Extended thoracic endovascular aortic repair is optimal therapy in acute complicated type B dissection.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) represents optimal therapy for complicated acute type B aortic dissection (aTBAD). Persistent knowledge gaps remain, including the optimal length of aortic coverage, impact on distal aortic remodeling, and fate of the dissected abdominal aorta. METHODS: Review of the Emory Aortic Database identified 92 patients who underwent TEVAR for complicated aTBAD from 2012 to 2018. Standard TEVAR covered aortic zones 3 and 4 (from the left subclavian to the mid-descending thoracic aorta). Extended TEVAR fully covered aortic zones 3 though 5 (from the left subclavian to the celiac artery). Long-term imaging, clinical follow-up, and overall and aortic-specific mortality were reviewed. RESULTS: Extended TEVAR (n = 52) required a greater length of coverage vs standard TEVAR (n = 40) (240 ± 32 mm vs 183 ± 23 mm; P < .01). In-hospital mortality occurred in 5.4% of patients (7.7% vs 2.5%; P = .27) owing to mesenteric malperfusion (n = 3) or rupture (n = 2). The overall incidences of postoperative stroke, transient paraparesis, paraplegia, and dialysis were 5.4% (3.9% vs 7.5%; P = .38), 3.2% (5.8% vs 0%; P = .18), 0%, and 0% respectively, equivalent between groups. Follow-up was 96.6% complete to a mean of 6.1 years (interquartile range, 3.5-8.6 years). There were significantly higher rates of complete thrombosis or obliteration of the entire thoracic false lumen after Extended TEVAR (82.2% vs 51.5%; P = .04). Distal aortic reinterventions were less frequent after extended TEVAR (5.8% vs 20%; P = .04). Late aorta-specific survival was 98.1% after extended TEVAR vs 92.3% for standard TEVAR (P = .32). CONCLUSIONS: Extended TEVAR for complicated aTBAD is safe, results in a high rate of total thoracic false lumen thrombosis/obliteration, and reduces distal reinterventions. Longer-term follow-up will be needed to demonstrate a survival benefit compared to limited aortic coverage.

Acute Type B Intramural Hematoma: Novel Insights in the Endovascular Era.

BACKGROUND: The pathophysiology and behavior of acute type B intramural hematoma (TBIMH) is poorly understood. The purpose of this study is to characterize the pathophysiology, fate, and outcomes of TBIMH in the endovascular era. METHODS: A retrospective analysis of a US Aortic Database identified 70 patients with TBIMH from 2008 to 2022. Patients were divided into groups and analyzed based upon subsequent management: early thoracic endovascular aortic repair (TEVAR; Group 1) or hospital discharge on optimal medical therapy (OMT) (Group 2). RESULTS: Of 70 total patients, 43% (30/70) underwent TEVAR (Group 1) and 57% (40/70) were discharged on OMT (Group 2). There were no significant differences in age, demographics, or comorbidities between groups. Indications for TEVAR in Group 1 were as follows: 1) Penetrating atheroscletoic ulcer (PAU) or ulcer-like projection (n = 26); 2) Descending thoracic aortic aneurysm (n = 3); or 3) Progression to type B aortic dissection (TBAD) (n = 2). Operative mortality was zero. No patient suffered a stroke or spinal cord ischemia. During the follow-up period, 50% (20/40) of Group 2 patients required delayed surgical intervention, including TEVAR in 14 patients and open repair in 6 patients. Indications for surgical intervention were as follows: 1) Development of a PAU / ulcer-like projection (n = 13); 2) Progression to TBAD (n = 3), or 3) Concomitant aneurysmal disease (n = 4). Twenty patients did not require surgical intervention. Of the initial cohort, 71% of patients required surgery, 9% progressed to TBAD, and 19% had regression or stability of TBIMH with OMT alone. CONCLUSIONS: The most common etiology of TBIMH is an intimal defect. Progression to TBAD and intramural hematoma regression without an intimal defect occurs in a small percentage of patients. An aggressive strategy with endovascular therapy and close surveillance for TBIMH results in excellent short-term and long-term outcomes.

A Perspective from New York of COVID 19: Effect and impact on cardiac surgery.

BACKGROUND AND AIM: First reported in December of 2019, the COVID-19 pandemic caused by SARS-CoV-2 has had a profound impact on the implementation of care. Here, we describe our institutional experience with a rapid influx of patients at the epicenter of the pandemic. METHODS: We retrospectively review our experience with the departments of cardiology, cardiothoracic surgery, anesthesia, and critical care medicine and summarize protocols developed in the midst of the pandemic. RESULTS: The rapid influx of patients requiring an intensive level of care required a complete restructuring of units, including the establishment of a new COVID-19 negative unit for the care of patients requiring urgent or emergent non-COVID-19 related care including open-heart surgery. This unique unit allowed for the delivery of safe and effective care in the epicenter of the pandemic. CONCLUSIONS: Here, we demonstrate the response of a large tertiary academic medical center to the COVID-19 pandemic. Specifically, we demonstrate how rapid structural changes can allow for the continued delivery of cardiac surgical care with similar outcomes as those reported before the pandemic.

Long-term Results of Valve-Sparing Aortic Root Replacement in Acute Type A Aortic Dissection.

BACKGROUND: Valve preservation in acute type A aortic dissection (ATAAD) can be accomplished with root repair or replacement. Long-term valve durability with root repair has been established, but limited data exist regarding long-term durability of valve-sparing root replacement (VSRR). In this study, long-term results of VSRR were compared with root repair in ATAAD. METHODS: From 2005 to 2023, 866 patients underwent ATAAD repair, of which 675 underwent root repair and 191 underwent root replacement (VSRR, n = 65; Bentall, n =126). VSRR patients were compared with 123 patients who underwent valve resuspension and root repair with postoperative echocardiograms ≥1 year. RESULTS: VSRR patients were younger (VSRR, 44 ± 11 years vs root repair, 55 ± 13 years; P < .001). Preoperatively, 57% of VSRR and 35% of root repair patients had moderate or more aortic insufficiency. Cardiopulmonary bypass and myocardial ischemia times were significantly longer in VSRR (P < .001). Postoperative echocardiograms with ≥1 year follow-up were analyzed in 58 VSRR patients with median follow-up of 4.8 years (interquartile range, 3-12 years) and in 123 root repair patients with median follow-up of 3.6 years (interquartile range, 3-8 years). At 10 years, VSRR patients had superior freedom from more than mild aortic insufficiency (VSRR, 91% vs root repair, 49%; P < .001). At 10 years, freedom from aortic valve replacement was equivalent (VSRR, 98% vs root repair, 92%; P = .269). CONCLUSIONS: VSRR provides equivalent long-term valve durability as root repair in ATAAD, even in patients with moderate or severe aortic insufficiency. In select young patients who require root replacement during ATAAD repair, VSRR represents an ideal therapy.

A novel hybrid prosthesis for open repair of acute DeBakey type I dissection with malperfusion: Early results from the PERSEVERE trial.

BACKGROUND: Outcomes after hemiarch repair for acute DeBakey type I aortic dissection (ADTI) remain unfavorable, with high rates of major adverse events and negative aortic remodeling. The PERSEVERE study evaluates the safety and effectiveness of the AMDS Hybrid prosthesis, a novel bare metal stent, in patients presenting with preoperative malperfusion. METHODS: PERSEVERE is a prospective single-arm investigational study conducted at 26 sites in the United States. Ninety-three patients underwent ADTI aortic dissection repair with AMDS implantation. The 30-day primary endpoints are a composite rate of 4 major adverse events and the rate of distal anastomotic new entry tears. The secondary endpoints include aortic remodeling. RESULTS: Clinical malperfusion was documented in 76 patients (82%); only radiographic malperfusion, in 17 (18%). The median follow-up in the 93 patients was 5.6 months. Within 30 days, 9 patients died (9.7%), 10 patients (10.8%) experienced new disabling stroke, and 18 patients (19.4%) had new-onset renal failure requiring ≥1 dialysis treatment. There were no cases of myocardial infarction. The composite rate of major adverse events (27%) was lower than that reported in the reference cohort (58%). There were no distal anastomotic new entry tears. Technical success was achieved in 99% of patients. Early remodeling indicated total aortic diameter stability, true lumen expansion, and false lumen reduction in the treated aortic segment. CONCLUSIONS: Early results show significant reductions in major adverse events and distal anastomotic new entry tears, successfully meeting both primary endpoints. The technical success rate was high. AMDS can be used safely in patients with ADTI dissection with malperfusion.

National trends in emergency coronary artery bypass grafting.

OBJECTIVES: Emergency coronary artery bypass grafting (CABG) is often omitted from current research, and volumes as well as outcomes are unknown. The purpose of this research is to examine national trends in emergency CABG. METHODS: The Society of Thoracic Surgeons national adult cardiac surgical database was queried from 2005 to 2017 for patients who underwent emergency and emergency salvage isolated CABG procedures, and 92 607 patients were included for analysis. Generalized linear mixed models were used to assess time trends, taking into account the clustering effect of region. RESULTS: Over the study period, volumes of emergency and emergency salvage CABG declined from 7991 to 6916 cases/year. Emergency and emergency salvage cases accounted for ∼4.9% of all CABG procedures performed nationwide in 2005 and 4.1% in 2017. The predicted risk of mortality (PROM) declined in the entire patient cohort over time from 12% to 8% (P < 0.0001). Rates of important postoperative morbidities also declined including prolonged intubation, re-exploration for haemorrhage and postoperative pneumonia (P < 0.001). Observed-to-expected mortality rates rose over the study period from 0.81 to 1.06 as the overall PROM declined from 9.3% to 7.6%. Emergency salvage CABG rates also declined over the course of the study from 358 to 323 cases/year. The observed-to-expected ratios for mortality increased for emergency salvage CABG during the study from 1.16 to 1.66, and emergency salvage mortality rates averaged 46.5%. CONCLUSIONS: The volume of patients undergoing emergency and emergency salvage CABG in the USA has declined. Increases in mortality are largely driven by emergency salvage cases, and the PROM algorithm may not accurately reflect the risk involved for these patients.

Retrograde Cerebral Perfusion May Decrease Stroke Risk During Elective Aortic Arch Surgery.

OBJECTIVE: Controversy remains regarding the optimal neuroprotection strategy for elective hemiarch replacement (HEMI). This study sought to compare outcomes in patients who underwent HEMI utilizing the 2 most common contemporary methods of cerebral protection. METHODS: The ARCH international aortic database was queried, and 782 patients undergoing elective HEMI with circulatory arrest from 2007 to 2012 were identified. There were 418 patients who underwent HEMI using moderate hypothermia (nasopharyngeal temperature 20.1 to 28.0 °C) and antegrade cerebral perfusion (MHCA/ACP). There were 364 patients who underwent HEMI using deep hypothermia (nasopharyngeal temperature 14.1 to 20 °C) and retrograde cerebral perfusion (DHCA/RCP). Adverse outcomes were compared between the groups using both univariable and multivariable analyses. RESULTS: Patients who underwent MHCA/ACP were older (64 vs 61 years, P = 0.01) and more frequently had peripheral vascular disease than DHCA/RCP patients (28.5% vs 7.1%, P < 0.001). Patients in the DHCA/RCP group had a greater incidence of full aortic root replacement (55.8% vs 26.4%, P < 0.001) and more frequently had a central cannulation strategy (83% vs 55.7%, P < 0.001). Cardiopulmonary bypass (170 vs 157 min, P = 0.002) and aortic cross-clamp (134 vs 92 min, P < 0.001) times were significantly longer in the DHCA/RCP group. On univariable analysis, overall mortality was statistically similar between groups (MHCA/ACP 3.4% vs DHCA/RCP 2.3%, P = 0.47), but permanent neurologic deficits were significantly lower in the DHCA/RCP cohort (MHCA/ACP 3.9% vs DHCA/RCP 1.0%, P = 0.02). Multivariable analysis showed no difference in mortality nor perioperative stroke between perfusion cohorts. CONCLUSIONS: Both MHCA/ACP and DHCA/RCP are excellent neuroprotective strategies that produce low mortality in patients undergoing elective HEMI. DHCA/RCP may demonstrate theoretically improved neurologic outcomes compared with MHCA/ACP, but this topic warrants further study.

Acute-on-Chronic Aortic Dissection: Management and Outcomes of the Unstable "Triple-Lumen" Aorta.

BACKGROUND: The impact of acute aortic dissection of the chronically dissected distal aorta is unknown. This study sought to describe the incidence and characteristics of the triple-lumen aortic dissection and its impact on survival. METHODS: From 2010 to 2021, a query of a single-institution aortic database identified 1149 patients with chronic distal aortic dissection. Thirty-three (2.9%) patients with at least 3 distinct lumens and 2 separate "primary" intimal tears were identified by analysis of contrast-enhanced cross-sectional imaging. Triple-lumen patients were exactly matched with a cohort of double-lumen patients on a 1:1 ratio using 5 preoperative variables, and outcomes between the groups were assessed. RESULTS: The median age at time of initial dissection in patients with a triple-lumen dissection was 46 years. Initial dissection was a type A in 33% and a type B in 67% of patients. The median time from initial dissection to triple-lumen diagnosis was 4.2 years. On diagnosis of the triple-lumen aorta, 85% of patients required urgent aortic repair for rapid growth (36%), aortic diameter ≥55 mm (30%), malperfusion (6%), intractable pain (6%), and rupture/type A (6%). Thirty-day mortality after triple lumen dissection was 12%. CONCLUSIONS: Acute-on-chronic distal dissection resulting in a triple-lumen aorta should be classified as a "complicated" type B dissection as these patients typically have large aneurysms and a high incidence of rapid false lumen expansion requiring urgent surgical repair.

Prolonged Periods of Antegrade Cerebral Perfusion Are Safe During Elective Arch Surgery.

BACKGROUND: Cerebral circulatory arrest times >40 minutes during aortic surgery have previously been shown to be associated with increased morbidity and mortality. The purpose of this study was to redefine what would constitute a safe period of circulatory arrest for patients who underwent elective proximal aortic operations requiring antegrade cerebral perfusion (ACP). METHODS: The ARCH International aortic database was queried, and 2008 patients undergoing elective arch operations with circulatory arrest using ACP were identified. Circulatory arrest time was categorized a priori in 10-minute intervals. To further determine the impact of this variable on outcomes, hierarchical multivariable regression analysis was performed. RESULTS: Unadjusted mortality increased with increasing circulatory arrest time from 4.8% (<40 minutes) to 13.5% (>90 minutes; P < .001), but risk of stroke was not impacted (P = .4). When treated as a continuous variable, mortality increased significantly with increasing circulatory arrest time, whereas the risk of permanent stroke did not. Using <40 minutes as the reference, multivariable analysis showed no statistical increase in mortality for ranges up to 80 minutes of circulatory arrest. The risk of permanent stroke was not significantly higher for any time interval >40 minutes up to 90 minutes. CONCLUSIONS: In this series of patients who underwent elective proximal aortic surgery using ACP, periods of circulatory arrest up to at least 80 minutes were not associated with significant increases in mortality or permanent stroke. Modern perfusion strategies have allowed for increased safety during elective arch cases requiring prolonged periods of circulatory arrest.

A tailored strategy for repair of acute type A aortic dissection.

OBJECTIVE: Innumerable surgical techniques are currently deployed for repairing acute type A aortic dissection (ATAAD). We analyzed our results using a conservative approach of root-sparing and hemiarch techniques in higher-risk patients and root and total arch replacement for lower-risk patients. METHODS: We queried our aortic database for consecutive patients who underwent ATAAD repair. Patients who underwent conservative repair (group 1) were compared with those who underwent extensive repair (group 2) using univariable and multivariable analysis. RESULTS: From 1997 to 2019, 343 patients underwent ATAAD repair. Two hundred forty had conservative repair (root-sparing, hemiarch) whereas 103 had extensive repair (root replacement and/or total arch). Group 1 was older with more comorbidities such as hypertension, previous myocardial infarction, and renal dysfunction. Group 2 had more connective tissue disease (2.1% vs 12.6%; P < .01), aortic insufficiency, and longer intraoperative times. The incidence of individual postoperative complications was similar regardless of approach. A composite of major adverse events (operative mortality, myocardial infarction, stroke, dialysis, or tracheostomy) was higher in the conservative group (15.1% vs 5.9%; P = .03). Operative mortality was 5.6% and not different between groups. Ten-year survival was similar with either surgical approach. Ten-year cumulative risk of reintervention was greater in group 2 (5.6% vs 21% at 10 years; P < .01). In multivariable analysis, ejection fraction and diabetes were predictors of major adverse events but not extensive approach. Extensive approach was a predictor of late reoperation (odds ratio, 3.03 [95% confidence interval, 1.29-7.2]; P = .01). CONCLUSIONS: A tailored conservative approach to ATAAD leads to favorable operative outcomes without compromising durability.

Cardiac Surgery Outcomes in an Epicenter of the COVID-19 Pandemic.

As New York State quickly became the epicenter of the COVID-19 pandemic, innovative strategies to provide care for the COVID-19 negative patients with urgent or immediately life threatening cardiovascular conditions became imperative. To date, there has not been a focused analysis of patients undergoing cardiothoracic surgery in the United States during the COVID-19 pandemic. Therefore, we seek to summarize the selection, screening, exposure/conversion, and recovery of patients undergoing cardiac surgery during the peak of the COVID-19 pandemic. We retrospectively reviewed a prospectively maintained institutional database for patients undergoing urgent or emergency cardiac surgery from March 16, 2020 to May 15, 2020, encompassing the peak of the COVID-19 pandemic. All patients were operated on in a single institution in New York City. Preoperative demographics, imaging studies, intraoperative findings, and postoperative outcomes were reviewed. Between March 16, 2020 and May 15, 2020, a total of 54 adult patients underwent cardiac surgery. Five patients required reoperative sternotomy and cardiopulmonary bypass was utilized in 81% of cases. Median age was 64.3 (56.0; 75.3) years. Two patients converted to COVID-19 positive during the admission. There was one operative mortality (1.9%) associated with an acute perioperative COVID-19 infection. Median length of hospital stay was 5 days (4.0; 8.0) and 46 patients were discharged to home. There was 100% postoperative follow up and no patient had COVID-19 conversion following discharge. The delivery of cardiac surgical care was safely maintained in the midst of a global pandemic. The outcomes demonstrated herein suggest that with proper infection control, isolation, and patient selection, results similar to those observed in non-COVID series can be replicated.

Diaphragm Preservation Reduces Respiratory Failure After Extent I Thoracoabdominal Aneurysm Repair.

BACKGROUND: We sought to evaluate the impact of surgical approach (thoracophrenolaparotomy vs thoracotomy crura splitting) on the outcomes of extent I thoracoabdominal aortic aneurysm repair. METHODS: Patient data were extracted from our aortic surgery database. The primary endpoint was need for tracheostomy, and secondary endpoints were operative mortality, myocardial infarction, stroke, spinal cord injury, de novo dialysis, and major adverse events (composite of secondary endpoints and tracheostomy). Freedom from death and reoperation during follow-up were calculated. Risk adjustment was obtained with propensity score matching and multivariable regression. RESULTS: Three hundred twenty-five patients underwent extent I repair. Compared with thoracophrenolaparotomy patients (n = 226), thoracotomy crura-splitting patients (n = 99) had a higher rate of previous coronary revascularization (27.3% vs 14.2%, P = .005), valvular disease (64.6% vs 50.4%, P = .018), and chronic obstructive pulmonary disease (61.6% vs 28.3%, P = .000) and a lower forced expiratory volume in 1 second (46% vs 69%, P = .000). In a matched sample thoracotomy crura splitting was associated with a decreased need for tracheostomy (4.0% vs 13.1%, P = .035). The need for tracheostomy was predicted by female gender (odds ratio, 3.11; 95% confidence interval, 1.17-8.30; P = .023), forced expiratory volume in 1 second (odds ratio, 0.95; 95% confidence interval, 0.91-0.98; P = .003), and thoracophrenolaparotomy (odds ratio, 3.66; 95% confidence interval, 1.14-11.73; P = .029). Five-year freedom from mortality and reoperation were similar. CONCLUSIONS: In patients undergoing extent I thoracoabdominal aortic aneurysm repair, thoracotomy crura splitting was associated with decreased need for tracheostomy.

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.

An overview of epigenetic assays.

A significant portion of ongoing epigenetic research involves the investigation of DNA methylation and chromatin modification patterns seen throughout many biological processes. Over the last few years, epigenetic research has undergone a gradual shift and recent studies have been directed toward a genome-wide assessment. DNA methylation and chromatin modifications are essential components of the regulation of gene activity. DNA methylation effectively down-regulates gene activity by addition of a methyl group to the five-carbon of a cytosine base. Less specifically, modification of the chromatin structure can be carried out by multiple mechanisms leading to either the upregulation or down-regulation of the associated gene. Of the many assays used to assess the effects of epigenetic modifications, chromatin immunoprecipitation (ChIP), which serves to monitor changes in chromatin structure, and bisulfite modification, which tracks changes in DNA methylation, are the two most commonly used techniques.

Relationships between the posterior interosseous nerve and the supinator muscle: application to peripheral nerve compression syndromes and nerve transfer procedures.

BACKGROUND AND STUDY AIMS: Little information can be found in the literature regarding the relationships of the posterior interosseous nerve (PIN) while it traverses the supinator muscle. Because compression syndromes may involve this nerve at this site and researchers have investigated using branches of the PIN to the supinator for neurotization procedures, the authors' aim was to elucidate information about this anatomy. MATERIALS AND METHODS: Dissection was performed on 52 cadaveric limbs to investigate branching patterns of the PIN within the supinator muscle. RESULTS: On 29 sides, the PIN entered the supinator muscle as a single nerve and from its medial side provided two to four branches to the muscle. On 23 sides, the nerve entered the supinator muscle as two approximately equal-size branches that arose from the radial nerve on average 2.2 cm from the proximal edge of this muscle. In these cases, the medial of the two branches terminated on the supinator muscle, and the lateral branch traveled through the supinator muscle; in 13 specimens, it provided additional smaller branches to the supinator muscle. The length of PIN within the supinator muscle was 4 cm on average, and the diameter of its branches to the supinator muscle ranged from 0.8 to 1.1 mm. In 10 specimens, the PIN left the supinator muscle before the most distal aspect of the muscle. In two specimens with a single broad PIN, muscle fibers of the supinator muscle pierced the PIN as it traveled through it. CONCLUSION: This knowledge of the anatomy of the PIN as it passes through the supinator muscle may be useful to neurosurgeons during decompressive procedures or neurotization.