Evaluating the Impact of Operative Team Familiarity on Cardiac Surgery Outcomes: A Retrospective Cohort Study of Medicare Beneficiaries.

OBJECTIVE: To associate surgeon-anesthesiologist team familiarity (TF) with cardiac surgery outcomes. BACKGROUND: TF, a measure of repeated team member collaborations, has been associated with improved operative efficiency; however, examination of its relationship to clinical outcomes has been limited. METHODS: This retrospective cohort study included Medicare beneficiaries undergoing coronary artery bypass grafting (CABG), surgical aortic valve replacement (SAVR), or both (CABG+SAVR) between January 1, 2017, and September 30, 2018. TF was defined as the number of shared procedures between the cardiac surgeon and anesthesiologist within 6 months of each operation. Primary outcomes were 30- and 90-day mortality, composite morbidity, and 30-day mortality or composite morbidity, assessed before and after risk adjustment using multivariable logistic regression. RESULTS: The cohort included 113,020 patients (84,397 CABG; 15,939 SAVR; 12,684 CABG+SAVR). Surgeon-anesthesiologist dyads in the highest [31631 patients, TF median (interquartile range)=8 (6, 11)] and lowest [44,307 patients, TF=0 (0, 1)] TF terciles were termed familiar and unfamiliar, respectively. The rates of observed outcomes were lower among familiar versus unfamiliar teams: 30-day mortality (2.8% vs 3.1%, P =0.001), 90-day mortality (4.2% vs 4.5%, P =0.023), composite morbidity (57.4% vs 60.6%, P <0.001), and 30-day mortality or composite morbidity (57.9% vs 61.1%, P <0.001). Familiar teams had lower overall risk-adjusted odds of 30-day mortality or composite morbidity [adjusted odds ratio (aOR) 0.894 (0.868, 0.922), P <0.001], and for SAVR significantly lower 30-day mortality [aOR 0.724 (0.547, 0.959), P =0.024], 90-day mortality [aOR 0.779 (0.620, 0.978), P =0.031], and 30-day mortality or composite morbidity [aOR 0.856 (0.791, 0.927), P <0.001]. CONCLUSIONS: Given its relationship with improved 30-day cardiac surgical outcomes, increasing TF should be considered among strategies to advance patient outcomes.

Five Year Results of Endovascular versus Medical Therapy in Acute Type B Aortic Intramural Haematoma: Meta-Analysis of Reconstructed Time to Event Data.

OBJECTIVE: To evaluate outcomes in the follow up of thoracic endovascular aortic repair (TEVAR) vs. medical therapy in patients with acute type B aortic intramural haematoma (IMH). DATA SOURCES: The following sources were searched for articles meeting the inclusion criteria and published by July 2023: PubMed/MEDLINE, EMBASE, CENTRAL/CCTR (Cochrane Controlled Trials Register). REVIEW METHODS: This systematic review with pooled meta-analysis of time to event data followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines, and its protocol was registered on the public platform PROSPERO (CRD42023456222). The following were analysed: overall survival (all cause mortality), aortic related mortality, and restricted mean survival time. Certainty of evidence was evaluated through the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) tool. RESULTS: Eight studies met the eligibility criteria, including 1 015 patients (440 in the TEVAR group and 575 in the medical therapy group). All studies were observational, and the pooled cohort had a median follow up of 5.1 years. Compared with patients who received medical therapy alone, those who underwent TEVAR had a statistically significantly lower risk of all cause death (HR 0.44, 95% CI 0.30 - 0.65; p < .001; GRADE certainty: low), lower risk of aortic related death (HR 0.04, 95% CI 0.01 - 0.31; p = .002; GRADE certainty: low) and lifetime gain (restricted mean survival time was overall 201 days longer with TEVAR; p < .001). CONCLUSION: Thoracic endovascular aortic repair may be associated with lower risk of all cause and aortic related death compared with medical therapy in patients with acute type B IMH; however, the underlying data are not strong enough to draw robust clinical conclusions. Randomised controlled trials with large sample sizes and longer follow up are warranted to elucidate this question.

CardioVision: A fully automated deep learning package for medical image segmentation and reconstruction generating digital twins for patients with aortic stenosis.

Aortic stenosis (AS) is the most prevalent heart valve disease in western countries that poses a significant public health challenge due to the lack of a medical treatment to prevent valve calcification. Given the aging population demographic, the prevalence of AS is projected to rise, resulting in a progressively significant healthcare and economic burden. While surgical aortic valve replacement (SAVR) has been the gold standard approach, the less invasive transcatheter aortic valve replacement (TAVR) is poised to become the dominant method for high- and medium-risk interventions. Computational simulations using patient-specific models, have opened new research avenues for optimizing emerging devices and predicting clinical outcomes. The traditional techniques of generating digital replicas of patients' aortic root, native valve, and calcification are time-consuming and labor-intensive processes requiring specialized tools and expertise in anatomy. Alternatively, deep learning models, such as the U-Net architecture, have emerged as reliable and fully automated methods for medical image segmentation. Two-dimensional U-Nets have been shown to produce comparable or more accurate results than trained clinicians' manual segmentation while significantly reducing computational costs. In this study, we have developed a fully automatic AI tool capable of reconstructing the digital twin geometry and analyzing the calcification distribution on the aortic valve. The developed automatic segmentation package enables the modeling of patient-specific anatomies, which can then be used to simulate virtual interventional procedures, optimize emerging prosthetic devices, and predict clinical outcomes.

Predicting one-year left ventricular mass index regression following transcatheter aortic valve replacement in patients with severe aortic stenosis: A new era is coming.

Aortic stenosis (AS) is the most common valvular heart disease in the western world, particularly worrisome with an ever-aging population wherein postoperative outcome for aortic valve replacement is strongly related to the timing of surgery in the natural course of disease. Yet, guidelines for therapy planning overlook insightful, quantified measures from medical imaging to educate clinical decisions. Herein, we leverage statistical shape analysis (SSA) techniques combined with customized machine learning methods to extract latent information from segmented left ventricle (LV) shapes. This enabled us to predict left ventricular mass index (LVMI) regression a year after transcatheter aortic valve replacement (TAVR). LVMI regression is an expected phenomena in patients undergone aortic valve replacement reported to be tightly correlated with survival one and five year after the intervention. In brief, LV geometries were extracted from medical images of a cohort of AS patients using deep learning tools, and then analyzed to create a set of statistical shape models (SSMs). Then, the supervised shape features were extracted to feed a support vector regression (SVR) model to predict the LVMI regression. The average accuracy of the predictions was validated against clinical measurements calculating root mean square error and R 2 score which yielded the satisfactory values of 0.28 and 0.67, respectively, on test data. Our work reveals the promising capability of advanced mathematical and bioinformatics approaches such as SSA and machine learning to improve medical output prediction and treatment planning.

Cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic. METHODS: A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed. RESULTS: Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID-19, they were most worried with exposing their family to COVID-19 (81%), followed by contracting COVID-19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID-19 burden, with higher COVID-19 burden institutions more likely to resort to PPE conservation strategies. CONCLUSIONS: The present study demonstrates the impact of COVID-19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.

Endovascular Repair of a Pseudoaneurysm After Multiple Open Repairs of Aortic Coarctation.

Successful surgical repair of aortic coarctation during childhood may have major late complications such as pseudoaneurysm formation. If left untreated, pseudoaneuryms put patients at risk for morbidity and death; if treated surgically, they are associated with complications. Endovascular aortic repair, an established safe alternative to open surgical repair, is associated with encouraging outcomes and fewer complications, and it is especially feasible for patients who have undergone multiple aortic surgeries. We report the case of a 41-year-old man who underwent endovascular repair of a pseudoaneurysm after previous surgical corrections of an aortic coarctation at 6 and 14 years of age. The pseudoaneurysm, involving the distal portion of an ascending-to-descending aortic 20-mm Dacron bypass graft, was successfully excluded with a thoracic stent-graft and sealed off with vascular plugs to prevent both blood flow into the pseudoaneurysm and type II endoleak.

Proximal Descending Thoracic Aortic Pseudoaneurysm in a 24-Year-Old Man after 2 Childhood Repairs of Interrupted Aortic Arch.

Improved management of interrupted aortic arch has increased long-term survival rates. Longer life expectancies in neonates and children surgically treated for interrupted aortic arch may necessitate complex reinterventions when sequelae develop in adulthood. We report the case of a 24-year-old man who had undergone initial repair of interrupted aortic arch type B at one week and reintervention at 6 years of age. He presented with a 5.5 × 9-cm pseudoaneurysm of the proximal descending thoracic aorta. He underwent surgical replacement of his distal aortic arch and proximal descending thoracic aorta, with a bypass to his left subclavian artery. In addition to our patient's case, we discuss considerations in treating recipients of early interrupted aortic arch repairs as they live longer and undergo multiple reinterventions.

Spinal cord deficit after 1114 extent II open thoracoabdominal aortic aneurysm repairs.

OBJECTIVE: Crawford extent II repairs are the most extensive thoracoabdominal aortic aneurysm operations and pose the greatest risk of postoperative spinal cord deficit. We sought to examine spinal cord deficit after open extent II thoracoabdominal aortic aneurysm repair to identify predictors of the most serious type: persistent paraplegia or paraparesis. METHODS: We included 1114 extent II thoracoabdominal aortic aneurysm repairs performed from 1991 to 2017. Intercostal/lumbar artery reattachment (n = 959, 86.1%) and cerebrospinal fluid drainage (n = 698, 62.7%) were used to mitigate the risk of postoperative spinal cord deficit. We used univariate and multivariable analyses to examine spinal cord deficit and identify predictors of persistent paraplegia or paraparesis, defined as paraplegia or paraparesis present at the time of early death or hospital discharge. RESULTS: Spinal cord deficit developed after 151 (13.6%) repairs: 86 (7.7%) cases of persistent paraplegia or paraparesis (51 paraplegia; 35 paraparesis) and 65 (6.1%) cases of transient paraplegia or paraparesis. Patients with spinal cord deficit were older (median 68 vs 65 years, P < .001) and had more rupture (6.6% vs 2.2%, P = .002) and urgent/emergency repair (25.2% vs 16.9%, P = .01) than those without. Persistent paraplegia or paraparesis developed immediately in 47 patients (4.2%) and was delayed in 39 patients (3.5%). Urgent/emergency repair (relative risk ratio, 2.31; P = .002), coronary artery disease (relative risk ratio, 1.80, P = .01), and chronic symptoms (relative risk ratio, 1.76, P = .02) independently predicted persistent paraplegia or paraparesis. Reattaching intercostal/lumbar arteries (relative risk ratio, 0.38, P < .001) and heritable disease (relative risk ratio, 0.36, P = .01) were protective. Early and late survival were poorer in those with persistent paraplegia or paraparesis than in those without. CONCLUSIONS: Spinal cord deficit after extent II thoracoabdominal aortic aneurysm repairs remains concerning; survival is worse in patients with persistent paraplegia or paraparesis. The complexity of spinal cord deficit and persistent paraplegia or paraparesis warrant further study.

Is incidental splenectomy during thoracoabdominal aortic aneurysm repair associated with reduced survival?

OBJECTIVE: The effect of incidental splenectomy during thoracoabdominal aortic aneurysm repair is unknown. We hypothesized incidental splenectomy was associated with decreased late survival. METHODS: We studied 1056 thoracoabdominal aortic aneurysm repairs from 2006 to 2016. Exclusion criteria were age less than 18 years (n = 9), prior splenectomy (n = 2), and intraoperative death (n = 3). This left 1042 thoracoabdominal aortic aneurysm repairs for analysis (median age, 65 years; interquartile range, 56-72), including 221 (21%) that were reoperations. Multivariable modeling identified predictors of operative mortality in the total cohort. Moreover, to adjust for baseline differences, propensity score matching was performed to examine the frequency of these outcomes in the total cohort (n = 132 pairs) and the early survivors (n = 110 pairs). Late survival was estimated by the Kaplan-Meier method, and risk of late mortality was assessed by Cox proportional hazards regression. RESULTS: Incidental splenectomy was performed in 135 patients (13%), 36% of whom underwent reoperation. Operative mortality rates of the incidental splenectomy and nonincidental splenectomy groups were 16% versus 8% in both the overall study (P = .005) and the propensity score-matched (P = .07) cohorts. In multivariable analysis, incidental splenectomy independently predicted operative mortality (odds ratio, 2.2; 95% confidence interval, 1.21-3.94; P = .008). For early survivors, incidental splenectomy did not increase the risk of late mortality. Survival estimates of matched early survivors did not differ between the incidental splenectomy and nonincidental splenectomy groups (P = .29). CONCLUSIONS: Incidental splenectomy during thoracoabdominal aortic aneurysm repair was associated with increased operative mortality but not reduced late survival. Splenic preservation is encouraged when feasible.

Acute type I aortic dissection with or without antegrade stent delivery: Mid-term outcomes.

OBJECTIVE: We determined the effect of antegrade stent delivery in the descending thoracic aorta on short- and mid-term clinical and imaging outcomes for patients who underwent repair of acute DeBakey type I aortic dissection. METHODS: Outcomes were evaluated for 178 patients who underwent acute type I aortic dissection between 2005 and 2016 (standard repair, n = 115 [64.6%]; antegrade stent delivery, n = 63 [35.4%]). Propensity score match and multivariable analyses were performed to assess outcomes. RESULTS: The stent and standard repair groups had similar rates of operative mortality (30-day or in-hospital) (12.7% vs 17.4%, P = .41), persistent stroke (6.3% vs 5.3%, P = .75), and persistent paraplegia/paraparesis (1.6% vs 0.9%, P = 1.0). Propensity score match analysis indicated that the operative mortality rate was higher in the standard repair group (P = .059), which the multivariable analysis confirmed. The persistent stroke rate was nonsignificantly higher in the stent group (P = .66). Persistent paraplegia/paraparesis rates were similar in both groups (P = 1.0), and the overall rates of spinal cord ischemia were nonsignificantly higher in the stent group (P = .18). During follow-up (mean duration, 4.6 ± 3.6 y), computed tomography showed that stented patients more often had remodeling of the descending thoracic aorta (P = .0002) and somewhat more often had remodeling of the thoracoabdominal aorta (P = .13). Stented patients also had fewer subsequent procedures (P = .25). The 3- and 5-year survivals were 73.3% ± 6.9% and 49.9% ± 7.6% in the matched stented group and 66.3% ± 9.4% and 41.6% ± 7.7% in the matched standard group, respectively (P = .015 for overall survival). CONCLUSIONS: In the short term, antegrade stent delivery was associated with less operative mortality. In the mid-term, promising remodeling of the false lumen was seen in stented patients, as were (nonsignificantly) lower rates of subsequent procedures in the thoracoabdominal aorta. Mid-term survival was also greater in the stented patients.

Tracheostomy After Thoracoabdominal Aortic Aneurysm Repair: Risk Factors and Outcomes.

BACKGROUND: Respiratory failure, the most frequent complication after thoracoabdominal aortic aneurysm (TAAA) repair, necessitates tracheostomy in severe cases. We examined risk factors for and outcomes of tracheostomy after TAAA repair. METHODS: We reviewed the records of 1267 consecutive patients who underwent TAAA repair. Patients with a preexisting tracheostomy were excluded. Extensive repairs (Crawford extent I or II) were performed in 716 patients (56.6%). Stepwise logistic regression analysis was used to identify risk factors for postrepair tracheostomy. RESULTS: Tracheostomy was necessary in 140 patients (11.1%). Operative mortality was significantly higher in patients with tracheostomy (27.9%) than in those without (5.8%; p < 0.001). As expected, tracheostomy patients had longer intensive care unit stays (24 vs 4 days, p < 0.001) and hospital stays (57 vs 10 days, p < 0.001) than nontracheostomy patients. Patients with tracheostomy were frequently transferred for additional long-term acute care or hospitalization (107, 76.4%), and many died after transfer (24/107, 22.4%). Kaplan-Meier curves showed markedly poorer late survival in patients with tracheostomy than in those without (47.9% ± 4.3% vs 87.3% ± 1.0% at 1 year; 27.8% ± 4.8% vs 68.6% ± 1.6% at 5 years). Independent predictors of post-TAAA repair tracheostomy included acute aortic dissection, chronic renal insufficiency, underweight body mass index, hypertension, history of stroke, extent II repair, diabetes, age at least 70 years, and greater platelet transfusion volume. CONCLUSIONS: Patients who undergo tracheostomy after TAAA repair have a high risk of early and late mortality as well as prolonged hospitalization. Strategies for improving survival outcomes in tracheostomy patients warrant investigation.

In the endovascular era, is elective open aortic arch surgery in elderly patients still justified?

OBJECTIVE: The data supporting performing elective aortic arch surgery in patients aged 75 years or older are equivocal. We evaluated short- and long-term outcomes after elective arch surgery in patients aged ≥75 years to determine whether complex arch operations are justified in such patients. METHODS: Over a 10-year period, 805 patients aged 50 to 89 years underwent elective proximal or total arch surgery. Composite adverse outcome was defined as operative mortality, persistent (ie, present at discharge) neurologic event, or persistent hemodialysis. Multivariable logistic regression was performed in the entire group. RESULTS: Multivariable analysis showed that age at admission independently predicted composite adverse outcome, operative mortality, and prolonged (>48 hours) ventilator support (P < .0001 for all), but not stroke. The same results were shown in a subgroup analysis in which older age (80-89 years) was associated with composite adverse outcome, operative mortality, and prolonged ventilator support. In a Cox proportional hazards regression model adjusted for antegrade cerebral perfusion time and prior history of renal disease, patients aged 50 to 74 years had significantly better overall survival than patients aged ≥75 years (P < .001). CONCLUSIONS: As endovascular technology evolves, having benchmark data from likely endovascular-therapy candidates is critical. This study, among the few to focus on elective aortic arch surgery in elderly patients, suggests that surgical intervention carries risk and that novel endovascular therapies are needed.

Early-Stage Acute Kidney Injury Adversely Affects Thoracoabdominal Aortic Aneurysm Repair Outcomes.

BACKGROUND: Acute kidney injury (AKI) necessitating renal replacement therapy adversely affects outcomes after thoracoabdominal aortic aneurysm (TAAA) repair. The effects of earlier stages of AKI are less known. We hypothesized that earlier stages of AKI would reduce early survival after TAAA repair. METHODS: We analyzed prospectively collected data from 1,056 consecutive TAAA repairs from our institution (2006 to 2016). We excluded patients less than 18 years of age, those with preexisting renal disease, and three patients who died intraoperatively, resulting in 873 patients. The Kidney Disease Improving Global Outcomes criteria grouped patients into three AKI stages; stage 3 necessitated initiation of renal replacement therapy. Multivariable modeling identified operative mortality predictors. Kaplan-Meier analysis assessed 1-year survival. RESULTS: Of 873 patients, 642 (73.5%) had no AKI and 231 (26.5%) had postoperative AKI (mild/stage 1, n = 92 [10.5%]; moderate/stage 2, n = 44 [5%]; severe/stage 3, n = 95 [10.9%]). Operative death occurred in 65 patients (7.4%): 14 (2.2%) with no AKI, 5 (5.4%) with mild AKI (p = 0.07 versus no AKI), 8 (18.2%) with moderate AKI (p = 0.02 versus mild), and 38 (40%) with severe AKI (p = 0.01 versus moderate). In multivariable analysis, moderate AKI independently predicted death (relative risk ratio: 9.4, 95% confidence interval: 3.4 to 25.9). Kaplan-Meier 1-year survival was 91.1% ± 1.2% for no AKI, 84.6% ± 3.9% for mild AKI (p = 0.07 versus no AKI), 67.4% ± 7.6% for moderate AKI (p = 0.01 versus mild), and 46.6% ± 5.3% for severe AKI (p = 0.02 versus moderate; p < 0.0001 across all groups). CONCLUSIONS: Moderate/stage 2 AKI reduced early survival after TAAA repair. Prevention, earlier detection, and optimal medical management of AKI may improve survival.

The impact of preoperative chronic kidney disease on outcomes after Crawford extent II thoracoabdominal aortic aneurysm repairs.

OBJECTIVE: To determine whether preoperative chronic kidney disease (CKD) is predictive of poor outcomes in patients who undergo Crawford extent II thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: Data were collected from patients with CKD (defined as a preoperative estimated glomerular filtration rate <60 mL/min/1.73 m2; n = 399) and without CKD (n = 604) who underwent extent II TAAA repair during 1991 to 2016. We used univariate, multivariable, and propensity score matching analyses to compare outcomes between these 2 groups. RESULTS: Compared with patients without CKD, patients who presented with CKD were older and had greater rates of comorbidities, including coronary artery disease, cerebrovascular disease, and peripheral vascular disease. Patients with CKD had higher rates of operative mortality and adverse events. After propensity analysis, patients with CKD had greater rates of adverse event and renal failure necessitating dialysis, but had comparable rates of operative death to patients without CKD. Multivariable modeling indicated that CKD independently predicted adverse event (relative risk ratio [RRR] = 1.61; P = .01) and renal failure (RRR = 1.86; P = .02) after repair. After adjustment for median age, patients with CKD had substantially worse mid-term survival than those without (23.9 ± 2.4% vs 48.5 ± 2.5% at 10 years; P < .001). CONCLUSIONS: In patients who present with CKD, extent II open TAAA repair carries considerable risks of operative death and adverse events. Further investigation is needed to improve renal protection during such repair.

Redo Aortic Root Operations in Patients with Marfan Syndrome.

Aortic root aneurysm is the most common cardiovascular manifestation requiring surgical intervention in patients with Marfan syndrome (MFS), a heritable thoracic aortic disease. Elective replacement of the aortic root is the treatment of choice for patients with aneurysmal complications of the aortic root and ascending aorta. There are two basic approaches to aortic root replacement: valve-sparing (VS) and valve-replacing (VR) techniques. After successful aortic root replacement surgery, several patients with MFS may develop a late complication related to their aortic disease process, such as developing a pseudoaneurysm of the coronary artery reattachment buttons, aneurysmal expansion, or aortic dissection in the remaining native aorta. These patients may also develop other late complications that are not specifically related to the heritable thoracic aortic disease, such as infections that can lead to dehiscence of some or all of the distal or proximal anastomosis. Because these complications are rare, the clinical volume of reoperations of the aortic root in patients with MFS is low, making it difficult to assess contemporary experiences with these procedures. Only a few published reports have examined reoperative aortic root surgery in patients with MFS, each of which had only a small series of patients. Herein, we describe our contemporary experience with reoperative aortic root replacement in patients with MFS and provide our operative approach for these uncommon procedures.

ECMO for Acute Respiratory Distress Syndrome After Thoracoabdominal Aortic Aneurysm Repair.

Acute respiratory distress syndrome (ARDS) after thoracoabdominal aortic aneurysm (TAAA) repair poses a formidable challenge. Despite conventional maneuvers in the operating room, perioperative ARDS may require extracorporeal membrane oxygenation (ECMO). We present three cases of successful ECMO for ARDS after TAAA repair and discuss management of anticoagulation and cerebrospinal fluid drains. Our experience suggests that ECMO is reasonable in selected patients after TAAA repair.