoL can be found in patients presenting with central nervous MPS – restoration of brain perfusion is feasible by excluding the dissection, however, in half of the patients presenting with central nervous MPS, neurological symptoms were present at discharge, 30% recovered and in-hospital mortality in central nervous MPS was close to 20%. The low mortality in this collective, in comparison to other studies, is due to the fact that in the present study 6 patients underwent in-depth neurological evaluation at the ICU (performed by a neurologist including EEG, CT-scan, etc.) – in 3 patients surgery was refused, due to severe brain damage, confirmed by neurological examination. All three patients died within 72 h after admission. In the remaining 3 patients focal neurological symptoms were present and delayed surgery was performed. One patient recovered totally and in 2 patients preoperative neurological symptoms persisted after surgery.
Two-year freedom from aortic reinterventions, due to secondary dilatation of the descending aorta, was significantly higher in the collective without MPS, which is consistent with the findings recently described by our group [11]. Of patients presenting with dilatation of the descending aorta at the time of AADA, 2-year freedom from reinterventions was 91.8% in patients without MPS and 86.7% in patients with MPS.
QoL after surgery for AADA was fairly good and similar to data reported in an age- and gender-matched standard population for patients without MPS. Limitations in QoL were mainly found in patients suffering from central nervous MPS, in which significant limitations in QoL could be observed. In the remaining patients with MPS QoL was equal to data reported in a standard population.
We therefore conclude that AADA associated to MPS carries a higher early and mid-term mortality. However, except in patients suffering from central nervous MPS, QoL is fairly good and freedom from aortic reintervention due to secondary dilatation is rather low. In patients with severe central nervous MPS, indication for surgery should be carefully evaluated.
References
Tanaka H, Okada K, Yamashita T, Morimoto Y, Kawanishi Y, Okita Y. Surgical results of acute aortic dissection complicated with cerebral malperfusion. Ann Thorac Surg 2005; 80:72–76.
Kawahito K, Adachi H, Murata S, Yamaguchi A, Ino T. Coronary malperfusion due to type A aortic dissection: mechanism and surgical management. Ann Thorac Surg 2003; 76:1471–1476.
Apaydin AZ, Buket S, Posacioglu H, Islamoglu F, Calkavur T, Yagdi T, Ozbaran M, Yuksel M. Perioperative risk factors for mortality in patients with acute type A aortic dissection. Ann Thorac Surg 2002; 74:2034–2039.
Barmettler H, Immer FF, Berdat PA, Eckstein FS, Kipfer B, Carrel TP. Risk-stratification in thoracic aortic surgery: should the EuroSCORE be modified Eur J Cardiothorac Surg May 2004; 25:691–694.
Ware JE, Snow KK, Kosinski M. SF-36 health survey manual and interpretation guide 1993;Boston MA: New England MedicalCenter The Health Institute.
Sullivan M, Karlsson J, Ware JE. SF-36 health questionnaire. Swedish manual and interpretation guide 1994;Gothenburg Sweden: Gothenburg University.
Bland JM, Altmann DG. Statistics notes. Cronbach's alpha. Br Med J 1997; 314:572.
Immer FF, Lippeck C, Barmettler H, Berdat PA, Eckstein FS, Kipfer B, Saner H, Schmidli J, Carrel TP. Improvement of quality of life after surgery on the thoracic aorta: effect of antegrade cerebral perfusion and short duration of deep hypothermic circulatory arrest. Circulation Sep 14, 2004; 110:11 Suppl 1II250–II255.
Shiono M, Hata M, Sezai A, Negishi N, Sezai Y. Surgical results in acute type A aortic dissection. Ann Thorac Surg 2005; 11:29–34.
Girardi LN, Krieger KH, Lee LY, Mack CA, Tortolani AJ, Isom OW. Management strategies for type A dissection complicated by peripheral vascular malperfusion. Ann Thorac Surg 2004; 77:1309–1314.
Immer FF, Hagen U, Berdat PA, Eckstein FS, Carrel TP. Risk factors for secondary dilatation of the aorta after acute type A aortic dissection. Eur J Cardiothorac Surg Apr 2005; 27:654–657.(Franz F. Immer, Veronique)