Taking the pulse of brain death: A meta-analysis of the natural history of brain death with somatic support.

BACKGROUND AND PURPOSE: The conceptualization of brain death (BD) was pivotal in the shaping of judicial and medical practices. Nonetheless, media reports of alleged recovery from BD reinforced the criticism that this construct is a self-fulfilling prophecy (by treatment withdrawal or organ donation). We meta-analyzed the natural history of BD when somatic support (SS) is maintained. METHODS: Publications on BD were eligible if the following were reported: aggregated data on its natural history with SS; and patient-level data that allowed censoring at the time of treatment withdrawal or organ donation. Endpoints were as follows: rate of somatic expiration after BD with SS; BD misdiagnosis, including "functionally brain-dead" patients (FBD; i.e. after the pronouncement of brain-death, ≥1 findings were incongruent with guidelines for its diagnosis, albeit the lethal prognosis was not altered); and length and predictors of somatic survival. RESULTS: Forty-seven articles were selected (1610 patients, years: 1969-2021). In BD patients with SS, median age was 32.9 years (range = newborn-85 years). Somatic expiration followed BD in 99.9% (95% confidence interval = 89.8-100). Mean somatic survival was 8.0 days (range = 1.6 h-19.5 years). Only age at BD diagnosis was an independent predictor of somatic survival length (coefficient = -11.8, SE = 4, p < 0.01). Nine BD misdiagnoses were detected; eight were FBD, and one newborn fully recovered. No patient ever recovered from chronic BD (≥1 week somatic survival). CONCLUSIONS: BD diagnosis is reliable. Diagnostic criteria should be fine-tuned to avoid the small incidence of misdiagnosis, which nonetheless does not alter the prognosis of FBD patients. Age at BD diagnosis is inversely proportional to somatic survival.

Diabetes Mellitus is an Independent Predictor of Spinal Cord Injury After Descending Thoracic and Thoracoabdominal Aneurysm Repair: Maximum Likelihood Conditional Regression in a Propensity-Score Matched Cohort.

OBJECTIVE: To discern the impact of diabetes mellitus (DM) on spinal cord injury (SCI) after open descending thoracic and thoracoabdominal aneurysm repair (DTAAAR). BACKGROUND: Compared with euglycemia, hyperglycemia, and ketosis make neurons respectively more vulnerable and more resilient to ischemia. METHODS: During the study period (1997-2021), patient who underwent DTAAAR were dichotomized according to the presence/absence of DM. The latter was investigated as predictor of our primary (SCI) and secondary [operative mortality (OM), myocardial infarction, stroke, need for tracheostomy, de novo dialysis, and survival] endpoints. Two-level risk-adjustment employed maximum likelihood conditional regression after 1:2 propensity-score matching. RESULTS: DTAAAR was performed in 934 patients. Ninety-two diabetics were matched to 184 nondiabetics. All preoperative variables had a standardized mean difference <0.1 between the matched groups. Patients with DM had higher SCI (6.5% vs. 1.6%, P 0.03) and OM (14.1% vs. 6.0%, P =0.01), while the other secondary endpoints were similar between groups in the matched sample. DM was an independent predictor for SCI in the matched sample (odds ratio: 5.05, 95% confidence interval: 1.17-21.71). Matched patients with DM presented decreased survival at 1 (70.2% vs. 86.2%), 5 (50.4% vas 67.5%), 10 years (31.7% vs. 36.7%) ( P =0.03). The results are summarized in the graphical abstract. CONCLUSION: DM is associated to increased OM and decreased survival, and it is an independent predictor of SCI after open DTAAAR. Strict perioperative glycemic control should be implemented, and exogenous ketones should be investigated as neuroprotective agents to reduce such adverse events.

Contemporary outcomes of open repair of acute complicated type B aortic dissection.

OBJECTIVE: Open repair of acute complicated type B aortic dissection (ACTBAD), required when endovascular repair is not possible, is historically considered high-risk. We analyze our experience with this high-risk cohort compared with the standard cohort. METHODS: We identified consecutive patients undergoing descending thoracic or thoracoabdominal aortic aneurysm (TAAA) repair from 1997 to 2021. Patients with ACTBAD were compared with those having surgery for other reasons. Logistic regression was used to identify associations with major adverse events (MAEs). Five-year survival and competing risk of reintervention were calculated. RESULTS: Of 926 patients, 75 (8.1%) had ACTBAD. Indications included rupture (25/75), malperfusion (11/75), rapid expansion (26/75), recurrent pain (12/75), large aneurysm (5/75), and uncontrolled hypertension (1/75). The incidence of MAEs was similar (13.3% [10/75] vs 13.7% [117/851], P = .99). Operative mortality was 5.3% (4/75) vs 4.8% (41/851) (P = .99). Complications included tracheostomy (8%, 6/75), spinal cord ischemia (4%, 3/75), and new dialysis (2.7%, 2/75). Renal impairment, urgent/emergent operation, forced expiratory volume in 1 second ≤50%, and malperfusion were associated with MAEs, but not ACTBAD (odds ratio: 0.48, 95% confidence interval [CI]: [0.20-1.16], P = .1). At 5 and 10 years, there was no difference in survival (65.8% [95% CI: 54.6-79.2] vs 71.3% [95% CI: 67.9-74.9], P = .42, and 47.3% [95% CI: 34.5-64.7] vs 53.7% [95% CI: 49.3-58.4], P = .29, respectively) or 10-year reintervention (12.5% [95% CI: 4.3-25.3] vs 7.1% [95% CI: 4.7-10.1], P = .17, respectively). CONCLUSIONS: In an experienced center, open repair of ACTBAD can be performed with low rates of operative mortality and morbidity. Outcomes similar to elective repair are achievable even in high-risk patients with ACTBAD. In patients unsuitable for endovascular repair, transfer to a high-volume center experienced in open repair should be considered.

Systematic Review - Neuroprotection of ketosis in acute injury of the mammalian central nervous system: A meta-analysis.

To evaluate the neuroprotection exerted by ketosis against acute damage of the mammalian central nervous system (CNS). Search engines were interrogated to identify experimental studies comparing the mitigating effect of ketosis (intervention) versus non-ketosis (control) on acute CNS damage. Primary endpoint was a reduction in mortality. Secondary endpoints were a reduction in neuronal damage and dysfunction, and an 'aggregated advantage' (composite of all primary and secondary endpoints). Hedges' g was the effect measure. Subgroup analyses evaluated the modulatory effect of age, insult type, and injury site. Meta-regression evaluated timing, type, and magnitude of intervention as predictors of neuroprotection. The selected publications were 49 experimental murine studies (period 1979-2020). The intervention reduced mortality (g 2.45, SE 0.48, p < .01), neuronal damage (g 1.96, SE 0.23, p < .01) and dysfunction (g 0.99, SE 0.10, p < .01). Reduction of mortality was particularly pronounced in the adult subgroup (g 2.71, SE 0.57, p < .01). The aggregated advantage of ketosis was stronger in the pediatric (g 3.98, SE 0.71, p < .01), brain (g 1.96, SE 0.18, p < .01), and ischemic insult (g 2.20, SE 0.23, p < .01) subgroups. Only the magnitude of intervention was a predictor of neuroprotection (g 0.07, SE 0.03, p 0.01 per every mmol/L increase in ketone levels). Ketosis exerts a potent neuroprotection against acute damage to the mammalian CNS in terms of reduction of mortality, of neuronal damage and dysfunction. Hematic levels of ketones are directly proportional to the effect size of neuroprotection.

Splanchnic occlusive disease predicts for spinal cord injury after open descending thoracic and thoracoabdominal aneurysm repair.

OBJECTIVE: In the present study, we sought to discern the effects of splanchnic occlusive disease (SOD; renal, superior mesenteric, and/or celiac axis arteries) on spinal cord injury (SCI; paraparesis or paraplegia) and major adverse events (MAE) after descending thoracic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) open repair. METHODS: Patients who had undergone DTA/TAAA repair at our institution were dichotomized according to the presence of SOD, which was investigated as a predictive factor of our primary (SCI) and secondary (operative mortality, myocardial infarction, stroke, tracheostomy, de novo dialysis, MAE, survival) endpoints. Risk adjustment used both propensity score matching and multivariable logistic regression. RESULTS: From July 1997 to October 2019, 888 patients had undergone DTA/TAAA repair, of whom 19 were excluded from our analysis for missing data. SOD was absent in 712 patients and present in 157 patients. The patients with SOD had presented with a greater incidence of preoperative renal impairment (61 [38.9%] vs 175 [24.6%]; P < .01) and peripheral arterial disease (60 [38.2%] vs 162 [22.8%]; P < .01] and decreased left ventricular ejection fraction (45%; interquartile range, 10%; vs 50%; interquartile range, 4%; P < .01). The etiology of aortic disease was more frequently dissection in the SOD group (56.1% vs 43.7%) and more frequently nondissecting aneurysm in the non-SOD group (56.3% vs 43.9%; P < .01). Patients without SOD had presented with aneurysms more cranially located (DTA, 34.0% vs 7.6%; extent I TAAA, 44.0% vs 7.6%). In contrast, patients with SOD had presented with aneurysms more caudally located (extent II TAAA, 36.9% vs 8.6%; extent III TAAA, 30.6% vs 11.0%; extent IV TAAA, 17.2% vs 2.5%; P < .01). Propensity score matching led to 144 pairs, with SOD significantly associated with SCI (10 [6.9%] vs 2 [1.4%]; P = .03) and MAE (47 [32.6%] vs 26 [15%]; P < .01). Ten-year survival was reduced in those with SOD (31.5% vs 45.2%; P < .01). Conditional multivariable regression confirmed SOD to be a predictor of SCI in the matched sample (odds ratio, 6.60; P = .02). CONCLUSIONS: Our results have shown that SOD is a significant predictor of SCI in patients undergoing open DTA/TAAA repair. The investigation of measures to prolong neuronal ischemia tolerance (eg, hypothermia) is warranted for such patients.

Endovascular vs. Medical Management for Uncomplicated Acute and Sub-acute Type B Aortic Dissection: A Meta-analysis.

OBJECTIVE: The aim was to compare peri-operative and late outcomes of patients with acute and subacute uncomplicated type B aortic dissection (uTBAD) treated by thoracic endovascular aortic repair (TEVAR) or best medical therapy (BMT). METHODS: This was a Systematic review and meta-analysis of observational studies and randomised controlled trials (RCTs). The review was undertaken according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and registered with the International Prospective Register of Systematic Reviews (number: CRD42018094607). Multiple electronic databases were searched to identify relevant articles. The methodological quality of the included studies was assessed. The primary outcome measures were early mortality and re-intervention, late all cause and aorta related mortality, and re-intervention. Meta-analysis was used to produce pooled odds ratios (OR) or risk difference (RD) for peri-operative outcomes. Random effects models were applied. For late outcomes a time to event meta-analysis was conducted using the inverse variance model, reporting the results as hazard ratios (HR). RESULTS: Eight original articles from six studies encompassing 14 706 patients (1 066 TEVARs) were eligible for inclusion. There were no statistically significant differences between TEVAR and BMT with regards to inpatient mortality (RD 0.01, 95% CI -0.01-0.02, p = .46), early re-intervention by TEVAR (RD 0.02, 95% CI -0.01-0.04, p = .19) or surgery (RD 0.00, 95% CI -0.01-0.01, p = 1.0). BMT was associated with a significantly lower risk of early stroke (OR 0.64, 95% CI 0.48-0.85, p = .002), whereas the risk of late all cause (HR 1.54, 95% CI 1.27-1.86, p < .001) and aorta related mortality (HR 2.71, 95% CI 1.49-4.94, p = .001) was significantly higher than with TEVAR. No suitable data regarding late aortic re-intervention was found for meta-analysis. CONCLUSION: Given the limited number and quality of suitable studies it remains uncertain whether TEVAR is beneficial in the management of acute/subacute uTBAD. Further research is required to understand which dissections would benefit from pre-emptive treatment.

The Effect of Acute Limb Ischemia on Mortality in Patients Undergoing Femoral Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a life-saving modality increasingly used in the management cardiopulmonary failure. However, ECMO itself is not without major complications. Mortality remains high, and morbidity such as stroke, renal failure, and acute limb threatening ischemia (ALI) are common among surviving patients. We analyzed the effect of one of these complications, ALI, on the survival of patients receiving venoarterial ECMO (VA ECMO) with femoral cannulation. METHODS: Patients with cardiopulmonary failure supported by VA ECMO inserted through femoral cannulation at two institutions from December 2010 to December 2017 were enrolled in this study. Data were collected retrospectively. Our primary outcome was ALI and its effect on hospital mortality. Secondary outcomes included six-month mortality, length of hospital stay, and other complications (stroke and renal failure); multivariate logistic regression analysis was used to identify predictors of ALI and hospital mortality. RESULTS: There were 71 patients included in this study. The overall VA ECMO hospital mortality was 53.5%. ALI was seen in 14 (19.7%) patients. Of these, four (5.6%) patients had fasciotomy, four patients (5.6%) had thrombectomy, and one underwent arterial repair (1.4%). Five additional patients (7.0%) with ALI expired and had no vascular intervention. None of the demographic and clinical characteristics significantly correlated with ALI except for stroke and renal failure requiring new-onset hemodialysis (HD). The rate of hospital and 6-month mortality in patients with and without vascular complications were 78.6%, 92.3% and 47.4%, 57.4%, respectively (P = 0.042 and P = 0.023). Multivariate analysis correlated hospital and six-month mortality with ALI, stroke, and new-onset HD. CONCLUSIONS: ALI correlates with higher mortality in VA ECMO patients with femoral cannulation. Although some of the contributing factors to mortality in these patients are related to the consequences of cardiopulmonary failure, strong efforts should be made to avoid ALI after femoral VA ECMO cannulation.

State of the art and meta-analysis of secondary open aortic procedure after abdominal endovascular aortic repair.

BACKGROUND: Secondary open aortic procedures (SOAP) treat complications of endovascular aneurysm repair, when further endovascular options are exhausted. We aimed at depicting the state of the art of SOAP with high-level evidence. METHODS: A systematic review of the SOAP literature, with a meta-analysis of its outcomes (primary outcome operative mortality; secondary outcome major morbidity) and metaregression of risk factors for mortality (PROSPERO 42017075631). RESULTS: Twenty-eight studies (1093 patients) were elected for analysis. SOAP was performed within the same hospitalization of or 30 days from domestic endovascular aneurysm repair (early SOAP) in 0.2% of the patients (85/40,256), and in a nonelective setting in 24.3% (95% confidence interval, 21.8-26.9). Most frequent indications were endoleak (44.4%; 95% confidence interval, 41.4-47.3) and rupture (12.7%; 95% confidence interval, 10.4-15.1). The most common procedures were infrarenal aortic replacement (85.2%; 95% confidence interval, 82.6-87.7) with high use of supravisceral clamping (suprarenal, 25% [95% confidence interval, 21.9-28.1] and supraceliac, 20.7% [95% confidence interval, 17.8-23.6]), and axillobifemoral bypass with stent explant (6.9%; 95% confidence interval, 5.1-8.7). Operative mortality (in-hospital or 30-day) was 10.9% (95% confidence interval, 8.7-13.5). The most frequent morbidities were respiratory (11.4%; 95% confidence interval, 8.1-15.9) and renal (9.5%; 95% confidence interval, 8.1-15.9). Risk factors for mortality were supravisceral clamping (Z = 3.007; Q = 9.044; P = .003) and nonelective status (Z = 3.382; Q = 11.440; P = .001). CONCLUSIONS: Endoleak is the main indication for SOAP, which mostly consists of infrarenal aortic replacement. Risk factors for operative mortality are nonelective status and supravisceral clamping.

Gender-related outcomes after open repair of descending thoracic and thoracoabdominal aortic aneurysms.

OBJECTIVE: Female sex has been associated with greater morbidity and mortality for a variety of major cardiovascular procedures. We sought to determine the influence of female sex on early and late outcomes after open descending thoracic aortic aneurysm (DTA) and thoracoabdominal aortic aneurysm (TAAA) repair. METHODS: We searched our aortic surgery database to identify patients having open DTA or TAAA repair. Logistic regression and Cox regression analyses were used to assess the effect of sex on perioperative and long-term outcomes. RESULTS: From 1997 until 2017, there were 783 patients who underwent DTA or TAAA repair. There were 462 male patients and 321 female patients. Female patients were significantly older (67.6 ± 13.9 years vs 62.6 ± 14.7 years; P < .001), had more chronic pulmonary disease (47.0% vs 35.7%; P = .001) and forced expiratory volume in 1 second <50% (28.3% vs 18.2%; P < .001), and were more likely to have degenerative aneurysms (61.7% vs 41.6%; P < .001). Operative mortality was not different between women and men (5.6% vs 6.2%; P = .536). However, women were more likely to require a tracheostomy after surgery (10.6% vs 5.0%; P = .003) despite a reduced incidence of left recurrent nerve palsy (3.4% vs 7.8%; P = .012). Logistic regression found female sex to be an independent risk factor for a composite of major adverse events (odds ratio, 2.68; confidence interval, 1.41-5.11) and need for tracheostomy (odds ratio, 3.73; confidence interval, 1.53-9.10). Women also had significantly lower 5-year survival. CONCLUSIONS: Women undergoing open DTA or TAAA repair are not at greater risk for operative mortality than their male counterparts are. Reduced preoperative pulmonary function may contribute to an increased risk for respiratory failure in the perioperative period.

The role of neo-sinus reconstruction in aortic valve-sparing surgery.

AIMS: The aim of this study was to evaluate the clinical and echocardiographic results and the predictors of outcomes in patients undergoing valve-sparing operation (VSO) at two aortic centers. In addition, we sought to evaluate the potential effect of recreation of the sinuses of Valsalva (SV) on the outcome of valve-sparing procedures. METHODS: During a 14-year period, 328 patients underwent aortic valve-sparing root replacement at two institutions. Clinical and echo evaluation was performed 6 months after surgery and every year thereafter or in case of clinical symptoms. Propensity weighting and propensity-weighted risk competing analysis were used. RESULTS: No operative mortality was reported; the most common complication was revision for bleeding, occurring in 15 patients (4.6%). At a mean follow-up of 30.0 ± 33.9 months, two patients died (0.6%). Recurrent aortic insufficiency (AI) >2+ was found in 11 patients (3.3%); five (1.5%) underwent reoperation. Recreation of the SV did not affect clinical outcome and aortic valve status. Need for aortic valve repair was the only independent predictor of recurrent AI, whereas a bicuspid aortic valve was a protective factor. CONCLUSIONS: Re-creation of the SV does not affect short-term outcomes following VSO.

Trends in the Management of Anterior Mitral Leaflet Regurgitation.

Importance: The overall prevalence of mitral valve replacement (MVR) or MV repair at the time of cardiac surgery in the setting of isolated anterior mitral leaflet degenerative pathologic status in the US population is unknown. Objective: To investigate the prevalence of MVR and MV repair using the Society of Thoracic Surgeons' Adult Cardiac Surgery Database. Design, Setting, and Participants: In a cross-sectional study, all patients diagnosed with isolated anterior mitral leaflet degenerative regurgitation who underwent either surgical MVR or MV repair between July 1, 2011, and June 30, 2022, were identified. Linear regression analysis was used to assess trends over time. Main Outcomes and Measures: Assessment of the trends in MV repair and MVR over time. Results: A total of 16 259 patients (9624 [59.2%] men) were identified, and the median age was 68 (IQR, 58-74) years. A total of 7214 patients (44.4%) had MVR, and 9045 (55.6%) had MV repair. There was a declining trend of MV repair from 58.0% in 2011 to 51.6% in 2022 (P = .05). The MVR group was older (median [IQR] age, 70 [62-77] vs 67 [58-74] years; P < .001) and had more comorbidities. A total of 85.1% of all patients underwent concomitant procedures. In 81.7% of MVR cases, no attempt at MV repair was made. The median (IQR) annual hospital volume was lower with MVR vs MV repair (2.50 [1.50-5.00] vs 4.00 [2.00-7.00]; P < .001). Conventional surgical approaches were most common (91.5%) but with a declining trend (P < .001). Minimally invasive approaches were used in 13.1% (robotic, 4.6%), and with an inclining trend from 5.0% in 2011 to 12.0% in 2022 (P < .001). Annuloplasty was performed in 88.8% of MV repair cases. Its use as a sole mean of MV repair decreased from 48.0% in 2011 to 13.9% in 2022 (P < .001). Repair maneuvers in addition to annuloplasty were neochordae (overall 40.1%, increasing from 22.5% in 2011 to 62.3% in 2022; P < .001), leaflet resection (overall 10.2%, decreasing from 13.1% in 2011 to 7.9% in 2022, P = .002), edge-to-edge MV repair (overall 5.3%, decreasing from 6.9% in 2011 to 4.5% in 2022; P = 0.04), and chordal transfer (overall 2.4%, decreasing from 2.7% in 2011 to 0.7% in 2022; P = .004). Conclusions and Relevance: In this cross-sectional study, MV repair was the preferred option for degenerative mitral valve disease but was only slightly more commonly performed than MVR for isolated anterior leaflet pathologic status. A large proportion of MVR was performed without an MV repair attempt, suggesting reluctance to repair this pathologic condition.

Interpapillary muscle distance independently predicts recurrent mitral regurgitation.

OBJECTIVE: Ischaemic secondary mitral regurgitation (ISMR) after surgery is due to the displacement of papillary muscles resulting from progressive enlargement of the left ventricle end-diastolic diameter (LVEDD). Our aim was to prove that if the interpapillary muscle distance (IPMD) is surgically stabilized, an increase in LVEDD will not lead to a recurrence of ischaemic mitral regurgitation (MR). METHODS: Ninety-six patients with ISMR, who underwent surgical revascularisation and annuloplasty, were randomly assigned in a 1:1 ratio to undergo papillary muscle approximation (PMA). At the 5-year follow-up, we assessed the correlation between PMA and echocardiographic improvements, the effect size of PMA on echocardiographic improvements, and a prediction model for recurrent MR using inferential tree analysis. RESULTS: There was a significant correlation between PMA and enhancements in both the α and ß angles (Spearman's rho > 0.7, p < 0.01). The α angle represents the angle between the annular plane and either the A2 annular-coaptation line or the P2 annular-coaptation line. The ß angle indicates the angle between the annular plane and either the A2 annular-leaflet tip line or the P2 annular-leaflet tip line. PMA led to substantial improvements in LVEDD, tenting area, α and ß angles, with a large effect size (Hedge's g ≥ 8, 95% CI ORs ≠ 1). The most reliable predictor of recurrent MR grade was the interpapillary distance, as only patients with an interpapillary distance greater than 40 mm developed ≥ 3 + grade MR. For patients with an IPMD of 40 mm or less, the best predictor of recurrent MR grade was LVEDD. Among the patients, only those with LVEDD greater than 62 mm showed moderate (2+) MR, while only those with LVEDD less than or equal to 62 mm had absent to mild (1+) MR. CONCLUSION: Prediction of recurrent ischaemic MR is not independent of progressive LVEDD increase. PMA-based surgical procedure stabilises IPMD.

Venovenous extracorporeal membrane oxygenation for respiratory failure refractory to high frequency percussive ventilation.

BACKGROUND: High frequency percussive ventilation (HFPV) has demonstrated improvements in gas exchange, but not in clinical outcomes. OBJECTIVES: We utilize HFPV in patients failing conventional ventilation (CV), with rescue venovenous extracorporeal membrane oxygenation (VV ECMO) reserved for failure of HFPV, and we describe our experience with such a strategy. METHODS: All adult patients (age >18 years) placed on HFPV for failure of CV at a single institution over a 10-year period were included. Those maintained on HFPV were compared to those that failed HFPV and required VV ECMO. Survival was compared to expected survival after upfront VV ECMO as estimated by VV ECMO risk prediction models. RESULTS: Sixty-four patients were placed on HFPV for failure of CV over a 10-year period. After HFPV initiation, the P/F ratio rose from 76mmHg to 153.3mmHg in the 69 % of patients successfully maintained on HFPV. The P/F ratio only rose from 60.3mmHg to 67mmHg in the other 31 % of patients, and they underwent rescue ECMO with the P/F ratio rising to 261.6mmHg. The P/F ratio continued to improve in HFPV patients, while it declined in ECMO patients, such that at 24 h, the P/F ratio was greater in HFPV patients. The strongest independent predictor of failure of HFPV requiring rescue VV ECMO was a lower pO2 (p = .055). Overall in-hospital survival (59.4 %) was similar to that expected with upfront ECMO (RESP score: 57 %). CONCLUSIONS: HFPV demonstrated significant and sustained improvements in gas exchange and may obviate the need for ECMO and its associated complications.

Outcomes After Heartmate 3 Left Ventricular Assist Device Implantation Using a 10 mm Outflow Graft.

The presence of adhesions and patent bypass grafts may create challenges for standard 14 mm outflow graft placement during left ventricular assist device implantation. We retrospectively describe our experience using a 10 mm Bioline Fusion graft (Getinge, Goteborg, Sweden) as the outflow graft in patients undergoing primary Heartmate 3 (Abbott, Abbott Park, IL) implantation. One hundred one patients underwent Heartmate 3 left ventricular assist device implantation, 80% via a thoracotomy approach, with the standard 14 mm outflow graft (78) or a 10 mm Bioline Fusion outflow graft (23). Initial postoperative rotor speed-to-flow ratio (the revolutions per minutes (RPMs) required to achieve a given flow) was significantly higher in 10 mm graft patients (1,472 vs. 1,283 RPM/L/min; p = 0.03), suggesting elevated resistance in the smaller graft. Furthermore, the initial postoperative vasoactive-inotrope score was higher in the 10 mm graft patients (24.1 vs. 17.6; p = 0.022). Postoperative outcomes were similar between groups. In conclusion, the use of a 10 mm graft was associated with higher RPMs needed to generate a given flow and a higher vasoactive-inotrope score, but these differences were not associated with increased right ventricular failure or mortality.

Surgical Strategy for the Repair of Acute Type A Aortic Dissection: A Multicenter Study.

Type A acute aortic dissection is associated with significant morbidity and mortality, with prompt referral imaging and management to tertiary referral centers needed urgently. Surgery is usually needed emergently, but the choice of surgery often varies depending on the patient and the presentation. Staff and center expertise also play a major role in determining the surgical strategy employed. The aim of this study was to compare the early- and medium-term outcomes of patients undergoing a conservative approach extended only to the ascending aorta and the hemiarch to those of patients subjected to extensive surgery (total arch reconstruction and root replacement) across three European referral centers. A retrospective study was conducted across three sites between January 2008 and December 2021. In total, 601 patients were included within the study, of which 30% were female, and the median age was 64.4 years. The most common operation was ascending aorta replacement (n = 246, 40.9%). The aortic repair was extended proximally (i.e., root n = 105; 17.5%) and distally (i.e., arch n = 250; 41.6%). A more extensive approach, extending from the root to the arch, was employed in 24 patients (4.0%). Operative mortality occurred in 146 patients (24.3%), and the most common morbidity was stroke (75, 12.6%). An increased length of ICU admission was noted in the extensive surgery group, which comprised younger and more frequently male patients. No significant differences were noted in surgical mortality between patients managed with extensive surgery and those managed conservatively. However, age, arterial lactate levels, "intubated/sedated" status on arrival, and "emergency or salvage" status at presentation were independent predictors of mortality both within the index hospitalization and during the follow-up. The overall survival was similar between the groups.

Survival following acute type A aortic dissection: a multicenter study.

Background: While surgery is almost always indicated for acute type A aortic dissections (ATAADs), the extent of surgery is often debated, with some surgeons preferring a conservative option and others preferring a more radical option This study aims to assess the outcome after surgery for ATAAD and the prognostic impact of surgical strategy (with vs. without aortic arch replacement). Methods: Data was gathered between 1 January 2005 and 31 December 2021 and retrospectively analyzed with multivariable logistic and Cox regression to ascertain risk factors and survival respectively. Results: A total of 601 patients underwent type A aortic dissection repair across the recruiting centers with an operative mortality of 24.3% (146 patients) which was considerably linked with the clinical condition at presentation. In-hospital mortality was 23.1% for ascending and root replacement alone vs. 28.7% for arch involvement. Overall survival was 73.3% after the first year, 68.2% at 5 years, and 53.5% at 10 years. The median follow-up period was 2.5 years [interquartile range (IQR), 6.6 years]. Aortic arch replacements were more often carried out in younger patients and those without adverse clinical conditions, although outcomes for patients who underwent either surgical option were comparable throughout apart from a higher rate of cerebrovascular complications in the arch group (7.6% vs. 21.9%) (P=0.01). Conclusions: Surgery for ATAAD still confers a relatively high mortality. In our study, there was a higher stroke rate associated with patients who underwent arch replacements at the time of dissection despite them being younger. The choice of repair with or without arch replacement should be individualized to the patient and the severity of clinical status presentation.

Geographic variation in malignant cardiac tumors and their outcomes: SEER database analysis.

Introduction: Primary malignant cardiac tumors (PMCTs) are rare. Geographical distribution has been demonstrated to affect cancer outcomes, making the reduction of geographical inequalities a major priority for cancer control agencies. Geographic survival disparities have not been reported previously for PMCT and the aim of this study is to compare the prevalence and the long-term survival rate with respect to the geographic location of PMCTs using the Surveillance, Epidemiology, and End Results (SEER) research plus data 17 registries between 2000 and 2019. Methods: The SEER database was queried to identify geographic variation among PMCTs. We classified the included states into 4 geographical regions (Midwest, Northeast, South and West regions) based on the U.S. Census Bureau-designated regions and divisions. Different demographic and clinical variables were analyzed and compared between the four groups. Kaplan Meier curves and Cox regression were used for survival assessment. Results: A total of 563 patients were included in our analysis. The median age was 53 years (inter-quartile range (IQR): 38 - 68 years) and included 26, 90, 101, and 346 patients from the Midwest, Northeast, South, and West regions respectively. Sarcoma represented 65.6% of the cases, followed by hematological tumors (26.2%), while mesothelioma accounted for 2.1%. Treatment analysis showed no significant differences between different regions. Median overall survival was 11, 21, 13, and 11 months for Midwest, Northeast, South and West regions respectively and 5-year overall survival was 22.2%, 25.4%, 14.9%, and 17.6% respectively. On multivariate Cox regression, significant independent predictors of late overall mortality among the entire cohort included age (Hazard Ratio [HR] 1.028), year of diagnosis (HR 0.967), sarcoma (HR 3.36), surgery (HR 0.63) and chemotherapy (HR 0.56). Conclusion: Primary malignant cardiac tumors are rare and associated with poor prognosis. Sarcoma is the most common pathological type. Younger age, recent era diagnosis, surgical resection, and chemotherapy were the independent predictors of better survival. While univariate analysis revealed that patients in the South areas had a worse survival trend compared to other areas, geographic disparity in survival was nullified in multivariate analysis.

Lactate-Based Difference as a Determinant of Outcomes following Surgery for Type A Acute Aortic Dissection: A Multi-Centre Study.

Type A acute aortic dissection (TAAAD) is a serious condition within the acute aortic syndromes that demands immediate treatment. Despite advancements in diagnostic and referral pathways, the survival rate post-surgery currently sits at almost 20%. Our objective was to pinpoint clinical indicators for mortality and morbidity, particularly raised arterial lactate as a key factor for negative outcomes. METHODS: All patients referred to the three cardiovascular centres between January 2005 and December 2022 were included in the study. The inclusion criteria required the presence of a lesion involving the ascending aorta, symptoms within 7 days of surgery, and referral for primary surgical repair of TAAAD based on recommendations, with consideration for other concomitant major cardiac surgical procedures needed during TAAAD and retrograde extension of TAAAD. We conducted an analysis of both continuous and categorical variables and utilised predictive mean matching to fill in missing numeric features. For missing binary variables, we used logistic regression to impute values. We specifically targeted early postoperative mortality and employed LASSO regression to minimise potential collinearity of over-fitting variables and variables measured from the same patient. RESULTS: A total of 633 patients were recruited for the study, out of which 449 patients had complete preoperative arterial lactate data. The average age of the patients was 64 years, and 304 patients were male (67.6%). The crude early postoperative mortality rate was 24.5% (110 out of 449 patients). The mortality rate did not show any significant difference when comparing conservative and extensive surgeries. However, malperfusion had a significant impact on mortality [48/131 (36.6%) vs. 62/318 (19.5%), p < 0.001]. Preoperative arterial lactates were significantly elevated in patients with malperfusion. The optimal prognostic threshold of arterial lactate for predicting early postoperative mortality in our cohort was ≥2.6 mmol/L. CONCLUSION: The arterial lactate concentration in patients referred for TAAAD is an independent factor for both operative mortality and postoperative complications. In addition to mortality, patients with an upper arterial lactate cut-off of ≥2.6 mmol/L face significant risks of VA ECMO and the need for dialysis within the first 48 h after surgery. To improve recognition and facilitate rapid transfer and surgical treatment protocol, more diligent efforts are required in the management of malperfusion in TAAAD.

Sex-Based Difference in Aortic Dissection Outcomes: A Multicenter Study.

BACKGROUND: Type A Acute Aortic Dissection (TAAAD) repair is a surgical emergency associated with high morbidity and mortality. Registry data have noted several sex-specific differences in presentation with TAAAD which may account for the differences in men and women undergoing surgery for this condition. METHODS: A retrospective review of data from three departments of cardiac surgery (Centre Cardiologique du Nord, Henri-Mondor University Hospital, San Martino University Hospital, Genoa) between January 2005 and 31 December 2021 was conducted. Confounders were adjusted using doubly robust regression models, a combination of regression models with inverse probability treatment weighting by propensity score. RESULTS: 633 patients were included in the study, of which 192 (30.3%) were women. Women were significantly older with reduced haemoglobin levels and pre-operative estimated glomerular filtration rate compared to men. Male patients were more likely to undergo aortic root replacement and partial or total arch repair. Operative mortality (OR 0.745, 95% CI: 0.491-1.130) and early postoperative neurological complication results were comparable between the groups. The adjusted survival curves using IPTW by propensity score confirmed the absence of a significant impact of gender on long-term survival (HR 0.883, 95% CI 0.561-1.198). In a subgroup analysis of women, preoperative levels of arterial lactate (OR 1.468, 95% CI: 1.133-1.901) and mesenteric ischemia after surgery (OR 32.742, 95% CI: 3.361-319.017) were significantly associated with increased operative mortality. CONCLUSIONS: The advancing age of female patients alongside raised preoperative level of arterial lactate may account for the increasing preponderance among surgeons to perform more conservative surgery compared to their younger male counterparts although postoperative survival was similar between the groups.