Acute Type A Aortic Dissection Repair Outcomes Didn’t Suffer in Early COVID-19

As seen for other emergent conditions, the number of patients presenting to US hospitals with acute type A aortic dissections dropped during the initial phase of the COVID-19 pandemic, although operative repair outcomes remained reassuringly similar, nationwide data show.

The average number of monthly cases fell from 372 before the pandemic to 286 during the first wave of SARS-CoV-2 infections (P = 0.01), with a more-pronounced reduction seen at high-volume centers performing more than 10 repairs per year, Tyler Wallen, DO (Geisinger Health, Danville, PA), reported during the virtual Society of Thoracic Surgeons (STS) 2022 meeting over the weekend.

What didn’t change, however, is how patients fared once they made it to the operating room. The operative mortality rate—within 30 days of surgery—was 19.01% in the year before COVID-19 spread across the world and 18.83% during the first 4 months of the pandemic (P = 0.8919).

“We believe that these findings may impact public policy and management of acute type A aortic dissection during future stages of the COVID pandemic or other future public health crises,” Wallen concluded during his presentation.

Speaking with TCTMD, Wallen said the marked decline in the number of patients presenting with this condition in the initial months of the pandemic is unlikely to have been due to a true change in its occurrence, which could theoretically have happened as more people stayed home and avoided the stress of the daily commute, leading to better blood pressure control, for instance. Instead, he said, it’s more likely that many people were afraid to come to the hospital even when they had chest pain and other symptoms, with some ultimately dying at home.

Messaging about the pandemic from the healthcare community to the public needs to change, Wallen said. It’s important to highlight when hospitals are struggling and running low on resources during a surge in cases, he said, “but I really think there needs to be a message to the public that even though we’re working really hard to take care of COVID patients, even though our health system is strained because of COVID patients, we still have the ability to take care of people with other problems. You should not sacrifice your own health or [avoid] care when you believe you need it out of a belief or a fear that the hospital is really full or that health systems are all overwhelmed.”

A National Look

When SARS-CoV-2 first started to spread across the US, it not only affected patients with COVID-19 but also influenced the ability to care for others, Wallen noted, citing cancellations of elective surgery and limitations on patients’ time in the clinic. Numbers of patients presenting with various acute conditions—including STEMI and bowel obstruction, for example—dropped initially, a phenomenon that coincided with an increase in out-of-hospital cardiac arrests. Other groups reported declines in admissions for acute type A aortic dissection at their centers, with some evidence of poorer outcomes from operative repair for those who made it to the hospital.

You should not sacrifice your own health or [avoid] care when you believe you need it out of a belief or a fear that the hospital is really full or that health systems are all overwhelmed. Tyler Wallen

To explore whether that was seen on a national level, Wallen and his colleagues examined data from the STS Adult Cardiac Surgery Database, comparing patients with acute type A aortic dissection who underwent surgical repair between March 2019 and February 2020 (n = 4,346) with those treated between March and June 2020 (n = 1,134), the first 4 months of the COVID-19 pandemic. Patient characteristics did not differ significantly between the two time periods. Mean age was 60, and 33% of patients were women.

Though the number of cases declined during the initial phase of the pandemic, outcomes largely remained unchanged. Mortality and other operative outcomes—including aortic cross clamp time, circulatory arrest, circulatory arrest time, any malperfusion, aortic root replacement, and aortic valve replacement—were not significantly different between the prepandemic and pandemic periods. Hemiarch, however, was more frequent in the latter period (44.2% vs 40.8%; P = 0.0459).

No differences were seen in secondary outcomes either. Major morbidity (prolonged ventilation, reexploration for bleeding, acute kidney injury, and deep wound infection) occurred in slightly more than half of patients in each group.

Risk factors for operative mortality and/or major morbidity included factors like dialysis, use of inotropes, higher creatinine, and any malperfusion, but not the time period during which patients were treated.

‘Reassuring Data’

Asked whether he would have expected to see sicker patients and worse outcomes among those who underwent surgical repair during the early phase of the pandemic, Wallen pointed out that acute type A aortic dissection differs from a condition like acute MI, for example.

With infarctions, patients may develop symptoms that steadily worsen until they’re convinced to get to the hospital. In contrast, Wallen explained, “in the dissection world, the fact of the matter is 80% of the people usually pass within the first 48 hours of suffering the aortic dissection. But those who don’t, those who sort of declare themselves as survivors, if you will, they don’t have that precipitous drop that one might expect in other conditions, so likely we weren’t seeing people coming in sicker.”

That outcomes didn’t suffer while COVID-19 surged is “a testament to the physicians, the nurses, everybody else who takes care of these patients, [showing] that even in an era where the hospitals are strained, the ICUs are busy, we’re a little short on labor, we don’t have a litany of resources available to us, we’re still providing really high-quality care to patients with a highly lethal disease,” Wallen said. “And I think that adds even more oomph to the idea that even though we’re all really busy and overwhelmed with this COVID stuff, we can still do a good job taking care of people with other issues, other issues like aortic dissection.”

Commenting for TCTMD, Robbin Cohen, MD (University of Southern California, Los Angeles), said it’s not particularly surprising to have confirmation that the number of patients presenting for surgical repair of acute type A aortic dissection declined during the early days of the pandemic, when hospitals were reorganizing resources to be able to manage COVID-19.

As for the similar outcomes seen when comparing the prepandemic and pandemic periods, Cohen said, “that was actually pretty reassuring. And the result of that is that we can say to the patients, ‘Listen, if you’re having chest pain, you need to get to the hospital, because if you do we can take care of you the same as we could if it wasn’t COVID.’”

Bo Yang, MD, PhD (University of Michigan, Ann Arbor), echoed that sentiment, noting that every hospital has procedures in place to protect non-COVID patients from those infected with the virus. “If patients have chest pain, they need care and should go to the hospital,” he told TCTMD.