Extended thoracic endovascular aortic repair is optimal therapy in acute complicated type B dissection.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) represents optimal therapy for complicated acute type B aortic dissection (aTBAD). Persistent knowledge gaps remain, including the optimal length of aortic coverage, impact on distal aortic remodeling, and fate of the dissected abdominal aorta. METHODS: Review of the Emory Aortic Database identified 92 patients who underwent TEVAR for complicated aTBAD from 2012 to 2018. Standard TEVAR covered aortic zones 3 and 4 (from the left subclavian to the mid-descending thoracic aorta). Extended TEVAR fully covered aortic zones 3 though 5 (from the left subclavian to the celiac artery). Long-term imaging, clinical follow-up, and overall and aortic-specific mortality were reviewed. RESULTS: Extended TEVAR (n = 52) required a greater length of coverage vs standard TEVAR (n = 40) (240 ± 32 mm vs 183 ± 23 mm; P < .01). In-hospital mortality occurred in 5.4% of patients (7.7% vs 2.5%; P = .27) owing to mesenteric malperfusion (n = 3) or rupture (n = 2). The overall incidences of postoperative stroke, transient paraparesis, paraplegia, and dialysis were 5.4% (3.9% vs 7.5%; P = .38), 3.2% (5.8% vs 0%; P = .18), 0%, and 0% respectively, equivalent between groups. Follow-up was 96.6% complete to a mean of 6.1 years (interquartile range, 3.5-8.6 years). There were significantly higher rates of complete thrombosis or obliteration of the entire thoracic false lumen after Extended TEVAR (82.2% vs 51.5%; P = .04). Distal aortic reinterventions were less frequent after extended TEVAR (5.8% vs 20%; P = .04). Late aorta-specific survival was 98.1% after extended TEVAR vs 92.3% for standard TEVAR (P = .32). CONCLUSIONS: Extended TEVAR for complicated aTBAD is safe, results in a high rate of total thoracic false lumen thrombosis/obliteration, and reduces distal reinterventions. Longer-term follow-up will be needed to demonstrate a survival benefit compared to limited aortic coverage.

Clinical, Functional, and Quality of Life Outcomes after Computer Assisted Vacuum Thrombectomy for Pulmonary Embolism: Interim Analysis of the STRIKE-PE Study.

PURPOSE: To report 90-day results from the first interim analysis of the STRIKE-PE study, which is evaluating safety, effectiveness, and functional and quality of life (QoL) outcomes of Computer Assisted Vacuum Thrombectomy (CAVT) with the Indigo Aspiration System for the treatment of acute pulmonary embolism (PE). METHODS: STRIKE-PE is a prospective, international, multicenter study that will enroll 600 adult patients with acute PE of ≤14 days and a right ventricle/left ventricle (RV/LV) ratio of ≥0.9 who receive first-line endovascular treatment with CAVT. Primary endpoints are change in RV/LV ratio and incidence of composite major adverse events (MAEs) within 48 hours. Secondary endpoints include functional and QoL assessments. RESULTS: The first 150 consecutive patients were treated with Lightning 12 CAVT. Mean age was 61.3 years, 54.7% were men, 94.7% presented with intermediate-risk PE, and 5.3% presented with high-risk PE. Median thrombectomy and procedure times were 33.5 minutes and 70 minutes, respectively, resulting in a mean reduction in systolic pulmonary artery pressure of 16.3% (P < .001). Mean RV/LV ratio decreased from 1.39 before thrombectomy to 1.01 at 48 hours, a 25.7% reduction (P < .001). Four patients (2.7%) experienced a composite MAE within 48 hours. At 90-day follow-up, patients exhibited statistically significant improvements in the Borg dyspnea scale and QoL measures, and the NYHA class distribution returned to that reported before the index PE. CONCLUSION: These interim results demonstrate a rapid reduction in RV/LV ratio, achieved with a fast thrombectomy time while maintaining safety. This is accompanied by improvements in 90-day functional and QoL outcomes.

Acute Type B Intramural Hematoma: Novel Insights in the Endovascular Era.

BACKGROUND: The pathophysiology and behavior of acute type B intramural hematoma (TBIMH) is poorly understood. The purpose of this study is to characterize the pathophysiology, fate, and outcomes of TBIMH in the endovascular era. METHODS: A retrospective analysis of a US Aortic Database identified 70 patients with TBIMH from 2008 to 2022. Patients were divided into groups and analyzed based upon subsequent management: early thoracic endovascular aortic repair (TEVAR; Group 1) or hospital discharge on optimal medical therapy (OMT) (Group 2). RESULTS: Of 70 total patients, 43% (30/70) underwent TEVAR (Group 1) and 57% (40/70) were discharged on OMT (Group 2). There were no significant differences in age, demographics, or comorbidities between groups. Indications for TEVAR in Group 1 were as follows: 1) Penetrating atheroscletoic ulcer (PAU) or ulcer-like projection (n = 26); 2) Descending thoracic aortic aneurysm (n = 3); or 3) Progression to type B aortic dissection (TBAD) (n = 2). Operative mortality was zero. No patient suffered a stroke or spinal cord ischemia. During the follow-up period, 50% (20/40) of Group 2 patients required delayed surgical intervention, including TEVAR in 14 patients and open repair in 6 patients. Indications for surgical intervention were as follows: 1) Development of a PAU / ulcer-like projection (n = 13); 2) Progression to TBAD (n = 3), or 3) Concomitant aneurysmal disease (n = 4). Twenty patients did not require surgical intervention. Of the initial cohort, 71% of patients required surgery, 9% progressed to TBAD, and 19% had regression or stability of TBIMH with OMT alone. CONCLUSIONS: The most common etiology of TBIMH is an intimal defect. Progression to TBAD and intramural hematoma regression without an intimal defect occurs in a small percentage of patients. An aggressive strategy with endovascular therapy and close surveillance for TBIMH results in excellent short-term and long-term outcomes.

Sitagliptin for the prevention and treatment of perioperative hyperglycaemia in patients with type 2 diabetes undergoing cardiac surgery: A randomized controlled trial.

AIM: To assess whether treatment with sitagliptin, starting before surgery and continued during the hospital stay, can prevent and reduce the severity of perioperative hyperglycaemia in patients with type 2 diabetes undergoing coronary artery bypass graft (CABG) surgery. MATERIALS AND METHODS: We conducted a double-blinded, placebo-controlled trial in adults with type 2 diabetes randomly assigned to receive sitagliptin or matching placebo starting 1 day prior to surgery and continued during the hospital stay. The primary outcome was difference in the proportion of patients with postoperative hyperglycaemia (blood glucose [BG] > 10 mmol/L [>180 mg/dL]) in the intensive care unit (ICU). Secondary endpoints included differences in mean daily BG in the ICU and after transition to regular wards, hypoglycaemia, hospital complications, length of stay and need of insulin therapy. RESULTS: We included 182 participants randomized to receive sitagliptin or placebo (91 per group, age 64 ± 9 years, HbA1c 7.6% ± 1.5% and diabetes duration 10 ± 9 years). There were no differences in the number of patients with postoperative BG greater than 10 mmol/L, mean daily BG in the ICU or after transition to regular wards, hypoglycaemia, hospital complications or length of stay. There were no differences in insulin requirements in the ICU; however, sitagliptin therapy was associated with lower mean daily insulin requirements (21.1 ± 18.4 vs. 32.5 ± 26.3 units, P = .007) after transition to a regular ward compared with placebo. CONCLUSION: The administration of sitagliptin prior to surgery and during the hospital stay did not prevent perioperative hyperglycaemia or complications after CABG. Sitagliptin therapy was associated with lower mean daily insulin requirements after transition to regular wards.

Outcomes of convergent atrial fibrillation ablation with continuous rhythm monitoring.

BACKGROUND: Outcomes of catheter ablation for persistent atrial fibrillation (PeAF) are suboptimal. The convergent procedure (CP) may offer improved efficacy by combining endocardial and epicardial ablation. METHODS: We reviewed 113 consecutive patients undergoing the CP at our institution. The cohort was divided into two groups based on the presence (n = 92) or absence (n = 21) of continuous rhythm monitoring (CM) following the CP. Outcomes were reported in two ways. First, using a conventional definition of any atrial fibrillation/atrial tachycardia (AF/AT) recurrence lasting >30 seconds, after a 90 day blanking period. Second, by determining AF/AT burden at relevant time points in the group with CM. RESULTS: Across the entire cohort, 88% had either persistent or long-standing persistent AF, mean duration of AF diagnosis before the CP was 5.1 ± 4.6 years, 45% had undergone at least one prior AF ablation, 31% had impaired left ventricle ejection fraction and 62% met criteria for moderate or severe left atrial enlargement. Mean duration of follow-up after the CP was 501 ± 355 days. In the entire cohort, survival free from any AF/AT episode >30 seconds at 12 months after the blanking period was 53%. However, among those in the CM group who experienced recurrences, mean burden of AF/AT was generally very low (<5%) and remained stable over the duration of follow-up. Ten patients (9%) required elective cardioversion outside the 90 day blanking period, 11 patients (9.7%) underwent repeat ablation at a mean of 229 ± 178 days post-CP and 64% were off AADs at the last follow-up. Procedural complications decreased significantly following the transition from transdiaphragmatic to sub-xiphoid surgical access: 23% versus 3.8% (P = .005) CONCLUSIONS: In a large, consecutive series of patients with predominantly PeAF, the CP was capable of reducing AF burden to very low levels (generally <5%), which appeared durable over time. Complication rates associated with the CP decreased significantly with the transition from transdiaphragmatic to sub-xiphoid surgical access. Future trials will be necessary to determine which patients are most likely to benefit from the convergent approach.

Impact of Tricuspid Regurgitation on Outcomes After Transcatheter Mitral Valve Replacement.

Development of functional tricuspid regurgitation (TR) because of chronic mitral disease and subsequent heart failure is common. However, the effect of TR on clinical outcomes after transcatheter mitral valve replacement (TMVR) remains unclear. We aimed to evaluate the impact of baseline TR on outcomes after TMVR. This was a single-center, retrospective analysis of patients who received valve-in-valve or valve-in-ring TMVR between 2012 and 2022. Patients were categorized into none/mild TR and moderate/severe TR based on baseline echocardiography. The primary outcome was 3 years all-cause death and the secondary outcomes were in-hospital events. Of the 135 patients who underwent TMVR, 64 (47%) exhibited none/mild TR at baseline, whereas 71 (53%) demonstrated moderate/severe TR. There were no significant differences in in-hospital events between the groups. At 3 years, the moderate/severe TR group exhibited a significantly increased risk of all-cause death (adjusted hazard ratio 3.37, 95% confidence interval 1.35 to 8.41, p = 0.009). When patients with baseline moderate/severe TR were stratified by echocardiography at 30 days into improved (36%) and nonimproved (64%) TR groups, although limited by small sample size, there was no significant difference in 3-year all-cause mortality (p = 0.48). In conclusion, this study investigating the impact of baseline TR on clinical outcomes revealed that moderate/severe TR is prevalent in those who underwent TMVR and is an independent predictor of 3-year all-cause mortality. Earlier mitral valve intervention before the development of significant TR may play a pivotal role in improving outcomes after TMVR.

Stabilizing endothelium of donor hearts with fusogenic liposomes reduces myocardial injury and dysfunction.

BACKGROUND: Myocardial injury after heart transplantation is a consequence of pathophysiologic events initiated by local ischemia/reperfusion injury that is further aggravated by the inflammatory response due to blood exposure to the pump's artificial surfaces during cardiopulmonary bypass. The purpose of the present study was to determine the effectiveness of fusogenic lipid vesicles (FLVs) in enhancing the cardioprotective effect of St. Thomas organ preservation solution (ST). We hypothesized that donor hearts preserved with ST+FLVs will stabilize the endothelium during reperfusion, which, in turn, will reduce both endothelial barrier dysfunction and myocardial damage. METHODS: To examine the effect of ST+FLVs therapy in vitro, C3b deposition and adhesion molecule expression studies were performed on human umbilical vein endothelial cells challenged with plastic contact-activated plasma. To assess the therapy in vivo, a cervical heterotopic working heart transplantation model in rats was used. Donor hearts were preserved for 1 h at 27°C (15 min) and 4°C (45 min) and, after transplantation, were followed up for 2 h. Left ventricular function and the blood cardiac troponin I levels were quantified. RESULTS: Human umbilical vein endothelial cells treated with ST+FLVs had reduced C3b deposition and expression of adhesion molecules compared with ST alone (P < 0.05). Donor hearts receiving ST+FLVs therapy had reduced left ventricular dysfunction and cardiac troponin I compared with ST alone. CONCLUSIONS: We concluded that FLVs enhanced the cardioprotective effect of ST and reduced postischemic left ventricular dysfunction and myocardial damage. The mechanism of protection appears to be associated with the stabilization of endothelial cell membranes owing to incorporation of FLV-derived lipids.

Hybrid Closure of Postinfarction Apical Ventricular Septal Defect Using Septal Occluder Device and Right Ventricular Free Wall: The Apical BASSINET Concept.

BACKGROUND: Postinfarction ventricular septal defect (VSD) is a catastrophic complication of myocardial infarction. Surgical repair still has poor outcomes. This report describes clinical outcomes after a novel hybrid transcatheter/surgical repair in patients with apical VSD. METHODS: Seven patients with postmyocardial infarction apical VSD underwent hybrid transcatheter repair via subxiphoid surgical access. A transcatheter occluder (Amplatzer Septal Occluder) with a trailing premounted suture was deployed through the right ventricular wall and through the ventricular septum into the left ventricular apex. The trailing suture was used to connect an anchor external to the right ventricular wall. Tension on the suture then collapses the right ventricular free wall against the septum and left ventricular occluder, thereby obliterating the VSD. Outcomes were compared with 9 patients who underwent surgical repair using either patch or primary suture closure. RESULTS: All patients had significant left-to-right shunt (Qp:Qs 2.5:1; interquartile range [IQR, 2.1-2.6] hybrid repair versus 2.0:1 [IQR, 2.0-2.5] surgical repair), and elevated right ventricular systolic pressure (62 [IQR, 46-71] versus 49 [IQR, 43-54] mm Hg, respectively). All had severely depressed stroke volume index (22 versus 21 mL/m2) with ≈45% in each group requiring mechanical support preprocedurally. The procedure was done 15 (IQR, 10-50) versus 24 (IQR, 10-134) days postmyocardial infarction, respectively. Both groups of patients underwent repair with technical success and without intraprocedural death. One patient in the hybrid group and 4 in the surgical group developed multiorgan failure. The hybrid group had a higher survival at discharge (86% versus 56%) and at 30 days (71% versus 56%), but similar at 1 year (57% versus 56%). During follow-up, 1 patient in each group required reintervention for residual VSD (hybrid: 9 months versus surgical: 5 days). CONCLUSIONS: Early intervention with a hybrid transcatheter/surgical repair may be a viable alternative to traditional surgery for postinfarction apical VSD.

A comparison of surgical pulmonary embolectomy and catheter-directed lysis for life-threatening pulmonary emboli.

OBJECTIVES: Patients with life-threatening pulmonary emboli (PE) have traditionally been treated with anticoagulation alone, yet emerging data suggest that more aggressive therapy may improve short-term outcomes. The purpose of this study was to compare postoperative outcomes between catheter-directed thrombolysis (CDL) and surgical pulmonary embolectomy (SPE) in the treatment of life-threatening PE. METHODS: A retrospective single-centre observational study was conducted for patients who underwent SPE or CDL at a single US academic centre. Preprocedural and postprocedural echocardiographic data were collected. Unadjusted regression models were constructed to assess the significance of the between-group postoperative differences. RESULTS: A total of 126 patients suffered a life-threatening PE during the study period [60 SPE (47.6%), 66 CDL 52.4%]. Ten (24.4%) SPE patients and 10 (15.2%) CDL patients had massive PEs marked by preprocedural hypotension. Six (10.0%) SPE patients and 4 (6.0%) CDL patients suffered a preprocedure cardiac arrest (P = 0.41). In-hospital mortality rate was 3.3% (2) for SPE, and 3.0% (2) for CDL (P = 0.99). SPE patients were more likely to require prolonged ventilation (15.0% vs 1.5%, P = 0.01). No significant differences were found in other major complications. At baseline echocardiography, 76.9% of SPE patients and 56.9% of CDL patients had moderate or severe right ventricular (RV) dysfunction. Both treatment groups showed marked and durable improvement in echocardiographic markers of RV function from baseline at midterm follow-up. CONCLUSIONS: Both SPE and CDL can be applied to well-selected high-risk patients with low rates of morbidity and mortality. Further research is necessary to delineate which patients would benefit most from either SPE or CDL following a life-threatening PE.

Outcomes Following Shock Aortic Valve Replacement: Transcatheter Versus Surgical Approaches.

OBJECTIVES: To compare transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) for patients in shock. BACKGROUND: There are minimal data on the clinical and echocardiographic outcomes for patients in shock that undergo TAVR and no data comparing these outcomes to similar patients undergoing SAVR. METHODS: This is a single center, retrospective cohort study of patients having Society of Thoracic Surgeons (STS)-defined urgent or emergent AVR for aortic stenosis with clinical signs and symptoms of shock. Inclusion criteria were based on the Society of Cardiovascular Angiography & Interventions (SCAI) shock consensus statement and included: the need for inotropic or vasopressor agents, mechanical ventilation, continuous renal replacement therapy or newly initiated hemodialysis, and/or utilization of mechanical hemodynamic support. Clinical and echocardiographic outcomes for TAVR and SAVR were compared. RESULTS: Thirty-seven patients met the inclusion criteria for this study (17 TAVR, 20 SAVR). TAVR patients had a higher STS Predicted Risk of Mortality (PROM) score of 22.3% compared to 11.8% for SAVR patients (p = 0.001). No significant differences were found in baseline echocardiographic results. TAVR procedures required less procedure room time (185.9 min TAVR, 348.5 min SAVR, p < 0.001) and fewer intraoperative packed red blood cell (pRBC) transfusions (0.2 units TAVR, 3.4 units SAVR, p < 0.001). TAVR patients also had lower rates of prolonged postoperative ventilation compared to SAVR patients (38.5% TAVR, 75.0% SAVR, p = 0.047). TAVR and SAVR had similar rates of mortality at discharge (2 TAVR, 1 SAVR, p = 0.584), 30-days (2 TAVR, 1 SAVR, p = 0.584), and 1-year (8 TAVR, 5 SAVR, p = 0.149). CONCLUSIONS: Despite a higher risk TAVR group, patients in shock undergoing either TAVR or SAVR have similar 30-day mortality. At one year, SAVR patients have a numerically better, though not statistically significant, survival. These findings support the use of TAVR for patients in shock with aortic stenosis.

Regional antibiotic delivery for the treatment of experimental prosthetic graft infections.

OBJECTIVES: To evaluate the efficacy of antibiotic-impregnated polymethylmethacrylate (PMMA) beads in eradication of an arterial prosthetic graft methicillin-resistant Staphylococcus aureus (MRSA) biofilm in an experimental animal model. METHODS: Forty rats underwent subcutaneous implantation of a MRSA-colonized arterial polytetrafluoroethylene (PTFE) 1 x 1 cm wafer on the back. The effect of regional antibiosis produced by antibiotic PMMA bead placement adjacent to the infected PTFE wafer was determined using four 10-animal study groups: control (no antibiotic), PMMA bead with no antibiotic, PMMA bead with 10% vancomycin, and PMMA bead with 10% daptomycin. After 3 d, the PTFE wafers were explanted and quantitative biofilm cultures, expressed as colony-forming units (CFU) per graft wafer, performed using real-time polymerase chain reaction to assess MRSA eradication. No systemic antibiotic was administered. Bioassays of antibiotic bead bacteriocidal were performed by measuring zone of inhibition diameters on MRSA colonized agar culture plates prior to and following graft explantation. RESULTS: All animal tolerated implantation of the MRSA-infected PTFE wafer and survived the 3 d until graft explantation. Quantitative biofilm cultures demonstrated a significant decrease (P < 0.01) in MRSA CFUs present on the PTFE wafer surfaces in the presence of both the vancomycin- and daptomycin-impregnated beads compared to controls and plain PMMA beads. Both vancomycin and daptomycin PMMA beads retained antibacterial activity after 3 d of implantation with decrease in zones of inhibition of 15% and 45%, respectively. CONCLUSIONS: Regional antibiotic delivery using an antibiotic-impregnated PMMA bead reduced the bacterial biofilm concentration in experimental subcutaneous pocket model of vascular surgical site infection. The delivery of antibiotics via a PMMA bead may be a useful adjunct in the treatment of vascular surgical site infection.

The "thoracic endovascular aortic repair-first" strategy for acute type A dissection with mesenteric malperfusion: Initial results compared with conventional algorithms.

OBJECTIVE: Acute type A dissection with mesenteric malperfusion is a rare but lethal variant of aortic dissection. This study examines outcomes from various treatment algorithms. METHODS: A review from 2003 to 2017 of the Emory Aortic Database identified 34 patients who presented with acute type A dissection with mesenteric malperfusion. Outcomes from 4 different treatment strategies were analyzed: ascending aortic/arch replacement followed by laparotomy (n = 13), axillary-bifemoral artery bypass followed by ascending/arch replacement (n = 3); ascending/arch and concomitant antegrade thoracic endovascular aortic repair (TEVAR) (n = 5), and TEVAR followed by delayed ascending/arch replacement (TEVAR-1st) (n = 13). RESULTS: The mean age of all patients was 53 ± 13 years and was equivalent among the groups. The incidence of concomitant renal and ileofemoral malperfusion was 52% and 41%, and the initial serum lactate level was 4.3 ± 2.1 mmol/L. Overall mortality was 55.8%. In the ascending aortic/arch replacement followed by laparotomy group, 77% of patients had postoperative bowel necrosis or intractable acidosis and the mortality was 69.2%. All patients in the axillary-bifemoral artery bypass followed by ascending/arch replacement group survived, but 66% required postoperative dialysis. In the ascending/arch and concomitant antegrade/TEVAR group, the mortality was 80% secondary to persistent postoperative bowel necrosis or intractable acidosis. Three patients in the TEVAR-1st group died before aortic replacement. In the 10 patients who underwent TEVAR followed by delayed aortic replacement, the mortality was 30%. There were no cases of postoperative bowel necrosis or intractable acidosis in the TEVAR-1st group. CONCLUSIONS: The TEVAR-1st strategy delays central aortic replacement until end-organ ischemia has resolved. This novel paradigm serves as a bridge to decision, and may improve survival compared with conventional treatment strategies in acute type A dissection with mesenteric malperfusion.

Superior mesenteric artery stent fracture producing stenosis and recurrent chronic mesenteric ischemia: case report.

Endovascular modalities are being increasingly employed in the treatment of a variety of vascular diseases. With new technologies come novel complications, and one such complication unique to endovascular surgery is stent fracture. We present two cases of stent fracture following stenting of the superior mesenteric artery and discuss possible causes and treatments.

Salvage Coronary Artery Bypass Predicts Increased Mortality During Aortic Root Operation.

BACKGROUND: Aortic root replacement (ROOT) has been an established therapy, yet the impact of adding coronary artery bypass grafting (CABG) to ROOT (CABG-R) is unknown. The purpose of this research was to investigate the impact of CABG on the outcomes of ROOT. METHODS: A retrospective review from 2004 to 2016 of patients undergoing nonemergent ROOT surgical procedure was performed. Cohorts were established based on the presence or absence of added CABG. A propensity-score weighted comparison of outcomes was then conducted. RESULTS: A total of 867 patients met inclusion criteria and were analyzed (711 ROOT [72.0%], 156 CABG-R [18.0%]). CABG-R patients were older and had higher proportions of previous valve operation, hypertension, endocarditis, immunosuppressive therapy, renal insufficiency, and redo operation (all p < 0.01). Indications for CABG included anatomy (n = 48, 30.8%), coronary artery disease (80, 51.3%), and ventricular failure (28, 17.9%). The permanent stroke rate was not significantly increased with the addition of CABG-R (p = 0.06). Thirty-day mortality was 5.5% for the entire cohort but was substantially higher in patients who underwent concomitant CABG (3.4% ROOT, 15.4% CABG-R). Mortality rates were highest among patients with acute ventricular failure and CABG (28.8%) compared with patients who underwent CABG for coronary artery disease (6.3%) or patients for anatomy (22.9%; p = 0.003). CONCLUSIONS: CABG-R results in increased postoperative morbidity or mortality compared with isolated ROOT. Outcomes, however, are influenced by the specific clinical indication. CABG for coronary artery disease was associated with similar outcomes compared with isolated ROOT. Patients undergoing unplanned CABG for acute ventricular failure had the worst outcomes, thus underscoring the importance of technical success during coronary reimplantation.

Safety of Moderate Hypothermia With Antegrade Cerebral Perfusion in Total Aortic Arch Replacement.

BACKGROUND: Total aortic arch replacement (TOTAL) is a complicated operation and has traditionally required deep hypothermic circulatory arrest. In this study, the impact of moderate hypothermic circulatory arrest (MHCA) and antegrade cerebral perfusion (ACP) for TOTAL were examined. METHODS: The ARCH International aortic database was queried and 3,265 patients undergoing TOTAL using ACP were identified. Patients were divided into groups based on lowest cooling temperature: MHCA (20° to 28°C) or deep hypothermia (DHCA) (12° to 20°C). Propensity-matched scoring using 15 variables was used in 669 matched pairs. Multivariable analyses were performed. RESULTS: In the unmatched cohort, more patients underwent MHCA (2,586; 79.2%) who were also younger (p < 0.001) and more frequently underwent emergent operations (p < 0.001) than DHCA patients. For the propensity-matched patients, there were significant differences in cardiopulmonary bypass (CPB) time (MHCA 200 minutes versus DHCA 243 minutes, p < 0.001), aortic crossclamp time (MHCA 120 minutes versus DHCA 142 minutes, p < 0.001), and cerebral perfusion time (MHCA 63 minutes versus DHCA 58 minutes, p < 0.001). Of note, there was no difference in neurologic outcomes nor in-hospital mortality for the two temperature groups. Multivariable analysis of risk factors for mortality included CPB time (odds ratio [OR] 1.006; p < 0.001), concomitant mitral valve surgery (OR 3.070; p = 0.003), emergent operation (OR 2.924; p < 0.001), and poor ejection fraction (OR 3.133; p = 0.011). Independent risk factors for stroke included coronary artery disease (OR 1.856; p < 0.001), cerebral vascular disease (OR 2.172; p < 0.001), emergent operation (OR 2.109; p < 0.001), and CPB time (OR 1.004; p < 0.001). CONCLUSIONS: In this series, TOTAL with MHCA and ACP can be safely performed with acceptable operative risk. MHCA and ACP represent an effective strategy for TOTAL and may obviate the need for DHCA.

Hypothermia and Selective Antegrade Cerebral Perfusion Is Safe for Arch Repair in Type A Dissection.

BACKGROUND: Unilateral selective antegrade cerebral perfusion with moderate hypothermic circulatory arrest has been shown to be a safe and effective method of cerebral protection during surgery for acute type A dissection. This study evaluates the impact of this cerebral protection strategy on clinical outcomes after extended aortic arch reconstruction in patients undergoing emergent repair of acute type A dissection. METHODS: A retrospective review from 2004 to 2016 at a US academic center of patients undergoing surgery for acute type A dissections using moderate hypothermic circulatory arrest and selective antegrade cerebral perfusion was performed. Patient data were abstracted from The Society of Thoracic Surgeons (STS) institutional database and patient charts. Cohorts were established based on extent of arch replacement: a hemiarch group and a transverse arch group were created. Owing to a dearth of events, a risk score was estimated using a logistic regression model with 30-day mortality as outcome and preoperative variables as predictors, including non-STS variables such as malperfusion. Postoperative outcomes were then adjusted in subsequent regression analyses for the estimated risk score. RESULTS: In all, 342 patients met inclusion criteria and were included for analysis (299 hemiarch, 43 transverse arch). The mean age was 55.4 years and not different between groups (p = 0.79). Preoperative comorbidities, including prior stroke, diabetes mellitus, and renal failure, were also similar between groups (p > 0.2). Inhospital mortality was 11.7% for the entire cohort (11.7% hemiarch, 9.3% transverse arch; p = 0.60), and the permanent stroke rate was 7.3% (7.7% hemiarch, 4.3% transverse arch; p = 0.47). Median circulatory arrest time was 38.9 ± 19.2 minutes (35.0 ± 13.2 hemiarch, 65.1 ± 30.1 transverse arch; p < 0.0001). Lowest median circulatory arrest temperature was 25.9° ± 3.1C° and not different between groups (25.9° ± 3.2°C hemiarch, 26.2° ± 2.6°C transverse arch; p = 0.50). In unadjusted analysis, no increase in operative mortality, temporary neurologic dysfunction, stroke, or renal failure was observed in the transverse arch group when compared with the hemiarch group. These results persisted when adjusted analysis was performed. CONCLUSIONS: Unilateral selective antegrade cerebral perfusion with moderate hypothermic circulatory arrest remains a safe strategy for cerebral protection during emergent surgical repair of acute type A dissection and provides equivalent outcomes for both limited and extensive aortic arch reconstruction. Based on these data, unilateral selective antegrade cerebral perfusion and moderate hypothermic circulatory arrest may represent an optimal strategy for cerebral protection in this acute setting.

Severity of Preoperative Aortic Regurgitation Does Not Impact Valve Durability of Aortic Valve Repair Following the David V Valve Sparing Aortic Root Replacement.

BACKGROUND: The David V valve-sparing aortic root replacement (VSRR) is an established and durable method of root reconstruction for varying pathologies. However, the impact of the severity of preoperative aortic regurgitation (AR) on long-term durability remains unclear. The purpose of this research was to investigate the impact of the degree of preoperative AR on midterm durability following VSRR. METHODS: A retrospective review of the adult cardiac surgical database at a single academic center was undertaken from 2005 to 2015 for 223 adult patients who underwent VSRR. Patients were followed annually with echocardiograms, and a prospectively maintained database kept track of patient data. Follow-up was 97.7% complete, and the median echocardiographic follow-up was 25.5 months (range, 1 to 123 months). Patients with preoperative AR less than or equal to 2 were compared with patients with AR greater than 2 to determine the impact of preoperative AR upon valve repair durability. RESULTS: There were 223 patients who underwent VSRR during the study period, including 114 (51.1%) who required concomitant cusp repair. The operative mortality was 5 (2.2%). Ninety-seven patients (43.5%) had preoperative AR greater than 2. A total of 213 patients (95.5%) were available for long-term follow-up; of these patients, 7 (3.3%) had AR greater than 2. Fifty-two patients had a bicuspid aortic valve (22 AR ≤2 and 30 AR >2; p = 0.02). Patients with preoperative AR greater than 2 experienced greater reverse left ventricular remodeling and increases in left ventricular ejection fraction than did patients with preoperative AR less than or equal to 2 (p < 0.01). The midterm freedom from AR greater than 2 was similar for both preoperative AR groups (p = 0.57). The 8-year freedom from AR greater than 2 was 89.1% (95% confidence interval, 55.3% to 97.8%) for patients with preoperative AR less than or equal to 2 and 92.7% (95% confidence interval, 78.8% to 97.6%) for preoperative AR greater than 2. Five patients (2.4%) required aortic valve replacement during the follow-up period (3 preoperative AR ≤2, 2 preoperative AR >2). CONCLUSIONS: VSRR remains an effective and durable treatment for severe AR and preserved leaflet architecture. The severity of preoperative AR does not appear to impact midterm freedom from moderate to severe AR. VSRR results in significant left ventricular remodeling in patients with preoperative AR greater than 2.

The Racial Paradox in Multiarterial Conduit Utilization for Coronary Artery Bypass Grafting.

BACKGROUND: It has been established that outcomes for black patients undergoing coronary artery bypass graft surgery (CABG) are inferior to those of their white counterparts. The purpose of this study was to determine (1) whether rates of multiarterial grafting are different among black patients and white patients, and (2) whether racial differences exist in postoperative outcomes after accounting for grafting strategy. METHODS: A retrospective review of black patients (n = 2,810) and white patients (n = 13,569) who underwent isolated, primary CABG from January 2002 to June 2014 at a US academic institution was performed. A modified predicted risk of mortality (M-PROM) score was calculated for each patient using all The Society of Thoracic Surgeons variables for CABG excluding race. Multivariable linear, logistic, and Cox regression analyses were used to assess between-group differences, adjusted for M-PROM. RESULTS: Overall, 16,379 patients underwent CABG, and 2,441 (14.9%) received more than one arterial graft. When adjusted for M-PROM, the odds of blacks undergoing multiarterial CABG were 10% greater than for whites (p = 0.05). Blacks had worse inhospital outcomes, including higher odds of stroke (odds ratio 2.41, 95% confidence interval [CI]: 1.80 to 3.25) and prolonged intubation (odds ratio 2.01, 95% CI: 1.77 to 2.28). The increase in postoperative complications did not translate to a difference in inhospital mortality (p = 0.10) between racial cohorts. Moreover, among patients who underwent multiarterial grafting strategies, blacks had a hazard of mortality that was 34% higher (95% CI: 22% to 51%)) than that of their white counterparts. Among black patients, those who underwent multiarterial grafting strategies showed better long-term survival than those undergoing single grafting strategies (hazard ratio 0.86, 95% CI: 0.78 to 0.96). CONCLUSIONS: Despite similar rates of arterial grafting for black patients and white patients in this large single-center cohort, black patients continued to have significantly worse late survival when compared with white patients. Continued evaluation as to the causes of this disparity is warranted.

Hypothermia and cerebral protection strategies in aortic arch surgery: a comparative effectiveness analysis from the STS Adult Cardiac Surgery Database.

OBJECTIVES: Hypothermic circulatory arrest is essential to aortic arch surgery, although consensus regarding optimal cerebral protection strategy remains lacking. We evaluated the current use and comparative effectiveness of hypothermia/cerebral perfusion (CP) strategies in aortic arch surgery. METHODS: Using the Society of Thoracic Surgeons Database, cases of aortic arch surgery with hypothermic circulatory arrest from 2011 to 2014 were categorized by hypothermia strategy-deep/profound (D/P; ≤20°C), low-moderate (L-M; 20.1-24°C), and high-moderate (H-M; 24.1-28°C)-and CP strategy-no CP, antegrade (ACP), retrograde (RCP) or both ACP/RCP. After adjusting for potential confounders, strategies were compared by composite end-point (operative mortality or neurologic complication). RESULTS: Of the 12 521 aortic arch repairs with hypothermic circulatory arrest, the most common combined strategies were straight D/P without CP (25%), D/P + RCP (16%) and D/P + ACP (14%). Overall rates of the primary end-point, operative mortality and stroke were 23%, 12% and 8%, respectively. Among the 7 most common strategies, the 2 not utilizing CP (straight D/P and straight L-M) appeared inferior, associated with significantly higher risk of the composite end-point (odds ratio: 1.6; P < 0.01); there was no significant difference in composite outcome between the remaining strategies (D/P + ACP, D/P + RCP, L-M + ACP, L-M + RCP and H-M + ACP). CONCLUSIONS: In a comparative effectiveness study of cerebral protection strategies for aortic arch repair, strategies without adjunctive CP, including the most commonly utilized strategy of straight D/P hypothermia, appeared inferior to those utilizing CP. There was no clearly superior strategy among remaining techniques, and randomized trials are needed to define best practice.

Bedside modified Clagett procedure for empyema after pulmonary resection.

The objective of this study is to demonstrate the effectiveness and feasibility in treating empyema after pulmonary resection with a modified Clagett procedure performed at the bedside (BMCP). A retrospective review of a single surgeon's experience at a single institution was undertaken. All operative, postoperative, and outcome data were analyzed. Follow-up data were obtained from subsequent clinic charts. Five patients, including four males, were identified who underwent BMCP after pulmonary resection. The original operative procedures included two lobectomies, one pneumonectomy, one bilobectomy, and one bilateral metastastectomy. Patients were diagnosed with an empyema (positive thoracostomy tube culture, fever, and radiographic abnormality) at a mean time of 31 days from their initial procedure. Culture results disclosed Gram-positive empyemas in all patients. Three patients underwent BMCP as an outpatient, whereas the other two had BMCP during their hospitalizations. All patients are free from complications or recurrence at a mean follow up of 11.2 months. No patient required a further procedure after BMCP. The bedside modified Clagett procedure is both safe and effective. It is a valuable option in the management of postoperative empyema because it avoids additional operative procedures. This procedure is cost-effective when compared with operative management of perioperative empyema.