Decision analysis and personalized clinical tool for cerebrospinal fluid drains in thoracoabdominal aortic aneurysms repair.

BACKGROUND AND AIM: The routine use of cerebrospinal fluid (CSF) drainage in patients undergoing operative repair of thoracoabdominal aneurysms (TAAA) has been associated with decreased rates of spinal cord ischemia. The use of CSF drains is not without consequence, however with complications including subarachnoid hemorrhage, epidural hematoma, meningitis, and, in 1% of cases, death. To date, a decision analysis tool to help clinicians decide when to use and not to use a CSF drain does not exist. In this analysis, we set out to develop a decision analysis tool for CSF drain placement in patients undergoing operative repair of TAAA. METHODS: A Markov state-transition cohort model that compared TAAA repair with adjunctive CSF drain insertion to TAAA repair without drain insertion for the outcome of life expectancy was developed in TreeAge 2020. The cycle length was 1 month and the time horizon was 60 months. RESULTS: The use of a CSF drain was associated with improved 5-year life expectancy (3.21 ± 0.10 vs. 3.09 ± 0.11 life-years gained). In the sensitivity analysis that varied the effectiveness of a CSF drain (odds ratio closer to 1 = less effective), the use of a CSF drain resulted in higher life expectancy in almost all scenarios. CONCLUSIONS: The routine use of a CSF drain in patients undergoing TAAA repair is safe and effective, with few exceptions. This decision analysis tool can be used by clinicians to develop a personalized approach.

Diagnosis and management of low-flow, low-gradient aortic stenosis.

PURPOSE OF REVIEW: The severity of low-flow, low-gradient aortic stenosis cases continue to be misunderstood because of challenging diagnosis, and treatment remains complex. We discuss current diagnostic and treatment modalities for low-flow, low-gradient aortic stenosis. RECENT FINDINGS: This article summarizes current guidelines and best practices for the management of low-flow, low-gradient aortic stenosis. SUMMARY: Low-flow, low-gradient aortic stenosis is a difficult entity to diagnose and treat. Various diagnostic modalities are needed to accurately determine the severity of aortic stenosis and potential treatment benefit. True-severe classical and paradoxical low-flow, low-gradient aortic stenosis can be distinguished from pseudo-severe aortic stenosis by dobutamine stress echocardiography and/or multidetector computed tomography. Once the distinction is made, aortic valve replacement results in better outcomes compared with conservative management. Although both surgical and transcatheter aortic valve replacement result in adequate outcomes, the decision between the two treatment strategies is based on patient characteristics, valve morphology, and other risk factors.

An assessment of the quality of current clinical meta-analyses.

BACKGROUND: The objective of this study was to assess the overall quality of study-level meta-analyses in high-ranking journals using commonly employed guidelines and standards for systematic reviews and meta-analyses. METHODS: 100 randomly selected study-level meta-analyses published in ten highest-ranking clinical journals in 2016-2017 were evaluated by medical librarians against 4 assessments using a scale of 0-100: the Peer Review of Electronic Search Strategies (PRESS), Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), Institute of Medicine's (IOM) Standards for Systematic Reviews, and quality items from the Cochrane Handbook. Multiple regression was performed to assess meta-analyses characteristics' associated with quality scores. RESULTS: The overall median (interquartile range) scores were: PRESS 62.5(45.8-75.0), PRISMA 92.6(88.9-96.3), IOM 81.3(76.6-85.9), and Cochrane 66.7(50.0-83.3). Involvement of librarians was associated with higher PRESS and IOM scores on multiple regression. Compliance with journal guidelines was associated with higher PRISMA and IOM scores. CONCLUSION: This study raises concerns regarding the reporting and methodological quality of published MAs in high impact journals Early involvement of information specialists, stipulation of detailed author guidelines, and strict adherence to them may improve quality of published meta-analyses.

Sinus of Valsalva aneurysm repairs: Operative technique and lessons learned.

OBJECTIVE: Sinus of Valsalva (SOV) aneurysms are rare and data on operative management are limited. They can cause right ventricular outflow tract or pulmonary artery compression, and rupture may be fatal. In this study, we describe our experience with the repair of 13 SOV aneurysms. METHODS: All patients who underwent SOV aneurysm repair from May 2001 to December 2017 at our single tertiary referral center were reviewed retrospectively. RESULTS: Thirteen patients (92% male) with a mean age of 60 years underwent repair of an SOV aneurysm; mean aneurysm diameter was 5.9 ± 0.8 cm and four patients (30.7%) presented with rupture into another cardiac chamber. Operative interventions included six Bentall procedures, five patch repairs (one with aortic valve replacement [AVR]), and two primary aneurysm closures both with concomitant AVR. There were no strokes, myocardial infarctions, re-explorations, or deaths in the postoperative period. After an average of 2.25 years, computed tomographic imaging in five patients demonstrated no aneurysm recurrence. CONCLUSIONS: Surgery is a safe option for both ruptured and nonruptured SOV aneurysms. A variety of repair strategies may be used. Larger studies are needed.

Pulmonary artery aneurysms: Preoperative, intraoperative, and postoperative findings.

BACKGROUND: Pulmonary artery aneurysms (PAAs) are a rare but potentially lethal cardiovascular pathology. PAAs tend to develop in young patients with no gender discrepancy; they are most often associated with congenital heart disorders but also with systemic infections, vasculitis, pulmonary arterial hypertension, chronic pulmonary embolism, and malignancies. Dissection and rupture carry significant morbidity and mortality, thus patients require careful management, especially those with associated pulmonary hypertension. Given the rarity of this condition, physicians have yet to establish standard treatment guidelines. Most studies published to date are case reports with one or two patients; here, we describe our experience with six cases of large PAAs treated surgically at our institution. METHODS: We identified and retrospectively analyzed clinical data for patients who underwent surgery for PAAs between 2009 and 2017. RESULTS: The average age at surgery was 59.73 years, five patients were females, and 83.3% had baseline hypertension. Systolic murmurs were the most common clinical finding. The average aneurysmal size was 65.0 mm. We repaired the PAA with a woven Dacron graft (22-26 mm) in four patients. We performed concomitant pulmonary valve procedures on five patients: four replacements and one repair. Mean pump and cross-clamp times were 108.5 and 65 minutes. Operative and 30-day mortality was 0%. Average length of stay was 10.5 days. CONCLUSIONS: Postoperative mortality was 0%; all patients showed improvement of symptoms after surgery. These findings confirm that PAA repair has an acceptable risk profile in select patients.

Characteristics and anatomic distribution of early vs late stroke after cardiac surgery.

BACKGROUND: The primary objective of this study was to identify the specific predictors of early and late stroke in patients after open heart surgery. Secondary outcomes included (a) risk factors for perioperative stroke, (b) anatomic location of stroke according to time of presentation, and (c) the impact of stroke on operative mortality. METHODS: Adult patients undergoing open cardiac surgery with cardiopulmonary bypass from 2006 to 2016 at the New York Presbyterian Hospital/Weill Cornell Medicine were retrospectively reviewed. In total 7957 patients were included. We compared the demographic and perioperative variables in three groups: no stroke, early stroke, and late stroke using regression analysis. RESULTS: The incidence of perioperative stroke for the entire study period was 1.5% (117 of 7957). Early stroke occurred in 84 (71.8%) patients, whereas late stroke occurred in 33 (28.2%). Early strokes were usually embolic events (64 of 66, 97.0%, P = .66) on the right side (30 of 66, 45.5%, P < .001), in the anterior circulation (38 of 66, 57.6%, P = .001), or in multiple distributions (28 of 66, 42.4%, P = .002). Late strokes were more likely left-sided (16 of 28, 57.1%, P < .001) and uncommonly in both the anterior and posterior hemispheres (1 of 28, 3.6%, P = .001). Stroke, regardless of timing, was a significant predictor of operative mortality (odds ratio, 11.0, confidence interval, 6.1-19.7, P < .001). CONCLUSIONS: Early and late strokes after cardiac surgery have distinct incidence, location, and likely etiology. Both early and late strokes portend a very high incidence of operative mortality.

AngioVac for extraction of venous thromboses and endocardial vegetations: A meta-analysis.

BACKGROUND: AngioVac is a new device for filtering intravascular thrombi and emboli. Publications on the device are limited and underpowered to objectively estimate its safety and efficacy. We aimed to overcome this by performing a meta-analysis on the results of AngioVac for treating venous thromboses and endocardial vegetations. METHODS: A systematic literature review was performed to identify all articles reporting cardiac vegetation and/or thrombosis extraction using AngioVac. Endpoints were successful removal, operative mortality, conversion to open surgery, hospital stay, recurrent thromboembolism, and follow-up mortality. Random effect model was used, and pooled event rates (PERs) and incidence rate (IR) were calculated. RESULTS: A total of 42 studies with 182 patients (81 vegetation and 101 thrombosis) were included. Overall mean follow-up times were 3.1 and 0.7 years in vegetation and thrombosis patients, respectively. The PERs for successful removal were 74.5 (confidence interval [CI]: 48.2-90.2), 80.5 (CI: 70.0-88.0), and 32.4 (CI: 17.0-52.8) in vegetation, right atrial/caval venous thrombi, and pulmonary emboli (PE) patients, respectively. The PERs for operative mortalities were 14.6 (CI: 7.7-25.8), 14.8 (CI: 8.5-24.5), and 32.3 (CI: 15.1-56.3), respectively. The PERs for conversion to open surgery were 25.0 (CI: 9.3-51.9) and 12.3 (CI: 5.4-25.6) in vegetation and thrombosis patients, respectively. The IR of recurrent thromboembolism was 0.18 per person per year (PPY) (CI: 0.00-14.69) in vegetation and 0.19 PPY (CI: 0.08-0.48) in thrombosis patients. IR of follow-up mortality was 0.37 PPY (CI: 0.11-1.21) in thrombosis patients. CONCLUSIONS: AngioVac is a viable option for extracting right-sided vegetations and right atrial/caval venous thrombi. Rates of successful extraction and mortality are significantly worse for PE.

Volume outcome relationship in post-esophagectomy leak: A systematic review and meta-analysis.

BACKGROUND: Anastomotic leak after esophagectomy carries important short and long-term sequelae. We conducted a systematic review and meta-analysis to determine its association with surgical volume. MATERIALS AND METHODS: A systematic literature review was performed to identify all studies reporting on anastomotic leak after esophagectomy. Studies with <100 cases were excluded. The primary outcome was post-esophagectomy anastomotic leak, while secondary outcomes were operative mortality overall and after anastomotic leak. Pooled event rates (PER) were calculated and association with annual esophagectomy volume by center was investigated. RESULTS: Of the 3,932 retrieved articles, 472 were included (n=177,566 patients). The PER of anastomotic leak was 8.91% [95%CI=8.32; 9.53%]. The PER of early mortality overall and after anastomotic leak was 2.49% [95%CI=2.27; 2.74] and 11.39% [95%CI=9.66; 13.39], respectively. Centers with <37 annual esophagectomies had a higher leak rate compared to those with ≥37 annual esophagectomies (9.58% vs. 8.34%; P=0.040). On meta-regression, surgical volume was inversely associated with the PER of esophageal leak and of early mortality. CONCLUSION: The frequency of anastomotic leaks after esophagectomy, perioperative and leak associated mortality are inversely associated with esophagectomy volume.

Nonoperative management of contained retrohepatic caval injury.

Traumatic inferior vena cava (IVC) injuries are associated with high mortality rates, despite all improvements in the technical skills and prehospital and hospital care. Selective conservative management of the penetrating abdominal injuries involving IVC has not been widely discussed before. Here, we report a case of a young female with a single gunshot wound to her abdomen, who presented to our level 1 trauma center 10 minutes after injury and was hemodynamically stable. A computed tomographic scan revealed a large liver laceration with a trajectory through the liver and the IVC. The IVC was surrounded by a moderate amount of fluid, consistent with a contained retroperitoneal hematoma. We discuss the outcome of nonoperative management of this patient along with a review of the literature.

Spinal cord injury after open and endovascular repair of descending thoracic and thoracoabdominal aortic aneurysms: A meta-analysis.

OBJECTIVE: An inclusive contemporary analysis of spinal cord injury (SCI) rates in patients undergoing aneurysm repair and the factors associated with complications has not been performed. METHODS: Following a systematic literature search, studies from 2008 to 2018 on repair of descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) were pooled in a meta-analysis performed using the generic inverse variance method. The primary outcome was permanent SCI. Secondary outcomes were temporary SCI, operative mortality, long-term mortality, postoperative stroke, and cerebrospinal fluid (CSF) drain-related complications. RESULTS: One-hundred sixty-nine studies (22,634 patients) were included. The pooled rate of permanent SCI was 4.5% (95% confidence interval [CI], 3.8-5.4); 3.5% (95% CI, 1.8-6.7) for DTA and 7.6% (96% CI, 6.2-9.3) for TAAA repair (P for subgroups = .02), 5.7% (95% CI, 4.3-7.5) for open repair and 3.9% (95% CI, 3.1-4.8) for endovascular repair (P for subgroups = .03). Rates for Crawford extents I, II, III, IV, and V aneurysms were 4.0% (95% CI, 3.0-5.0), 15.0% (95% CI, 10.0-22.0), 7.0% (95% CI, 6.0-9.0), 2.0% (95% CI, 2.0-4.0), and 7.0% (95% CI, 2.0-23.0) respectively (P for subgroups <.001). The pooled rates for operative mortality, late mortality at a mean follow-up of 5.0 years, stroke, and temporary SCI were 7.4% (95% CI, 6.1-9.4), 1.0% (95% CI, 0.0-1.0), 4.2% (95% CI, 3.6-4.8), and 3.7% (95% CI, 3.0-4.6), respectively. The pooled rates for severe, moderate, and minor CSF-drain related complications were 5.1% (95% CI, 2.23-11.1), 4.1% (95% CI, 0.6-22.0), and 3.6% (95% CI, 1.2-8.0) respectively. CONCLUSIONS: Despite improvement, both open and endovascular aneurysm repair remain associated with a substantial risk of permanent SCI. The risk is greater for TAAA repair, especially extent II, III, and V.

Impact of left ventricular ejection fraction on the outcomes of open repair of descending thoracic and thoracoabdominal aneurysms.

OBJECTIVE: To discern the impact of depressed left ventricular ejection fraction (LVEF) on the outcomes of open descending thoracic aneurysm (DTA) and thoracoabdominal aneurysms (TAAA) repair. METHODS: Restricted cubic spline analysis was used to identify a threshold of LVEF, which corresponded to an increase in operative mortality and major adverse events (MAE: operative death, myocardial infarction, stroke, spinal cord injury, need for tracheostomy or dialysis). Logistic and Cox regression were performed to identify independent predictors of MAE, operative mortality, and survival. RESULTS: DTA/TAAA repair was performed in 833 patients between 1997 and 2018. Restricted cubic spline analysis showed that patients with LVEF <40% (n = 66) had an increased risk of MAE (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.22-3.87; P < .01) and operative mortality (OR, 2.72; 95% CI, 1.21-6.12; P = .02) compared with the group with LVEF ≥40% (n = 767). The group with LVEF <40% had a worse preoperative profile (eg, coronary revascularization, 48.5% vs 17.3% [P < .01]; valvular disease, 82.8% vs 49.39% [P < .01]; renal insufficiency, 45.5% vs 26.1% [P < .01]; respiratory insufficiency, 36.4% vs 21.2% [P = .01]) and worse long-term survival (35.5% vs 44.7% at 10 years; P = .01). Nonetheless, on multivariate regression, depressed LVEF was not an independent predictor of operative mortality, MAE, or survival. CONCLUSIONS: LVEF is not an independent predictor of adverse events in surgery for DTA.

A pairwise meta-analytic comparison of aortic valve area determined by planimetric versus hemodynamic methods in aortic stenosis.

BACKGROUND: Aortic valve area (AVA) is commonly determined from 2-dimensional transthoracic echocardiography (2D TTE) by the continuity equation; however, this method relies on geometric assumptions of the left ventricular outflow tract which may not hold true. This study compared mean differences and correlations for AVA by planimetric (2-dimensional transesophageal echocardiography [2D TEE], 3-dimensional transesophageal echocardiography [3D TEE], 3-dimensional transthoracic echocardiography [3D TTE], multi-detector computed tomography [MDCT], and magnetic resonance imaging [MRI]) with hemodynamic methods (2D TTE and catheterization) using pairwise meta-analysis. METHOD: Ovid MEDLINE®, Ovid EMBASE, and The Cochrane Library (Wiley) were queried for studies comparing AVA measurements assessed by planimetric and hemodynamic techniques. Pairwise meta-analysis for mean differences (using random effect model) and for correlation coefficients (r) were performed. RESULTS: Forty-five studies (3014 patients) were included. Mean differences between planimetric and hemodynamic techniques were 0.12 cm2 (95%CI 0.10-0.15) for AVA (pooled r = 0.84; 95%CI 0.76-0.90); 1.36cm2 (95%CI 1.03-1.69) for left ventricular outflow tract area; and 0.13 cm (95%CI 0.07-0.20) for annular diameter (pooled r = 0.76; 95% CI 0.64-0.94); 0.67 cm2 (95%CI 0.59-0.76) for annular area (pooled r = 0.74; 95%CI 0.55-0.86). CONCLUSIONS: Planimetric techniques slightly, but significantly, overestimate AVA when compared to hemodynamic techniques.

Treatment strategies in ischaemic left ventricular dysfunction: a network meta-analysis.

OBJECTIVES: The optimal revascularization strategy for patients with ischaemic left ventricular systolic dysfunction (iLVSD) remains controversial. We aimed to compare percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG) and medical therapy (MT) in a network meta-analysis. METHODS: All randomized controlled trials and observational studies comparing any combination of PCI, CABG and MT in patients with iLVSD were analysed in a frequentist network meta-analysis (generic inverse variance method). Primary outcome was mortality at longest available follow-up. Secondary outcomes were cardiac death, stroke, myocardial infarction (MI) and repeat revascularization (RR). RESULTS: Twenty-three studies were included (n = 23 633; 4 randomized controlled trials). Compared to CABG, PCI was associated with higher mortality [incidence rate ratio (IRR) 1.32, 95% confidence interval (CI) 1.13-1.53], cardiac death (IRR 1.65, 95% CI 1.18-2.33), MI (IRR 2.18, 95% CI 1.70-2.80) and RR (IRR 3.75, 95% CI 2.89-4.85). Compared to CABG, MT was associated with higher mortality (IRR 1.52, 95% CI 1.26-1.84), cardiac death (IRR 3.83, 95% CI 2.12-6.91), MI (IRR 3.22, 95% CI 1.52-6.79) and RR (IRR 3.37, 95% CI 1.67-6.79). Compared to MT, PCI was associated with lower cardiac death (IRR 0.43, 95% CI 0.24-0.78). CABG ranked as the best revascularization strategy for mortality, cardiac death, MI and RR; MT ranked as the strategy associated with the lowest incidence of stroke. Left ventricular ejection fraction, year of study, use of drug-eluting stents did not affect relative treatment effects. CONCLUSIONS: CABG appears to be the best therapy for iLVSD, although mainly based on observational data. Definitive randomized controlled trials comparing CABG and PCI in iLVSD are required. PROSPERO REGISTRATION ID: 132414.

The translation of surgical animal models to human clinical research: A cross-sectional study.

BACKGROUND: Surgical animal models are used in pre-clinical scientific studies. To date there has not been an analysis of how effective these data are when translated to human/clinical research. In this retrospective review, we evaluate the impact of studies using surgical animal models on human/clinical research through study-level analysis of citations. METHODS: The top two ranking clinical journals based on impact factor for the top ten surgical specialties were identified and a search was run on PubMed to identify studies using surgical animal models published in the years 2007 and 2008. The translation to human/clinical research of each study was evaluated by analyzing the frequency of citation in human studies over the ten years following publication. Regression was used to identify predictors of citation in human/clinical research. RESULTS: 411 animal studies using surgical models were identified. Over the course of the 10 years following publication the original animal studies were cited 6063 times, with 1300 (21.4%) citations in human/clinical studies and 4763 (78.6%) in animal/basic science studies. The median number of citations in human/clinical research was 1 (IQR 0-5). Regression showed an association between citation in human/clinical research and the use of porcine models and the specialties of general surgery, oral and maxillofacial surgery, orthopedic surgery, transplant, and plastic surgery. CONCLUSION: The use of animal models in surgical research shows poor translation to human/clinical research. Alternative surgical models should urgently be explored.

Characteristics of Contemporary Randomized Clinical Trials and Their Association With the Trial Funding Source in Invasive Cardiovascular Interventions.

Importance: Changes in evidence-based practice and guideline recommendations depend on high-quality randomized clinical trials (RCTs). Commercial device and pharmaceutical manufacturers are frequently involved in the funding, design, conduct, and reporting of trials, the implications of which have not been recently analyzed. Objective: To evaluate the design, outcomes, and reporting of contemporary randomized clinical trials of invasive cardiovascular interventions and their association with the funding source. Design, Setting, and Participants: This cross-sectional study analyzed published RCTs between January 1, 2008, to May 31, 2019. The trials included those involving coronary, vascular and structural interventional cardiology, and vascular and cardiac surgical procedures. Main Outcomes and Measures: We assessed (1) trial characteristics, (2) finding of a statistically significant difference in the primary end point favoring the experimental intervention, (3) reporting of implied treatment advantage in trials without significant differences in primary end point, (4) existence of major discrepancies between registered and published primary outcomes, (5) number of patients whose outcomes would need to switch from a nonevent to an event to convert a significant difference in primary end point to nonsignificant, and (6) association with funding source. Results: Of the 216 RCTs analyzed, 115 (53.2%) reported having commercial sponsorship. Most trials had 80% power to detect an estimated treatment effect of 30%, and 128 trials (59.3%) used composite primary end points. The median (interquartile range [IQR]) sample size was 502 (204-1702) patients, and the median (IQR) follow-up duration was 12 (1.0-14.4) months. Overall, 123 trials (57.0%) reported a statistically significant difference in the primary outcome favoring the experimental intervention; reporting strategies that implied an advantage were identified in 55 (65.5%) of 84 trials that reported nonsignificant differences. Commercial sponsorship was associated with a statistically significantly greater likelihood of favorable outcomes reporting (exponent of regression coefficient ß, 2.80; 95% CI, 1.09-7.18; P = .03) and with the reporting of findings that are inconsistent with the trial results. Discrepancies between the registered and published primary outcomes were found in 82 trials (38.0%), without differences in trial sponsorship. A median (IQR) number of 5 (2.8-12.5) patients experiencing a different outcome would have change statistically significant results to nonsignificant. Commercial sponsorship was associated with a greater number of patients (exponent of regression coefficient ß, 1.29; 95% CI, 1.00-1.66; P = .04). Conclusions and Relevance: These results suggest that contemporary RCTs of invasive cardiovascular interventions are relatively small and fragile, have short follow-up, and have limited power to detect large treatment effects. Commercial support appeared to be associated with differences in trial design, results, and reporting.

Open Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms: A Meta-Analysis.

BACKGROUND: Contemporary outcomes of open repair of thoracoabdominal aortic aneurysms (TAAAs) and descending thoracic aortic aneurysms (DTAs) have not been analyzed in an inclusive meta-analysis. METHODS: After a systematic literature search, studies from 2008 to 2018 reporting outcomes of open repair of DTAs or TAAAs were pooled in a single-arm meta-analysis performed using the generic inverse variance method. Primary outcome was operative mortality. Secondary outcomes were late mortality, postoperative stroke, permanent and temporary spinal cord injury, renal failure, respiratory failure, and myocardial infarction. RESULTS: Fifty-four studies with 12,245 patients were included. Pooled operative mortality for open repair was 10.4% (95% confidence interval [CI], 8.3-12.8): 6.6% (95% CI, 3.7-11.6) for DTA and 10.5% (95% CI, 7.5-14.5) for TAAA. Pooled incidence rate of late mortality was 0.6% (95% CI, 0.5-0.8) per person-year. Pooled rates for postoperative outcomes were 4.9% (95% CI, 3.9-6.1) for stroke; 5.7% (95% CI, 4.3-7.5) and 3.0% (95% CI, 2.1-4.2) for permanent and temporary spinal cord injury, respectively; 13.2% (95% CI, 9.9-17.3) for renal failure; 23.3% (95% CI, 17.5-30.4) for respiratory failure; and 2.7% (95% CI, 1.8-4.1) for myocardial infarction. At metaregression, year of publication, use of the clamp-and-sew technique, and use of the cerebrospinal fluid drain were associated with lower operative mortality. Ruptured aneurysms were associated with higher operative mortality. CONCLUSIONS: Despite improvement, open repair of DTAs and TAAAs continues to be associated with a considerable risk for operative death and perioperative complications. Use of the cerebrospinal fluid drain is associated with better outcomes.

Cerebral protection strategies in aortic arch surgery: A network meta-analysis.

OBJECTIVE: Cerebral protection for aortic arch surgery has been widely studied, but comparisons of all the available strategies have rarely been performed. We performed direct and indirect comparisons of antegrade cerebral perfusion, retrograde cerebral perfusion, and deep hypothermic circulatory arrest in a network meta-analysis. METHODS: After a systematic literature search, studies comparing any combination of antegrade cerebral perfusion, retrograde cerebral perfusion, and deep hypothermic circulatory arrest were included, and a frequentist network meta-analysis was performed using the generic inverse variance method. The primary outcomes were postoperative stroke and operative mortality. Secondary outcomes were postoperative transient neurologic deficits, myocardial infarction, respiratory complications, and renal failure. RESULTS: A total of 68 studies were included with a total of 26,968 patients. Compared with deep hypothermic circulatory arrest, both antegrade cerebral perfusion and retrograde cerebral perfusion were associated with significantly lower postoperative stroke and operative mortality rates: antegrade cerebral perfusion (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.51-0.75; and OR, 0.63, 95% CI, 0.51-0.76, respectively) and retrograde cerebral perfusion (OR, 0.66; 95% CI, 0.54-0.82; and OR, 0.57; 95% CI, 0.45-0.71, respectively). Antegrade cerebral perfusion and retrograde cerebral perfusion were associated with similar incidence of primary outcomes. No difference among the 3 techniques was found in secondary outcomes. At meta-regression, circulatory arrest duration correlated with the neuroprotective effect of antegrade cerebral perfusion and retrograde cerebral perfusion compared with deep hypothermic circulatory arrest. Unilateral or bilateral antegrade cerebral perfusion and arrest temperature did not influence the results. CONCLUSIONS: Antegrade cerebral perfusion and retrograde cerebral perfusion are associated with better postoperative outcomes compared with deep hypothermic circulatory arrest, and the relative benefit increases with the duration of the circulatory arrest. No differences between antegrade cerebral perfusion and retrograde cerebral perfusion were found for all the explored outcomes.

Disagreement Between Randomized and Observational Evidence on the Use of Bilateral Internal Thoracic Artery Grafting: A Meta-Analytic Approach.

Background The ART (Arterial Revascularization Trial) showed no difference in survival at 10 years between patients assigned to the single versus bilateral internal thoracic artery grafting strategies. This finding is in contrast with the results of most observational studies, where the use of 2 internal thoracic arteries has been associated with improved survival. Methods and Results We selected propensity-matched studies from the most comprehensive observational meta-analysis on the long-term outcomes of patients receiving 1 versus 2 internal thoracic arteries. Individual participant survival data from each study and the ART were reconstructed using an iterative algorithm that was applied to solve the Kaplan-Meier equations. The reconstructed individual participant survival data were aggregated to obtain combined survival curves and Cox regression hazard ratios with 95% CIs. Individual participant survival data were obtained from 14 matched observational studies (24 123 patients) and the ART. The 10-year survival of the control group of ART was significantly higher than that of the matched observational studies (hazard ratio, 0.86; 95% CI, 0.80-0.93). The 10-year survival of the experimental group of ART was significantly lower than that of the bilateral internal thoracic artery group of the observational studies (hazard ratio, 1.11; 95% CI, 1.03-1.20). Conclusions Both the improved outcome of the control arm and the lower beneficial effect of the intervention had played a role in the difference between observational evidence and ART.

Are racial differences in hospital mortality after coronary artery bypass graft surgery real? A risk-adjusted meta-analysis.

BACKGROUND: Despite several reports, there are still conflicting data on the influence of ethnicity on mortality rates associated with coronary artery bypass grafting (CABG). We aimed to get further insights into the effect of race on mortality following CABG by performing a risk adjusted meta-analysis. METHODS: Relevant studies were searched on PubMed, Embase, BioMed Central, and the Cochrane Central register. Pairwise meta-analysis was used to estimate the relative risk of hospital death of black, Hispanic, and Asian patients using white patients as reference. Risk adjusted meta-analytic estimates were obtained using generic inverse variance methods with random effect model. RESULTS: A total of 28 studies were selected for analysis. A total of 21 studies reported on hospital mortality in black (n = 222,892) versus white (n = 3,884,043) patients, 7 studies reported on Hispanic (n = 91,256) versus white (n = 1,458,524) and 9 studies reported on Asian (n = 27,820) versus white (n = 1,081,642). When compared with white patients, adjusted risk of hospital death was significantly greater for black patients (adjusted odds ratio [OR], 1.25; 95% confidence interval [CI], 1.13-1.39; P < .001), and not statistically different for Asian (OR, 1.33; 95% CI, 0.99-1.77; P = .05) and Hispanic patients (adjusted OR, 1.08; 95% CI, 0.94-1.23; P = .26). Meta-regression showed a significant trend toward lower mortality rates in most recent series in both black (P = .02) and white (P = .0007) and Asian (P = .01) but not for Hispanic (P = .41). However, as mortality rates were lower across the different races, the relative disadvantage between the study groups persisted, which may explain the lack of interaction between study period and race effect on mortality for black (adjusted P = .09), Asian (adjusted P = .63), and Hispanic (adjusted P = .97) patients. CONCLUSIONS: The present meta-analysis showed that despite progress is being made in lowering in-hospital mortality rates among the major racial/ethnic groups, ethnical disparities in hospital mortality after CABG remain.