Does methylprednisolone provide protective effect in total aortic arch replacement requiring hypothermia circulatory arrest and selective cerebral perfusion?

BACKGROUND: Glucocorticoids (GC)were applied in total aortic arch replacement (TAAR) at various dosages in many centers, but with limited evidence. METHODS: The retrospective study was aimed to evaluate whether methylprednisolone was associated with better postoperative outcomes in patients undergoing TAAR. Patients undergoing TAAR with moderate hypothermia and selective cerebral perfusion between 2017.1 to 2018.12 in Fuwai hospital were classified into three groups according to doses of methylprednisolone given in the surgery: large-GC group (1500-3000 mg); medium-GC group (500-1000 mg) and no-GC group (0 mg). Postoperative outcomes were compared among three groups. Multivariable analysis was performed to identify the association of methylprednisolone with outcomes. RESULTS: Three hundred twenty-eight patients were enrolled. Two hundred twenty-eight were in the large-GC group, 34 were in the medium-GC group, and 66 were in the no-GC group. The incidences of major adverse outcomes in large-GC, medium-GC and no-GC groups were 22.8%, 17.6% and 18.2%, respectively, with no statistical difference. A significant difference was observed in post-cardiopulmonary bypass (CPB) fresh frozen plasma (FFP) transfusion (p < .001) and chest drainage volume (p < .001). Multivariable analysis demonstrated that methylprednisolone was not associated with better outcomes (p = .455), while large doses of methylprednisolone were significantly associated with excessive chest drainage (over 2000 mL) [OR (99% CI) 4.282 (1.66-11.044), p < .001] and excessive post-CPB FFP transfusion (over 400 mL) [OR (99% CI) 2.208 (1.027-4.747), p = .008]. CONCLUSIONS: Large doses of methylprednisolone (1500-3000 mg) did not show a protective effect in TAAR with moderate hypothermia arrest plus selective cerebral perfusion and might increase postoperative bleeding and FFP transfusion.

Long-term risk of arch complications in Loeys Dietz syndrome patients undergoing proximal ascending aortic replacement.

PURPOSE: Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder. In LDS patients with normal arch morphology, whether the arch should be prophylactically replaced at the time of proximal aortic replacement remains unknown. We evaluated the risk of long-term arch complications in genetically confirmed LDS patients who underwent proximal ascending aortic replacement. METHODS: We retrospectively reviewed the records of patients with LDS who have been followed at our institution between 1994 and 2020. Patients were only included if whole exome genetic testing confirmed a mutation in an LDS-causing gene (TGFBR1, TGFBR2, SMAD3, TGFB2, or TGFB3). Mutations were categorized as pathogenic, benign, or of unknown significance. We collected demographic information, aortic dimensions, comorbidities, mortality, and operative course from patients' charts. Descriptive statistics and freedom from reoperation plots were generated. RESULTS: Of the 18 patients with a mutation in an LDS-causing gene, 15 had known pathogenic variants, two had mutations of unknown significance, and one had a benign genetic variant. For the 15 patients with confirmed pathogenic variants of LDS the median follow-up duration was 5 years (interquartile range [IQR]: 4-8). Eleven patients underwent ascending aortic replacements (AAR) ± aortic valve replacement. Two patients required an additional operation; one required arch and staged elephant trunk for a dissection 18 years post-AAR and the other patient required an isolated descending aortic replacement for dissection 5 years post-AAR. Among patients who underwent surgery, the median ascending aortic diameter at intervention was 5.0 cm (IQR: 4.3-5.3). There was no surgical or late follow-up mortality observed for any of the 18 patients in the study. CONCLUSION: LDS patients who underwent proximal aortic replacement appeared to have low long-term risk of arch complications. While our study is somewhat limited by its sample size and follow-up duration, it suggests that routine prophylactic total arch replacement may not be warranted in LDS patients with nonaneurysmal aortic arches.

Intimal-protected adventitial inversion technique accelerates the obliteration of a patent false lumen.

BACKGROUND AND AIMS: The optimal procedure for reconstructing the dissected aortic stump for acute type A dissection remains controversial. We routinely used the intimal-protected adventitial inversion technique (iPAIT), a modified adventitial inversion technique, to protect the fragile intima by inserting a graft and assessed the safety and efficacy of this technique. METHODS: Between August 2008 and April 2020, 146 consecutive patients with acute type A dissections underwent thoracic aortic surgery in our hospital. Extended total aortic arch replacement was performed in 119 patients (81.5%). Sixty-nine patients underwent treatment for distal aortic anastomosis with the iPAIT. To compare the iPAIT to a historical control, we assessed 69 iPAIT patients and 25 patients who underwent total arch replacement using gelatin-resorcinol-formaldehyde (GRF) glue. RESULTS: Hospital mortality was 2.9% in the iPAIT group and 8.0% in the GRF group. Perioperative characteristics were similar between the two groups. However, postoperative computed tomography revealed that the obliteration rate was significantly higher in the iPAIT group (60/66, 90.9%) than in the GRF group (15/23, 65.2%) (p = .01), not including the patients who had died or developed severe renal dysfunction. The 8-year aortic event-free survival rate in the iPAIT group (81.3%) was significantly higher than that in the GRF group (47.4%). CONCLUSIONS: The use of this technique for acute type A dissections resulted in a low mortality rate and demonstrated promising midterm survival and may accelerate the obliteration of a patent false lumen and prevent late aortic events.

Perfusion management of arch-clamping technique in total arch replacement with frozen elephant trunk.

A technique called arch-clamping was used at our institute to ensure perfusion of the lower body and brain during total arch replacement with frozen elephant trunk (TAR and FET). The aortic arch clamp is inserted between the left common carotid artery and the left subclavian artery after inserting the stented elephant trunk into the true lumen of the descending aorta during the procedure, and then clamps the aorta and graft together as the distal anastomotic edge of the aorta. After the arch clamp was in place, lower body perfusion was resumed through the femoral artery was resumed and time to circulatory arrest was reduced to approximately 4 min. Cardiopulmonary bypass (CPB) flow was gradually restored to full rate. Thereafter, the left carotid artery anastomosis was completed and rewarming began. Finally, during the rewarming period, other branches of the aortic arch and ascending aorta were reconstructed. In this paper, we describe the perfusion management strategy, discuss intraoperative monitoring parameters, and examine the feasibility of the technique from a perfusion perspective.

The impact of comprehensive blood conservation program on major complications after total aortic arch replacement.

INTRODUCTION: Patients undergoing total aortic arch replacement (TAAR) usually require blood products perioperatively. This cohort study aimed to investigate the impact of a comprehensive blood conservation program on the major complications in these patients. METHODS: Patients with traditional or comprehensive blood management intraoperatively from January 2017 to December 2018 were included. We compared the rates of major complications (cerebral vascular accident, acute kidney injury, or mortality) between the two groups after propensity score matching (PSM). The association between blood management and outcomes was assessed by logistic regression. Restricted cubic splines (RCS) were built to evaluate the impact of fresh frozen plasma (FFP) on complications. Patients were stratified by the ratio of FFP/RBC (red blood cell) to investigate the effect of the ratio on complications. RESULTS: After 1:1 PSM, 200 patients were selected. 35% (35/100) of patients suffered major complications in the traditional group, while it decreased to 22% (22/100) in the comprehensive management group (OR = 0.524, p = 0.043). Multivariable logistic regression showed that FFP was a risk factor (OR = 1.186, p = 0.014). RCS results indicated that with the increase of FFP, the risk of complications gradually increases. The cut-off value was 402 mL. Patients in the group of ratio = 0 ∼ 0.5 had a higher chance than those without transfusion (OR = 7.487, p < 0.001). CONCLUSIONS: Comprehensive blood conservation program in patients undergoing TAAR is safe and can reduce the incidence of major complications, which are associated with FFP volume and the ratio of FFP/RBC.

Blood Transfusion and Acute Kidney Injury After Total Aortic Arch Replacement for Acute Stanford Type A Aortic Dissection.

AIM: To evaluate the effect of packed red blood cells (pRBCs), fresh frozen plasma (FFP), and platelet concentrate (PC) transfusions on acute kidney injury (AKI) in patients with acute Stanford type A aortic dissection (ATAAD) with total arch replacement (TAR). METHOD: From December 2015 to October 2017, 421 consecutive patients with ATAAD undergoing TAR were included in the study. The clinical data of the patients and the amount of pRBCs, FFP, and PC were collected. Acute kidney injury was defined using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Logistic regression was used to identify whether pRBCs, FFP, and platelet transfusions were risk factors for KDIGO AKI, stage 3 AKI, and AKI requiring renal replacement therapy (RRT). RESULTS: The mean ± standard deviation age of the patients was 47.67±10.82 years; 77.7% were men; and the median time from aortic dissection onset to operation was 1 day (range, 0-2 days). The median transfusion amount was 8 units (range, 4-14 units) for pRBCs, 400 mL (range, 0-800 mL) for FFP, and no units (range, 0-2 units) for PC. Forty-one (41; 9.7%) patients did not receive any blood products. The rates of pRBC, PC, and FFP transfusions were 86.9%, 49.2%, and 72.9%, respectively. The incidence of AKI was 54.2%. Considering AKI as the endpoint, multivariate logistic regression showed that pRBCs (odds ratio [OR], 1.11; p<0.001) and PC transfusions (OR, 1.28; p=0.007) were independent risk factors. Considering KDIGO stage 3 AKI as the endpoint, multivariate logistic regression showed that pRBC transfusion (OR, 1.15; p<0.001), PC transfusion (OR, 1.28; p<0.001), a duration of cardiopulmonary bypass (CPB) ≥293 minutes (OR, 2.95; p=0.04), and a creatinine clearance rate of ≤85 mL/minute (OR, 2.12; p=0.01) were independent risk factors. Considering RRT as the endpoint, multivariate logistic regression showed that pRBC transfusion (OR, 1.12; p<0.001), PC transfusion (OR, 1.33; p=0.001), a duration of CPB ≥293 minutes (OR, 3.79; p=0.02), and a creatinine clearance rate of ≤85 mL/minute (OR, 3.34; p<0.001) were independent risk factors. CONCLUSIONS: Kidney Disease: Improving Global Outcomes-defined stage AKI was common after TAR for ATAAD. Transfusions of pRBCs and PC increased the incidence of AKI, stage 3 AKI, and RRT. Fresh frozen plasma transfusion was not a risk factor for AKI.

Retrograde inferior vena caval perfusion for total aortic arch replacement surgery: a randomized pilot study.

OBJECTIVES: Antegrade cerebral perfusion (ACP) under moderate hypothermic circulatory arrest is used during total aortic arch replacement surgery (TARS) in patients with acute type A aortic dissection, but it is associated with high mortality and morbidity. We hypothesized that combining ACP with retrograde inferior vena caval perfusion (RIVP) improves outcomes. METHODS: This pilot study was prospective, randomized, controlled and assessor-blinded. Patients scheduled for TARS were randomly treated with either ACP or RIVP + ACP. The primary outcome was a composite of mortality and major complications including paraplegia, postoperative renal failure, severe liver dysfunction, and gastrointestinal complications. Secondary outcomes included neurological complications, length of intubation and requirement of blood products. RESULTS: A total of 76 patients were recruited (n = 38 per group). Primary outcome occurred in 23 patients (61%) in the ACP group and 16 (42%) in the RIVP + ACP group (OR: 0.60, 95% CI: 0.21-1.62; p = 0.31). There was a lower incidence of transient neurological deficits in the RIVP + ACP group (26% vs. 58%, OR: 0.26; 95% CI: 0.10-0.67,p = 0.006;). The RIVP + ACP group underwent shorter intubation (25 vs 47 h, p = 0.022) and required fewer blood products (red cells, 3.8 units vs 6.5 units, p = 0.047; platelet: 2.0 units vs 2.0 units, p = 0.023) compared with the ACP group. CONCLUSIONS: RIVP + ACP may be associated with lower incidence of transient neurological deficits, shorter intubation and less blood transfusion requirement than ACP alone during TARS. Multi-center, randomized trials with larger samples are required to determine whether RIVP + ACP is associated with lower rates of mortality and major complications. TRIAL REGISTRATION: Pilot study of a RCT registered in clinicaltrials.gov (NCT03607786), Registered 30 July, 2018-Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03607786 .

90 days impacts of remote ischemic preconditioning on patients undergoing open total aortic arch replacement: a post-hoc analysis of previous trial.

BACKGROUND: In the previous randomized controlled trial by our research group, we evaluated the effect of remote ischemic preconditioning (RIPC) in 130 patients (65 per arm) on acute kidney injury (AKI) within 7 days of open total aortic arch replacement. Significantly fewer RIPC-treated patients than sham-treated patients developed postoperative AKI, and, epically, RIPC significantly reduced serious AKI (stage II-III). However, the long-term effect of RIPC in patients undergoing open total aortic arch replacement is unclear. METHODS: This study was a post-hoc analysis. We aimed to assess the roles of RIPC in major adverse kidney events (MAKE), defined as consisting persistent renal dysfunction, renal replacement therapy and mortality, within 90 days after surgery in patients receiving open total aortic arch replacement. RESULTS: In this 90-day follow-up study, data were available for all study participants. We found that RIPC failed to improve the presence of MAKE within 90 days after surgery (RIPC: 7 of 65[10.8%]) vs sham: 15 of 65[23.1%]; P = 0.061). In those patients who developed AKI after surgery, we found that the rate of MAKE within 90 days after surgery differed between the RIPC group and the sham group (RIPC: 4 of 36[11.2%]; sham: 14 of 48[29.2%]; P = 0.046). CONCLUSIONS: At 90 days after open total aortic arch replacement, we failed to find a difference between the renoprotective effects of RIPC and sham treatment. The effectiveness or ineffectiveness of RIPC should be further investigated in a large randomized sham-controlled trial. TRIAL REGISTRATION: This study was approved by the Ethics Committee of Fuwai Hospital (No. 2016-835) and our previous study was registered at clinicaltrials.gov before patient enrollment ( NCT03141385 ; principal investigator: G.W.; date of registration: March 5, 2017).

Perfusion management of aortic balloon occlusion technique in total arch replacement with frozen elephant trunk.

To ensure both cerebral and lower body perfusion during total arch replacement with frozen elephant trunk, aortic balloon occlusion technique has been applied in some cases at our institute. During the procedure, after stented elephant trunk is inserted into the true lumen of the descending aorta, an aortic balloon catheter is placed and inflated within the stented elephant trunk, occluding the orifice of descending aorta. Then, lower body perfusion is provided via femoral cannulae during distal aortic arch anastomosis. We describe the perfusion management strategy of the technique, elucidate intraoperative monitoring parameters, and clarify the feasibility of the method from the aspect of perfusion.

Noninvasive Cerebral Imaging and Monitoring Using Electrical Impedance Tomography During Total Aortic Arch Replacement.

OBJECTIVE: To explore the feasibility of using electrical impedance tomography (EIT) to provide noninvasive cerebral imaging and monitoring in total aortic arch replacement (TAAR). DESIGN: A prospective, observational study. SETTING: Department of cardiovascular surgery in a university hospital. PARTICIPANTS: Forty-two patients undergoing TAAR using hypothermic circulatory arrest and unilateral antegrade cerebral perfusion. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Cerebral impedances of the patients were monitored intraoperatively by an EIT system. The prognostic information of the patients, including postoperative neurological dysfunction, was collected during their hospitalizations. Eight (19.0%) subjects had at least 1 postoperative neurological dysfunction complication. The results show that cerebral impedance was related negatively to perfusion flow, and the gradual increase in cerebral resistivity might reflect the evolving process of brain tissue caused by hypoxia. Maximum resistivity asymmetry index was extracted from the reconstructed images to quantify the pathological changes of the brain. The area under the receiver operating characteristic curve of maximum resistivity asymmetry index for postoperative neurological dysfunction was 0.864. In multivariate logistic regression, maximum resistivity asymmetry index was the strongest independent predictor of neurological dysfunction with an odds ratio of 24.3. CONCLUSION: EIT is a promising technique to provide noninvasive cerebral imaging and monitoring in TAAR.

Hemolytic anaemia due to graft kinking progression and aortic stenosis exacerbation after aortic arch replacement: A case report.

INTRODUCTION: Hemolytic anaemia from graft kinking is a rare complication after aortic surgery, typically treated by graft replacement. This case highlights hemolytic anaemia caused by the interaction of aortic stenosis and a kinked graft, successfully managed with transcatheter aortic valve replacement (TAVR). PRESENTATION OF CASE: A 75-year-old male developed hemolytic anaemia 2 years after total aortic arch replacement for a saccular aneurysm, with a worsening graft kink and aortic stenosis. Phase-contrast MRI confirmed abnormal blood flow at the kink. Due to his frail condition from prostate cancer, TAVR was performed, resolving the anaemia. DISCUSSION: Factors contributing to graft kinking include intraoperative graft length determination, natural aortic elongation with ageing, and graft type. To determine the cause of hemolysis, we needed to evaluate whether it was due to the kinked graft, aortic stenosis, or their combined effect. Hemolytic anaemia appeared at a low pressure gradient of 15.5 mmHg across the aortic valve, making it unlikely that the valve alone was the cause of the hemolysis. Using phase-contrast cardiovascular magnetic resonance, we observed abnormally accelerated blood flow caused by aortic stenosis impinging on the kinked graft. Possible causes include an increased pressure gradient at the kink due to accelerated blood flow, as well as physical collisions that may have resulted in shear stress on the red blood cells. CONCLUSION: TAVR resolved hemolytic anaemia caused by aortic stenosis and graft kinking after aortic arch replacement. In high-risk patients, less invasive treatment of the primary condition may effectively resolve hemolytic anaemia.

The role of serum magnesium in the prediction of acute kidney injury after total aortic arch replacement: A prospective observational study.

Background: Considerable morbidity and death are associated with acute kidney damage (AKI) following total aortic arch replacement (TAAR). The relationship between AKI following TAAR and serum magnesium levels remains unknown. The intention of this research was to access the predictive value of serum magnesium levels on admission to the Cardiovascular Surgical Intensive Care Unit (CSICU) for AKI in patients receiving TAAR. Methods: From May 2018 to January 2020, a prospective, observational study was performed in the Guangdong Provincial People's Hospital CSICU. Patients accepting TAAR admitted to the CSICU were studied. The Kidney Disease: Improving Global Outcomes (KDIGO) definition of serum creatinine was used to define AKI, and KDIGO stages two or three were used to characterize severe AKI. Multivariable logistic regression and area under the curve receiver-operator characteristic curve (AUC-ROC) analysis were conducted to assess the predictive capability of the serum magnesium for AKI detection. Finally, the prediction model for AKI was established and internally validated. Results: Of the 396 enrolled patients, AKI occurred in 315 (79.5%) patients, including 154 (38.8%) patients with severe AKI. Serum magnesium levels were independently related to the postoperative AKI and severe AKI (both, P < 0.001), and AUC-ROCs for predicting AKI and severe AKI were 0.707 and 0.695, respectively. Across increasing quartiles of serum magnesium, the multivariable-adjusted odds ratios (95% confidence intervals) of postoperative AKI were 1.00 (reference), 1.04 (0.50-2.82), 1.20 (0.56-2.56), and 6.19 (2.02-23.91) (P for Trend < 0.001). When serum magnesium was included to a baseline model with established risk factors, AUC-ROC (0.833 vs 0.808, P = 0.050), reclassification (P < 0.001), and discrimination (P = 0.002) were further improved. Conclusions: Serum magnesium levels on admission are an independent predictor of AKI. In TAAR patients, elevated serum magnesium levels were linked to an increased risk of AKI. In addition, the established risk factor model for AKI can be considerably improved by the addition of serum magnesium in TAAR patients hospitalized in the CSICU.

Machine learning-based model to predict severe acute kidney injury after total aortic arch replacement for acute type A aortic dissection.

Background: Severe acute kidney injury (AKI) after total aortic arch replacement (TAAR) is related to adverse outcomes in patients with acute type A aortic dissection (ATAAD). However, the early prediction of severe AKI remains a challenge. This study aimed to develop a novel model to predict severe AKI after TAAR in ATAAD patients using machine learning algorithms. Methods: A total of 572 ATAAD patients undergoing TAAR were enrolled in this retrospective study, and randomly divided into a training set (70 %) and a validation set (30 %). Lasso regression, support vector machine-recursive feature elimination and random forest algorithms were used to screen indicators for severe AKI (defined as AKI stage III) in the training set, respectively. Then the intersection indicators were selected to construct models through artificial neural network (ANN) and logistic regression. The AUC-ROC curve was employed to ascertain the prediction efficacy of the ANN and logistic regression models. Results: The incidence of severe AKI after TAAR was 22.9 % among ATAAD patients. The intersection predictors identified by different machine learning algorithms were baseline serum creatinine and ICU admission variables, including serum cystatin C, procalcitonin, aspartate transaminase, platelet, lactic dehydrogenase, urine N-acetyl-ß-d-glucosidase and Acute Physiology and Chronic Health Evaluation II score. The ANN model showed a higher AUC-ROC than logistic regression (0.938 vs 0.908, p < 0.05). Furthermore, the ANN model could predict 89.1 % of severe AKI cases beforehand. In the validation set, the superior performance of the ANN model was further confirmed in terms of discrimination ability (AUC = 0.916), calibration curve analysis and decision curve analysis. Conclusion: This study developed a novel and reliable clinical prediction model for severe AKI after TAAR in ATAAD patients using machine learning algorithms. Importantly, the ANN model showed a higher predictive ability for severe AKI than logistic regression.

Long-term results of the frozen elephant trunk technique in primary chronic type B aortic dissection.

OBJECTIVES: The aim of this study is to analyze long-term results of the total aortic arch replacement with the frozen elephant trunk technique for primary chronic type B aortic dissection. METHODS: Among 322 patients who had the frozen elephant trunk technique, 43 (13.4%) patients (median age, 64.0 years) with primary chronic type B aortic dissection were analyzed. The patients underwent surgery at a median of 27.0 months after the onset of aortic dissection. The false lumen was patent in 30 (69.8%) patients preoperatively. RESULTS: Two patients suffered paraplegia and another died of cerebral infarction. Complete thrombosis of the peri-stent false lumen was achieved in 36 (83.7%) patients. Overall survival, freedom from aortic events, and freedom from aortic reintervention were 83.5%, 37.2%, and 42.2% at 5 years, respectively. Survival rates of the patients with or without aortic events were 75.0% and 95.8% at 5 years (Log-rank, p = 0.22). Late aortic events occurred in 19 (44.2%) patients including distal stent graft-induced new entry, type Ib endoleak, and false lumen dilation. The ratio of the stent graft diameter to the preoperative short axis diameter of the true lumen (hazard ratio, 1.90; 95% confidence interval, 1.01-3.59), and the maximal diameter of a postdissection aneurysm (1.07; 1.01-1.12) were the significant multivariate risk predictors of late aortic events. CONCLUSIONS: Late aortic events occurr fairly frequently, and new strategies need to be explored to enhance the effectiveness of this procedure in the future.

Branch-first aortic arch replacement strategy decreases perioperative mortality.

OBJECTIVE: Sparce evidence suggests superiority of total arch replacement with the branch-first technique and antegrade cerebral perfusion over conventional techniques with respect to morbidity and mortality. Thus, we aimed to compare perioperative outcomes of patients undergoing traditional total arch replacement versus branch-first total arch replacement. METHODS: We retrospectively reviewed 144 patients undergoing total arch replacement from January 2017 to December 2021. Patients were dichotomized based on technique, either traditional total arch replacement or branch-first total arch replacement. Primary end points were 30-day mortality and adverse events. Branch-first total arch replacement and traditional total arch replacement cohorts were compared using Student t tests and chi-square tests. Univariable and multivariable logistic regressions were performed to identify risk factors associated with 30-day mortality. RESULTS: A total of 68 patients (47.2%) underwent traditional total arch replacement, and 76 patients (52.8%) underwent branch-first total arch replacement. The branch-first total arch replacement cohort had higher rates of chronic kidney disease, hypertension, atrial fibrillation, and previous myocardial infarction (P = .04, .002, .035, and .031 respectively). The majority of total arch replacements (78, 55%) were performed for aneurysmal disease. Median antegrade cerebral perfusion times were significantly shorter in the branch-first total arch replacement cohort (P = .001). There were no significant differences in rates of stroke, reintubation, postoperative lumbar drainage, renal failure, reoperation for bleeding, or prolonged ventilation between total arch replacement cohorts. The branch-first total arch replacement group had significantly lower 30-day mortality compared with the traditional total arch replacement group (4% vs 19%, P = .004). After adjustment for chronic kidney disease, nonelective status, antegrade cerebral perfusion time, rates of dissections arriving in extremis or with malperfusion, and primary surgeon, undergoing a branch-first total arch replacement was associated with a 93% reduced odds of 30-day mortality (odds ratio, 0.07, 95% CI, 0.009-0.48, P = .007). CONCLUSIONS: We provide evidence that branch-first total arch replacement significantly reduces 30-day mortality compared with traditional total arch replacement.

Prediction of acute kidney injury after total aortic arch replacement with serum cystatin C and urine N-acetyl-ß-d-glucosaminidase: A prospective observational study.

BACKGROUND: Acute kidney injury (AKI) after total aortic arch replacement (TAAR) is frequent and associated with adverse outcomes, whereas its early detection remains a challenge. Serum cystatin C (sCysC) and urinary N-acetyl-ß-d-glucosaminidase (uNAG) are clinically available renal biomarkers, but their combination for AKI detection requires more evidence. This study aimed to assess the discriminative abilities of these biomarkers in AKI after TAAR. MATERIALS AND METHODS: Patients undergoing TAAR were included in this prospective observational study. The AKI prediction model was developed and internal verificated, and the significance of each variable was analyzed by random forest (RF). Finally, the best predictive critical values of sCysC and uNAG were explored by the AUC-ROC curve. RESULTS: The AUC-ROC of the prediction model was substantially enhanced by adding sCysC and uNAG (0.909 vs 0.844, p < 0.001), and the clinical utility and risk reclassification were significantly improved. Additionally, the RF showed that sCysC and uNAG ranked first and second. The AUC-ROC for each were 0.864 and 0.802 respectively, and the cut-off values were 1.395 mg/L and 31.90 U/g Cre respectively. CONCLUSION: The prediction model incorporating functional marker sCysC and tubular injury marker uNAG can improve the discriminative abilities of AKI after TAAR.

Serum Myoglobin Is Associated With Postoperative Acute Kidney Injury in Stanford Type A Aortic Dissection.

Background: The correlation between rhabdomyolysis and postoperative acute kidney injury has been reported in several surgical procedures. As a good predictor of rhabdomyolysis-related acute kidney injury, an elevated serum myoglobin level was often observed after total aortic arch replacement combined with frozen elephant trunk implantation. However, the correlation between serum myoglobin and acute kidney injury in such patients had not been established. Methods: Totally 398 stanford type A aortic dissection patients who underwent total aortic arch replacement combined with frozen elephant trunk implantation were enrolled in this retrospective study. The correlations between serum myoglobin and acute kidney injury as well as the 30-day mortality were assessed. Results: Overall, 268(67.3%) patients had acute kidney injury (KDIGO stage 1 or higher) and 75(18.8%) had severe acute kidney injury (KDIGO stage 2&3). Patients who developed acute kidney injury had higher level of perioperative serum myoglobin than patients without acute kidney injury. After adjusting for known acute kidney injury risk factors, logarithmically transformed preoperative serum myoglobin [OR = 1.58 (95% CI, 1.26-1.95), P < 0.001] and postoperative day 1 serum myoglobin [OR = 3.47 (95%CI, 2.27-5.29), P < 0.001] were associated with severe acute kidney injury. These correlation persisted after adjustment for decline in filtration via change in serum creatinine (ΔCr) and biomarkers of cardiac and kidney injury, including N-terminal prohormone of brain natriuretic peptide, cardiac troponin I, creatine kinase-MB, serum creatinine and Cystatin C. Compared with the clinical model, sMb considerably improved the risk discrimination and reclassification for AKI. Conclusion: For stanford type A aortic dissection patients underwent total aortic arch replacement with frozen elephant trunk implantation, serum myoglobin can improve postoperative acute kidney injury risk classification. Rhabdomyolysis may be an important supplement to the existing knowledge on the mechanism of acute kidney injury.

Monitoring of Post-Brain Injuries By Measuring Plasma Levels of Neuron-Derived Extracellular Vesicles.

Background: Extracellular vesicles (EV) released from neurons into the blood can reflect the state of nervous tissue. Measurement of neuron derived EV (NDE) may serve as an indicator of brain injury. Methods: A sandwich immunoassay was established to measure plasma NDE using anti-neuron CD171 and anti-EV CD9 ([CD171 + CD9+]). Plasma samples were obtained from commercial sources, cross-country (n = 9), football (n = 22), soccer (n = 19), and rugby (n = 18) athletes over time. Plasma was also collected from patients undergoing total aortic arch replacement (TAR) with selective cerebral perfusion during cardiopulmonary bypass before and after surgery (n = 36). Results: The specificity, linearity, and reproducibility of NDE assay (measurement of [CD171 + CD9+]) were confirmed. By scanning electron microscopy and nanoparticle tracking, spherical vesicles ranging in size from 150 to 300 nm were confirmed. Plasma levels of NDE were widely spread over 2 to 3 logs in different individuals with a significant age-dependent decrease. However, NDE were very stable in each individual within a ± 50% change over time (cross-country, football, soccer), whereas rugby players were more variable over 4 years. In patients undergoing TAR, NDE increased rapidly in days post-surgery and were significantly (P = .0004) higher in those developing postoperative delirium (POD) (n = 13) than non-delirium patients (n = 23). Conclusions: The blood test to determine plasma levels of NDE was established by a sandwich immunoassay using 2 antibodies against neuron (CD171) and exosomes (CD9). NDE levels varied widely in different individuals and decreased with age, indicating that NDE levels should be considered as a normalizer of NDE biomarker studies. However, NDE levels were stable over time in each individual, and increased rapidly after TAR with greater increases associated with patients developing POD. This assay may serve as a surrogate for evaluating and monitoring brain injuries.

Is aortic valve-sparing root reimplantation (David-I) justified in cardiac redo surgery?

OBJECTIVES: Aortic valve-sparing root reimplantation (AVSRR) is a complex procedure, which offers the benefit of preserving the native aortic valve. Cardiac redo surgery is complex and time-consuming, and it is not known if David procedure is safe or beneficial in this context. METHODS: Between 1993 and 2019, we performed a total of 544 elective AVSRR operations at our centre. Patients were assigned to either group A (n = 30, redo) or group B (n = 514, first-time sternotomy). RESULTS: Aortic cross-clamp time was higher in the redo group (173[62] vs 125[31], P < 0.001). Cardiopulmonary bypass time was higher in the redo group as well (250[78] vs 179[51], P < 0.001). There were significantly more concomitant total arch replacements in the redo group (43.3% vs 5.8%, P < 0.001) using the 'beating heart' technique (20.0% vs 1.9%, P < 0.001). In-hospital mortality was comparable in both groups (3.3% vs 1.8%, P = 0.44). The rates for perioperative complications in terms of permanent neurological deficit and rethoracotomy were comparable between the 2 groups, too. Follow-up was complete for 99.6% of all patients and comprised a total of 584 patient-years. The 1-, 5-, 10- and 15-year survival rates were 90%, 81%, 60% and 55%, in group A (redo) and 96%, 90%, 78% and 67% in group B (native, P = 0.16), respectively. The rates for freedom from valve-related reoperation at 1, 5, 10 and 15 years after initial surgery were 96%, 92%, 92% and 92% in group A (redo) and 97%, 92%, 87% and 84% in group B (native, P = 0.52), respectively. CONCLUSIONS: Despite significantly more concomitant total arch replacements in the redo group, early mortality was comparable in both groups. We conclude that AVSRR can be performed in redo cardiac surgery without compromising the early postoperative outcome. Careful patient assessment and selection are mandatory when evaluating patients with a history of previous cardiac surgery for David procedure.