Outcomes of Type A Aortic Dissection Repair (STAAD)

Surgical Strategy for Repair of Type A Aortic Dissection: A Multicenter Registry

Type A aortic dissection (TAAD) is a potentially life-threatening pathology associated with significant risk of mortality and morbidity. In acute forms of type A aortic dissection (TAAD) mortality is 50% by 24 h and 50% of patients die before reaching a specialist center. Rapid diagnosis and subsequent prompt surgical repair remain the primary goal for these patients.

In the last decade it has been observed that improvements in diagnostic techniques, initial management and increased clinical awareness have contributed to a substantial increase in the number of patients benefiting from a prompt diagnosis and undergoing surgery.However, survival after surgical repair has not yet reached optimal follow-ups and is burdened by high in-hospital mortality(16-18%)

Study Overview

• Status: Enrolling by invitation
• Conditions: Aortic Valve Insufficiency; Aortic Diseases; Ascending Aortic Dissection; Aortic Arch; Aortic Root Dissection; Aortic Root Dilatation; Type A Aortic Dissection
• Intervention / Treatment: Procedure: Conservative Root- Sparing Aortic Valve Resuspension with or without Hemiarch Repair; Procedure: Extensive Ascending Aorta Replacement (AAR) with Aortic Root Replacement (ARR); Procedure: Extensive Ascending Aorta Replacement (AAR) with Total Arch Replacement (TARP); Procedure: Extensive Root and Ascending Aorta Replacement with Total Arch Replacement

Detailed Description

For patients requiring surgical repair for a TAAD, there is still some disagreement regarding which factors should be considered during the preoperative evaluation, the best decision-making process to undertake that best assesses procedural risk, and how operative mortality can be predicted. Furthermore, the impact of different surgical strategies on outcomes remains unclear.This prospective study was designed to evaluate the impact of the center volume-outcome relationship and that on mortality which remain poorly understood. A better understanding of the determinants of outcome in patients undergoing surgery could support decision making, aid in the design of service delivery, and improve outcomes for surviving patients who are referred to specialized centers for treatment of aortic disease.Furthermore, the study aims to evaluate whether precise risk stratification can provide better patient counseling and be used for unit-surgeon benchmarking. Ultimately in the present study, we aimed to investigate outcome predictors in patients undergoing surgery for TAAD, including clinical and perioperative variables as well as to evaluate follow up beyond 15 years.

• Study Type: Observational
• Enrollment (Estimated): 1000

Contacts and Locations

Study Locations

• France
  • Saint-Denis, France, 93200
    • Francesco Nappi

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: Adult; Older Adult
• Accepts Healthy Volunteers: No

• Sampling Method: Probability Sample

Study Population

The STAAD study is a prospective multicenter registry including patients who will underwent surgery for acute TAAD at 6 centers of cardiac surgery located in 2 European countries and Japan (3 France, 2 Italy and 1 Hokkaido ). Data will be prospectively collected from patients (conservative vs estensive Type A aortic dissection repair) who will be treated during the study period. In addition, the aim will be to gather further data for future clinical research on this topic. Preoperative and postoperative variables will be included during in-hospital stay and follow-up data instead they will be included on subsequent encounters for all other patients who will be hospitalized.

Description

Inclusion Criteria:

• Patients aged > 18 years
• TAAD or intramural hematoma involving the ascending aorta
• Symptoms started within 7 days from surgery
• Primary surgical repair of acute TAAD
• Any other major cardiac surgical procedure concomitant with surgery for TAAD.

Exclusion Criteria:

• Patients aged < 18 years
• Onset of symptoms > 7 days from surgery
• Prior procedure for TAAD
• Concomitant endocarditis;
• TAAD secondary to blunt or penetrating chest trauma.

Study Plan

How is the study designed?

Number of groups / cohorts

4

Cohorts and Interventions

Group / Cohort	Intervention / Treatment
Ascending Aorta Replacement (AAR) with or without Hemiarch Repair; Patients who will require a conservative prosthetic replacement of the ascending aorta with or without hemiarch.Patients who required a concomitant aortic valve replacement with conventional xenograft or mechanical prosthesis	Procedure: Conservative Root- Sparing Aortic Valve Resuspension with or without Hemiarch Repair; Cardiac arrest will be performed by administering a potassium-rich antegrade cardioplegia solution delivered directly into the coronary ostium or in the case of aortic regurgitation after insertion of the coronary sinus cannula.The aorta will be resected up to the sinotubular junction and the thrombus located in the false lumen of the aortic root will be removed so that the aortic lesion can be visualized. The commissures will be resuspended using 4-0 or 5-0 sutures reinforced with a Teflon pledget above every commissure. A 4-0 or 5-0 polypropylene suture will be chosen to seal the proximal anastomosis and this suture line will also be used to secure the intima to the adventitia. In patients demonstrating normal-sized aortic roots associated with poor-quality valve leaflets, concomitant aortic valve replacement with conventional xenograft or mechanical prosthesis will be preferable.; Other Names: Ascending Aorta Replacement with Aortic Valve Replacement (AVR)
Ascending Aorta Replacement (AAR) with Aortic Root Replacement (ARR); Patient who will require the extensive procedure including ascending aorta replacement associated to root replacement with or without sparing of the aortic valve	Procedure: Extensive Ascending Aorta Replacement (AAR) with Aortic Root Replacement (ARR); Patients who experienced dilatation of the sinuses of Valsalva > 4.5 cm in diameter on computed tomography imaging, those with connective tissue disease, or those in whom intimal tears extended into the sinuses, will receive replacement of the aortic root using a biologic or mechanical composite valve graft or valve-sparing root reimplantation procedure associated to AAR; Other Names: ARR with or without aortic valve sparing
Ascending Aorta Replacement with Total Arch Replacement (TARP); Patient who will require the extensive procedure including ascending aorta replacement associated to TARP	Procedure: Extensive Ascending Aorta Replacement (AAR) with Total Arch Replacement (TARP); Total arch replacement procedures (TARP) will performed with the use of deep hypothermic circulatory arrest and with either antegrade or retrograde cerebral perfusion, maintaining systemic cooling between 19°C to 25°C and depending on the surgeon's practice.TARPs will be carried out using 1- and 4-branch grafts and involved the resection of all the aortic tissue up to the left common carotid artery (total arch); Other Names: AAR with TARP or Frozen Elephant Trunk (FET)
Root and Ascending Aorta Replacement with Total Arch Replacement; Patient who will require the extensive procedure including root and ascending aorta replacement associated to TARP	Procedure: Extensive Root and Ascending Aorta Replacement with Total Arch Replacement; This extensive procedure will include complete replacement of the anterior thoracic aorta extending to part or all of the aortic arch. It will be performed with the previously reported techniques; Other Names: Full anterior thoracic aorta replacement with partial hemiarch repair or TARP or FET

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Operative Mortality (OM)	Patients who died within 30 days	30-day
Rate of permanent Neurologic Deficit (PND)	Number of participants with acute episode of a focal or global neurological deficit. Rates of alteration of degree of consciousness, hemiplegia, hemiparesis, numbness or sensory loss affecting one side of the body, dysphasia or aphasia, hemianopsia, amaurosis fugax. To consider rate of other neurologic signs or symptoms consistent with stroke duration of focal or global neurologic deficit greater than 24 hours.	30-day
Rate of perioperative Myocardial Infarction (MI)	Number of participants with MI based on fourth universal definition.	30-day
Rate of composite of Major Adverse Events (MAE)	Number of participants with MAE which will include the composite rate of myocardial infarction, cerebrovascular accident, need for dialysis, or need for tracheostomy according to Common Terminology Criteria for Adverse Events v4.0 (CTCAE)	30-day
Rate of mesenteric ischemia	Rate of abdominal pain with or without nausea and vomiting and rectal bleeding or bloody diarrhea	30-day
Rate of acute heart failure (AHF)	Number of participants with postoperative AHF who will require prolonged use of concentration of inotropes for a period greater than 24 h and/or the insertion of any mechanical circulatory support device.	30-day and in-hospital mortality

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Rate of Transient Neurologic Deficit (TND)	Number of participants who will complicate postoperatively with episode of TND which will include complication rate such as confusion, delirium, agitation	30-day
Rate of spinal Cord Injury (SCI)	Number of participants with SCI intended as rate of paraplegia and/or paraparesis	30-day
Rate of composite of Major Adverse Pulmonary Events (MAPE)	Number of participants with MAPE which will include the composite rate of intubation >48 hours, pneumonia, reintubation, tracheostomy according to the Common Terminology Criteria for Adverse Events v4.0 (CTCAE)	30-day
Rate of mechanical circulatory support	Number of participants who will receive the use of intra-aortic balloon pump and/or venoarterial extracorporeal membrane oxygenation for postoperative acute heart failure.	30-day
Rate of acute kidney injury	Number of participants with postoperative change in serum creatinine concentration. Severity will be stratified on the basis of number of participants with the KDIGO (Kney Disease Improving Global Outcomes) criteria.	30-day
Rate of perioperative bleeding	Number of participants who will receive postoperative transfused red blood cell units. The E-CABG ( coronary artery by pass grafting) classification of bleeding rate has been proposed as a simple classification of perioperative bleeding	30-day
Reoperation for bleeding	Number of participants who will receive postoperative chest reopening for excessive bleeding.	30-day
Rate of reintervention	The number of participants who will require reoperation for the aortic valve, proximal aorta, or distal aorta.	18-years
Rate of late survival	Data on patient's survival status will be collected	18-years

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Rate of urgent procedure	Number of participants who will require scheduled procedure within 24 hours of admission.	30-day
Rate of emergency grade 1	Number of participants will require procedure within 24 hours of hospital admission and who are symptomatic or minimally symptomatic with stable hemodynamic conditions and no signs of malperfusion.	30-day
Rate of emergency grade 2	Number of participants who will require procedure within the first 6 hours of hospital admission due to hemodynamic instability despite use of concentration inotropes and/or malperfusion.	30-day
Rate of salvage grade 1	Number of participants who will require immediate surgical procedure. Rate of cardio pulmonary resuscitation with external chest compressions and/or open cardiac massage between induction of anesthesia and initiation of cardiopulmonary bypass.	30-day
Rate of salvage grade 2	Number of participants who will require immediate surgical procedure. Rate of cardiopulmonary resuscitation with external chest compressions en route to the operating theatre or prior to induction of anesthesia.	30-day

Collaborators and Investigators

• Sponsor: Centre Cardiologique du Nord
• Collaborators: Universita degli Studi di Genova; Henri Mondor University Hospital; Pitié-Salpêtrière Hospital
• Investigators: Study Chair: Francesco Nappi, MD, Cardiac Surgery Centre Cardiologique du Nord de Saint-Denis, Paris, France

Publications and helpful links

General Publications

• Benedetto U, Dimagli A, Kaura A, Sinha S, Mariscalco G, Krasopoulos G, Moorjani N, Field M, Uday T, Kendal S, Cooper G, Uppal R, Bilal H, Mascaro J, Goodwin A, Angelini G, Tsang G, Akowuah E. Determinants of outcomes following surgery for type A acute aortic dissection: the UK National Adult Cardiac Surgical Audit. Eur Heart J. 2021 Dec 28;43(1):44-52. doi: 10.1093/eurheartj/ehab586.
• Geirsson A, Shioda K, Olsson C, Ahlsson A, Gunn J, Hansson EC, Hjortdal V, Jeppsson A, Mennander A, Wickbom A, Zindovic I, Gudbjartsson T. Differential outcomes of open and clamp-on distal anastomosis techniques in acute type A aortic dissection. J Thorac Cardiovasc Surg. 2019 May;157(5):1750-1758. doi: 10.1016/j.jtcvs.2018.09.020. Epub 2018 Sep 29.
• Harris KM, Nienaber CA, Peterson MD, Woznicki EM, Braverman AC, Trimarchi S, Myrmel T, Pyeritz R, Hutchison S, Strauss C, Ehrlich MP, Gleason TG, Korach A, Montgomery DG, Isselbacher EM, Eagle KA. Early Mortality in Type A Acute Aortic Dissection: Insights From the International Registry of Acute Aortic Dissection. JAMA Cardiol. 2022 Oct 1;7(10):1009-1015. doi: 10.1001/jamacardio.2022.2718.
• Czerny M, Schoenhoff F, Etz C, Englberger L, Khaladj N, Zierer A, Weigang E, Hoffmann I, Blettner M, Carrel TP. The Impact of Pre-Operative Malperfusion on Outcome in Acute Type A Aortic Dissection: Results From the GERAADA Registry. J Am Coll Cardiol. 2015 Jun 23;65(24):2628-2635. doi: 10.1016/j.jacc.2015.04.030.
• O'Hara D, McLarty A, Sun E, Itagaki S, Tannous H, Chu D, Egorova N, Chikwe J. Type-A Aortic Dissection and Cerebral Perfusion: The Society of Thoracic Surgeons Database Analysis. Ann Thorac Surg. 2020 Nov;110(5):1461-1467. doi: 10.1016/j.athoracsur.2020.04.144. Epub 2020 Jun 26.
• Mahase E. Half of patients with acute aortic dissection in England die before reaching a specialist centre. BMJ. 2020 Jan 23;368:m304. doi: 10.1136/bmj.m304. No abstract available.
• Braverman AC. Acute aortic dissection: clinician update. Circulation. 2010 Jul 13;122(2):184-8. doi: 10.1161/CIRCULATIONAHA.110.958975. No abstract available.
• Howard DP, Banerjee A, Fairhead JF, Perkins J, Silver LE, Rothwell PM; Oxford Vascular Study. Population-based study of incidence and outcome of acute aortic dissection and premorbid risk factor control: 10-year results from the Oxford Vascular Study. Circulation. 2013 May 21;127(20):2031-7. doi: 10.1161/CIRCULATIONAHA.112.000483. Epub 2013 Apr 18.
• Biancari F, Juvonen T, Fiore A, Perrotti A, Herve A, Touma J, Pettinari M, Peterss S, Buech J, Dell'Aquila AM, Wisniewski K, Rukosujew A, Demal T, Conradi L, Pol M, Kacer P, Onorati F, Rossetti C, Vendramin I, Piani D, Rinaldi M, Ferrante L, Quintana E, Pruna-Guillen R, Rodriguez Lega J, Pinto AG, Acharya M, El-Dean Z, Field M, Harky A, Nappi F, Gerelli S, Di Perna D, Gatti G, Mazzaro E, Rosato S, Raivio P, Jormalainen M, Mariscalco G. Current Outcome after Surgery for Type A Aortic Dissection. Ann Surg. 2023 Oct 1;278(4):e885-e892. doi: 10.1097/SLA.0000000000005840. Epub 2023 Mar 13.

Study record dates

Study Major Dates

• Study Start (Actual): January 1, 2005
• Primary Completion (Actual): December 30, 2021
• Study Completion (Estimated): December 30, 2024

Study Registration Dates

• First Submitted: June 3, 2023
• First Submitted That Met QC Criteria: June 23, 2023
• First Posted (Actual): July 3, 2023

Study Record Updates

• Last Update Posted (Actual): January 22, 2024
• Last Update Submitted That Met QC Criteria: January 18, 2024
• Last Verified: January 1, 2024

More Information

Terms related to this study

• Keywords: Ascending Aorta Replacement; Type A Acute Aortic Dissection (TAAAD); Root-Sparing Replacement; Hemiarch Procedures; Total Arch Replacement (TARP); Partial Arch Repair; DeBakey type I Dissection; DeBakey type II Dissection; Frozen Elephant Trunk (FET) Hemiarch Procedures
• Additional Relevant MeSH Terms: Heart Diseases; Cardiovascular Diseases; Vascular Diseases; Aortic Valve Disease; Heart Valve Diseases; Aneurysm; Dissection, Blood Vessel; Acute Aortic Syndrome; Dissection, Thoracic Aorta; Aortic Valve Insufficiency; Aortic Diseases; Aortic Dissection; Dissection, Ascending Aorta
• Other Study ID Numbers: CN-202201173-3

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No