Baseline characteristics of a prospective cohort study of aging and cardiovascular diseases among people living with HIV.

OBJECTIVES: Our objective was to report the baseline characteristics of participants in the Canadian HIV and Aging Cohort Study (CHACS) and present amendments to the initial protocol. METHODS: CHACS is a multi-centred prospective cohort study that was initially set from 2011 to 2016 and will now continue recruitment until 2024. Four additional years of follow-up have been added, and additional outcomes and covariates will be prospectively collected. Frailty will be assessed using a modified version of the Fried's frailty phenotype. The four interrelated aspects of gender-gender roles, gender identity, gender relationships, and institutionalized gender-will be measured using the GENESIS-PRAXY questionnaire. Diet will be assessed using a validated, web-based, self-administered food frequency questionnaire. RESULTS: A total of 1049 participants (77% people living with HIV) were recruited between September 2011 and September 2019. Median age at baseline was 54 years (interquartile range 50-61). Most participants were male (84%) and white (83%). Compared with participants without HIV, those with HIV were more likely to be male; to report lower education levels and incomes; to be more sedentary; to use tobacco, recreational, and prescription drugs; to report a personal history of cardiovascular diseases; and to be frail. CONCLUSIONS: The new assessments added to the CHACS protocol will allow for an even more detailed portrait of the pathways leading to accentuated aging for people living with HIV. Participants in the CHACS cohort display important differences in socio-economic and cardiovascular risk factors according to HIV serostatus. These imbalances must be taken into account for all further inferential analyses.

Underrepresentation of African Americans in Plastic Surgery: Examining Demographics, Specialty Factors, and Medical School Experiences.

BACKGROUND: Racial representation among medical trainees translates into physicians that are able to communicate with diverse patient populations and are perceptive to health disparities. This is important within plastic surgery where an optimal physicianpatient relationship is essential to health outcomes. OBJECTIVE: The purpose of this study is to address underrepresentation of African Americans (AA) in plastic surgery through improving understanding of factors that may contribute to AA medical student interest in plastic surgery. DESIGN: This was a voluntary, cross-sectional survey. An online survey was designed to collect information on demographics, specialty factor importance, medical school experiences, and plastic surgery interest among medical students. The survey was distributed to medical students within three national medical organizations between August 2018 and February 2019. The following groups of respondents were statistically COMPARED: AAs interested vs. AAs not interested in plastic surgery and AA vs. Caucasian medical students both interested in plastic surgery. SETTING: Online survey for medical students in the United States. PARTICIPANTS: All 428 participants were medical students that belonged to at least 1 of the 3 national medical organizations between August 2018 and February 2019. RESULTS: The survey was completed by 428 participants of which 142 were excluded for incomplete surveys, leaving 286 (66.8%) participants to be included in the study. Among AA medical students, 128 (75.3%) were not interested in Plastic Surgery and 42 (24.7%) were interested. The 2 groups were similar demographically but differed significantly across multiple specialty factors and medical school experiences (p < 0.05). When compared to interested Caucasian medical students (n = 30), interested AA medical students differed significantly in demographics, specialty factors, and medical school experiences (p < 0.05). CONCLUSIONS: This study supports the implementation of medical school interventions emphasizing specialty factors and medical school experiences unique to AA medical students interested in plastic surgery to promote their application into the specialty.

Pinless Electromagnetic Neuronavigation During Awake Craniotomies: Technical Pearls, Pitfalls, and Nuances.

BACKGROUND: Awake craniotomies are often performed with rigid pin fixation to support optical neuronavigation. Newer electromagnetic (EM) neuronavigation technology now enables unpinned cranial neurosurgery while maintaining robust intraoperative image guidance. Here, we share technical nuances, operative pearls, and lessons learned from our institutional experience using Curve EM neuronavigation during awake, unpinned craniotomies. METHODS: We describe our process for patient positioning, instrumentation setup, system registration, intraoperative navigation, and surgical adjunct use (e.g., intraoperative neuromonitoring and intraoperative magnetic resonance imaging) in detail. At each step, we provide pearls for success and tips for pitfall avoidance based on our experience. RESULTS: Ten patients underwent awake pinless intra-axial tumor resection using Curve EM neuronavigation from May 2021 to August 2022 with a single surgeon. Postoperative transient neurological deficits were seen in 8 of 10 cases (80.0%), as all resections were taken to functional margins. Of the 9 patients with a 3-month follow-up visit at the time of publication, all 9 (100%) had improved or stable preoperative symptoms. No surgical complications, clinically appreciable inaccuracies, intraoperative losses of registration, unexpected postoperative magnetic resonance imaging findings, or errors related to the use of EM neuronavigation occurred. CONCLUSIONS: The technical pearls outlined here will help interested neurosurgeons integrate EM neuronavigation into awake craniotomies. In our experience, using unpinned neuronavigation during awake cases provides many advantages to the patient, surgeon, and entire operative team. It has thus become the standard practice at our institution.

A randomized control trial of high-dose micronutrient-antioxidant supplementation in healthy persons with untreated HIV infection.

BACKGROUND: Although micronutrient and antioxidant supplementation are widely used by persons with human immunodeficiency virus (HIV), a therapeutic role beyond recommended daily allowances (RDA) remains unproven. An oral high-dose micronutrient and antioxidant supplement (Treatment) was compared to an RDA supplement (Control) for time to progressive immunodeficiency or initiation of antiretroviral therapy (ART) in people living with HIV (PLWH). METHODS: This study was a randomized, double-blind, placebo-controlled multicenter clinical trial. PLWH were recruited from Canadian HIV Trials Network sites, and followed quarterly for two years. Eligible participants were asymptomatic, antiretroviral treatment (ART)-naïve, HIV-seropositive adults with a CD4 T lymphocyte count (CD4 count) between 375-750 cells/µL. Participants were randomly allocated 1:1 to receive Treatment or Control supplements. The primary outcome was a composite of time-to-first of confirmed CD4 count below 350 cells/µL, initiation of ART, AIDS-defining illness or death. Primary analysis was by intention-to-treat. Secondary outcomes included CD4 count trajectory from baseline to ART initiation or two years. A Data and Safety Monitoring Board reviewed the study for safety, recruitment and protocol adherence every six months. RESULTS: Of 171 enrolled participants: 66 (38.6%) experienced a primary outcome: 27 reached a CD4 count below 350 cells/µL, and 57 started ART. There was no significant difference in time-to-first outcome between groups (Hazard Ratio = 1.05; 95%CI: 0.65, 1.70), or in time to any component outcome. Using intent-to-treat censoring, mean annualized rates of CD4 count decline were -42.703 cells/µL and -79.763 cells/µL for Treatment and Control groups, with no statistical difference in the mean change between groups (-37.06 cells/µL/52 weeks, 95%CI: (-93.59, 19.47); p = 0.1993). Accrual was stopped at 171 of the 212 intended participants after an interim analysis for futility, although participant follow-up was completed. CONCLUSIONS: In ART-naïve PLWH, high-dose antioxidant, micronutrient supplementation compared to RDA supplementation had no significant effect on disease progression or ART initiation. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00798772.

Understanding Variable Motor Responses to Direct Electrical Stimulation of the Human Motor Cortex During Brain Surgery.

Direct electrical stimulation of the brain is the gold standard technique used to define functional-anatomical relationships during neurosurgical procedures. Areas that respond to stimulation are considered "critical nodes" of circuits that must remain intact for the subject to maintain the ability to perform certain functions, like moving and speaking. Despite its routine use, the neurophysiology underlying downstream motor responses to electrical stimulation of the brain, such as muscle contraction or movement arrest, is poorly understood. Furthermore, varying and sometimes counterintuitive responses can be seen depending on how and where the stimulation is applied, even within the human primary motor cortex. Therefore, here we review relevant neuroanatomy of the human motor system, provide a brief historical perspective on electrical brain stimulation, explore mechanistic variations in stimulation applications, examine neurophysiological properties of different parts of the motor system, and suggest areas of future research that can promote a better understanding of the interaction between electrical stimulation of the brain and its function.

Effectiveness and Renal Safety of Tenofovir Alafenamide Fumarate among Chronic Hepatitis B Patients: Real-World Study.

Tenofovir alafenamide fumarate (TAF) has high plasma stability resulting in fewer renal adverse events compared to tenofovir disoproxil fumarate (TDF) in chronic hepatitis B (CHB) patients. We aimed to study the effectiveness and renal safety of TAF in a real-world setting, in patients with or without compromised kidney function. CHB patients (Nucleos(t)ide Analogue [NA]-naïve or experienced) who received TAF >1 year from 11 academic institutions as part of the Canadian Hepatitis B Network (CanHepB) were included. Kidney function was measured by estimated glomerular filtration rate (eGFR) as per Cockcroft-Gault. Patients were followed for up to 160 weeks. Of 176 patients receiving TAF, 143 switched from NA (88% TDF), and 33(19%) were NA naïve. Majority of NA-naïve patients (75%) achieved undetectable HBV DNA after one year of TAF treatment. Majority of patients with eGFR <60 mL/min who had renal deterioration during TDF (76%) reversed to eGFR increase after one year of TAF (p=0.009). Among patients with stage 2 chronic kidney disease (CKD) (eGFR 60-89), the estimated eGFR decline during TDF was halted after switching to TAF (p=0.09). NA-experienced patients with abnormal ALT before TAF showed a significant decline after switching to TAF: -0.005 [-0.006 - -0.004] log10 ULN U/L/month, p<0.001). In CHB patients, TAF was safe, well-tolerated and effective in this real-world cohort. Switching to TAF led to improved kidney function, particularly in those with stage 2 CKD, which suggests that the indication for TAF in the guidelines could be extended to patients with an eGFR higher than 60 mL/min.

Characterizing risk behaviour and reinfection rates for successful programs to engage core transmitters in HCV elimination (C-RESPECT).

BACKGROUND: Development of robust treatment programs among core transmitters (CT) of hepatitis C virus (HCV) are needed, including strategies to address reinfection risk. The aim of this study was to describe the effectiveness of direct-acting antiviral (DAA) treatment in CT versus non-CT populations and assess reinfection rates after successful treatment. METHODS: Characterizing Risk Behaviour and Reinfection Rates for Successful Programs to Engage Core Transmitters in HCV Elimination (C-RESPECT) was a prospective, observational study of HCV-infected Canadian adult patients (genotypes 1, 3, and 4) treated with DAAs between 2017 and 2020. RESULTS: The full analysis set included 429 participants (259 CT, 170 non-CT). Key differences were observed in baseline profiles: CT participants were younger (mean 42.3 [SD 11.2] y versus 55.0 [SD 11.1] y, respectively) and reported higher rates of social assistance (35.7% versus 14.8%), smoking (83.7% versus 52.4%), low socioeconomic status (yearly income <$15,000: 69.6% versus 43.9%), illicit drug use (83.7% versus 34.3%), and previous incarcerations (62.7% versus 36.9%). DAA treatment adherence was similar; 93 .5% versus 98.3% of CT versus non-CT participants completed the assigned treatment duration. Cure rates (sustained virologic response) were comparable, ranging from 94.9% to 98.1%. All reinfections were among CT participants, with a rate of 13.8/100 person-years (95% CI 9.2-20.8) with mean time to reinfection of 24.6 (SD 0.6) months. CONCLUSIONS: CT and non-CT participants respond equally well to DAA treatment; however, with some reinfections among CT participants. Innovative multidisciplinary programs must be developed to mitigate this risk in this key population.

Eliminating Structural Barriers: The Impact of Unrestricted Access on Hepatitis C Treatment Uptake Among People Living With Human Immunodeficiency Virus.

BACKGROUND: High costs of direct-acting antivirals (DAAs) have led health-care insurers to limit access worldwide. Using a natural experiment, we evaluated the impact of removing fibrosis stage restrictions on hepatitis C (HCV) treatment initiation rates among people living with human immunodeficiency virus (HIV), and then examined who was left to be treated. METHODS: Using data from the Canadian HIV-HCV Coinfection Cohort, we applied a difference-in-differences approach. Changes in treatment initiation rates following the removal of fibrosis stage restrictions were assessed using a negative binomial regression with generalized estimating equations. The policy change was then specifically assessed among people who inject drugs (PWID). We then identified the characteristics of participants who remained to be treated using a modified Poisson regression. RESULTS: Between 2010-2018, there were a total of 585 HCV initiations among 1130 eligible participants. After removing fibrosis stage restrictions, DAA initiations increased by 1.8-fold (95% confidence interval [CI] 1.3-2.4) controlling for time-invariant differences and secular trends. Among PWID the impact appeared even stronger, with an adjusted incidence rate ratio of 3.6 (95% CI 1.8-7.4). However, this increased treatment uptake was not sustained. At 1 year following universal access, treatment rates declined to 0.8 (95% CI .5-1.1). Marginalized participants (PWID and those of indigenous ethnicity) and those disengaged from care were more likely to remain HCV RNA positive. CONCLUSIONS: After the removal of fibrosis restrictions, HCV treatment initiations nearly doubled immediately, but this treatment rate was not sustained. To meet the World Health Organization elimination targets, the minimization of structural barriers and adoption of tailored interventions are needed to engage and treat all vulnerable populations.

Role of Moderate Hypothermia and Antegrade Cerebral Perfusion during Repair of Type A Aortic Dissection.

The goal of this study was to compare early postoperative outcomes and actuarial survival between patients who underwent repair of acute type A aortic dissection with deep or moderate hypothermia. A total of 132 consecutive patients from a single academic medical center underwent repair of acute type A aortic dissection between January 2000 and June 2014. Of those, 105 patients were repaired under deep hypothermia (< 24 C°), while 27 patients were repaired under moderate hypothermia (≥24 C°). Median ages were 62 years (range: 27-86) and 59 years (range: 35-83) for patients repaired under deep hypothermia compared with patients repaired under moderate hypothermia, respectively ( p = 0.451). Major morbidity, operative mortality, and 10-year actuarial survival were compared between groups. Operative mortality was 17.1 and 7.4% in the deep and moderate hypothermia groups, respectively ( p = 0.208). Incidence of permanent stroke was 12.4% in the deep hypothermic circulatory arrest group and 0% in the moderate hypothermia group ( p = 0.054). Actuarial 5- and 10-year survival demonstrated a trend for lower long-term mortality with moderate hypothermia compared with deep hypothermia (69% 5-year and 54% 10-year for deep hypothermia vs. 79% 5-year and 10-year for moderate hypothermia, log-rank p = 0.161). Moderate hypothermia is a safe and efficient alternative to deep hypothermia and may have protective benefits. Stroke rate was lower with moderate hypothermia.

Proteomic fingerprinting in HIV/HCV co-infection reveals serum biomarkers for the diagnosis of fibrosis staging.

BACKGROUND: Hepatic complications of hepatitis C virus (HCV), including fibrosis and cirrhosis are accelerated in human immunodeficiency virus (HIV)-infected individuals. Although, liver biopsy remains the gold standard for staging HCV-associated liver disease, this test can result in serious complications and is subject to sampling errors. These challenges have prompted a search for non-invasive methods for liver fibrosis staging. To this end, we compared serum proteome profiles at different stages of fibrosis in HIV/HCV co- and HCV mono-infected patients using surface-enhanced laser desorption ionization time-of-flight mass spectrometry (SELDI-TOF MS). METHODS: Sera from 83 HIV/HCV co- and 68 HCV mono-infected subjects in 4 stages of fibrosis were tested. Sera were fractionated, randomly applied to protein chip arrays (IMAC, CM10 and H50) and spectra were generated at low and high laser intensities. RESULTS: Sixteen biomarkers achieved a p value < 0.01 (ROC values > 0.75 or < 0.25) predictive of fibrosis status in co-infected individuals and 14 in mono infected subjects. Five of these candidate biomarkers contributed to both mono- and co-infected subjects. Candidate diagnostic algorithms were created to distinguish between non-fibrotic and fibrotic individuals using a panel of 4 biomarker peaks. CONCLUSION: These data suggest that SELDI MS profiling can identify diagnostic serum biomarkers for fibrosis that are both common and distinct in HIV/HCV co-infected and HCV mono-infected individuals.

Bovine arch anatomy influences recoarctation rates in the era of the extended end-to-end anastomosis.

OBJECTIVES: Arch branching has never been shown to influence recoarctation after extended end-to-end anastomosis via thoracotomy, yet in each study bovine arch identification is grossly underreported. This study aims to (1) assess chart review reliability in bovine arch identification; (2) determine recoarctation risk with a bovine arch; and (3) explore an anatomic explanation for recurrent arch obstruction based on arch anatomy. PATIENTS: A total of 49 consecutive patients underwent thoracotomy with extended end-to-end aortic coarctation repair at a single institution (2007-2012). METHODS: Echocardiograms from these patients were reviewed for arch anatomy and compared with the echocardiographic reports. Recurrent arch obstruction was defined as an echocardiographic gradient across the repair of 20 mm Hg or greater. For cases with angiographic images (n = 17), a scaled clamping distance between the left subclavian artery and the maximal proximal clamp location on orthogonal projections was then calculated across arch anatomies. RESULTS: Chart review identified 6.1% (3/49) of patients with a bovine arch compared with 28.6% (14/49) on targeted image review. A total of 28.6% (4/14) of patients with a bovine arch had a follow-up gradient of 20 mm Hg or greater. Only 5.7% (2/35) of patients with normal arch branching had a follow-up gradient of 20 mm Hg or greater. The mean clamping index was significantly diminished in patients with bovine arch anatomy. CONCLUSIONS: Arch anatomy often goes undocumented on preoperative imaging, yet children undergoing extended end-to-end repair with bovine arch anatomy are at a significantly increased risk of recoarctation. This may be due to a reduced clampable distance to facilitate repair. These results should be considered in the preoperative assessment, parental counseling, and surgical approach for children with discrete aortic coarctation.

The Canadian HIV and aging cohort study - determinants of increased risk of cardio-vascular diseases in HIV-infected individuals: rationale and study protocol.

BACKGROUND: With potent antiretroviral drugs, HIV infection is becoming a chronic disease. Emergence of comorbidities, particularly cardiovascular disease (CVD) has become a leading concern for patients living with the infection. We hypothesized that the chronic and persistent inflammation and immune activation associated with HIV disease leads to accelerated aging, characterized by CVD. This will translate into higher incidence rates of CVD in HIV infected participants, when compared to HIV negative participants, after adjustment for traditional CVD risk factors. When characterized further using cardiovascular imaging, biomarkers, immunological and genetic profiles, CVD associated with HIV will show different characteristics compared to CVD in HIV-negative individuals. METHODS/DESIGN: The Canadian HIV and Aging cohort is a prospective, controlled cohort study funded by the Canadian Institutes of Health Research. It will recruit patients living with HIV who are aged 40 years or older or have lived with HIV for 15 years or more. A control population, frequency matched for age, sex, and smoking status, will be recruited from the general population. Patients will attend study visits at baseline, year 1, 2, 5 and 8. At each study visit, data on complete medical and pharmaceutical history will be captured, along with anthropometric measures, a complete physical examination, routine blood tests and electrocardiogram. Consenting participants will also contribute blood samples to a research biobank. The primary outcome is incidence of a composite of: myocardial infarction, coronary revascularization, stroke, hospitalization for angina or congestive heart failure, revascularization or amputation for peripheral artery disease, or cardiovascular death. Preplanned secondary outcomes are all-cause mortality, incidence of the metabolic syndrome, incidence of type 2 diabetes, incidence of renal failure, incidence of abnormal bone mineral density and body fat distribution. Patients participating to the cohort will be eligible to be enrolled in four pre-planned sub-studies of cardiovascular imaging, glucose metabolism, immunological and genetic risk profile. DISCUSSION: The Canadian HIV and Aging Cohort will provide insights on pathophysiological pathways leading to premature CVD for patients living with HIV.

Hepatitis C virus core antigen: A simplified treatment monitoring tool, including for post-treatment relapse.

BACKGROUND: Simple, affordable diagnostic tools are essential to facilitate global hepatitis C virus (HCV) elimination efforts. OBJECTIVES: This study evaluated the clinical performance of core antigen (HCVcAg) assay from plasma samples to monitor HCV treatment efficacy and HCV viral recurrence. STUDY DESIGN: Plasma samples from a study of response-guided pegylated-interferon/ribavirin therapy for people who inject drugs with chronic HCV genotype 2/3 infection were assessed for HCV RNA (AmpliPrep/COBAS Taqman assay, Roche) and HCVcAg (ARCHITECT HCV Ag, Abbott Diagnostics) during and after therapy. The sensitivity and specificity of the HCVcAg assay was compared to the HCV RNA assay (gold standard). RESULTS: A total of 335 samples from 92 enrolled participants were assessed (mean 4 time-points per participant). At baseline, end of treatment response (ETR) and sustained virological response (SVR) visits, the sensitivity of the HCVcAg assay with quantifiable HCV RNA threshold was 94% (95% CI: 88%, 98%), 56% (21%, 86%) and 100%, respectively. The specificity was between 98 to 100% for all time-points assessed. HCVcAg accurately detected all six participants with viral recurrence, demonstrating 100% sensitivity and specificity. One participant with detectable (non-quantifiable) HCV RNA and non-reactive HCVcAg at SVR12 subsequently cleared HCV RNA at SVR24. CONCLUSIONS: HCVcAg demonstrated high sensitivity and specificity for detection of pre-treatment and post-treatment viraemia. This study indicates that confirmation of active HCV infection, including recurrent viraemia, by HCVcAg is possible. Reduced on-treatment sensitivity of HCVcAg may be a clinical advantage given the moves toward simplification of monitoring schedules.

Rotational Dynamics in Ionic Liquids from NMR Relaxation Experiments and Simulations: Benzene and 1-Ethyl-3-Methylimidazolium.

Temperature-dependent (2)H longitudinal spin relaxation times (T1) of dilute benzene-d6 in 1-butyl-3-methylimidazolium tetrafluoroborate ([Im41][BF4]) and two deuterated variants of the 1-ethyl-3-methylimidazolium cation (Im21(+)-d1 and Im21(+)-d6) in 1-ethyl-3-methylimidazolium bis(trifluoromethylsulfonyl)imide ([Im21][Tf2N]), measured at multiple Larmor frequencies, were used to probe rotational dynamics in ionic liquids. Rotational correlation times significantly faster than predicted by slip hydrodynamic calculations were observed for both solutes. Molecular dynamics simulations of these systems enabled extraction of more information about the rotational dynamics from the NMR data than rotation times alone. The multifrequency (2)H T1(T) data could be fit to within uncertainties over a broad region about the T1 minimum using models of the relevant rotational time correlation functions and their viscosity/temperature dependence derived from simulation. Such simulation-guided fitting provided confidence in the semiquantitative accuracy of the simulation models and enabled interpretation of NMR measurements to higher viscosities than previously possible. Simulations of the benzene system were therefore used to explore the nature of solute rotation in ionic liquids and how it might differ from rotation in conventional solvents. Whereas "spinning" about the C6 axis of benzene senses similarly weak solvent friction in both types of solvents, "tumbling" (rotations about in-plane axes) differs significantly in conventional solvents and ionic liquids. In the sluggish environment provided by ionic liquids, orientational caging and the presence of rare but influential large-amplitude (180°) jumps about in-plane axes lead to rotations being markedly nondiffusive, especially below room temperature.

Effects of Gender on Outcomes and Survival Following Repair of Acute Type A Aortic Dissection.

Previous studies have demonstrated gender-related differences in early and late outcomes following type A dissection diagnosis. However, it is widely unknown whether gender affects early clinical outcomes and survival after repair of type A aortic dissection. The goal of this study was to compare the early and late clinical outcomes in women versus men after repair of acute type A aortic dissections. Between January 2000 and October 2010 a total of 251 patients from four academic medical centers underwent repair of acute type A aortic dissection. Of those, 79 were women and 172 were men with median ages of 67 (range, 20-87 years) and 58 years (range, 19-83 years), respectively (p < 0.001). Major morbidity, operative mortality, and 10-year actuarial survival were compared between the groups. Operative mortality was not significantly influenced by gender (19% for women vs. 17% for men, p = 0.695). There were similar rates of hemodynamic instability (12% for women vs. 13% men, p = 0.783) between the two groups. Actuarial 10-year survival rates were 58% for women versus 73% for men (p = 0.284). Gender does not significantly impact early clinical outcomes and actuarial survival following repair of acute type A aortic dissection.

A minimally invasive, algorithm-based approach for anomalous aortic origin of a coronary artery.

OBJECTIVE: Operative repair for anomalous aortic origin of a coronary artery (AAOCA) has been described using various innovative techniques. Common to each series is the use of a full sternotomy. As demand for minimally invasive approaches to adult cardiac surgery has increased, the upper hemisternotomy has emerged as a safe and effective technique for aortic valve and root replacement. This report reviews our results and describes the application of an upper hemisternotomy to an algorithm-based surgical approach for AAOCA. METHODS: From January 2012 to March 2013, the aortic root was approached via a 7-cm skin incision and upper hemisternotomy for all patients undergoing repair of an AAOCA. The type of repair performed was in accordance with a predefined surgical algorithm. The anomalous vessel had a slit-like ostium and followed a supracommissural intramural course in three patients with symptomatic anomalous right coronary artery. These patients underwent coronary unroofing. In contrast, a patient with an anomalous left coronary artery presented without an intramural segment and underwent vessel translocation and reimplantation. RESULTS: All patients underwent AAOCA repair according to our surgical algorithm and via an upper hemisternotomy. The median length of stay was 4 days. All patients had resolution of symptoms, and there were no reported complications at a median follow-up of 16.5 months. CONCLUSIONS: This series describes a minimally invasive approach to AAOCA repair. When used in conjunction with a defined surgical algorithm, this technique enables a safe and effective repair in all forms of AAOCA without concomitant coronary artery disease.

Improved clinical outcomes and survival following repair of acute type A aortic dissection in the current era.

OBJECTIVES: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute type A aortic dissection during 2000-2005 and 2006-2010. METHODS: A total of 251 patients from four academic medical centres underwent repair of acute type A aortic dissection between January 2000 and October 2010. Of those, 111 patients underwent repair during 2000-2005, whereas 140 patients underwent repair during 2006-2010. Median ages were 62 years (range 20-83) and 58 years (range 30-80) for patients repaired from 2000-2005 compared with those repaired during 2006-2010, respectively (P = 0.180). Major morbidity, operative mortality and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality. RESULTS: Operative mortality was strongly influenced by surgical era (24% for 2000-2005 vs 12% for 2006-2010, P = 0.013). In multivariable logistic regression analysis, haemodynamic instability [odds ratio (OR) = 17.8, 95% confidence intervals (CIs) = 0.05-0.35, P <0.001], cardiopulmonary bypass time >200 min (OR = 9.5, 95% CI = 0.14-0.64, P = 0.002) and earlier date of surgery (OR = 5.8, 95% CI = 1.18-5.14, P = 0.016) emerged as independent predictors of operative mortality. Actuarial 5-year survival was worse for earlier compared with later date of surgery (64% for 2000-2005 vs 77% for 2006-2010, log-rank P <0.001). CONCLUSIONS: Surgical era significantly impacts early outcomes and actuarial survival following repair of acute type A aortic dissection.

Effects of Hemodynamic Instability on Early Outcomes and Late Survival Following Repair of Acute Type A Aortic Dissection.

BACKGROUND: The goal of this study was to compare operative mortality and actuarial survival between patients presenting with and without hemodynamic instability who underwent repair of acute Type A aortic dissection. Previous studies have demonstrated that hemodynamic instability is related to differences in early and late outcomes following acute Type A dissection occurrence. However, it is unknown whether hemodynamic instability at the initial presentation affects early clinical outcomes and survival after repair of Type A aortic dissection. METHODS: A total of 251 patients from four academic medical centers underwent repair of acute Type A aortic dissection between January 2000 and October 2010. Of those, 30 presented with hemodynamic instability while 221 patients did not. Median ages were 63 years (range 38-82) and 60 years (range 19-87) for patients presenting with hemodynamic instability compared to patients without hemodynamic instability, respectively (P = 0.595). Major morbidity, operative mortality, and 10-year actuarial survival were compared between groups. RESULTS: Operative mortality was profoundly influenced by hemodynamic instability (patients with hemodynamic instability 47% versus 14% for patients without hemodynamic instability, P < 0.001). Actuarial 10-year survival rates for patients with hemodynamic instability were 44% versus 63% for patients without hemodynamic instability (P = 0.007). CONCLUSIONS: Hemodynamic instability has a profoundly negative impact on early outcomes and operative mortality in patients with acute Type A aortic dissection. However, late survival is comparable between hemodynamically unstable and non-hemodynamically unstable patients.