Improving outcomes after low-risk coronary artery bypass grafting: understanding phase of care mortality analysis, failure to rescue and recent perioperative recommendations.

PURPOSE OF REVIEW: Avoidable adverse events are responsible for up to 50% of deaths after low-risk coronary artery bypass grafting. This article reviews recent quality improvement efforts to improve outcomes after cardiac surgery. RECENT FINDINGS: Systematic quality improvement methodology in cardiac surgery has improved significantly over the past decade. Contemporary efforts with phase of care mortality analysis (POCMA) focus on identifying and addressing root causes for mortality. Each patient's perioperative course is an interconnected sequence of clinical events, decisions, interventions, and treatment responses occurring across five perioperative phases. A single seminal event within a specific phase of care has been found to often trigger the eventual death of a patient. Several groups have made significant improvements to perioperative outcomes by addressing these avoidable mortality trigger events. Failing that, failure to rescue (FTR) metrics can be used to identify institutional factors responsible for poor perioperative outcomes. This ongoing focus on quality improvement serves to further improve outcomes after low-risk cardiac surgery. SUMMARY: Modern quality improvement methodology, including POCMA and FTR analysis, has the potential to significantly improve outcomes after cardiac surgery. Larger future studies with multiinstitutional data sharing will be key to facilitate ongoing quality improvement and knowledge translation in this field.

Two-year outcomes from the PARTNER 3 trial: where do we stand?

PURPOSE OF REVIEW: The PARTNER 3 trial was conducted to compare outcomes after transcatheter aortic valve replacement (TAVR) with a balloon-expandable valve and surgical aortic valve replacement (SAVR) in individuals at low surgical risk with aortic stenosis. Recently reported rates of death, stoke and valve thrombosis in the TAVR arm have raised concerns about the longevity of this intervention in low-risk individuals. It is incumbent on all members of the Heart Team to understand the potential consequences of these findings. RECENT FINDINGS: TAVR was initially superior to SAVR at 1 year for a primary composite endpoint of death, stroke and rehospitalization. Results at 2 years now indicate noninferiority. Potential causative factors, comparisons with other transcatheter valves and implications for patients, providers and trainees are explored. Recommendations are additionally provided regarding TAVR and SAVR in individuals with aortic stenosis. SUMMARY: Concerns regarding the longevity of TAVR in low-risk individuals notwithstanding, results from PARTNER 3 indicate that TAVR is at least noninferior to SAVR out to 2 years. Longer follow-up will be required to determine whether these newly founded concerns are justifiable.

Sex-Related Differences in Patients Undergoing Thoracic Aortic Surgery.

BACKGROUND: Contemporary outcomes after surgical management of thoracic aortic disease have improved; however, the impact of sex-related differences is poorly understood. METHODS: A total of 1653 patients (498 [30.1%] female) underwent thoracic aortic surgery with hypothermic circulatory arrest between 2002 and 2017 in 10 institutions of the Canadian Thoracic Aortic Collaborative. Outcomes of interest were in-hospital death, stroke, and a modified Society of Thoracic Surgeons-defined composite for mortality or major morbidity (stroke, renal failure, deep sternal wound infection, reoperation, prolonged ventilation). Multivariable logistic regression was used to determine independent predictors of these outcomes. RESULTS: Women were older (mean±SD, 66±13 years versus 61±13 years; P<0.001), with more hypertension and renal failure, but had less coronary disease, less previous cardiac surgery, and higher ejection fraction than men. Rates of aortic dissection were similar between women and men. Rates of hemiarch, and total arch repair were similar between the sexes; however, women underwent less aortic root reconstruction including aortic root replacement, Ross, or valve-sparing root operations (29% versus 45%; P<0.001). Men experienced longer cross-clamp and cardiopulmonary bypass times, but similar durations of circulatory arrest, methods of cerebral perfusion, and nadir temperatures. Women experienced a higher rate of mortality (11% versus 7.4%; P=0.02), stroke (8.8% versus 5.5%; P=0.01), and Society of Thoracic Surgeons-defined composite end point for mortality or major morbidity (31% versus 27%; P=0.04). On multivariable analyses, female sex was an independent predictor of mortality (odds ratio, 1.81; P<0.001), stroke (odds ratio, 1.90; P<0.001), and Society of Thoracic Surgeons-defined composite end point for mortality or major morbidity (odds ratio, 1.40; P<0.001). CONCLUSIONS: Women experience worse outcomes after thoracic aortic surgery with hypothermic circulatory arrest. Further investigation is required to better delineate which measures may reduce sex-related outcome differences after complex aortic surgery.

The COMPASS trial: practical considerations for application after coronary artery bypass surgery.

PURPOSE OF REVIEW: We review the cardiovascular outcomes for people using anticoagulation strategies (COMPASS) trial with particular emphasis on patients with a history of remote coronary artery bypass grafting (CABG) and those who were enrolled 4-14 days after CABG. We provide practical guidance for selecting patients with the greatest potential to benefit who have acceptable bleeding risk. In particular, we address concerns about postoperative bleeding and discuss the relative merits of rivaroxaban and aspirin versus P2Y12 inhibition and aspirin. RECENT FINDINGS: The COMPASS trial demonstrated that rivaroxaban and aspirin reduce myocardial infarction, stroke, and cardiovascular death in patients with coronary artery disease, without a demonstrated effect on bypass graft patency in the first postoperative year. SUMMARY: After CABG, cardiac surgeons should consider using the COMPASS regimen in patients at high risk of thrombosis whose risk of bleeding is acceptable. If used, the COMPASS regimen should be continued indefinitely in conjunction with other pharmacological risk reduction therapies to prevent long-term atherothrombotic events.

The effect of restrictive versus liberal transfusion strategies on longer-term outcomes after cardiac surgery: a systematic review and meta-analysis with trial sequential analysis.

PURPOSE: Blood transfusions are frequently administered in cardiac surgery. Despite a large number of published studies comparing a "restrictive" strategy with a "liberal" strategy, no clear consensus has emerged to guide blood transfusion practice in cardiac surgery patients. The purpose of this study was to identify, critically appraise, and summarize the evidence on the overall effect of restrictive transfusion strategies compared with liberal transfusion strategies on mortality, other clinical outcomes, and transfusion-related outcomes in adult patients undergoing cardiac surgery. SOURCE: We searched MEDLINE (OvidSP), EMBASE (OvidSP) and Cochrane CENTRAL (Wiley) from inception to 1 December 2017 and queried clinical trial registries and conference proceedings for randomized-controlled trials of liberal vs restrictive transfusion strategies in cardiac surgery. PRINCIPAL FINDINGS: From 7,908 citations, we included ten trials (9,101 patients) and eight companion publications. Overall, we found no significant difference in mortality between restrictive and liberal transfusion strategies (risk ratio [RR], 1.08; 95% confidence interval [CI], 0.76 to 1.54; I2 = 33%; seven trials; 8,661 patients). The use of a restrictive transfusion strategy did not appear to adversely impact any of the secondary clinical outcomes. As expected, the proportion of patients who received red blood cells (RBCs) in the restrictive group was significantly lower than in the liberal group (RR, 0.68; 95% CI, 0.64 to 0.73; I2 = 56%; 5 trials; 8,534 patients). Among transfused patients, a restrictive transfusion strategy was associated with fewer transfused RBC units per patient than a liberal transfusion strategy. CONCLUSIONS: In adult patients undergoing cardiac surgery, a restrictive transfusion strategy reduces RBC transfusion without impacting mortality rate or the incidence of other perioperative complications. Nevertheless, further large trials in subgroups of patients, potentially of differing age, are needed to establish firm evidence to guide transfusion in cardiac surgery. TRIAL REGISTRATION: PROSPERO (CRD42017071440); registered 20 April, 2018.

RéSUMé: OBJECTIF: Les transfusions sanguines sont fréquentes après une chirurgie cardiaque. Malgré le nombre important d'études publiées comparant une stratégie « restrictive ¼ à une stratégie « libérale ¼, aucun consensus clair n'est apparu pour guider la pratique de la transfusion sanguine chez les patients de chirurgie cardiaque. L'objectif de cette étude était d'identifier, d'évaluer de façon critique et de résumer les données probantes sur l'effet global des stratégies de transfusion restrictives comparativement aux stratégies libérales sur la mortalité, les autres devenirs cliniques, et les devenirs liés à la transfusion chez des patients adultes subissant une chirurgie cardiaque. SOURCE: Nous avons réalisé des recherches dans les bases de données MEDLINE (OvidSP), EMBASE (OvidSP) et Cochrane CENTRAL (Wiley) de leur création jusqu'au 1er décembre 2017 et avons exploré les registres d'études cliniques et les actes de conférence pour en tirer les études randomisées contrôlées évaluant des stratégies transfusionnelles restrictives vs libérales en chirurgie cardiaque. CONSTATATIONS PRINCIPALES: Sur 7908 citations, nous avons inclus dix études (9101 patients) et huit publications connexes. Globalement, nous n'avons observé aucune différence significative en matière de mortalité entre les stratégies transfusionnelles restrictives et libérales (risque relatif [RR], 1,08; intervalle de confiance [IC] 95 %, 0,76 à 1,54; I2 = 33 %; sept études; 8661 patients). Le recours à une stratégie de transfusion restrictive n'a semblé avoir aucun impact négatif sur quelque résultat clinique secondaire que ce soit. Comme anticipé, la proportion de patients ayant reçu des érythrocytes dans le groupe restrictif était significativement plus basse que dans le groupe libéral (RR, 0,68; IC 95 %, 0,64 à 0,73; I2 = 56 %; 7 études; 8534 patients). Parmi les patients transfusés, une stratégie de transfusion restrictive a été associée à un nombre moindre d'unités d'érythrocytes transfusées par patient que dans une stratégie transfusionnelle libérale. CONCLUSION: Dans une population de patients adultes subissant une chirurgie cardiaque, une stratégie transfusionnelle restrictive réduit la transfusion d'érythrocytes sans avoir d'impact sur le taux de mortalité ou sur l'incidence d'autres complications périopératoires. D'autres grandes études sur différents sous-groupes de patients, peut-être d'âges différents, sont toutefois nécessaires afin d'établir des données probantes concluantes pour guider les transfusions en chirurgie cardiaque. ENREGISTREMENT DE L'éTUDE: PROSPERO (CRD42017071440); enregistrée le 20 avril 2018.

Variability in opioid prescribing practices among cardiac surgeons and trainees.

BACKGROUND AND AIM: The opioid epidemic has become a major public health crisis in recent years. Discharge opioid prescription following cardiac surgery has been associated with opioid use disorder; however, ideal practices remain unclear. Our aim was to examine current practices in discharge opioid prescription among cardiac surgeons and trainees. METHODS: A survey instrument with open- and closed-ended questions, developed through a 3-round Delphi method, was circulated to cardiac surgeons and trainees via the Canadian Society of Cardiac Surgeons. Survey questions focused on routine prescription practices including type, dosage and duration. Respondents were also asked about their perceptions of current education and guidelines surrounding opioid medication. RESULTS: Eighty-one percent of respondents reported prescribing opioids at discharge following routine sternotomy-based procedures, however, there remained significant variability in the type and dose of medication prescribed. The median (interquartile range) number of pills prescribed was 30 (20-30) with a median total dose of 135 (113-200) Morphine Milligram Equivalents. Informal teaching was the most commonly reported primary influence on prescribing habits and a lack of formal education regarding opioid prescription was associated with a higher number of pills prescribed. A majority of respondents (91%) felt that there would be value in establishing practice guidelines for opioid prescription following cardiac surgery. CONCLUSIONS: Significant variability exists with respect to routine opioid prescription at discharge following cardiac surgery. Education has come predominantly from informal sources and there is a desire for guidelines. Standardization in this area may have a role in combatting the opioid epidemic.

The impact of hyperoxia on outcomes after cardiac surgery: a systematic review and narrative synthesis.

PURPOSE: Historically, cardiac surgery patients have often been managed with supraphysiologic intraoperative oxygen levels to protect against the risks of cellular hypoxia inherent in the un-physiologic nature of surgery and cardiopulmonary bypass. This may result in excessive reactive oxygen species generation and exacerbation of ischemia-reperfusion injury. In this review, we synthesize all available data from randomized controlled trials (RCTs) to investigate the impact that hyperoxia has on postoperative organ dysfunction, length of stay, and mortality during adult cardiac surgery. SOURCE: We searched Medline, Embase, Scopus, and Cochrane Central Register of Controlled Trials databases using a high-sensitivity strategy for RCTs that compared oxygenation strategies for adult cardiac surgery. Our primary outcome was postoperative organ dysfunction defined by postoperative increases in myocardial enzymes, acute kidney injury, and neurologic dysfunction. Secondary outcomes were mortality, ventilator days, and length of stay in the hospital and intensive care unit. PRINCIPAL FINDINGS: We identified 12 RCTs that met our inclusion criteria. Risk of bias was unclear to high in all but one trial. Significant heterogeneity in timing of the treatment period and the oxygenation levels targeted was evident and precluded meta-analysis. The large majority of trials found no difference between hyperoxia and normoxia for any outcome. Two trials reported reduced postoperative myocardial enzymes and one trial reported reduced mechanical ventilation time in the normoxia group. CONCLUSIONS: Hyperoxia had minimal impact on organ dysfunction, length of stay, and mortality in adult cardiac surgery. The current evidence base is small, heterogeneous, and at risk of bias. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) (CRD42017074712). Registered 17 August 2017.

Point-of-care viscoelastic hemostatic testing in cardiac surgery patients: a systematic review and meta-analysis.

PURPOSE: Thromboelastography and rotational thromboelastometry are point-of-care (POC) viscoelastic tests used to help guide blood product administration. It is unclear whether these tests improve clinical or transfusion-related outcomes. The objective of this study was to appraise data from randomized trials evaluating the benefit of POC testing in cardiac surgery patients. Primary outcomes were the proportion of patients transfused with blood products and all-cause mortality. SOURCE: Medline (Ovid), EMBASE (Ovid), CENTRAL (the Cochrane Library-Wiley), Web of Science, Biosis, Scopus, and CINAHL databases, as well as clinical trial registries and conference proceedings were queried from inception to February 2018. PRINCIPAL FINDINGS: We identified 1,917 records, 11 of which were included in our analysis (8,294 patients). Point-of-care testing was not associated with a difference in the proportion of patients transfused with any blood product (risk ratio [RR], 0.90; 95% confidence interval [CI], 0.79 to 1.02; I2 = 51%; four trials, 7,623 patients), or all-cause mortality (RR, 0.73; 95% CI, 0.47 to 1.13; I2 = 5%; six trials, 7,931 patients). Nevertheless, POC testing was weakly associated with a decrease in the proportion of patients receiving red blood cells (RBC) (RR, 0.91; 95% CI, 0.85 to 0.96; I2 = 0%; seven trials, 8,029 patients), and heterogeneous reductions in frozen plasma (FP) (RR, 0.58; 95% CI, 0.34 to 0.99; I2 = 87%; six trials, 7,989 patients) and platelets (RR, 0.66; 95% CI, 0.49 to 0.90; I2 = 65%; seven trials, 8,029 patients). Meta-analysis of the number of units of RBCs and FP was not possible due to heterogeneity in reporting, however POC testing significantly reduced the units of platelets transfused (standard mean difference, -0.09; 95% CI, -0.18 to 0.00; four trials, 7,643 patients). CONCLUSION: Our review indicates that in cardiac surgery patients, POC viscoelastic hemostatic testing is not associated with a reduction in the proportion of patients receiving any blood product or all-cause mortality. However, viscoelastic testing is weakly associated with a reduction in proportion of patients transfused with specific blood products. Presently, the benefits associated with viscoelastic testing in cardiac surgery patients are insufficiently robust to recommend routine implementation of this technology. TRIAL REGISTRATION: PROSPERO (CRD4201706577). Registered 11 May 2017.

Coronary Angiography Within 30 Days From Coronary Artery Bypass Graft Surgery: Indications, Findings, and Outcomes.

BACKGROUND: The incidence, indications, and outcomes of coronary angiography (CAG) performed within 30 days following coronary artery bypass graft surgery (CABG) have received limited study. METHODS: We reviewed patients who underwent CAG within 30 days following CABG between April 2018 and September 2021 at a large quaternary healthcare system. RESULTS: Of 2209 patients who underwent CABG during the study, 111 (5%) underwent CAG within 30 days following CABG. Mean age was 65 ± 10 years and they had high prevalence of comorbidities. Graft utilization was as follows: left internal mammary artery (LIMA) (84%); saphenous vein graft(s) (SVG) (81%); and right internal mammary artery (RIMA) (22%). The most common presentations/indications for angiography were cardiogenic shock (41%), ST-segment-elevation myocardial infarction (32%), and achieving complete revascularization by percutaneous coronary intervention (PCI) (16%). The LIMA, RIMA, and SVGs were completely/partially occluded in 41 (44%), 10 (42%), and 11 (50%) of patients, respectively. Of the 111 patients who underwent CAG, 55 (50%) underwent PCI, including 47 (85%) to the native vessel and 8 (15%) to the bypass graft, and 19 (17%) underwent repeat sternotomy. Overall, 29 patients (26%) required 30-day readmission following CAG and 19 (17%) died. CONCLUSION: The incidence of CAG within 30 days following CABG is approximately 5%. Patients who need CAG following CABG have high complication rates (26% readmission and 17% mortality, respectively, at 30 days).

Postpartum Endocarditis and Left Main Embolization.

Postpartum infective endocarditis is a rare disease, especially in people with no risk factors (ie, intravenous drug use), that can be followed by severe morbidity and mortality. Here, we report a case of postpartum infective endocarditis with an unusual acute coronary syndrome-like presentation in a patient with minimal risk factors. In addition to lesions on the aortic valve causing severe aortic insufficiency, the patient's case was also complicated by left main coronary artery embolization, which was subsequently aspirated during surgery. Repeat angiography demonstrated complete removal, with no evidence of downstream embolization.

L'endocardite infectieuse du post-partum est une maladie rare, en particulier en l'absence de facteur de risque (comme l'utilisation de drogues intraveineuses), qui peut être une cause de morbidité grave ou de mortalité. Nous décrivons ici un cas d'endocardite infectieuse du post-partum caractérisé par des symptômes inhabituels s'apparentant à un syndrome coronarien aigu, chez une patiente présentant peu de facteurs de risque. En plus de lésions de la valve aortique entraînant une insuffisance aortique grave, le cas de cette patiente a été compliqué par une embolie de l'artère coronaire gauche principale, traitée ultérieurement par aspiration au cours du traitement chirurgical. Une angiographie post-intervention a révélé la disparition complète des lésions sans signe d'embolie en aval.

Prevention and management of spinal cord ischemia following aortic surgery: A survey of contemporary practice.

OBJECTIVE: Spinal cord ischemia (SCI) is a devastating complication of thoracoabdominal aortic aneurysm repair. We aim to characterize current practices pertaining to SCI prevention and treatment across Canada. METHODS: Two questionnaires were developed by the Canadian Thoracic Aortic Collaborative and the Canadian Cardiovascular Critical Care Society targeting aortic surgeons and intensivists. A list of experts in the management of patients at risk of SCI was developed, with representation from each of the Canadian centers that perform complex aortic surgery. RESULTS: The response rate was 91% for both intensivists (21/23), and from cardiac and vascular surgeons (39/43). Most surgeons agreed that staging is important during endovascular repair of extent II thoracoabdominal aortic aneurysm (60%) but not for open repair (34%). All of the surgeons felt prophylactic lumbar drains were effective in reducing SCI, whereas only 66.7% of intensivists felt that lumbar drains were effective (P < .001). There was consensus among surgeons over when to employ lumbar drains. A majority of surgeons preferred to keep the hemoglobin over 100 g/L if the patient demonstrated loss of lower-extremity function, whereas most intensivists felt a target of 80 g/L was adequate (P < .001). Management of perioperative antihypertensives, use of intraoperative adjuncts, and management of venous thromboembolism prophylaxis in the presence of a lumbar drain, were highly variable. CONCLUSIONS: We observed some consensus but considerable variability in the approach to SCI prevention and management across Canada. Future studies focused on the areas of variability may lead to more consistent and improved care for this high-risk population.

Frozen Elephant Trunk for Aortic Arch Reconstruction is Associated with Reduced Mortality as Compared to Conventional Techniques.

To examine the perioperative outcomes following aortic arch repair using frozen elephant trunk (FET) vs conventional elephant trunk (ET) techniques. Between 2002 and 2018, 390 patients underwent aortic repair with elephant trunk reconstruction at 9 centers: 172 patients received a FET (mean age: 65+/-13 years, 30% female, 37% aortic dissection) and 218 patients received an ET (mean age: 63+/-13 years, 37% female, 43% aortic dissection). Outcomes of interest included in-hospital mortality; stroke; and spinal cord injury (SCI). In-hospital mortality rate was 11% (n = 43) overall, 9% (n = 15) for FET and 13% (n = 28) for ET. Post-operative stroke occurred in 13% (n = 49) overall, 13% (n = 22) for FET and 12% (n = 27) for ET. The rate of post-operative SCI was 3% (n = 13) overall, 5.0% (n = 9) for FET and 2.0% (n = 4) for ET. When compared to ET, the propensity score analysis confirmed FET to be associated with lower mortality (adjusted risk difference -7.0% (95% CI -13.0 to -1.0), P = 0.02). There was no significant difference in the propensity score-adjusted risk difference for stroke between FET and ET (-0.7%, 95% CI -7.4% to 6.1%, P = 0.85), nor for SCI (3.3%, 95% CI -0.4% to 7.0%, P = 0.085) On multivariable analysis, FET was associated with lower odds of mortality (OR 0.44, 95% CI 0.21-0.95, P = 0.04), and had similar odds of stroke (OR 0.83, 95% CI 0.41-1.70, P = 0.62) and SCI (OR 2.83, 95% CI 0.83-9.60, P = 0.1). FET repair is associated with lower in-hospital mortality as compared to conventional ET, and results in similar risk of stroke and spinal cord injury. Further investigation is warranted.

GABA-B receptor activation inhibits the in vitro migration of malignant hepatocytes.

There are conflicting data regarding whether activation of γ-aminobutyric acid-B (GABA-B) receptors results in inhibition of tumor growth and invasion. The objectives of this study were to document the effects of the GABA-B receptor agonist baclofen on malignant hepatocyte proliferation and migration. We also sought to determine whether any effects on cell migration were mediated by changes in cyclic adenosine monophosphate (cAMP) signaling or matrix metalloproteinase (MMP) expression. Finally, GABA-B(1) and -B(2) receptor expression was documented in 2 malignant hepatocyte cell lines (PLC/PRF/5 and Huh-7) and 12 sets of human hepatocellular carcinoma and adjacent nontumor tissues. Cell proliferative activity was documented by WST-1 absorbance, migration by wound healing assays, cAMP levels by enzyme-linked immunoassay (ELISA), MMP by immunohistochemistry and ELISA, and GABA-B receptor expression by flow cytometry and reverse transcriptase - polymerase chain reaction. Although baclofen had no effect on cell proliferation, wound healing was delayed, an effect that was reversed by the GABA-B receptor antagonist CGP. cAMP levels were decreased in Huh-7 but not PLC cells exposed to baclofen. MMP expression remained unaltered in both cell lines. Finally, GABA-B(1) receptor expression was present and consistently expressed, but GABA-B(2) expression was limited and varied with the number of cell passages and (or) duration of culture. In conclusion, activation of GABA-B receptors has no effect on malignant hepatocyte proliferation but does decrease cell migration. This inhibitory effect may involve cAMP signaling but not MMP expression. GABA-B(2) receptor expression is limited and variable, which may help to explain discrepancies with previously published results.

Does adding an aortic root replacement or sinus repair during arch repair increase postoperative mortality? Evidence from the Canadian Thoracic Aortic Collaborative.

OBJECTIVES: The aim of this study was to examine the effect of the addition of an aortic root replacement or sinus repair on mortality and morbidity during aortic arch repair. METHODS: A total of 2472 patients underwent proximal or total aortic arch repair with hypothermic circulatory arrest between 2002 and 2018 at 12 centres. Multivariable logistic regressions (MV) and propensity score (PS) with inverse probability of treatment weighting (IPTW) analyses were performed. RESULTS: A total of 1099 (44.5%) patients had additional aortic root replacement (n = 934) or sinus repair (n = 165). Those with aortic root interventions were younger (61 ± 13 vs 64 ± 13 years, P < 0.001) and had less females (23% vs 35%, P < 0.001), less dissection (31% vs 36%, P = 0.004), less urgent cases (35% vs 39%, P = 0.047), more connective tissue disease (7% vs 3%, P < 0.001) and less total arch replacements (14% vs 22%, P < 0.001). On adjusted analyses, the addition of aortic root procedure was associated with increased mortality [MV: odds ratio (OR) 1.41, 95% confidence interval (CI) 1.03-1.92; PS-IPTW: risk increased by 3.7%, 95% CI 1.2-6.3%, P = 0.004]. Reoperation for bleeding was also increased with the addition of aortic root intervention (MV: OR 1.48, 95% 1.10-1.99; PS-IPTW: risk increased by 3.2%, 95% CI 0.8-5.6%, P = 0.009). The risks of stroke and dialysis-dependent renal failure were similar. When looking only at non-elective cases, the increased risk of mortality was more pronounced (MV: OR 1.60, 95% CI 1.11-2.32, P = 0.013; PS-IPTW: risk increased by 6.8%, 95 CI 1.7-11.8%, P = 0.008, and a number need to harm of 15 patients to cause 1 additional death). CONCLUSIONS: The addition of aortic root replacement or sinus repair during proximal or total aortic arch repair seems to increase postoperative mortality only in non-elective cases.

A Province-Wide Analysis of the Epidemiology of Thoracic Aortic Disease: Incidence Is Increasing in a Sex-Specific Way.

BACKGROUND: The contemporary incidence and prevalence of thoracic aortic aneurysm and dissection (TAAD) remains understudied. Epidemiological research on TAAD has been limited by incomplete case identification within administrative data sources. The objectives of this study were to develop a case identification method and determine the incidence and prevalence of TAAD, based on data from Manitoba, Canada. METHODS: Hospital records and medical claims housed at the Manitoba Centre for Health Policy, and data from the Manitoba Thoracic Aortic Diseases Clinic were used to develop a case definition and identify patients with TAAD in Manitoba, Canada. The age-standardized incidence and prevalence of thoracic aortic disease was determined and stratified by sex from 1998 to 2016. RESULTS: We identified 4264 patients with TAAD, of whom 63% were male. The age standardized incidence was 2 times higher in men, peaking at 42 cases per 100,000 in 2013. Although the overall incidence was lower in female patients, the number of incident cases increased 68% compared with 25% in male patients. In hospitalized patients, the incidence and prevalence of aneurysms increased over time, whereas the incidence of dissection and rupture has remained stable. CONCLUSIONS: The use of a novel case identification method provided a more complete description of the epidemiology of TAAD. The incidence and prevalence of TAAD is rising, more so in female patients over time. These data support increased resource allocation to thoracic aortic diseases clinics to ensure appropriate monitoring, treatment, and follow-up for the growing number patients with thoracic aortic disease.

Impact of brain protection strategies on mortality and stroke in patients undergoing aortic arch repair with hypothermic circulatory arrest: evidence from the Canadian Thoracic Aortic Collaborative.

OBJECTIVES: The aim of this study was to investigate the impact of various brain perfusion techniques and nadir temperature cooling strategies on outcomes after aortic arch repair in a contemporary, multicentre cohort. METHODS: A total of 2520 patients underwent aortic arch repair with hypothermic circulatory arrest (HCA) between 2002 and 2018 in 11 centres of the Canadian Thoracic Aortic Collaborative. Primary outcomes included mortality; stroke; a composite of mortality or stroke; and a Society of Thoracic Surgeons-defined composite (STS-COMP) end point for mortality or major morbidity including stroke, reoperation, renal failure, prolonged ventilation and deep sternal wound infection. Multivariable logistic regression and propensity score matching were performed for cerebral perfusion and nadir temperature practices. RESULTS: Antegrade cerebral perfusion was found on multivariable analysis to be protective against mortality [odds ratio (OR) 0.64, 95% confidence interval (CI) 0.48-0.86; P = 0.005], stroke (OR 0.55, 95% CI 0.37-0.81; P = 0.006), composite of mortality or stroke (OR 0.57, 95% CI 0.45-0.72; P = 0.0001) and STS-COMP (OR 0.53, 95% CI 0.41-0.67; P < 0.0001), as compared to HCA alone. Retrograde cerebral perfusion yielded similar outcomes as compared to antegrade cerebral perfusion. When compared to HCA with nadir temperature <24°C, a propensity score analysis of 647 matched pairs identified nadir temperature ≥24°C as predictor of lower mortality (OR 0.62, 95% CI 0.40-0.98; P = 0.04), stroke (OR 0.51, 95% CI 0.31-0.84; P = 0.008), composite of mortality or stroke (OR 0.62, 95% CI 0.43-0.89; P = 0.01) and STS-COMP (OR 0.64, 95% CI 0.49-0.85; P = 0.002). CONCLUSIONS: Antegrade cerebral perfusion and nadir temperature ≥24°C during HCA for aortic arch repair are predictors of improved survival and neurological outcomes.

Extracorporeal Membrane Oxygenation, Pulmonary Embolectomy, and Right Ventricular Assist Device for Massive Pulmonary Embolism.

Consensus regarding the management of massive pulmonary embolism (PE) and persistent shock after thrombolysis is lacking. A 30-year-old man collapsed with massive PE 3 days after an exploratory laparotomy for penetrating trauma, and he remained hypoxic and hypotensive despite thrombolytic therapy. Extracorporeal membrane oxygenation (ECMO) was instituted as a bridge to surgical embolectomy, and placement of a right ventricular assist device (RVAD) was used to facilitate separation from cardiopulmonary bypass. After 48 hours, the RVAD was removed, and the patient survived to discharge. ECMO and temporary RVAD to support surgical embolectomy are lifesaving therapeutic considerations.