Predicting death in patients with acute type A aortic dissection

p⫽0.001), cardiovascular events (0% vs. 10%, p⫽0.08) and the need for secondary surgery (4% vs. 15%, p⫽0.07). Median length of stay was 11 days (range 7–55 days) in the intervention group and 13 days (range 8 – 65 days) in the control group (p⫽0.41). Conclusions: Postoperative morbidity is successfully reduced by an effective smoking cessation program 6 – 8 weeks prior to hip and knee replacement surgery. Perspective: Several features of this study should be considered before interpreting the results. The overall rate of wound complication was high (17.6%). Perioperative management such as early mobilization, deep breathing exercise, incentive spirometer, beta-blockers for patients with known coronary disease, and bronchodilators for patients with chronic airway disease were not reported. The specifics of wound care and prophylactic antibiotic use were as per individual hospital/physician specific protocols and were not reported. This may have been different for different hospitals and may have varied in the two groups of patients. The length of stay was much longer than that seen in US hospitals after such a surgery and suggests slower mobilization of the study patients. Despite these limitations, it makes common sense that patients should be encouraged to stop smoking 6 – 8 weeks prior to any planned surgery. This intervention likely reduces periprocedural complications and enhances the possibility of long-term smoking cessation. RM

analysis revealed good model discrimination (area under the ROC curve ⫽0.74) and the Hosmer-Lemeshow statistic was not significant (p⫽0.75), indicating good model calibration. There was excellent correlation between the calculated score, the predicted probability of death and the observed in-hospital mortality rate. Conclusions: Acute Type A aortic dissection is associated with a high in-hospital mortality rate. Baseline clinical characteristic that can be incorporated in a simple bedside risk prediction tool identify patients with acute Type A aortic dissection at high risk of death in the hospital. Perspective: This study illustrates the value of multicenter registries designed to develop a better understanding of the relationships between clinical characteristics, practice variations and outcomes. As shown by the results, baseline clinical predictors of increased risk of death in acute aortic dissection can be easily incorporated in a simple risk prediction tool that could be used to assess patient prognoses and potentially to triage patients toward different treatments. Similar risk prediction tools have been developed for the prediction of in-hospital mortality after percutaneous coronary interventions, CABG, non-cardiac surgery and for the prediction of in-hospital mortality in acute coronary syndromes. Incorporating these risk prediction tools in clinical practice has the potential to bridge the gap between clinical judgment and mathematical modeling. MM

Predicting Death in Patients With Acute Type A Aortic Dissection

Staged Repair of Extensive Aortic Aneurysms: Morbidity and Mortality in the Elephant Trunk Technique

Mehta RH, Suzuki T, Hagan PG, et al., on behalf of the International Registry of Acute Aortic Dissection (RAD) Investigators. Circulation 2002;105:200 – 6.

Safi HJ, Miller CC, Estrera AL, et al. Circulation 2001;104:2938 – 42.

Study Question: To identify predictors of in-hospital mortality for patients with acute Type A aortic dissection. Methods: The study sample included 547 patients enrolled in the International Registry of Acute Aortic Dissection (IRAD) between January 1996 and December 1999. Independent predictors of death in the hospital were identified using multivariate logistic regression analysis. A simplified bedside additive risk prediction tool was then developed from the regression model by rounding coefficients to the nearest decimal and by plotting calculated total scores, observed mortality and predicted mortality. Results: In this large registry of Type A aortic dissection, the overall in hospital mortality rate was 32.5%. Independent predictors of death in the hospital included: age ⬎70 years (OR, 1.7: 95% CI, 1.05 to 2.77, p⫽0.03), sudden onset of chest pain (OR 2.6; 95% CI, 1.22 to 5.54; p⫽0.01), hypotension/shock/tamponade (OR, 2.97; 95% CI, 1.83 to 4.81; p⬍0.0001), renal failure (OR, 4.77; 95% CI, 1.80 to 12.6; p⫽0.002), pulse deficit (OR, 2.03; 95% CI, 1.25 to 3.29, p⫽0.004) and abnormal ECG (OR, 1.77; 95%CI, 1.06 to 2.95; p⫽0.03). Receiver operating characteristic curve

Study Question: What is the morbidity and mortality of patients undergoing surgical repair of extensive aortic aneurysms (ascending aorta, aortic arch and descending or thoracoabdominal aorta) using a two-staged procedure (elephant trunk technique, surgery on aortic or mitral valve, coronary artery bypass surgery along with repair of ascending aorta and arch initially, followed weeks later by repair of the thoracoabdominal portion)? Methods: The investigators performed 1146 aortic operations between February 1991 and May 2000, 182 (15.9%) operations were first- or second-stage elephant trunk procedures, performed in a total of 117 patients. While Stage 1 was completed in all 117 patients, Stage 2 was completed in 65 (55.6%) patients. Results: Death at 30 days occurred in 5.1% (6/117) of patients with Stage 1 repair and an additional 3.6% died (4/111) during the interval between the operations. The interval deaths were predominantly from rupture of the aneurysm (3 of 4). Sixty-five patients underwent Stage 2 operation with a 30-day mortality of 6.2% (4/65), while 43 patients did not return for second-stage repair. Among

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