Adverse Technical Events During Aortic Root Replacement.

BACKGROUND: Although adverse technical events during aortic root replacement (ARR) are not uncommon and are extremely challenging, there is scant literature to help surgeons prepare for such situations. We describe our experience of outstanding technical events during ARR. METHODS: This is a retrospective study of 830 consecutive ARRs at a single center from 2012 to 2022. Technical events were defined as intraoperative events that led to an unplanned cardiac procedure, need for mechanical circulatory support, or additional aortic cross-clamping. Logistic regression identified factors associated with operative mortality and technical events. RESULTS: Technical events occurred in 90 patients (10.8%) and were attributed to bleeding (n = 26), nonischemic ventricular dysfunction (n = 23), residual valve disease (n = 20), myocardial ischemia (n = 19), and iatrogenic dissection (n = 2). Prior sternotomy (odds ratio [OR], 2.38; 95% CI, 1.36-4.19; P = .002) and complex aortic valve disease (OR, 3.09; 95% CI, 1.09-8.75; P = .03) were associated with technical events. Patients with technical events had higher rates of operative mortality (6.7% vs 2.3%, P = .03) and all major postoperative complications. Surgical indications of dissection (OR, 13.57; 95% CI, 4.95-37.23; P < .001) and complex aortic valve disease (OR, 14.09; 95% CI, 3.67-54.02; P < .001) but not adverse technical events (OR, 2.42; 95% CI, 0.81-7.26; P = .11) were associated with operative mortality. CONCLUSIONS: Adverse technical events occurred in 10.8% of ARRs and were associated with reoperative sternotomies. Technical events are associated with increased postoperative complications.

Long-term outcomes after aortic root replacement for bicuspid aortic valve-associated aneurysm.

OBJECTIVE: Patients with congenital bicuspid aortic valve often require root replacement. This study aims to describe their long-term rates of mortality and reoperation. METHODS: This is a multicenter retrospective study of 747 patients with bicuspid aortic valve who underwent aortic root replacement for aortic aneurysm between 2004 and 2020. Cumulative incidence curves for aortic valve and aortic reoperations were graphed. A Kaplan-Meier survival curve for the patient cohort was created alongside an age- and sex-matched curve for the US population. Multivariable Cox regression was used to determine characteristics associated with long-term mortality. RESULTS: The median age of our cohort was 54 [43-64] years old, and 101 (13.5%) patients were female. In patients with bicuspid aortic valve dysfunction, 274 (36.7%) had aortic insufficiency, 187 (25.0%) had aortic stenosis, and 142 (19.0%) had both. In-hospital mortality occurred in 10 (1.3%) patients. There were 56 aortic valve reoperations and 19 aortic reoperations, with a combined cumulative incidence of 35% (95% confidence interval [CI], 23%-46%) at 15 years. In addition, there was comparable survival between the patient cohort and the age- and sex-matched US population. Age (hazard ratio [HR], 1.04; 95% CI, 1.01-1.06), concomitant CABG (HR, 2.28; 95% CI, 1.29-4.04), and bypass time (HR, 1.01; 95% CI, 1.00-1.01) were associated with increased mortality. CONCLUSIONS: Patients who undergo aortic root replacement with bicuspid aortic valve have an increased rate of aortic reoperation (35%; 95% CI, 23%-46%) while their survival appears to be comparable to the general US population (79%; 95% CI, 73%-87%) at 15 years.

Is surgical risk of aortic arch aneurysm repair underestimated? A novel perspective based on 30-day versus 1-year mortality.

OBJECTIVES: The decision to undergo aortic aneurysm repair balances the risk of operation with the risk of aortic complications. The surgical risk is typically represented by perioperative mortality, while the aneurysmal risk relates to the 1-year risk of aortic events. We investigate the difference in 30-day and 1-year mortality after total arch replacement for aortic aneurysm. METHODS: This was an international two-centre study of 456 patients who underwent total aortic arch replacement for aneurysm between 2006 and 2020. Our primary end-point of interest was 1-year mortality. Our secondary analysis determined which variables were associated with 1-year mortality. RESULTS: The median age of patients was 65.4 years (interquartile range 55.1-71.1) and 118 (25.9%) were female. Concomitantly, 91 (20.0%) patients had either an aortic root replacement or aortic valve procedure. There was a drop in 1-year (81%, 95% confidence interval (CI) 78-85%) survival probability compared to 30-day (92%, 95% CI 90-95%) survival probability. Risk hazards regression showed the greatest risk of mortality in the first 4 months after discharge. Stroke [hazard ratio (HR) 2.54, 95% CI (1.16-5.58)], renal failure [HR 3.59 (1.78-7.25)], respiratory failure [HR 3.65 (1.79-7.42)] and reoperation for bleeding [HR 2.97 (1.36-6.46)] were associated with 1-year mortality in patients who survived 30 days. CONCLUSIONS: There is an increase in mortality up to 1 year after aortic arch replacement. This increase is prominent in the first 4 months and is associated with postoperative complications, implying the influence of surgical insult. Mortality beyond the short term may be considered in assessing surgical risk in patients who are undergoing total arch replacement.

An Ex Vivo Porcine Model for Hydrodynamic Testing of Experimental Aortic Valve Procedures and Novel Medical Devices.

The options for testing new cardiac procedures and investigative medical devices prior to use in an animal model are limited. In this study, we present a method for mounting a porcine aortic valve in a pulse duplicator to evaluate its hydrodynamic properties. These properties can then be evaluated before and after the procedure under investigation is performed and/or the investigative medical device is applied. Securing the inflow segment presents some difficulty owing to the lack of circumferential myocardium in the left ventricular outflow tract. This method addresses that issue by securing the inflow segment using the anterior leaflet of the mitral valve and then suturing the left ventricular free wall around the inflow fixture. The outflow segment is secured simply by inserting the fixture into an incision in the superior aspect of the aortic arch. We found that specimens had significantly different hydrodynamic properties before and after tissue fixation. This finding induced us to use fresh specimens in our testing and should be considered when using this method. In our work, we used this method to test novel intracardiac patch materials for use in the valvular position by performing an aortic valve neocuspidization procedure (Ozaki procedure) on the mounted porcine aortic valves. These valves were tested before and after the procedure to assess the change in hydrodynamic properties in comparison to the native valve. Herein, we report a platform for hydrodynamic testing of experimental aortic valve procedures that enables comparison with the native valve and between different devices and techniques used for the procedure under investigation.

Long-term outcome of hemiarch replacement in a proximal aortic aneurysm repair: analysis of over 1000 patients.

OBJECTIVES: The aim of this study was to investigate the impact of hemiarch replacement in patients undergoing an open repair of proximal thoracic aortic aneurysm without arch aneurysm. METHODS: A retrospective review was performed on 1132 patients undergoing proximal aortic aneurysm repair at our Aortic Center between 2005 and 2019. Inclusion criteria were all patients undergoing root or ascending aortic aneurysm repair with or without hemiarch replacement. Exclusion criteria were age <18 years, aortic arch diameter ≥4.5 cm, type A aortic dissection, previous ascending aortic replacement, ruptured aneurysm and endocarditis. Propensity score matching in a 2:1 ratio (573 non-hemiarch: 288 hemiarch) on 19 baseline characteristics was performed. The median follow-up time was 46.8 months (range 0.1-170.4 months). RESULTS: Hemiarch patients had significantly lower 10-year survival in the matched cohort (hemiarch 73.8%; 66.9-81.4%; vs non-hemiarch 86.5%; 81.1-92.3%; P < 0.001), driven by higher in-hospital mortality rate (4% vs 1%; P < 0.001). Cumulative incidence of aortic arch reintervention rates at 10 years was similarly low (hemiarch 1.0%; 0-2.5% vs non-hemiarch 1.3%; 0-2.6%, P = 0.615). Multivariate analysis with hazard ratios of the overall cohort showed hemiarch as an independent factor associated with long-term mortality (2.16; 1.42-3.27; P < 0.001) but not with aortic arch reintervention (0.76; 0.14-4.07, P = 0.750). CONCLUSIONS: Hemiarch repair may be associated with higher short-term mortality compared to non-hemiarch. Arch reintervention was rare after a repair of proximal thoracic aortic aneurysm without arch aneurysm. Our data call for larger and prospective studies to further delineate the utility of hemiarch repair in proximal aortic surgery.

Reactions to the opioid epidemic: A text-mining analysis of tweets.

OBJECTIVE: This study analyzed public reactions to the opioid epidemic using Twitter discourse. Methods: One month of unique tweets (n = 26,079) from July 23, 2018 to August 22, 2018 were identified using the keyword "opioid" in conjunction with the words "crisis, epidemic, misuse, prescription, and death." Twelve topics, each representing more than 1% of all tweets, together accounted for 17,206 (66%) of identified tweets. Results: The top four tweet topics (representing 38% of the total) addressed lawsuits and public policy, people who use opioids to treat persistent pain, programs to alleviate the opioid epidemic, and one specific initiative, the "#onelesspill" movement. The next seven topics (representing 27% of the total) addressed news articles relating to the opioid epidemic. The 12th topic was a book about the opioid crisis (1.7% of the total tweets). Conclusions: These tweets exhibited polarization of opinions with some people calling for tighter restrictions on opioids and others desperate to preserve their daily use of opioids for alleviation of illnesses characterized by persistent pain. Social media posts can help inform efforts to craft public policy and communication strategies to support optimal opioid stewardship.

Themes in published obituaries of people who have died of opioid overdose.

This study gauged public perceptions of the opioid epidemic in online obituaries related to opioid overdose by analyzing emotional themes and tones. A thematic analysis was performed on a consecutive listing of online obituaries from the United States. Three hundred electronic obituaries of people who died due to opioid, heroin, and prescription drug overdose, identified in an online obituary platform (Legacy.com) using the keyword "overdose" were used. Tones, emotions, terms used to describe death, and types of opioids were measured using the string search function of Stata and IBM Watson Tone Analyzer. Our analysis showed that joy and sadness are the most prevalent tones in these obituaries (92% and 88%, respectively) and the most common emotion was love (79%). The two most commonly used terms to describe death due to opioid overdose were 'accidental' (53%) and 'addiction' (34%). The two types of narcotics named were 'heroin' (35%) and 'prescription opioids' (7.8%). Obituaries of people who have died due to opioid overdose contain main themes of love, joy, and sadness. The fact that stigma and shame were less prevalent themes might suggest support of the concept that addiction should be regarded as a disease rather than a criminal behavior.

Quantifying Hydrogen-Bond Populations in Dimethyl Sulfoxide/Water Mixtures.

Dimethyl sulfoxide (DMSO) disrupts the hydrogen-bond networks in water. The widespread use of DMSO as a cosolvent, along with its unusual attributes, have inspired numerous studies. Herein, infrared absorption spectroscopy of the S=O stretching mode combined with molecular dynamics and quantum chemistry models were used to directly quantify DMSO/water hydrogen-bond populations in binary mixtures. Singly H-bonded species are dominant at 10 mol %, due to strong DMSO-water interactions. We found an unexpected increase in non-hydrogen-bonded DMSO near the eutectic point (ca. 35 mol %) which also correlates with several abnormalities in the bulk solution properties. We find evidence for three distinct regimes: 1) strong DMSO-water interactions (<30 mol %), 2) ideal-solution-like (30-90 mol %), and 3) self-interaction, or aggregation, regime (>90 mol %). We propose a "step in" mechanism, which involves hydrogen bonding between water and the DMSO aggregate species.