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Preventza O, Henry J, Khan L, Cornwell LD, Simpson KH, Chatterjee S, Amarasekara HS, Moon MR, Coselli JS. Unplanned readmissions, community socioeconomic factors, and their effects on long-term survival after complex thoracic aortic surgery. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00093-X. [PMID: 38295953 DOI: 10.1016/j.jtcvs.2024.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 01/19/2024] [Accepted: 01/23/2024] [Indexed: 03/03/2024]
Abstract
OBJECTIVE We evaluated community socioeconomic factors in patients who had unplanned readmission after undergoing proximal aortic surgery (ascending aorta, aortic root, or arch). METHODS Unplanned readmissions for any reason within 60 days of the index procedure were reviewed by race, acuity at presentation, and gender. We also evaluated 3 community socioeconomic factors: poverty, household income, and education. Kaplan-Meier survival curves were used to assess long-term survival differences by group (race, acuity, and gender). RESULTS Among 2339 patients who underwent proximal aortic surgery during the 20-year study period and were discharged alive, our team identified 146 (6.2%) unplanned readmissions. Compared with White patients, Black patients lived in areas characterized by more widespread poverty (20.8% vs 11.1%; P = .0003), lower income ($42,776 vs $65,193; P = .0007), and fewer residents with a high school diploma (73.7% vs 90.1%; P < .0001). Compared with patients whose index operation was elective, patients who had urgent or emergency index procedures lived in areas with lower income ($54,425 vs $64,846; P = .01) and fewer residents with a high school diploma (81.1% vs 89.2%; P = .005). Community socioeconomic factors did not differ by gender. Four- and 6-year survival estimates were 63.1% and 63.1% for Black patients versus 89.1% and 83.0% for White patients (P = .0009). No significant differences by acuity or gender were found. CONCLUSIONS Among readmitted patients, Black patients and patients who had emergency surgery had less favorable community socioeconomic factors and poorer long-term survival. Earlier and more frequent follow-up in these patients should be considered. Developing off-campus clinics and specific postdischarge measures targeting these patients is important.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, University of Virginia Health, Charlottesville, Va; Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex.
| | - Jaymie Henry
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Lubna Khan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Katherine H Simpson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Tex
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Preventza O, Akpan-Smart E, Lubna K, Simpson K, Cornwell L, Schmitt S, Amarasekara HS, LeMaire SA, Coselli JS. Racial disparities in thoracic aortic surgery: Myth or reality? J Thorac Cardiovasc Surg 2024; 167:3-12.e1. [PMID: 36549985 DOI: 10.1016/j.jtcvs.2022.11.013] [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: 05/12/2022] [Revised: 09/30/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We examined the relationship between Black or White race and adverse outcomes in patients who underwent surgery of the ascending aorta, aortic root, or aortic arch at our center. METHODS We analyzed 2335 consecutive patients who identified as Black (n = 217, 9.3%) or White (n = 2118, 90.7%) and underwent proximal aortic surgery. Patient zip codes were used to determine community socioeconomic (CSE) characteristics. The composite adverse outcome comprised mortality, persistent neurologic injury, and renal failure necessitating dialysis at discharge. We performed multivariable analysis, Kaplan-Meier analysis, and propensity score matching adjusted for CSE factors. RESULTS Median follow-up time was 3.7 years. Compared with White patients, Black patients lived in areas characterized by a higher percentage living below poverty level, lower income, and lower education level (P < .0001). Black patients had higher rates of emergency presentation (P < .0001) and lower 5- and 10-year survival rates (P = .0002). Short-term outcomes were similar between groups, except for respiratory failure and length of stay (P < .0001), which were higher in the Black population. After propensity score matching adjusted for CSE factors, Black and White patients (n = 204 each) had similar short-term outcomes and 5- and 10-year survival rates (P = .30). Multivariable analysis stratified by race showed that CSE factors independently predicted adverse outcomes in Black but not White patients. CONCLUSIONS This is among few studies that have analyzed the relationship between race and proximal aortic surgery. Although outcomes were similar between Black and White patients in our cohort after adjusting for CSE factors, unfavorable CSE factors predicted adverse outcomes in Black but not White patients. More patient-specific studies are needed.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex.
| | - Elizabeth Akpan-Smart
- Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Khan Lubna
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Katherine Simpson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Lorraine Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Sydney Schmitt
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Hiruni S Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
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Preventza O, Akpan-Smart E, Simpson KK, Cornwell LD, Amarasekara H, Green SY, Chatterjee S, LeMaire SA, Coselli JS. The intersection of community socioeconomic factors with gender on outcomes after thoracic aortic surgery. J Thorac Cardiovasc Surg 2023; 166:1572-1582.e10. [PMID: 36396474 DOI: 10.1016/j.jtcvs.2022.10.014] [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: 05/16/2022] [Revised: 09/23/2022] [Accepted: 10/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE We evaluated the relationship among community socioeconomic factors (poverty, income, and education), gender, and outcomes in patients who underwent ascending aortic, root, and arch surgery. METHODS For 2634 consecutive patients, we associated patients' ZIP codes with community socioeconomic factors. The composite adverse outcome comprised death, persistent neurological injury, and renal failure necessitating dialysis at discharge. Multivariable analysis and Kaplan-Meier survival curves were used. Men and women from the full cohort and from the elective patients were propensity matched. RESULTS Median follow-up was 3.6 years (interquartile range, 1.2-9.3). Men lived in areas characterized by less poverty (P = .03), higher household income (P = .01), and more education (P = .02) than women; likewise, in the elective cohort, all community socioeconomic factors favored men (P ≤ .009). Female gender predicted composite adverse outcome (P = .006). In the propensity-matched women and men (820 pairs), the composite adverse outcome rates were 14.2% and 11%, respectively (P = .06). In 583 propensity-matched pairs of elective patients, men had less composite adverse outcome (P = .02), operative mortality (P = .04), and renal (P = .02) and respiratory failure (P = .0006). The 5- and 10-year survivals for these men and women were 74.2% versus 71.4% and 50.2% versus 48.2%, respectively (P = .06). All community socioeconomic factors in both propensity-matched groups nonsignificantly favored men. CONCLUSIONS This study is among the first to examine the association among community socioeconomic factors, gender, and outcomes in patients who undergo proximal aortic surgery. Female gender predicted a composite adverse outcome. In the elective patients, most adverse outcomes were significantly less in men. In the propensity-matched patients, all community socioeconomic factors favored men, although not significantly. Larger studies with patient-level socioeconomic information are needed.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex.
| | | | - Katherine K Simpson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Hiruni Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; The Texas Heart Institute, Houston, Tex; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Tex
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ, Faxon DP, Upchurch GR, Aday AW, Azizzadeh A, Boisen M, Hawkins B, Kramer CM, Luc JGY, MacGillivray TE, Malaisrie SC, Osteen K, Patel HJ, Patel PJ, Popescu WM, Rodriguez E, Sorber R, Tsao PS, Santos Volgman A, Beckman JA, Otto CM, O'Gara PT, Armbruster A, Birtcher KK, de Las Fuentes L, Deswal A, Dixon DL, Gorenek B, Haynes N, Hernandez AF, Joglar JA, Jones WS, Mark D, Mukherjee D, Palaniappan L, Piano MR, Rab T, Spatz ES, Tamis-Holland JE, Woo YJ. 2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2023; 166:e182-e331. [PMID: 37389507 PMCID: PMC10784847 DOI: 10.1016/j.jtcvs.2023.04.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Coselli JS. Commentary: An oldie is not always a goodie. J Thorac Cardiovasc Surg 2023; 166:1032-1033. [PMID: 35016784 DOI: 10.1016/j.jtcvs.2021.12.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 12/21/2021] [Accepted: 12/22/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Tex.
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Yadav I, Saifullah H, Mandal AK, I Kh Almadhoun MK, Elsheikh Elabadi HM, Eugene M, Suleman M, Bushra Himedan HO, Fariha F, Ahmed H, Muzammil MA, Varrassi G, Kumar S, Khatri M, Elder M, Mohamad T. Cannulation Strategies in Type A Aortic Dissection: Overlooked Details and Novel Approaches. Cureus 2023; 15:e46821. [PMID: 37954771 PMCID: PMC10636502 DOI: 10.7759/cureus.46821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Aortic dissection type A is a life-threatening condition that frequently necessitates surgical intervention. This review focuses on central aortic cannulation, arch branch vessel (ABV) cannulation, and proximal arch cannulation as key techniques during aortic surgery. It discusses innovative solutions for addressing these challenges. The review synthesizes findings from recent studies and emphasizes the significance of meticulous planning and execution of cannulation in aortic dissection repair. This review aims to contribute to the advancement of surgical practices and the enhancement of patient outcomes in the management of type A aortic dissection (AAD) by addressing these frequently overlooked details.
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Affiliation(s)
- Indresh Yadav
- Internal Medicine, Samar Hospital and Research Center Pvt. Ltd., Janakpur, NPL
- Internal Medicine, Community Based Medical College, Bangladesh, Mymensingh, BGD
| | - Hanya Saifullah
- Medicine and Surgery, CMH Lahore Medical College and the Institute of Dentistry, Lahore, PAK
| | - Arun Kumar Mandal
- Internal Medicine, Manipal College of Medical Sciences/Oda Foundation, Pokhara, NPL
| | | | | | | | | | | | - Fnu Fariha
- Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Hanzala Ahmed
- Medicine and Surgery, Islamic International Medical College, Riphah International University, Karachi, PAK
| | | | | | - Satesh Kumar
- Medicine and Surgery, Shaheed Mohtarma Benazir Bhutto Medical University, Karachi, PAK
| | - Mahima Khatri
- Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Mahir Elder
- Interventional Cardiology, Heart and Vascular Institute, Detroit, USA
| | - Tamam Mohamad
- Cardiovascular, Wayne State University, Detroit, USA
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Wang X, Liu N, Wang H, Liu Y, Sun L, Zhu J, Hou X. Femoral artery cannulation increases the risk of postoperative stroke in patients with acute DeBakey I aortic dissection. J Thorac Cardiovasc Surg 2023; 166:1023-1031.e15. [PMID: 35153061 DOI: 10.1016/j.jtcvs.2021.12.049] [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: 07/13/2021] [Revised: 11/30/2021] [Accepted: 12/02/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The selection of different arterial cannulation site influences the incidence of postoperative stroke in patients with DeBakey I acute aortic dissection. The study aimed to explore the optimal arterial cannulation for these patients. METHODS From January 2009 to 2019, a total of 1514 patients with DeBakey I acute aortic dissection underwent frozen elephant trunk and total arch replacement at a tertiary center. They were divided into 2 groups: the axillary artery only cannulation group (n = 1075) and the femoral artery cannulation group (n = 439). After balancing the differences of baseline condition by propensity score matching, the prognosis was compared. RESULTS The incidence of stroke and acute brain infarction in the femoral artery cannulation group was higher than in the axillary artery only cannulation group (stroke, 11.7% vs 7.0%, P = .03; acute brain infarction, 6.0% vs 2.7%, P < .01). The femoral artery cannulation group was further divided into 2 groups: femoral artery only cannulation group (n = 106) and axillary combined with femoral artery cannulation group (n = 333). The comparison was performed between the axillary combined with femoral artery cannulation group and the axillary artery only cannulation group. After propensity score matching, the incidence of stroke and acute brain infarction in the axillary combined with femoral artery cannulation group was higher than in the axillary artery only cannulation group (stroke, 13.5% vs 7.2%, P < .01; acute brain infarction, 6.9% vs 2.5%, P < .01). CONCLUSIONS Axillary artery only cannulation is recommended as the optimal arterial cannulation strategy for most patients with DeBakey I acute aortic dissection. For those patients who are not suitable for axillary artery only cannulation, axillary combined with femoral artery cannulation is not recommended.
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Affiliation(s)
- Xiaomeng Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nan Liu
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yongmin Liu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lizhong Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junming Zhu
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Xiaotong Hou
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Feier H, Grigorescu A, Braescu L, Falnita L, Sintean M, Luca CT, Mocan M. Systematic Innominate Artery Cannulation Strategy in Acute Type A Aortic Dissection: Better Perfusion, Better Results. J Clin Med 2023; 12:jcm12082851. [PMID: 37109188 PMCID: PMC10141089 DOI: 10.3390/jcm12082851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 04/09/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023] Open
Abstract
(1) Background: Arterial cannulation in type A acute aortic dissection (TAAAD) is still subject to debate. We describe a systematic approach of using the innominate artery for arterial perfusion (2) Methods: The hospital records of 110 consecutive patients with acute TAAAD operated on between January 2014 and December 2022 were retrospectively analyzed. The effect of the cannulation site on early and late mortality, as well as on cardio-pulmonary perfusion indices (lactate and base excess levels, and cooling and rewarming speed) were investigated. (3) Results: There was a significant difference in early mortality (8.82% vs. 40.79%, p < 0.01) but no difference in long-term survival beyond the first 30 days. Using the innominate artery enabled the use of approximately 20% higher CPB flows (2.73 ± 0.1 vs. 2.42 ± 0.06 L/min/m2 BSA, p < 0.01), which resulted in more rapid cooling (1.89 ± 0.77 vs. 3.13 ± 1.62 min/°C/m2 BSA, p < 0.01), rewarming (2.84 ± 1.36 vs. 4.22 ± 2.23, p < 0.01), lower mean base excess levels during CPB (-5.01 ± 2.99 mEq/L vs. -6.66 ± 3.37 mEq/L, p = 0.01) and lower lactate levels at the end of the procedure (4.02 ± 2.48 mmol/L vs. 6.63 ± 4.17 mmol/L, p < 0.01). Postoperative permanent neurologic insult (3.12% vs. 20%, p = 0.02) and acute kidney injury (3.12% vs. 32.81%, p < 0.01) were significantly reduced. (4) Conclusions: systematic use of the innominate artery enables better perfusion and superior results in TAAAD repair.
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Affiliation(s)
- Horea Feier
- Institute for Cardiovascular Diseases, 300310 Timisoara, Romania
- Department of Cardiology, University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Andrei Grigorescu
- Institute for Cardiovascular Diseases, 300310 Timisoara, Romania
- Department of Cardiology, University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Laurentiu Braescu
- Institute for Cardiovascular Diseases, 300310 Timisoara, Romania
- Department of Cardiology, University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Lucian Falnita
- Institute for Cardiovascular Diseases, 300310 Timisoara, Romania
- Department of Cardiology, University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Marius Sintean
- Institute for Cardiovascular Diseases, 300310 Timisoara, Romania
| | - Constantin Tudor Luca
- Institute for Cardiovascular Diseases, 300310 Timisoara, Romania
- Department of Cardiology, University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Mihaela Mocan
- Department of Internal Medicine, University of Medicine and Pharmacy Iuliu Hatieganu, 400012 Cluj-Napoca, Romania
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Isselbacher EM, Preventza O, Hamilton Black J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Schuyler Jones W, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Gyang Ross E, Schermerhorn ML, Singleton Times S, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation 2022; 146:e334-e482. [PMID: 36322642 PMCID: PMC9876736 DOI: 10.1161/cir.0000000000001106] [Citation(s) in RCA: 397] [Impact Index Per Article: 198.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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Affiliation(s)
| | | | | | | | | | | | | | - Bruce E Bray
- AHA/ACC Joint Committee on Clinical Data Standards liaison
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- AHA/ACC Joint Committee on Clinical Practice Guidelines liaison
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10
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Isselbacher EM, Preventza O, Hamilton Black Iii J, Augoustides JG, Beck AW, Bolen MA, Braverman AC, Bray BE, Brown-Zimmerman MM, Chen EP, Collins TJ, DeAnda A, Fanola CL, Girardi LN, Hicks CW, Hui DS, Jones WS, Kalahasti V, Kim KM, Milewicz DM, Oderich GS, Ogbechie L, Promes SB, Ross EG, Schermerhorn ML, Times SS, Tseng EE, Wang GJ, Woo YJ. 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2022; 80:e223-e393. [PMID: 36334952 PMCID: PMC9860464 DOI: 10.1016/j.jacc.2022.08.004] [Citation(s) in RCA: 138] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AIM The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes). METHODS A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. STRUCTURE Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.
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11
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Kong X, Ruan P, Yu J, Jiang H, Chu T, Ge J. Innominate artery direct cannulation provides brain protection during total arch replacement for acute type A aortic dissection. J Cardiothorac Surg 2022; 17:165. [PMID: 35733173 PMCID: PMC9219173 DOI: 10.1186/s13019-022-01919-2] [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: 12/17/2021] [Accepted: 06/18/2022] [Indexed: 11/18/2022] Open
Abstract
Background This study aimed to investigate the safety of direct innominate arterial (IA) cannulation using a pediatric arterial cannula to establish selective antegrade cerebral perfusion (ACP) during total arch replacement (TAR) for acute Stanford type A aortic dissection (ATAAD). Methods This retrospective study included patients with ATAAD who underwent TAR with the frozen elephant trunk (FET) technique between October 2020 and November 2021. Patients treated with direct IA cannulation using a pediatric arterial cannula for selective anterograde cerebral perfusion were included in the study. Results Of the 29 patients, 24 (82.8%) were male. The average age was 50.9 ± 9.47 years. Proximal repair included aortic root plasty (27 patients, [93.1%]) and Bentall surgery (2 patients, [6.9%]). Perioperative mortality and stroke rates were 3.4% and 6.9%, respectively. The mean lowest core temperature was 23.8 ± 0.74 °C and the mean ACP time was 25 ± 6.4 min. The aortic cross-clamp and cardiopulmonary bypass times were 141 ± 28 and 202 ± 29 min, respectively. There were no cases of IA injuries. Conclusion Direct IA cannulation using a pediatric arterial cannula is a simple, safe, and effective technique for establishing ACP during TAR with the FET technique for ATAAD and can avoid the potential complications of axillary artery cannulation.
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Affiliation(s)
- Xiang Kong
- Department of Cardiovascular Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China.
| | - Peng Ruan
- Department of Cardiovascular Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China
| | - Jiquan Yu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China
| | - Hui Jiang
- Department of Cardiovascular Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China
| | - Tianshu Chu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China
| | - Jianjun Ge
- Department of Cardiovascular Surgery, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China (USTC), Hefei, 230001, Anhui, China.
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12
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Choudhary SK, Reddy PR. Cannulation strategies in aortic surgery: techniques and decision making. Indian J Thorac Cardiovasc Surg 2022; 38:132-145. [PMID: 35463714 PMCID: PMC8980986 DOI: 10.1007/s12055-021-01191-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Revised: 03/27/2021] [Accepted: 03/30/2021] [Indexed: 11/26/2022] Open
Abstract
Arterial cannulation for cardiopulmonary bypass (CPB) is an important determinant of outcome in aortic surgery. Unlike traditional cardiac operations, aortic pathology may preclude the cannulation of the distal ascending aorta. In other cases, special need of the pathology/operation may demand an alternative cannulation site. Choosing the right cannulation site, especially in type A aortic dissection, is the most crucial initial step. The decision about cannulation sites should be individualized and patient-specific. Various cannulation techniques include femoral, right axillary, innominate, carotid, central aortic, direct true lumen, transapical, and trans-atrial left ventricle cannulation. The ideal cannulation should be easy, quick, and suitable for all clinical scenarios. It should allow smooth conduct of CPB without malperfusion or cerebral embolization. The cannulation strategy should also provide an option for selective antegrade cerebral perfusion and it should be free from neurovascular and local site complications. There is no ideal cannulation technique. Each technique has its pros and cons. Excellent results and drawbacks have been reported with each technique. Final selection of the cannulation site is dependent upon several factors. However, a surgeon's familiarity with a particular technique plays a major role in selection. Despite this, there is a definite shift in surgeons' preference from femoral to central cannulation (axillary, carotid, innominate, aortic) over the last few decades. The aim of this review is to give a brief overview of the cannulation techniques in aortic surgery and discuss the decision-making process.
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Affiliation(s)
- Shiv K. Choudhary
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-29, India
| | - Pradeep R. Reddy
- Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi-29, India
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13
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Gergen AK, Kemp C, Ghincea CV, Feng Z, Ikeno Y, Aftab M, Reece TB. Direct Innominate Artery Cannulation versus Side Graft for Selective Antegrade Cerebral Perfusion during Aortic Hemiarch Replacement. AORTA 2022; 10:26-31. [PMID: 35640584 PMCID: PMC9179210 DOI: 10.1055/s-0042-1744136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Background
Selective antegrade cerebral perfusion (SACP) has become our preferred method for cerebral protection during open arch cases. While the initial approach involved sewing a graft to the innominate artery as the arterial cannulation site, our access strategy has since evolved to central aortic cannulation with use of a percutaneous cannula in the innominate for SACP. We hypothesized that SACP delivered via direct innominate cannulation using a 12- or 14-Fr cannula results in equivalent outcomes to cases utilizing a side graft.
Methods
This was a single-center, retrospective analysis of 211 adult patients who underwent elective hemiarch replacement using hypothermic circulatory arrest with SACP via the innominate artery between 2012 and 2020. Urgent and emergent cases were excluded.
Results
A side graft sutured to the innominate was utilized in 81% (
n
= 171) of patients, while direct innominate artery cannulation was performed in 19% (
n
= 40) of patients. Baseline patient characteristics were similar between groups aside from a higher baseline creatinine in the direct cannulation group (1.3 vs. 0.9,
p
= 0.032). Patients undergoing direct cannulation demonstrated shorter cardiopulmonary bypass time (132.7 vs. 154.9 minutes,
p
= 0.020) and shorter circulatory arrest time (8.1 vs. 10.9 minutes,
p
= 0.004). Nadir bladder temperature did not significantly differ between groups (27.2°C for side graft vs. 27.6°C for direct cannulation,
p
= 0.088). There were no significant differences in postoperative outcomes.
Conclusion
Direct cannulation of the innominate artery with a 12- or 14-Fr cannula for SACP during hemiarch replacement is a safe alternative to using a sutured side graft. While cardiopulmonary bypass and circulatory arrest times appear improved, this is likely attributable to accumulation of experience and proficiency in technique. However, direct innominate artery cannulation may facilitate quicker completion of these procedures by eliminating the time necessary to suture a graft to the innominate artery.
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Affiliation(s)
- Anna K. Gergen
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Cenea Kemp
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Christian V. Ghincea
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Zihan Feng
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Yuki Ikeno
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Muhammad Aftab
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - T. Brett Reece
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
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14
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Preventza O, Cekmecelioglu D, Chatterjee S, Green SY, Amarasekara H, Zhang Q, LeMaire SA, Coselli JS. Sex Differences in Ascending Aortic and Arch Surgery: A Propensity-matched Comparison of 1153 Pairs. Ann Thorac Surg 2021; 113:1153-1158. [PMID: 33971171 DOI: 10.1016/j.athoracsur.2021.04.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 04/01/2021] [Accepted: 04/27/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND We investigated the relationship of sex with clinical outcomes after proximal aortic (ascending and arch) operations, and whether sex-specific preoperative factors are associated with mortality. METHODS Of 3745 patients who underwent elective, urgent, and emergency proximal aortic operations over a 20-year period, 1153 pairs of men and women were propensity-matched, and their early and long-term outcomes were compared. Kaplan-Meier survival analysis was used to estimate late survival. RESULTS Women and men had similar operative mortality (9.1% vs 8.8%, P=0.8), stroke (5.7% vs 5.6%, P=0.9), and renal failure rates (7.0% vs 6.6%, P=0.7). Thirty-day mortality was 7.5% versus 5.6% (P=0.06), respectively. Results were less favorable for women than for men regarding respiratory failure (34.3% vs 29.2%, P=0.008) and intensive care unit length of stay (9.11±11.9 vs 7.87±12.48 days; P=0.023). Long-term survival was not significantly different between women and men: 66.3% (95%CI 62.8-69.5) versus 67.1% (95%CI 63.6-70.4) at 5 years, and 45.9% (95%CI 41.76-50.0) versus 46.2% (95%CI 41.7-50.6) at 10 years (P=0.4). Preoperative factors including diabetes, prior stroke, prior renal insufficiency, and peripheral vascular disease were associated with operative mortality in men, whereas chronic obstructive pulmonary disease was the main risk factor in women. CONCLUSIONS No differences were seen between the sexes in life-changing adverse outcomes after ascending aortic and arch procedures, although specific preoperative variables were associated with specific adverse events. Recognizing differences in preoperative risk factors for mortality between the sexes may facilitate targeted preoperative assessment, preparation, and counseling.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center.
| | - Davut Cekmecelioglu
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Division of General Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Texas
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Hiruni Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Qianzi Zhang
- Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center; Office of Surgical Research, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute; Department of Cardiovascular Surgery, CHI St Luke's Health-Baylor St Luke's Medical Center; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas
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15
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Malaisrie SC, Szeto WY, Halas M, Girardi LN, Coselli JS, Sundt TM, Chen EP, Fischbein MP, Gleason TG, Okita Y, Ouzounian M, Patel HJ, Roselli EE, Shrestha ML, Svensson LG, Moon MR. 2021 The American Association for Thoracic Surgery expert consensus document: Surgical treatment of acute type A aortic dissection. J Thorac Cardiovasc Surg 2021; 162:735-758.e2. [PMID: 34112502 DOI: 10.1016/j.jtcvs.2021.04.053] [Citation(s) in RCA: 128] [Impact Index Per Article: 42.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 04/22/2021] [Indexed: 01/16/2023]
Affiliation(s)
- S Christopher Malaisrie
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill.
| | - Wilson Y Szeto
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pa
| | - Monika Halas
- Bluhm Cardiovascular Institute and Division of Cardiac Surgery in the Department of Surgery, Northwestern University, Chicago, Ill
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Edward P Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC
| | | | - Thomas G Gleason
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Maral Ouzounian
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Hospitals, Ann Arbor, Mich
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Malakh L Shrestha
- Division of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc R Moon
- Division of Cardiothoracic Surgery, Washington University School of Medicine, Barnes-Jewish Hospital, St Louis, Mo
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16
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Peterson MD, Garg V, Mazer CD, Chu MWA, Bozinovski J, Dagenais F, MacArthur RGG, Ouzounian M, Quan A, Jüni P, Bhatt DL, Marotta TR, Dickson J, Teoh H, Zuo F, Smith EE, Verma S. A randomized trial comparing axillary versus innominate artery cannulation for aortic arch surgery. J Thorac Cardiovasc Surg 2020; 164:1426-1438.e2. [PMID: 33431219 DOI: 10.1016/j.jtcvs.2020.10.152] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 10/13/2020] [Accepted: 10/28/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cerebral protection remains the cornerstone of successful aortic surgery; however, there is no consensus as to the optimal strategy. OBJECTIVE To compare the safety and efficacy of innominate to axillary artery cannulation for delivering antegrade cerebral protection during proximal aortic arch surgery. METHODS This randomized controlled trial (The Aortic Surgery Cerebral Protection Evaluation CardioLink-3 Trial, ClinicalTrials.gov Identifier: NCT02554032), conducted across 6 Canadian centers between January 2015 and June 2018, allocated 111 individuals to innominate or axillary artery cannulation. The primary safety outcome was neuroprotection per the appearance of new severe ischemic lesions on the postoperative diffusion-weighted-magnetic resonance imaging. The primary efficacy outcome was the difference in total operative time. Secondary outcomes included 30-day all-cause mortality and postoperative stroke. RESULTS One hundred two individuals (mean age, 63 ± 11 years) were in the primary safety per-protocol analysis. Baseline characteristics between the groups were similar. New severe ischemic lesions occurred in 19 participants (38.8%) in the axillary versus 18 (34%) in the innominate group (P for noninferiority = .0009). Total operative times were comparable (median, 293 minutes; interquartile range, 222-411 minutes) for axillary versus (298 minutes; interquartile range, 231-368 minutes) for innominate (P for superiority = .47). Stroke/transient ischemic attack occurred in 4 (7.1%) participants in the axillary versus 2 (3.6%) in the innominate group (P = .43). Thirty-day mortality, seizures, delirium, and duration of mechanical ventilation were similar in both groups. CONCLUSIONS diffusion-weighted magnetic resonance imaging assessments indicate that antegrade cerebral protection with innominate cannulation is safe and affords similar neuroprotection to axillary cannulation during aortic surgery, although the burden of new neurological lesions is high in both groups.
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Affiliation(s)
- Mark D Peterson
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Vinay Garg
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
| | - C David Mazer
- Department of Anesthesia, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada; Department of Physiology, University of Toronto, Toronto, Ontario, Canada.
| | - Michael W A Chu
- Division of Cardiac Surgery, Lawson Health Research Institute, Western University, London, Ontario, Canada
| | - John Bozinovski
- Division of Cardiac Surgery, Royal Jubilee Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - François Dagenais
- Institut universitaire de cardiologie et de pneumologie de Québec, Université Laval, Québec City, Québec, Canada
| | - Roderick G G MacArthur
- Division of Cardiac Surgery, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Maral Ouzounian
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Adrian Quan
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Peter Jüni
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Thomas R Marotta
- Department of Medicine, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Division of Diagnostic and Therapeutic Neuroradiology, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Medical Imaging, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Jeffrey Dickson
- Department of Anesthesia, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Hwee Teoh
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Division of Endocrinology and Metabolism, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Fei Zuo
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada
| | - Eric E Smith
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Subodh Verma
- Division of Cardiac Surgery, Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada
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17
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Preventza O, Amarasekara H, Price MD, Chatterjee S, Green SY, Woodside S, Zhang Q, LeMaire SA, Coselli JS. Propensity score analysis in patients with and without previous isolated coronary artery bypass grafting who require proximal aortic and arch surgery. J Thorac Cardiovasc Surg 2020; 164:1390-1396.e2. [PMID: 33419538 DOI: 10.1016/j.jtcvs.2020.10.153] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 10/26/2020] [Accepted: 10/30/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The risk posed by previous isolated coronary artery bypass grafting (CABG) in patients who require proximal aortic or aortic arch surgery is unclear. We compared outcomes of ascending aortic and arch procedures in patients with and without previous CABG. METHODS Using propensity scores, we created 2 matched groups of patients who underwent proximal aortic surgery, including total arch repairs, at our institution: 126 patients who underwent isolated CABG before the index operation and 126 without previous CABG. Forty-four percent of aortic operations were emergency procedures. Eighty-six patients had a patent previous left internal mammary graft. We compared outcomes between the 2 groups and calculated Kaplan-Meier survival curves. RESULTS The following outcomes were recorded for the patients with previous isolated CABG versus no CABG: operative mortality, 15.9% versus 11.1% (P = .3); 30-day mortality, 13.5% versus 7.1% (P = .1); persistent stroke, 6.3% versus 4.8% (P = .6); and renal failure necessitating hemodialysis at discharge, 7.9% versus 4.0% (P = .2). Previous CABG did not independently predict any adverse outcome, even though patients who underwent previous CABG more frequently needed intra-aortic balloon support (P < .01). The P value for the overall intergroup difference in long-term survival was .06. CONCLUSIONS This is one of the largest studies yet reported to examine the impact of previous isolated CABG on proximal aortic or arch surgery outcomes. Although these results may be specific to aortic centers of excellence, in this complicated patient cohort, previous isolated CABG did not independently predict any adverse outcome. These results could serve as a benchmark for assessing future endovascular therapies.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
| | - Hiruni Amarasekara
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Matt D Price
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Subhasis Chatterjee
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Sandra Woodside
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Qianzi Zhang
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Scott A LeMaire
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Surgical Research Core, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
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18
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Huang LC, Xu QC, Chen DZ, Dai XF, Chen LW. Combined femoral and axillary perfusion strategy for Stanford type a aortic dissection repair. J Cardiothorac Surg 2020; 15:326. [PMID: 33172480 PMCID: PMC7654610 DOI: 10.1186/s13019-020-01371-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 11/02/2020] [Indexed: 11/16/2022] Open
Abstract
Background The optimal cannulation strategy in surgery for Stanford type A aortic dissection is critical to patient survival but remains controversial. Different cannulation strategies have their own advantages and drawbacks during cardiopulmonary bypass. Our centre used a combined femoral and axillary perfusion strategy for the surgical treatment of type A aortic dissection. The purpose of this study was to review and clarify the clinical outcome of femoral artery cannulation combined with axillary artery cannulation for the treatment of Stanford type A aortic dissection. Methods We performed a retrospective study that included 327 patients who were surgically treated for type A aortic dissection in our institution from January 2017 to June 2019. Femoral and axillary artery cannulation was used to establish cardiopulmonary bypass in patients with type A aortic dissection. The demographic data, surgical data, and clinical results of the patients were calculated. Results Femoral artery combined with axillary artery cannulation was technically successful in 327 patients. The cardiopulmonary bypass time was 141.60 ± 34.89 min, and the selective antegrade cerebral perfusion time was 14.94 ± 2.76 min. The early mortality rate was 3.06%. The incidence of permanent neurologic dysfunction was 0.92%. Sixteen patients had postoperative renal insufficiency, and five patients had liver failure. Conclusion Femoral artery combined with axillary artery cannulation for type A aortic dissection can significantly improve the prognosis of patients, especially in terms of cerebral protection, and can reduce the occurrence of adverse malperfusion syndrome and neurological complications.
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Affiliation(s)
- Ling-Chen Huang
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Qi-Chen Xu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Dao-Zhong Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Xiao-Fu Dai
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China
| | - Liang-Wan Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Fuzhou, 350001, People's Republic of China.
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Payabyab EC, Hemli JM, Mattia A, Kremers A, Vatsia SK, Scheinerman SJ, Mihelis EA, Hartman AR, Brinster DR. The use of innominate artery cannulation for antegrade cerebral perfusion in aortic dissection. J Cardiothorac Surg 2020; 15:205. [PMID: 32736644 PMCID: PMC7393698 DOI: 10.1186/s13019-020-01249-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 07/21/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Direct cannulation of the innominate artery for selective antegrade cerebral perfusion has been shown to be safe in elective proximal aortic reconstructions. We sought to evaluate the safety of this technique in acute aortic dissection. METHODS A multi-institutional retrospective review was undertaken of patients who underwent proximal aortic reconstruction for Stanford type A dissection between 2006 and 2016. Those patients who had direct innominate artery cannulation for selective antegrade cerebral perfusion were selected for analysis. RESULTS Seventy-five patients underwent innominate artery cannulation for ACP for Stanford Type A Dissections. Isolated replacement of the ascending aorta was performed in 36 patients (48.0%), concomitant aortic root replacement was required in 35 patients (46.7%), of whom 7 had a valve-sparing aortic root replacement, ascending aorta and arch replacement was required in 4 patients (5%). Other procedures included frozen elephant trunk (n = 11 (14.7%)), coronary artery bypass grafting (n = 20 (26.7%)), and peripheral arterial bypass (n = 4 (5.3%)). Mean hypothermic circulatory arrest time was 19 ± 13 min. Thirty-day mortality was 14.7% (n = 11). Perioperative stroke occurred in 7 patients (9.3%). CONCLUSIONS This study is the first comprehensive review of direct innominate artery cannulation through median sternotomy for selective antegrade cerebral perfusion in aortic dissection. Our experience suggests that this strategy is a safe and effective technique compared to other reported methods of cannulation and cerebral protection for delivering selective antegrade cerebral perfusion in these cases.
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Affiliation(s)
- Eden C Payabyab
- Division of Cardiac Surgery, Virginia Commonwealth University Health Systems, Richmond, VA, USA.
- Department of Cardiothoracic Surgery, New York Presbyterian-Weill Cornell Medicine, New York, NY, USA.
| | - Jonathan M Hemli
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
| | - Allan Mattia
- Department of Cardiovascular and Thoracic Surgery, North Shore University Hospital / Northwell Health, Manhasset, NY, USA
| | - Alex Kremers
- Division of Cardiac Surgery, Virginia Commonwealth University Health Systems, Richmond, VA, USA
- Rush University, Chicago, IL, USA
| | - Sohrab K Vatsia
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
| | - S Jacob Scheinerman
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
| | - Efstathia A Mihelis
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
| | | | - Derek R Brinster
- Department of Cardiovascular and Thoracic Surgery, Lenox Hill Hospital / Northwell Health, New York, NY, USA
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Frankel WC, Green SY, Orozco-Sevilla V, Preventza O, Coselli JS. Contemporary Surgical Strategies for Acute Type A Aortic Dissection. Semin Thorac Cardiovasc Surg 2020; 32:617-629. [PMID: 32615305 DOI: 10.1053/j.semtcvs.2020.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/21/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Abstract
Surgical techniques and organ protection strategies for acute type A aortic dissection (ATAAD) have evolved considerably over the years. Nonetheless, open surgical repair remains a complex procedure, and there is a lack of consensus regarding many aspects of repair. In patients with dissection limited to the ascending aorta (DeBakey type II), repair typically involves replacement of only the affected segment, barring substantial aortic dilation to address elsewhere. In contrast, most patients with ATAAD have dissection extending into the thoracoabdominal aorta (DeBakey type I); in these cases, consideration must be given as to how much of the aortic arch and distal aorta to incorporate into the index repair, and several open and hybrid options exist. Herein, we review contemporary surgical strategies for ATAAD and clarify specific areas of controversy, in an effort to elucidate the optimal operative approach. In general, a limited index repair aimed at ensuring operative survival is typically the best option, whereas extended repair should be reserved for carefully selected patients who are most likely to benefit.
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Affiliation(s)
- William C Frankel
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Susan Y Green
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Vicente Orozco-Sevilla
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas
| | - Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Section of Adult Cardiac Surgery, Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas; CHI St Luke's Health-Baylor St Luke's Medical Center, Houston, Texas; Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas.
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Wai Sang SL, Beute TJ, Timek T. A simple method to establish antegrade cerebral perfusion during hemiarch reconstruction. JTCVS Tech 2020; 2:10-15. [PMID: 34317734 PMCID: PMC8298922 DOI: 10.1016/j.xjtc.2020.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Revised: 02/09/2020] [Accepted: 03/13/2020] [Indexed: 01/16/2023] Open
Abstract
Objective We describe a novel and safe technique using a 12F-14F pediatric arterial cannula to establish unilateral, selective, antegrade cerebral perfusion (ACP) during open hemiarch reconstruction. Methods Between January 2015 and September 2018, 42 patients underwent elective aortic aneurysm repair requiring an open distal anastomosis and at least a hemiarch replacement via hypothermic circulatory arrest by 2 surgeons. All distal reconstructions were performed at moderate hypothermia (22°C-26°C) with direct cannulation of the innominate artery (IA) using a pediatric arterial cannula to allow ACP at 10-15 mL/kg/min. Data were collected by retrospective chart review. Results Thirty-one of the 42 patients (74%) were male. The mean patient age was 65 ± 13 years, and the mean body surface area was 2.1 ± 0.3 m2. Proximal repairs included a modified Bentall with a valve-graft composite (n = 17), valve-sparing root replacement (n = 2), and aortic valve replacement (n = 15). Perioperative mortality was 2% (n = 1), and the incidence of stroke was 0%. The mean lowest core body temperature reached during circulatory arrest was 23.8 ± 2.7°C with a mean ACP time of 21.8 ± 3.6 minutes. The mean aortic cross-clamp and cardiopulmonary bypass times were 160.6 ± 55.5 minutes and 204.7 ± 57.5 minutes, respectively. There were no cases of IA injury. Conclusions Direct IA cannulation with a pediatric arterial cannula is a safe and efficient method to allow ACP in aortic surgery requiring hypothermic circulatory arrest and may circumvent the potential complications of axillary cannulation.
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Affiliation(s)
- Stephane Leung Wai Sang
- Department of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich.,Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Tyler J Beute
- Michigan State University College of Human Medicine, Grand Rapids, Mich
| | - Tomasz Timek
- Department of Cardiothoracic Surgery, Spectrum Health, Grand Rapids, Mich.,Michigan State University College of Human Medicine, Grand Rapids, Mich
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Application of a Modified Extracorporeal Circulation Perfusion Method During Surgery for Acute Stanford Type A Aortic Dissection. Heart Lung Circ 2020; 29:1203-1209. [PMID: 32059950 DOI: 10.1016/j.hlc.2019.11.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/10/2019] [Accepted: 11/23/2019] [Indexed: 11/20/2022]
Abstract
AIM The aim of this study was to investigate the effect of the modified extracorporeal circulation perfusion method during surgery for acute Stanford type A aortic dissection in patients who underwent stented elephant trunk implantation and arch replacement. METHOD A total of 69 patients with acute Stanford type A aortic dissection who underwent stented elephant trunk implantation and arch replacement were retrospectively analysed from 2017 to 2018. According to the perfusion method of extracorporeal circulation, patients were divided into a routine perfusion (RP) group and a modified perfusion (MP) group. Clinical data were collected, including the time of extracorporeal circulation and deep hypothermic circulatory arrest, incidence of acute kidney injury and neurological complications, and comparisons between the two groups were conducted by using independent sample t-tests for normally distributed qualitative data, the Mann-Whitney U-test for skewed qualitative data, and the chi square test or Fisher's exact test for categorical data. RESULTS There were 55 (80%) males and 14 (20%) females in the entire cohort, and the mean ± standard deviation age was 50.4±9.0 years. A total of 53 (77%) patients were included in the RP group, and 16 (23%) were included in the MP group. Patients in the MP group were older (55.5±7.8 vs 48.8±8.9 years), and the difference was significant (p=0.008). Compared with the RP group, the time of extracorporeal circulation (218.0 [44.7] vs 246.0 [58.0] min; p=0.005) and deep hypothermic circulatory arrest (4.0 [2.0] vs 25.0 [10.0] min; p<0.001) was shorter, and the incidence of postoperative acute kidney injury (n=6 [37.5%] vs n=36 [67.9%]; p=0.029) was lower in the MP group; the differences were significant. Six (6) patients died in the RP group; no patients died in the MP group. The total in-hospital mortality rate was 8.7%. CONCLUSIONS The modified extracorporeal circulation perfusion method is feasible, with satisfactory results.
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Wang X, Yang F, Zhu J, Liu Y, Sun L, Hou X. Aortic arch surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion: Perioperative outcomes. J Thorac Cardiovasc Surg 2020; 159:374-387.e4. [DOI: 10.1016/j.jtcvs.2019.01.127] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 01/24/2019] [Accepted: 01/31/2019] [Indexed: 01/16/2023]
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Harky A, Oo S, Gupta S, Field M. Proximal arterial cannulation in thoracic aortic surgery-Literature review. J Card Surg 2019; 34:598-604. [PMID: 31212386 DOI: 10.1111/jocs.14087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 04/11/2019] [Accepted: 05/03/2019] [Indexed: 11/30/2022]
Abstract
Surgery on thoracic aorta is complex with a number of approaches being required depending on the pathology and anatomy that is specific to each patient and therefore, careful planning is required to ensure successful outcomes. Among the key factors that determine a satisfactory and safe operation is the choice of arterial cannulation site to establish cardiopulmonary bypass and deliver brain protection adequately. Direct proximal aortic cannulation is the gold-standard method for elective aortic root surgery and traditionally femoral arterial cannulation has been used in complex aortic surgeries such as redo or acute pathologies; however, axillary and innominate artery (IA) cannulation has evolved dramatically and several centers are currently using proximal cannulation sites as the default cannulation choice in elective and emergency settings of complex thoracic aortic surgeries. The evidence behind cannulating the IA is growing; however, it is yet to be well established through large studies or trial to confirm its superiority to other methods of central cannulation techniques.
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Affiliation(s)
- Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Shwe Oo
- Department of Cardiothoracic Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Shubhi Gupta
- School of Medicine, Department of Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Mark Field
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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Mazine A, Stevens LM, Ghoneim A, Chung J, Ouzounian M, Dagenais F, El-Hamamsy I, Boodhwani M, Bozinovski J, Peterson MD, Chu MW. Developing skills for thoracic aortic surgery with hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2019; 157:1360-1368.e8. [DOI: 10.1016/j.jtcvs.2018.11.110] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 11/13/2018] [Accepted: 11/22/2018] [Indexed: 02/07/2023]
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26
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Dolapoglu A, Avcı E, Bugra O. Cannulation of Innominate Artery During Proximal Aortic Aneurysm Repair. DICLE MEDICAL JOURNAL 2019. [DOI: 10.5798/dicletip.474696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Harky A, Wong CHM, Chan JSK, Zaki S, Froghi S, Bashir M. Innominate artery cannulation in aortic surgery: A systematic review. J Card Surg 2018; 33:818-825. [PMID: 30548686 DOI: 10.1111/jocs.13962] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The innominate artery is considered an alternative site for establishing cardiopulmonary bypass in surgical procedures involving the thoracic aorta. This systematic review examines the use of innominate artery cannulation in aortic surgery. METHODS A systematic literature search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all studies that utilized innominate artery cannulation for establishing cardiopulmonary bypass and providing cerebral perfusion in thoracic aortic surgery. The data were reviewed up to September 2018. RESULTS Acute type A aortic dissection contributed to 36% (n = 818) of the total 2,290 patients. 31.5% (n = 719) underwent surgery on the aortic root only; 54.5% (n = 1246) had ascending and hemi-arch replacement, while 11.5% had total aortic arch replacement and 2.5% had a frozen elephant trunk inserted. Postoperative stroke rate was 1.25% (n = 28), temporary neurological deficit was 4.8% (n = 111). All-cause 30-day mortality rate was 2.7% (n = 61). CONCLUSION Innominate artery cannulation is a safe technique in patients who undergo thoracic aortic surgery. It can be utilized, in selected cases, as a reliable route for establishing cardiopulmonary bypass and maintaining cerebral perfusion.
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Affiliation(s)
- Amer Harky
- Department of Vascular Surgery, Countess of Chester Hospital, Chester, UK
| | - Chris Ho Ming Wong
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Jeffrey Shi Kai Chan
- Faculty of Medicine, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Shady Zaki
- Department of Vascular Surgery, Countess of Chester Hospital, Chester, UK
| | - Saied Froghi
- Department of Surgery, Imperial College NHS Trust, Hammersmith Hospital, London, UK
| | - Mohamad Bashir
- Department of Aortovascular Surgery, Manchester Royal Infirmary, Manchester, UK
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Urbanski PP, Irimie V, Lenos A, Bougioukakis P, Atieh A, Lehmkuhl L. Innominate artery pathology in the setting of aortic arch surgery: incidences, surgical considerations and operative outcomes. Eur J Cardiothorac Surg 2018; 55:351-357. [DOI: 10.1093/ejcts/ezy267] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 06/26/2018] [Indexed: 12/15/2022] Open
Affiliation(s)
- Paul P Urbanski
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Vadim Irimie
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Aristidis Lenos
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Petros Bougioukakis
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Alaa Atieh
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Lukas Lehmkuhl
- Department of Radiology, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
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Preventza O, Price MD, Spiliotopoulos K, Amarasekara HS, Cornwell LD, Omer S, de la Cruz KI, Zhang Q, Green SY, LeMaire SA, Rosengart TK, Coselli JS. In elective arch surgery with circulatory arrest, does the arterial cannulation site really matter? A propensity score analysis of right axillary and innominate artery cannulation. J Thorac Cardiovasc Surg 2018; 155:1953-1960.e4. [DOI: 10.1016/j.jtcvs.2017.11.095] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 11/14/2017] [Accepted: 11/26/2017] [Indexed: 10/18/2022]
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30
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Osaka S, Tanaka M. Strategy for Porcelain Ascending Aorta in Cardiac Surgery. Ann Thorac Cardiovasc Surg 2018; 24:57-64. [PMID: 29491196 DOI: 10.5761/atcs.ra.17-00181] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Shunji Osaka
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Masashi Tanaka
- Department of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
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31
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Risteski P, El-Sayed Ahmad A, Monsefi N, Papadopoulos N, Radacki I, Herrmann E, Moritz A, Zierer A. Minimally invasive aortic arch surgery: Early and late outcomes. Int J Surg 2017; 45:113-117. [DOI: 10.1016/j.ijsu.2017.07.105] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/02/2017] [Accepted: 07/31/2017] [Indexed: 01/19/2023]
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Bergeron EJ, Mosca MS, Aftab M, Justison G, Reece TB. Neuroprotection Strategies in Aortic Surgery. Cardiol Clin 2017; 35:453-465. [DOI: 10.1016/j.ccl.2017.03.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Urbanski PP, Sabik JF, Bachet JE. Cannulation of an arch artery for hostile aorta. Eur J Cardiothorac Surg 2017; 51:2-9. [PMID: 28077502 DOI: 10.1093/ejcts/ezw325] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/18/2016] [Accepted: 08/24/2016] [Indexed: 12/12/2022] Open
Affiliation(s)
- Paul P Urbanski
- Department of Cardiovascular Surgery, Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany
| | - Joseph F Sabik
- Department of Thoracic & Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
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Moderate hypothermia at warmer temperatures is safe in elective proximal and total arch surgery: Results in 665 patients. J Thorac Cardiovasc Surg 2017; 153:1011-1018. [DOI: 10.1016/j.jtcvs.2016.09.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 08/30/2016] [Accepted: 09/09/2016] [Indexed: 11/19/2022]
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Patient management in aortic arch surgery†. Eur J Cardiothorac Surg 2017; 51:i4-i14. [DOI: 10.1093/ejcts/ezw337] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Revised: 08/23/2016] [Accepted: 09/02/2016] [Indexed: 12/31/2022] Open
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Preventza O, Coselli JS, Akvan S, Kashyap SA, Garcia A, Simpson KH, Price MD, Mayor J, de la Cruz KI, Cornwell LD, Omer S, Bakaeen FG, Haywood-Watson RJL, Rammou A. The impact of temperature in aortic arch surgery patients receiving antegrade cerebral perfusion for >30 minutes: How relevant is it really? J Thorac Cardiovasc Surg 2016; 153:767-776. [PMID: 28087112 DOI: 10.1016/j.jtcvs.2016.11.059] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 11/10/2016] [Accepted: 11/25/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE We examined the early outcomes and the long-term survival associated with different degrees of hypothermia in patients who received antegrade cerebral perfusion (ACP) for >30 minutes. METHODS During a 10-year period, 544 consecutive patients underwent proximal and total aortic arch surgery and received ACP for >30 minutes and 1 of 3 levels of hypothermia: deep (14.1°C-20°C; n = 116 [21.3%]), low-moderate (20.1°C-23.9°C; n = 262 [48.2%]), and high-moderate (24°C-28°C; n = 166 [30.5%]). A variable called "predicted temperature" was used in propensity-score analysis. Multivariate analysis was done to evaluate the effect of actual temperature on outcomes. RESULTS The operative mortality rate was 12.5% (n = 68) overall and was 15.5%, 11.8%, and 11.5% in the deep, low-moderate, and high-moderate hypothermia patients, respectively (P = .54). The persistent stroke rate was 6.6% overall and 12.2%, 4.6%, and 6.0% in these 3 groups, respectively (P = .024 on univariate analysis). On multivariate analysis, actual temperature was not associated with mortality, but lower temperatures predicted persistent stroke and reoperation for bleeding. In the propensity-matched subgroups, the patients with predicted deep hypothermia had (nonsignificantly) greater rates of persistent stroke (12.2% vs 4.9%; relative risk, 1.08; 95% CI, 0.87-1.15) and reoperation for bleeding (14.6% vs 2.4%; relative risk, 1.14; 95% CI, 0.87-1.15) than the patients with predicted moderate hypothermia. On long-term follow-up (mean duration, 5.12 years), 4- and 8-year survival rates were 62.3% and 55.7% in the deep hypothermia group and 75.4% and 74.2% in the moderate hypothermia group (P = .0015). CONCLUSIONS In proximal and arch operations involving ACP for >30 minutes, greater actual temperatures were associated with less stroke and reoperation for bleeding. There were no significant differences among the predicted hypothermia levels, although a trend toward a higher rate of adverse events was noticed in the deep hypothermia group. Long-term survival was better in the moderate hypothermia group.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Shahab Akvan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Sarang A Kashyap
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Andrea Garcia
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Katherine H Simpson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Matt D Price
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Jessica Mayor
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Kim I de la Cruz
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Shuab Omer
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Faisal G Bakaeen
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Ricky J L Haywood-Watson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Athina Rammou
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
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Preventza O, Coselli JS, Garcia A, Akvan S, Kashyap S, Simpson KH, Price MD, de la Cruz KI, Spiliotopoulos K, Cornwell LD, Bakaeen FG, Omer S, Cooley DA. Aortic root surgery with circulatory arrest: Predictors of prolonged postoperative hospital stay. J Thorac Cardiovasc Surg 2016; 153:511-518. [PMID: 27964981 DOI: 10.1016/j.jtcvs.2016.10.090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 09/30/2016] [Accepted: 10/07/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Little is known about the outcomes of aortic root operations that involve inducing hypothermic circulatory arrest for relatively extensive proximal aortic surgery. We attempted to identify predictors of postoperative hospital length of stay (LOS) and factors that affect postoperative recovery. METHODS During 2006-2014, 247 of 265 patients (93.2%) with disease extending into the aortic arch survived aortic root operations (206 elective, 41 urgent/emergent) in which hypothermic circulatory arrest with moderate hypothermia was used. Stepwise multivariate regression analysis was performed to identify predictors of LOS (as a continuous variable) and prolonged LOS (defined as LOS >9 days, the median for the cohort). By this definition, 111 patients (45%) had prolonged LOS and 136 (55%) did not. RESULTS Preoperative factors that independently predicted longer LOS in the entire cohort included age (P = .0014), redo sternotomy (P = .0047), and intraoperative packed red blood cell (PRBC) transfusion (P = .0007). Redo sternotomy and intraoperative PRBC transfusion also predicted longer LOS in 3 subgroup analyses: one of elective cases, one from which total arch replacement procedures were excluded, and one limited to patients who were discharged home. Age predicted longer LOS in the non-total arch (hemiarch) replacement patients. Ventilator support >48 hours (P < .0001) was associated with longer LOS. Elective aortic valve-sparing root replacement predicted a shorter LOS than valve replacement in multivariate regression analysis (P = .028). CONCLUSIONS In patients undergoing aortic root surgery with hypothermic circulatory arrest for disease extending into the aortic arch, reducing intraoperative PRBC transfusion except when absolutely necessary may reduce postoperative LOS and expedite recovery. Performing aortic valve-sparing root replacement, when feasible, may also reduce LOS.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex.
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Andrea Garcia
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Shahab Akvan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Sarang Kashyap
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Katherine H Simpson
- Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Matt D Price
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Kim I de la Cruz
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Konstantinos Spiliotopoulos
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Faisal G Bakaeen
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Shuab Omer
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex; Division of Cardiothoracic Surgery, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex
| | - Denton A Cooley
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Tex
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Mosca MS, Justison G, Reece TB. A Clinical Protocol for Goal Directed Cerebral Perfusion during Aortic Arch Surgery. Semin Cardiothorac Vasc Anesth 2016; 20:289-297. [PMID: 27742818 DOI: 10.1177/1089253216672854] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The optimal strategy to deliver antegrade cerebral perfusion for cerebral protection during hypothermic circulatory arrest has not been established. The purpose of this review was to present our current clinical protocol utilizing selective antegrade cerebral perfusion during aortic arch surgery and to compare it to other published experience. CLINICAL PROTOCOL Since 2013, our clinical protocol for aortic arch surgery has evolved to using selective antegrade cerebral perfusion via the innominate artery, moderate hypothermia, and ancillary strategies such as goal-directed perfusion (GDP). Other published techniques favored antegrade cerebral perfusion but were limited by smaller cannulae, multiple cannulation sites, and lower cooling temperatures. CONCLUSION Our clinical protocol may offer higher flow rates, avoid complications associated with additional cannulae, and provide an easy setup for dual arterial perfusion. Additionally, GDP has enhanced our understanding of metabolic physiology and may facilitate the development of a better cerebral protection strategy.
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Preventza O, Coselli JS. Differential aspects of ascending thoracic aortic dissection and its treatment: the North American experience. Ann Cardiothorac Surg 2016; 5:352-9. [PMID: 27563548 DOI: 10.21037/acs.2016.07.01] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Acute type A aortic dissection is a deadly disease with significant morbidity and mortality. We describe the differential aspects of the disease and the North American experience with its treatment.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA;; Division of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, Texas, USA;; Division of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas, USA
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40
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Preventza O, Garcia A, Kashyap SA, Akvan S, Cooley DA, Simpson K, Rammou A, Price MD, Omer S, Bakaeen FG, Cornwell LD, Coselli JS. Moderate hypothermia ≥24 and ≤28°C with hypothermic circulatory arrest for proximal aortic operations in patients with previous cardiac surgery. Eur J Cardiothorac Surg 2016; 50:949-954. [PMID: 27190198 DOI: 10.1093/ejcts/ezw163] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 04/13/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To determine whether, in patients with previous cardiac operations, moderate hypothermia (between 24 and 28°C) for hypothermic circulatory arrest (HCA) during antegrade cerebral perfusion (ACP) is safe for use during surgery on the proximal aorta and transverse aortic arch. METHODS Over a 7-year period, 118 patients underwent ascending aortic and hemiarch repair (n = 70; 59.3%), total arch replacement (n = 47; 39.8%) or ascending aortic replacement to treat porcelain aorta (n = 1; 0.9%). Simultaneous procedures included aortic root repair or replacement (n = 33; 28.0%) and coronary artery bypass grafting (n = 21; 17.8%). All patients had previously undergone cardiac operations via a median sternotomy. Eighteen patients (15.3%) had more than 1 previous sternotomy, and 24 patients (20.3%) required emergent/urgent operation. Median cardiopulmonary bypass, cardiac ischaemic, circulatory arrest and ACP times (min) were 136.0 [118-180 interquartile range (IQR)], 91.0 (68-119 IQR), 34.0 (21-59 IQR) and 33.5 (20-59 IQR), respectively. The median temperature when HCA was initiated was 24.2°C (24.1-24.8°C IQR). RESULTS The operative mortality rate was 10.2% (n = 12). Six patients (5.1%) had a permanent stroke, and 16 patients (13.6%) had a composite adverse outcome (operative mortality and/or a permanent neurological event and/or permanent haemodialysis at discharge). Preoperative renal disease was significantly more prevalent (P= 0.020) and the median circulatory arrest time significantly longer (48.5 vs 33 min; P= 0.058) in patients with composite adverse outcomes. Multivariable analysis of the redo patients showed that age (P =0.025), preoperative renal disease (P =0.024) and ACP time (P =0.012) were independent risk factors for a new postoperative renal injury. CONCLUSIONS Moderate hypothermia for HCA during ACP is being used with increasing frequency, but has not been thoroughly evaluated in patients undergoing cardiovascular reoperations. Our experience suggests that in patients with previous cardiac surgery who are undergoing hemiarch and total aortic arch operations, moderate hypothermia is safe and produces respectable results.
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Affiliation(s)
- Ourania Preventza
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA .,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Andrea Garcia
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Sarang A Kashyap
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Shahab Akvan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Denton A Cooley
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Kiki Simpson
- The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Athina Rammou
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - Matt D Price
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
| | - Shuab Omer
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Faisal G Bakaeen
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA.,The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Lorraine D Cornwell
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,The Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Joseph S Coselli
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.,Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
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Direct innominate artery cannulation: An alternate technique for antegrade cerebral perfusion during aortic hemiarch reconstruction. J Thorac Cardiovasc Surg 2016; 151:1073-8. [DOI: 10.1016/j.jtcvs.2015.11.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 11/08/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
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42
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Options for arterial cannulation to provide antegrade cerebral perfusion: Everything old is new again. J Thorac Cardiovasc Surg 2016; 151:1079-80. [PMID: 26809425 DOI: 10.1016/j.jtcvs.2015.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 12/10/2015] [Indexed: 11/21/2022]
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43
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State-of-the-Art Surgical Management of Acute Type A Aortic Dissection. Can J Cardiol 2016; 32:100-9. [DOI: 10.1016/j.cjca.2015.07.736] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Revised: 07/29/2015] [Accepted: 07/29/2015] [Indexed: 01/16/2023] Open
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Berretta P, Alfonsi J, Di Bartolomeo R, Di Eusanio M. Innominate artery cannulation during aortic surgery. Multimed Man Cardiothorac Surg 2015; 2015:mmv030. [PMID: 26658194 DOI: 10.1093/mmcts/mmv030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Accepted: 09/14/2015] [Indexed: 11/14/2022]
Abstract
During aortic surgery, the cannulation of arteries preserving an antegrade flow in the thoracic aorta [ascending aorta, axillary artery, innominate artery (IA) and carotid artery] has been associated with superior survival and neurological outcomes compared with the cannulation of the femoral artery. However, the ideal site of cannulation for both cardiopulmonary bypass (CPB) and antegrade selective cerebral perfusion remains under debate. Here, we present our technique of IA cannulation for CPB and antegrade selective cerebral perfusion during surgery of the thoracic aorta.
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Affiliation(s)
- Paolo Berretta
- Department of Cardiac Surgery, G. Mazzini Hospital, Teramo, Italy
| | - Jacopo Alfonsi
- Department of Cardiac Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Roberto Di Bartolomeo
- Department of Cardiac Surgery, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Marco Di Eusanio
- Department of Cardiac Surgery, G. Mazzini Hospital, Teramo, Italy
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Preventza O, Garcia A, Cooley DA, Haywood-Watson RJ, Simpson K, Bakaeen FG, Cornwell LD, Omer S, de la Cruz KI, Price MD, Rosengart TK, LeMaire SA, Coselli JS. Total aortic arch replacement: A comparative study of zone 0 hybrid arch exclusion versus traditional open repair. J Thorac Cardiovasc Surg 2015; 150:1591-8; discussion 1598-600. [DOI: 10.1016/j.jtcvs.2015.08.117] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 08/11/2015] [Accepted: 08/22/2015] [Indexed: 10/23/2022]
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Abstract
The common carotid artery is not widely used for arterial return in cardiovascular surgery with the use of extracorporeal circulation; however, in our opinion, it is an artery that most ideally fits several criteria for cannulation use. It is easy and very fast to access, even in obese patients, and it is large and strong enough to provide a sufficient arterial return. Moreover, the risk of local injuries and wound infection is extremely low, and finally, the use of the common carotid artery for cannulation is very advantageous for cerebral perfusion in many pathologies of the aortic arch and its branches.
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47
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Di Eusanio M. Innominate artery cannulation during surgery of the thoracic aorta is simple, safe and effective. Eur J Cardiothorac Surg 2015; 48:943-4. [DOI: 10.1093/ejcts/ezu542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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