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Yuanxi L, Li Z, Jiang X, Jiang Y, Wang D, Xue Y. A novel nomogram for predicting prolonged mechanical ventilation after acute type A aortic dissection surgery: a retrospective study investigating the impact of ventilation duration on postoperative outcomes. Ann Med 2024; 56:2392871. [PMID: 39172547 PMCID: PMC11342815 DOI: 10.1080/07853890.2024.2392871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 06/01/2024] [Accepted: 07/01/2024] [Indexed: 08/24/2024] Open
Abstract
OBJECTIVE Acute type A aortic dissection (ATAAD) is a devastating cardiovascular disease with extraordinary morbidity and mortality. Prolonged mechanical ventilation (PMV) is a common complication following ATAAD surgery, leading to adverse outcomes. This study aimed to investigate the correlation between mechanical ventilation time (MVT) and prognosis and to devise a nomogram for predicting PMV after ATAAD surgery. METHODS This retrospective study enrolled 1049 ATAAD patients from 2011 to 2019. Subgroups were divided into < 12 h, 12 h to < 24 h, 24 h to < 48 h, 48 h to < 72 h, and ≥ 72 h according to MVT. Clinical characteristics and outcomes were compared among the groups. Using multivariable logistic regression analyses, we investigated the relationship between each stratification of MVT and mortality. A nomogram was constructed based on the refined multivariable logistic regression model for predicting PMV. RESULTS The total mortality was 11.8% (124/1049). The results showed that the groups with MVT 48 h to < 72 h and ≥ 72 h had significantly higher operative mortality compared to other MVT categories. Multivariate logistic regression analysis showed that MVT ≥72 h was significantly associated with higher short-term mortality. Thus, a nomogram was presented to elucidate the association between PMV (MVT ≥72 h) and risk factors including advanced age, preoperative cerebral ischemia, ascending aorta replacement, concomitant coronary artery bypass grafting (CABG), longer cardiopulmonary bypass (CPB), and large-volume intraoperative fresh frozen plasma (FFP) transfusion. The nomogram exhibited strong predictive performance upon validation. CONCLUSIONS Safely extubating patients within 72 h after ATAAD surgery is crucial for achieving favorable outcomes. The developed and validated nomogram provides a valuable tool for predicting PMV and optimizing postoperative care to improve patient prognosis. This novel nomogram has the potential to guide clinical decision-making and resource allocation in the management of ATAAD patients.
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Affiliation(s)
- Luo Yuanxi
- Department of Cardiovascular Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Graduate School, Nanjing, China
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Zeshi Li
- Department of Cardiovascular Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Graduate School, Nanjing, China
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Xinyi Jiang
- Department of Cardiovascular Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Graduate School, Nanjing, China
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yi Jiang
- Department of Cardiovascular Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Graduate School, Nanjing, China
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Dongjin Wang
- Department of Cardiovascular Surgery, Nanjing Drum Tower Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Peking Union Medical College Graduate School, Nanjing, China
- Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
- Department of Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
| | - Yunxing Xue
- Department of Cardiovascular Surgery, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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Diaz-Castrillon CE, Brown JA, Navid F, Serna-Gallegos D, Yousef S, Thoma F, Punu K, Zhu J, Sultan I. The impact of prolonged mechanical ventilation after acute type A aortic dissection repair. J Thorac Cardiovasc Surg 2024; 167:1672-1679.e2. [PMID: 35989122 DOI: 10.1016/j.jtcvs.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/24/2022] [Accepted: 07/03/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Patients with type A aortic dissection have increased resource use. The objective of this study was to describe the relationship between prolonged mechanical ventilation and longitudinal survival in patients undergoing type A aortic dissection repair. METHODS We conducted a retrospective analysis of patients with type A aortic dissection undergoing repair from 2010 to 2018; Kaplan-Meier function and adjusted Cox regression analysis were used to compare in-hospital mortality and longitudinal survival accounting for time on mechanical ventilatory support. RESULTS A total of 552 patients were included. The study population was divided into 12 hours or less (n = 291), more than 12 to 24 or less hours (n = 101), more than 24 to 48 hours or less (n = 60), and more than 48 hours (n = 100) groups. Patients within the 12 or less hours group were the youngest (60.0 vs 63.5 years vs 63.6 vs 62.8 years; P = .03) and less likely to be female (31.6% vs 43.6% vs 46.7% vs 56.0%; P < .001). On the other hand, the more than 48 hours group presented with malperfusion syndrome at admission more often (24.4% vs 29.7% vs 28.3% vs 53.0%; P < .001) and had longer cardiopulmonary and ischemic times (P < .05). In-hospital mortality was significantly higher in the more than 48 hours group (5.2% vs 6.9% vs 3.3% vs 30.0%; P < .001). Multivariable analysis demonstrated worse longitudinal survival for the 24 to 48 hours group (hazard ratio, 1.94, confidence interval, 1.10-3.43) and more than 48 hours ventilation group (hazard ratio, 2.25, confidence interval, 1.30-3.92). CONCLUSIONS The need for prolonged mechanical ventilatory support is prevalent and associated with other perioperative complications. More important, after adjusting for other covariates, prolonged mechanical ventilation is an independent factor associated with increased longitudinal mortality.
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Affiliation(s)
- Carlos E Diaz-Castrillon
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Sarah Yousef
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Floyd Thoma
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Kristian Punu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa
| | - Jianhui Zhu
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pa; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa.
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Chung JM, Wogsland AA, Bose S, Schilz R, Onders RP, Cho JS. Temporary diaphragm pacing for patients at risk of prolonged mechanical ventilation after extensive aortic repair. J Vasc Surg Cases Innov Tech 2023; 9:101319. [PMID: 37860728 PMCID: PMC10582765 DOI: 10.1016/j.jvscit.2023.101319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/24/2023] [Indexed: 10/21/2023] Open
Abstract
Objective Prolonged mechanical ventilation (MV) after extensive aortic reconstructive surgery is common. Studies have demonstrated that diaphragm pacing (DP) improves lung function in patients with unilateral diaphragm paralysis. The goal of this study is to determine whether this technology can be applied to complex aortic repair to reduce prolonged MV and other respiratory sequelae. Methods A retrospective review was performed of patients who underwent temporary DP after extensive aortic reconstructive surgery between 2019 and 2022. The primary end point was prolonged MV incidence. Other measured end points included diaphragm electromyography improvement, length of hospitalization, duration of intensive care unit stay, and reintubation rates. Results Fourteen patients deemed at high risk of prolonged MV based on their smoking and respiratory history underwent DP after extensive aortic repair. The mean age was 70.2 years. The indications for aortic repair were a thoracoabdominal aortic aneurysm (n = 8, including 2 ruptured, 2 symptomatic, and 1 mycotic), a perivisceral aneurysm (n = 4), and a perivisceral coral reef aorta (n = 2). All patients had a significant smoking history (active or former) or other risk factors for ventilator-induced diaphragmatic dysfunction and prolonged MV. The mean total duration of MV postoperatively was 31.9 hours (range, 8.1-76.5 hours). The total average pacing duration was 4.4 days. Two patients required prolonged MV, with an average of 75.4 hours. Two patients required reintubation. No complications related to DP wire placement or removal occurred. Conclusions DP is safe and feasible for patients at high risk of pulmonary insufficiency after extensive aortic reconstructive surgery.
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Affiliation(s)
- Jane M. Chung
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
| | | | - Saideep Bose
- Division of Vascular Surgery, Saint Louis University Hospital, St. Louis, MO
| | - Robert Schilz
- Division of Pulmonary Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Raymond P. Onders
- Division of General Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH
| | - Jae S. Cho
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, OH
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Jeon BH, Lee CH, Bae CH, Jang JS, Cho JW. Surgical Treatment of an Innominate Artery Aneurysm Using Near-Infrared Spectroscopy for Cerebral Monitoring: A Case Report. J Chest Surg 2021; 54:517-520. [PMID: 34667133 PMCID: PMC8646058 DOI: 10.5090/jcs.21.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/29/2021] [Accepted: 06/03/2021] [Indexed: 11/23/2022] Open
Abstract
Innominate artery aneurysms are challenging for surgeons to treat because of the requirement for brain protection during surgery. In innominate artery aneurysms, the endovascular approach does not require cardiopulmonary bypass, but patients who can be treated using this approach are limited in number, and the long-term results of endovascular treatment are unclear. Here, we report our experience of successfully treating a patient with an innominate artery aneurysm using near-infrared spectroscopy without cardiopulmonary bypass support or hypothermic circulatory arrest.
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Affiliation(s)
- Byeng Hun Jeon
- Department of Thoracic and Cardiovascular Surgery, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Chul Ho Lee
- Department of Thoracic and Cardiovascular Surgery, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Chi Hoon Bae
- Department of Thoracic and Cardiovascular Surgery, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Jae Seok Jang
- Department of Thoracic and Cardiovascular Surgery, Daegu Catholic University School of Medicine, Daegu, Korea
| | - Jun Woo Cho
- Department of Thoracic and Cardiovascular Surgery, Daegu Catholic University School of Medicine, Daegu, Korea
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Zhang C, Yang L, Shi S, Fang Z, Li J, Wang G. Risk Factors for Prolonged Mechanical Ventilation After Pulmonary Endarterectomy: 7 Years' Experience From an Experienced Hospital in China. Front Surg 2021; 8:679273. [PMID: 34179069 PMCID: PMC8222625 DOI: 10.3389/fsurg.2021.679273] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Prolonged mechanical ventilation (PMV) is common after cardiothoracic surgery, whereas the mechanical ventilation strategy after pulmonary endarterectomy (PEA) has not yet been reported. We aim to identify the incidence and risk factors for PMV and the relationship between PMV and short-term outcomes. Methods: We studied a retrospective cohort of 171 who undergoing PEA surgery from 2014 to 2020. Cox regression with restricted cubic splines was performed to identify the cutoff value for PMV. The Least absolute shrinkage and selection operator regression and logistic regressions were applied to identify risk factors for PMV. The impacts of PMV on the short-term outcomes were evaluated. Results: PMV was defined as the duration of mechanical ventilation exceeding 48 h. Independent risk factors for PMV included female sex (OR 2.911; 95% CI 1.303–6.501; P = 0.009), prolonged deep hypothermic circulatory arrest (DHCA) time (OR 1.027; 95% CI 1.002–1.053; P = 0.036), increased postoperative blood product use (OR 3.542; 95% CI 1.203–10.423; P = 0.022), elevated postoperative total bilirubin levels (OR 1.021; 95% CI 1.007–1.034; P = 0.002), increased preoperative pulmonary artery pressure (PAP) (OR 1.031; 95% CI 1.014–1.048; P < 0.001) and elongated postoperative right ventricular anteroposterior dimension (RVAD) (OR 1.119; 95% CI 1.026–1.221; P = 0.011). Patients with PMV had longer intensive care unit stays, higher incidences of postoperative complications, and higher in-hospital medical expenses. Conclusions: Female sex, prolonged DHCA time, increased postoperative blood product use, elevated postoperative total bilirubin levels, increased preoperative PAP, and elongated postoperative RVAD were independent risk factors for PMV. Identification of risk factors associated with PMV in patients undergoing PEA may facilitate timely diagnosis and re-intervention for some of these modifiable factors to decrease ventilation time and improve patient outcomes.
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Affiliation(s)
- Congya Zhang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China.,Department of Anesthesiology, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Lijing Yang
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Sheng Shi
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Zhongrong Fang
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Jun Li
- Department of Anesthesiology, National Center of Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, Beijing, China
| | - Guyan Wang
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
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Ge M, Wang Z, Chen T, Cheng Y, Ye J, Lu L, Chen C, Wang D. Risk factors for and outcomes of prolonged mechanical ventilation in patients received DeBakey type I aortic dissection repairment. J Thorac Dis 2021; 13:735-742. [PMID: 33717545 PMCID: PMC7947516 DOI: 10.21037/jtd-20-2736] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background This study aimed to identify risk factors for prolonged mechanical ventilation (PMV) and its association with disease prognosis following acute DeBakey type I aortic dissection surgery. Methods A total of 582 patients who received emergency surgery for acute DeBakey type I aortic dissection from 2014 to 2018 were enrolled in this study. Mechanical ventilation period after surgery longer than 48 hours was defined as postoperative PMV. Multiple logistic regression analysis was used to identify risk factors for PMV. This study also compared short- and long-term outcomes in patients who developed PMV with patients who did not develop this complication. To identify and compare long-term cumulative survival rate, Kaplan-Meier survival curve was plotted. Results Among all enrolled patients, 259 (44.5%) received PMV treatment. Our data suggested that the length of intensive care unit and hospital stay were longer for patients who received PMV treatment. Thirty-day mortality was also higher in patients with PMV than in patients without PMV. Elevated leukocyte count and increased serum cystatin C level upon admission, lower preoperative platelet count and longer cardiopulmonary bypass (CPB) duration were identified as risk factors for PMV. Interestingly, our data suggested that there was no significant difference of survival rate between patients with or without PMV history. Conclusions PMV after DeBakey type I aortic dissection repair surgery was a common complication and associated with increased short-term mortality rate but did not affect long-term mortality rate. Elevated preoperative leukocyte count, increased preoperative serum cystatin C level, lower preoperative platelet count and longer CPB duration were risk factors for PMV.
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Affiliation(s)
- Min Ge
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Zhigang Wang
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Tao Chen
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Yongqing Cheng
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Jiaxin Ye
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Lichong Lu
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Cheng Chen
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Dongjin Wang
- Department of Cardio-thoracic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
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Pei X, Zhu SQ, Long X, Qiu BQ, Lin K, Lu F, Xu JJ, Wu YB. Modified Distal Aortic Arch Occlusion During Aortic Arch Replacement. Heart Lung Circ 2020; 29:e245-e252. [PMID: 32430219 DOI: 10.1016/j.hlc.2020.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 02/12/2020] [Accepted: 03/11/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Circulatory arrest has been identified as an independent risk factor related to postoperative mortality in patients with Stanford type A aortic dissection. This study described a modified technique for distal aortic arch occlusion that markedly shortened the circulatory arrest time. The early results are encouraging. METHODS From May 2016 to September 2018, 51 patients with Stanford type A aortic dissection underwent the modified procedure for aortic arch replacement. All operations were performed via transitory circulatory arrest by clamping the distal aorta between the left common carotid artery and the left subclavian artery. The in-hospital and follow-up data of the treated patients were investigated. RESULTS Successful repair of the involved vasculature was achieved in all patients. One (1) patient died due to postoperative aspiration and infection, and three patients required continuous renal replacement therapy due to poor preoperative renal function. The remaining patients were successfully discharged. The median average circulatory arrest time was 5.0 (3.0-6.0) minutes. No cases of tracheotomy, delayed closure, secondary thoracotomy, or other complications occurred. During the follow-up period of 2.4-18.6 months, the implanted grafts and stented elephant trunks were all fully open and not kinked. CONCLUSIONS A modified distal aortic arch occlusion can considerably shorten the duration of circulatory arrest. Current experience suggests that this approach can serve as a feasible alternative for patients during aortic arch replacement because of its simplicity and satisfactory clinical effects.
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Affiliation(s)
- Xu Pei
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Shu-Qiang Zhu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Xiang Long
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Bai-Quan Qiu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Kun Lin
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Feng Lu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China
| | - Jian-Jun Xu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China.
| | - Yong-Bing Wu
- Department of Cardiothoracic Surgery, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, People's Republic of China.
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Haensig M, Kempfert J, Kempfert PM, Girdauskas E, Borger MA, Lehmann S. Thrombelastometry guided blood-component therapy after cardiac surgery: a randomized study. BMC Anesthesiol 2019; 19:201. [PMID: 31694568 PMCID: PMC6833285 DOI: 10.1186/s12871-019-0875-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 10/24/2019] [Indexed: 12/13/2022] Open
Abstract
Background Significant bleeding is a well known complication after cardiac surgical procedures and is associated with worse outcome. Thrombelastometry (ROTEM®) allows point-of-care testing of the coagulation status but only limited data is available yet. The aim was to evaluate the ROTEM®-guided blood component therapy in a randomized trial. Methods In case of significant postoperative bleeding (> 200 ml/h) following elective isolated or combined cardiac surgical procedures (including 14% re-do procedures and 4% requiring circulatory arrest) patients were randomized to either a 4-chamber ROTEM®-guided blood-component transfusion protocol or received treatment guided by an algorithm based on standard coagulation testing (control). One hundred four patients (mean age: 67.2 ± 10.4 years, mean log. EuroSCORE 7.0 ± 8.8%) met the inclusion criteria. Mean CPB-time was 112.1 ± 55.1 min., mean cross-clamp time 72.5 ± 39.9 min. Results Baseline demographics were comparable in both groups. Overall there was no significant difference in transfusion requirements regarding red blood cells, platelets, plasma, fibrinogen or pooled factors and the re-thoracotomy rate was comparable (ROTEM®: 29% vs. control: 25%). However, there was a trend towards less 24-h drainage loss visible in the ROTEM®-group (ROTEM®: 1599.1 ± 834.3 ml vs. control: 1867.4 ± 827.4 ml; p = 0.066). In the subgroup of patients with long CPB-times (> 115 min.; n = 55) known to exhibit an increased risk for diffuse coagulopathy ROTEM®-guided treatment resulted in a significantly lower 24-h drainage loss (ROTEM®: 1538.2 ± 806.4 ml vs. control: 2056.8 ± 974.5 ml; p = 0.032) and reduced 5-year mortality (ROTEM®: 0% vs. control: 15%; p = 0.03). Conclusion In case of postoperative bleeding following cardiac surgical procedures a treatment algorithm based on “point-of-care” 4-chamber ROTEM® seems to be at least as effective as standard therapy. In patients with long CPB-times ROTEM®-guided treatment may result in less bleeding, a marked reduction in costs and long-term mortality. Trial registration German Clinical Trials Register, TRN: DRKS00017367, date of registration: 05.06.2019, ‘retrospectively registered’.
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Affiliation(s)
- Martin Haensig
- Department of Vascular Surgery, Cardiovascular Center, University of Leipzig, Liebigstr 20, 04103, Leipzig, Germany.
| | - Joerg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Pia-Maria Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Evaldas Girdauskas
- Department of Cardiac and Cardiovascular Surgery, University Heart Center Hamburg, Hamburg, Germany
| | | | - Sven Lehmann
- Clinic of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig, Germany
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Jin M, Ma WG, Liu S, Zhu J, Sun L, Lu J, Cheng W. Predictors of Prolonged Mechanical Ventilation in Adults After Acute Type-A Aortic Dissection Repair. J Cardiothorac Vasc Anesth 2017; 31:1580-1587. [DOI: 10.1053/j.jvca.2017.03.036] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Indexed: 01/23/2023]
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10
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Development of an open-heart intraoperative risk scoring model for predicting a prolonged intensive care unit stay. BIOMED RESEARCH INTERNATIONAL 2014; 2014:158051. [PMID: 24818129 PMCID: PMC4004196 DOI: 10.1155/2014/158051] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/07/2014] [Accepted: 03/21/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Based on a pilot study with 34 patients, applying the modified sequential organ failure assessment (SOFA) score intraoperatively could predict a prolonged ICU stay, albeit with only 4 risk factors. Our objective was to develop a practicable intraoperative model for predicting prolonged ICU stay which included more relevant risk factors. METHODS An extensive literature review identified 6 other intraoperative risk factors affecting prolonged ICU stay. Another 168 patients were then recruited for whom all 10 risk factors were extracted and analyzed by logistic regression to form the new prognostic model. RESULTS The multivariate logistic regression analysis retained only 6 significant risk factors in the model: age ≥ 60 years, PaO2/FiO2 ratio ≤ 200 mmHg, platelet count ≤ 120,000/mm(3), requirement for inotrope/vasopressor ≥ 2 drugs, serum potassium ≤ 3.2 mEq/L, and atrial fibrillation grading ≥ 2. This model was then simplified into the Open-Heart Intraoperative Risk (OHIR) score, comprising the same 6 risk factors for a total score of 7-a score of ≥ 3 indicating a likely prolonged ICU stay (AUC for ROC of 0.746). CONCLUSIONS We developed a new, easy to calculate OHIR scoring system for predicting prolonged ICU stay as early as 3 hours after CPB. It comprises 6 risk factors, 5 of which can be manipulated intraoperatively.
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Czerny M, König T, Reineke D, Sodeck GH, Rieger M, Schoenhoff F, Basciani R, Jenni H, Schmidli J, Carrel TP. Total surgical aortic arch replacement as a safe strategy to treat complex multisegmental proximal thoracic aortic pathology. Interact Cardiovasc Thorac Surg 2013; 17:532-6. [PMID: 23788196 DOI: 10.1093/icvts/ivt260] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To analyse the results after elective open total aortic arch replacement. METHODS We analysed 39 patients (median age 63 years, median logistic EuroSCORE 18.4) who underwent elective open total arch replacement between 2005 and 2012. RESULTS In-hospital mortality was 5.1% (n = 2) and perioperative neurological injury was 12.8% (n = 5). The indication for surgery was degenerative aneurysmal disease in 59% (n = 23) and late aneurysmal formation following previous surgery of type A aortic dissection in 35.9% (n = 14); 5.1% (n = 2) were due to anastomotical aneurysms after prior ascending repair. Fifty-nine percent (n = 23) of the patients had already undergone previous proximal thoracic aortic surgery. In 30.8% (n = 12) of them, a conventional elephant trunk was added to total arch replacement, in 28.2% (n = 11), root replacement was additionally performed. Median hypothermic circulatory arrest time was 42 min (21-54 min). Selective antegrade cerebral perfusion was used in 95% (n = 37) of patients. Median follow-up was 11 months [interquartile range (IQR) 1-20 months]. There was no late death and no need for reoperation during this period. CONCLUSIONS Open total aortic arch replacement shows very satisfying results. The number of patients undergoing total arch replacement as a redo procedure and as a part of a complex multisegmental aortic pathology is high. Future strategies will have to emphasize neurological protection in extensive simultaneous replacement of the aortic arch and adjacent segments.
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Affiliation(s)
- Martin Czerny
- Department of Cardiovascular Surgery, University Hospital Berne, Berne, Switzerland.
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Takagi Y, Ando M, Akita K, Ishida M, Kaneko K, Sato M. Arch replacement using antegrade selective cerebral perfusion for shaggy aorta. Asian Cardiovasc Thorac Ann 2013; 21:31-6. [DOI: 10.1177/0218492312446205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Embolic stroke during arch replacement is a serious concern in patients with shaggy aorta. Objective: To evaluate shaggy aorta in patients who received total aortic arch replacement with antegrade selective cerebral perfusion utilizing axillary perfusion. Method: Between January 2005 and December 2010, 63 patients underwent preoperative contrast-enhanced computed tomography scanning of the aorta to evaluate atheromatous plaque. We analyzed operative data to investigate which factors were associated with outcomes and survival. Results: Shaggy aorta was found in 34 (54%) patients. There were 3 (5%) cases in the ascending aorta, 26 (41%) in the aortic arch, and 19 (30%) in the descending aorta. Operative mortality occurred in 1 (2%) patient. Although stroke occurred in 2 (3%) shaggy aorta patients, shaggy aorta was not associated with an increased likelihood of stroke ( p = 0.4951). Survival was significantly lower in patients with shaggy descending aorta ( p = 0.0411) and in patients >75-years old ( p = 0.0200); these traits were identified as independent risk factors for late death ( p = 0.0368 and p = 0.0100, respectively). Conclusion: We concluded that our perfusion technique protects patients with shaggy aorta against embolism, and that the survival is lower in patients with shaggy descending aorta.
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Affiliation(s)
- Yasushi Takagi
- Department of Cardiovascular Surgery, Fujita Health University, Toyoake, Japan
| | - Motomi Ando
- Department of Cardiovascular Surgery, Fujita Health University, Toyoake, Japan
| | - Kiyotoshi Akita
- Department of Cardiovascular Surgery, Fujita Health University, Toyoake, Japan
| | - Michiko Ishida
- Department of Cardiovascular Surgery, Fujita Health University, Toyoake, Japan
| | - Kan Kaneko
- Department of Cardiovascular Surgery, Fujita Health University, Toyoake, Japan
| | - Masato Sato
- Department of Cardiovascular Surgery, Fujita Health University, Toyoake, Japan
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Lei Q, Chen L, Jin M, Ji H, Yu Q, Cheng W, Li L. Preoperative and intraoperative risk factors for prolonged intensive care unit stay after aortic arch surgery. J Cardiothorac Vasc Anesth 2009; 23:789-94. [PMID: 19729322 DOI: 10.1053/j.jvca.2009.05.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The present study was performed to evaluate preoperative and intraoperative risk factors for prolonged intensive care unit (ICU) stay after aortic arch surgery. DESIGN A retrospective study. Prolonged ICU stay was defined as >5 days (120 hours). SETTING Cardiovascular operating rooms and the ICU. PARTICIPANTS Adults requiring aortic arch surgery with deep hypothermic circulatory arrest plus antegrade selective cerebral perfusion. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After 11 patients who underwent 1-stage total or subtotal aortic replacement were excluded, 298 patients were enrolled in the study. The average age of patients was 44.9 +/- 10.7 years with male predominance (74.8%). Sixty-one patients (20.5%) stayed longer than 5 days in the ICU. Univariate analyses found age, body mass index, New York Heart Association classification, preoperative serum creatinine, creatinine clearance, emergency, inotropes, cardiopulmonary bypass time, myocardial ischemia time, and fresh-frozen plasma transfused intraoperatively were significantly associated with prolonged ICU stay (p < 0.05). Independent risk factors for prolonged ICU stay were found to be New York Heart Association classification (class III and IV), emergency, inotropes used intraoperatively, and prolonged cardiopulmonary bypass time (p < 0.05). CONCLUSION The authors identified 4 preoperative and intraoperative risk factors for prolonged ICU stay. This is helpful to identify patients with increased risk for prolonged ICU stay, implement specific strategies, and allocate medical resources.
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Affiliation(s)
- Qian Lei
- Department of Anesthesiology, Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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