English (United Kingdom)

https://curated-unify.zendy.io/wp-json/zendy-region/v1/featured_content/oa?rat=en

https://curated-unify.zendy.io/wp-json/zendy-region/v1/highlighted_journal/

Global: Zendy Tools annual

Presents the keyphrase highlighting as premium feature

Keyphrase Highlighting

Presents the summarisation as premium feature

Summarisation

Insights

Presents the pdf analysis as premium feature

PDF Analysis

Presents the zaia usage as premium feature

ZAIA

Global: Zendy Tools monthly

Global: Zendy Plus monthly

Presents the access of premium content as premium feature

Premium Content

Global: Zendy Plus annual

Global: Zendy Free Plan

Improvements in the treatment of acute ascending aortic dissection have occurred slowly. In our institution, the mortality rate dropped from around 30–15% in the mid-1980s as we learned to standardize repair with the use of circulatory arrest and improved techniques for obtaining haemostasis [1]. Since that time, further improvements in care have led to acute mortality rates consistently between 5 and 10% for all comers at the Cleveland Clinic. Other centres of excellence have demonstrated similar improvements in survival, but the pace of improvement has not occurred as quickly or extensively one would like, as evidenced by recent reviews of the International Registry of Aortic Dissection (IRAD) and large national administrative databases [2–4]. The mean mortality has decreased by 4% over a decade, but the national average is still greater than 20%. Analysis of these large databases is important because it demonstrates that larger volume centres and more experienced surgeons have significantly better outcomes. The problem with these databases is that they lack the granularity to assess details critical to making those improvements. Something that has consistently been found to be the most important factor in predicting survival is the presence of malperfusion at presentation [2]. In an analysis of acute outcomes after emergency type A dissection repair from Geirsson et al., the overall mortality rate was 12.7%, and was strongly associated with malperfusion. In patients with malperfusion, it was 25.8% compared with only 3.1% in those without [5]. We have also seen increased mortality in patients presenting with malperfusion. It is possible that, as a tertiary referral centre drawing from a large region, there may be an element of selection such that patients with the worst cases of malperfusion do not get transferred. Nonetheless, we have seen that as many as 40% of patients referred for DeBakey type 1 dissection will have an element of malperfusion to distal vascular beds [6]. It is this consequence of the acute dissection process that seems to be the most malignant contributor to the pathophysiology of acute dissection. Fortunately, timely treatment can relieve associated tamponade, correct acute aortic valve insufficiency and re-establish coronary and brain perfusion so that most patients will recover from the acute event. This has been the standard of care for over two decades and has led to an increasing appreciation for what happens to patients in the chronic state [7]. Although we have seen some improvement in early survival at centres of excellence, long-term survival after emergency repair of type A dissection is still poor with a 10-year survival of 60% at 10 years for a group of relatively young (mean age 45–62 years) patients [2–5,8].

Clearing the next hurdles in the treatment of acute ascending aortic syndrome