Outcomes of 3309 thoracoabdominal aortic aneurysm repairs Coselli, Joseph S., MD; LeMaire, Scott A., MD; Preventza, Ourania, MD ...
The Journal of thoracic and cardiovascular surgery,
05/2016, Letnik:
151, Številka:
5
Journal Article
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Abstract Objective Since the pioneering era of E. Stanley Crawford, our multimodal strategy for thoracoabdominal aortic aneurysm repair has evolved. We describe our approximately 3-decade ...single-practice experience regarding 3309 thoracoabdominal aortic aneurysm repairs and identify predictors of early death and other adverse postoperative outcomes. Methods We analyzed retrospective (1986-2006) and prospective data (2006-2014) obtained from patients (2043 male; median age, 67 59-73 years) who underwent 914 Crawford extent I, 1066 extent II, 660 extent III, and 669 extent IV thoracoabdominal aortic aneurysm repairs, of which 723 (21.8%) were urgent or emergency. Repairs were performed to treat degenerative aneurysm (64.2%) or aortic dissection (35.8%). The outcomes examined included operative death (ie, 30-day or in-hospital death) and permanent stroke, paraplegia, paraparesis, and renal failure necessitating dialysis, as well as adverse event, a composite of these outcomes. Results There were 249 operative deaths (7.5%). Permanent paraplegia and paraparesis occurred after 97 (2.9%) and 81 (2.4%) repairs, respectively. Of 189 patients (5.7%) with permanent renal failure, 107 died in the hospital. Permanent stroke was relatively uncommon (n = 74; 2.2%). The rate of the composite adverse event (n = 478; 14.4%) was highest after extent II repair (n = 203; 19.0%) and lowest after extent IV repair (n = 67; 10.2%; P < .0001). Estimated postoperative survival was 83.5% ± 0.7% at 1 year, 63.6% ± 0.9% at 5 years, 36.8% ± 1.0% at 10 years, and 18.3% ± 0.9% at 15 years. Conclusions Repairing thoracoabdominal aortic aneurysms poses substantial risks, particularly when the entire thoracoabdominal aorta (extent II) is replaced. Nonetheless, our data suggest that thoracoabdominal aortic aneurysm repair, when performed at an experienced center, can produce respectable outcomes.
Abstract Objective We attempted to identify predictors of adverse outcomes after traditional open and hybrid zone 0 total aortic arch replacement. Methods We performed multivariable analysis using 16 ...variables to identify predictors of adverse outcomes (mortality, permanent neurologic events, and permanent renal failure necessitating hemodialysis) in 319 consecutive patients who underwent total aortic arch replacement in the past 8.5 years and a subgroup analysis in 25 propensity-matched pairs. A total of 274 patients (85.9%) had traditional open repair, and 45 patients (14.1%) had hybrid zone 0 total arch exclusion. Results Operative mortality was 10.3% (n = 33): 11.1% (n = 5) in the hybrid group and 10.2% (n = 28) in the traditional group ( P = .79). A total of 19 patients (5.9%) had permanent stroke (15 traditional 5.5% vs 4 hybrid 8.9%; P = .32), and 2 patients (both traditional) had permanent paraplegia ( P = 1.00). The hybrid group had more total neurologic events ( P = .051) but not more permanent strokes ( P = .32). Prior cardiac disease unrelated to the aorta ( P = .0033) and congestive heart failure ( P = .0053) independently predicted permanent adverse outcome (operative mortality, permanent neurologic event, or permanent renal failure). Concomitant coronary artery bypass grafting independently predicted permanent stroke ( P = .032), as did previous cerebrovascular disease ( P = .032). In multivariable analysis, procedure type (hybrid or traditional) was not an independent predictor of stroke ( P = .09). During a median follow-up of 4.5 years (95% confidence interval, 3.9-4.9), survival was 78.7%, with no intergroup difference ( P = .14). Conclusions Among contemporary cases, both traditional and hybrid total aortic arch replacement had acceptable results. Comparing these 2 different surgical treatment options is challenging, and an individualized approach offers the best results. Permanent adverse outcome was not significantly different between the 2 groups. Procedure type is not an independent predictor of permanent stroke. Prior cardiac disease, past or current smoking, and congestive heart failure predict adverse outcomes for total aortic arch replacement.
Abstract Objective To evaluate adverse outcomes after elective aortic arch surgery performed at higher or lower temperatures (24.0°C-28.0°C vs 20.1°C-23.9°C) within the wide range of moderate ...hypothermia. Methods Over a 9-year period, a total of 665 patients underwent elective proximal (n = 479) or total (n = 186) arch replacement with moderate hypothermia and antegrade cerebral perfusion. Circulatory arrest was initiated at an actual temperature of 20.1°C to 23.9°C in the lower-temperature group (n = 334; 223 proximal, 111 total) and at 24.0°C to 28.0°C in the higher-temperature group (n = 331; 256 proximal, 75 total). Composite adverse outcome was defined as operative mortality or persistent neurologic event or persistent hemodialysis at discharge. Multivariate logistic regression analysis was used to model adverse outcome. In addition to the actual temperature, a new, balanced variable, “predicted temperature,” was analyzed to eliminate surgeon bias. We used this variable in a propensity score–matching analysis to validate the multivariate analysis results. Results A composite adverse outcome occurred in 7.2% of cases. Operative mortality was 5.1%. The rate of postoperative persistent neurologic deficits was 2.4%. No significant differences were found between the lower– and higher–predicted temperature groups within the moderate hypothermia range in the propensity score–matching analysis. The higher–actual temperature group had a lower rate of ventilator support at >48 hours ( P = .036) and less need for tracheostomy ( P = .023). Packed red blood cell transfusion and previous coronary artery bypass independently predicted composite adverse outcome ( P = .0053 and .0002, respectively), operative mortality ( P = .0051 and .0041), and postoperative stroke ( P = .045 and .048). Cardiopulmonary bypass time independently predicted composite outcome ( P = .0005), operative mortality ( P < .0001), ventilatory support for >48 hours ( P < .0001), and renal dysfunction ( P = .0005). Conclusions In elective proximal or total arch surgery, higher temperatures (≥24.0°C-28.0°C) within the wide range of moderate hypothermia (20.1°C-28°C) are safe and, compared with colder temperatures, not associated with significantly different rates of composite and adverse outcomes.
We examined our contemporary experience with hemiarch and total arch replacement in patients with previous acute type I aortic dissection.
Over an 8.5-year period, 137 consecutive patients (median ...age 58 years, interquartile range, 50 to 67) underwent hemiarch or total transverse aortic arch replacement a median of 7.7 years (range, 67 days to 32 years; interquartile range, 2.8 to 12.3 years) after previous acute type I aortic dissection repair. Interventions involving only the aortic root, aortic valve, descending aorta, or thoracoabdominal aorta were excluded. Multivariate analysis of 20 potential preoperative and intraoperative risk factors was performed to examine early death, neurologic deficit, composite endpoint (operative death, permanent neurologic deficit, or hemodialysis at discharge), and long-term mortality.
Total arch replacement was performed in 103 patients (75.2%), hemiarch replacement in 34 (24.8%), and elephant trunk procedures in 77 (56.2%). Thirty-one repairs (22.6%) were emergent or urgent. There were 16 operative deaths (11.7%), 4 permanent strokes (3.6%), and 21 (15.3%) instances of the composite endpoint. In the multivariate analysis, congestive heart failure and cardiopulmonary bypass time independently predicted operative mortality (p = 0.0027, p = 0.018). Emergency operation approached significance for stroke (p = 0.088). Predictors of long-term mortality (during a median follow-up period of 5.1 years, 95% confidence interval: 4.4 to 5.8) were female sex (p = 0.0036), congestive heart failure (p = 0.0045), and circulatory arrest time (p = 0.0013); preoperative pulmonary disease approached significance (p = 0.074). Five-year survival was 73.2%.
In patients with previous acute type I aortic dissection repair, hemiarch and total arch operations have respectable morbidity and survival rates. Congestive heart failure predicts operative death, long-term mortality, and our adverse event endpoint. Cardiopulmonary bypass time predicts operative mortality, and female sex and circulatory arrest time predict long-term mortality.
St Jude Medical Epic porcine bioprosthesis: Results of the regulatory evaluation Jamieson, W. R. Eric, MD; Lewis, Clifton T.P., MD; Sakwa, Marc P., MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
06/2011, Letnik:
141, Številka:
6
Journal Article
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Background The St Jude Medical Epic heart valve (St Jude Medical, Inc, St Paul, Minn) is a tricomposite glutaraldehyde-preserved porcine bioprosthesis. The St Jude Medical Biocor porcine ...bioprosthesis is the precursor valve to the St Jude Medical Epic valve. The Epic valve is identical to the Biocor valve except that it is treated with Linx AC ethanol-based calcium mitigation therapy. Methods The St Jude Medical Epic valve was implanted in 761 patients (mean age 73.9 ± 9.2 years) between 2003 and 2006 in the US Food and Drug Administration regulatory study in 22 investigational centers. The position distribution was 557 aortic valve replacements, 175 mitral valve replacements, and 29 double valve replacements. Concomitant coronary artery bypass grafting was performed in 50.8% of patients undergoing aortic valve replacement and 36.6% of those undergoing mitral valve replacement. Results The early mortality was 3.6% in aortic and 2.3% in mitral valve replacement. The follow-up was 1675.5 patient-years with a mean of 2.2 ± 1.2 years/patient. Late mortality was 5.2%/patient-year in aortic and 6.6%/patient-year in mitral valve replacement. The late major thromboembolism rate was 0.98%/patient-year for aortic and 2.6%/patient-year for mitral valve replacement. There were 19 reoperations, including 2 for structural valve deterioration, 1 for thrombosis, 9 for nonstructural dysfunction, and 7 for prosthetic valve endocarditis. The actuarial freedom from reoperation owing to structural valve deterioration for aortic valve replacement at 4 years for age 60 years or less was 93.3% ± 6.4%; for ages 61 to 70 years, 98.1% ± 1.9%; and for older than 70 years, 100% ( P = .0006 > 70 vs ≤ 60 years). There were no events of structural deterioration with mitral valve replacement. The actuarial freedom from major thromboembolism for all patients at 4 years was 93.6% ± 1.0%. The 2 cases of structural valve deterioration occurred in aortic valves that became perforated without calcification causing aortic regurgitation. Conclusions The performance of the St Jude Medical Epic porcine bioprosthesis is satisfactory at 4 years for both aortic and mitral valve replacement. This study establishes the early clinical performance including durability of this porcine bioprosthesis.
Antegrade cerebral perfusion (ACP) is standard treatment for complex aortic pathology and includes both unilateral (u-ACP) and bilateral (b-ACP) techniques. Focusing on proximal acute aortic ...dissection, we investigated the clinical effect of u-ACP versus b-ACP.
From January 2005 to May 2013, 157 consecutive patients presented with acute type A aortic dissection. Antegrade cerebral perfusion was used in 153 patients (97.4%). Ninety patients (58.8%) received u-ACP, and 63 (41.2%) received b-ACP. No retrograde cerebral perfusion was used. The target systemic hypothermia temperature during ACP was 22° to 24°C. The mean ACP, cardiopulmonary bypass, and cardiac ischemia times were 34.6 ± 18.0, 125.6 ± 48.0, and 92.6 ± 34.1 minutes, respectively.
The p values from logistic regression models indicated that in both groups combined, the ACP, cardiopulmonary bypass, and cardiac ischemia times predicted hospital mortality (p = 0.035, p = 0.0033, and p = 0.035, respectively) but not stroke. The operative mortality was 13.3% (n = 12) with u-ACP and 12.7% (n = 8) with b-ACP (p = 0.91). Of the survivors, 13 of 88 u-ACP patients (14.8%) and 8 of 62 b-ACP patients (12.9%) had a postoperative stroke (p = 0.75). A circulatory arrest time of >30 minutes was associated with stroke (p = 0.031). Temporary neurologic dysfunction was present in 10 u-ACP (11.4%) and 5 b-ACP (8.2%) patients (p = 0.53). Postoperative renal failure occurred in 10 u-ACP (11.4%) and 10 b-ACP patients (16.1%) (p = 0.40). Antegrade stent delivery in the descending thoracic aorta did not affect the ACP, cardiac ischemia, circulatory arrest, or cardiopulmonary bypass times.
As one of the largest single-center studies of the efficacy of u-ACP and b-ACP in patients with type A aortic dissection, operative mortality, stroke, temporary neurologic dysfunction, and renal failure rates were similar in both. In this intrinsically complex disease, survival is the most important outcome; u-ACP may provide cardiac surgeons with valuable technical simplicity during challenging procedures, and b-ACP may be justified for circulatory arrest times of more than 30 minutes.
Objective We compared the short-term outcomes between patients who had undergone classic repair for type I aortic dissection and those who had undergone concomitant antegrade stenting in the ...descending thoracic aorta. Methods From January 2005 to December 2012, 112 patients were treated for acute type I aortic dissection. Eighty-seven patients (group A) underwent traditional operations on the ascending and proximal arch (n = 79, 90.8%), total arch (n = 7, 8.1%), or ascending aorta (n = 1, 1.2%). Twenty-five patients (group B) underwent ascending and proximal arch repair and antegrade stent grafting in the descending thoracic aorta. Various concomitant procedures were performed in both groups. The circulatory arrest times were similar between the 2 groups. Results The 30-day mortality was 13.8% (n = 12) in group A and 12% (n = 3) in group B. Nine patients in group A (10.3%) and 3 in group B (12%) experienced a postoperative stroke. In group A, 1 patients (1.5%) developed transient spinal cord ischemia, and in group B, 2 patients had transient paraparesis (8.0%). Preoperatively, 24 group A patients and 19 group B patients had malperfusion; this condition resolved postoperatively in 13 group A patients (54.2%) and 16 group B patients (84.2%; P < .037). Eight group A patients (10.8%) and 1 group B patient (4.5%) underwent additional postoperative procedures on the thoracoabdominal aorta a median of 776.5 days (range, 168.5-1102.0) and 54 days postoperatively, respectively. Conclusions Antegrade endovascular grafting of the descending thoracic aorta during repair of acute type I aortic dissection is technically safe, does not increase the circulatory arrest time, and could help patients with preoperative malperfusion. Long-term follow-up data are needed.
Objectives We examined the early and midterm outcomes of homograft use in reoperative aortic root and proximal aortic surgery for endocarditis and estimated the associated risk of postoperative ...reinfection. Methods From January 2001 to January 2014, 355 consecutive patients underwent reoperation of the proximal thoracic aorta. Thirty-nine patients (10.9%; mean age, 55.4 ± 13.3 years) presented with active endocarditis; 30 (76.9%) had prosthetic aortic root infection with or without concomitant ascending and arch graft infection, and 9 (23.1%) had proximal ascending aortic graft infection with or without aortic valve involvement. Sixteen patients (41.0%) had genetically triggered thoracic aortic disease. Twelve patients (30.8%) had more than 1 prior sternotomy (mean, 2.4 ± 0.6). Results Valved homografts were used to replace the aortic root in 29 patients (74.4%); nonvalved homografts were used to replace the ascending aorta in 10 patients (25.6%). Twenty-five patients (64.1%) required concomitant proximal arch replacement with a homograft, and 2 patients (5.1%) required a total arch homograft. Median cardiopulmonary bypass, cardiac ischemia, and circulatory arrest times were 186 (137-253) minutes, 113 (59-151) minutes, and 28 (16-81) minutes. Operative mortality was 10.3% (n = 4). The rate of permanent stroke was 2.6% (n = 1); 3 additional patients had transient neurologic events. One patient (1/35, 2.9%) returned with aortic valve stenosis 10 years after the homograft operation. During the follow-up period (median, 2.5 years; range, 1 month to 12.3 years), no reinfection was reported, and survival was 65.7%. Conclusions This is one of the largest North American single-center series of homograft use in reoperations on the proximal thoracic aorta to treat active endocarditis. In this high-risk population, homograft tissue can be used with acceptable early and midterm survival and a low risk of reinfection. When necessary, homograft tissue may be extended into the distal ascending and transverse aortic arch, with excellent results. These patients require long-term surveillance for both infection and implant durability.
Dosing of recombinant activated factor VII (rFVIIa) is controversial and unstandardized, and there is growing concern about thromboembolic complications, especially in left ventricular assist device ...(LVAD)-supported patients. We reviewed our experience with rFVIIa administration in patients with LVADs and examined its effectiveness and adverse effects, including the incidence of thromboembolic events and its correlation with increasing doses.
We retrospectively reviewed the records of 62 patients who received an LVAD and rFVIIa at our center between January 2004 and November 2006. Patients who received a single dose of 10 to 20 microg/kg (n = 32; 52%) constituted the "low-dose" cohort, and patients who received 30 to 70 microg/kg (n = 30; 48%) constituted the "high-dose" cohort. Laboratory values obtained before and after rFVIIa administration, as well as patients' transfusion requirements, were compared to determine the effectiveness of rFVIIa in reversing coagulopathy and reducing blood loss. We also compared the incidence of thromboembolic events in the low- and high-dose groups.
Administration of rFVIIa was associated with significant decreases in prothrombin time, activated partial thromboplastin time and transfusion requirements. This association was seen in both the low- and high-dose groups. In addition, the incidence of thromboembolic events was significantly higher in the high-dose group (36.7%) than in the low-dose group (9.4%) (p < or = 0.001).
Although rFVIIa administration seemed helpful in controlling life-threatening hemorrhage, patients requiring higher doses (30 to 70 microg/kg) had a dramatically higher incidence of serious thromboembolic events.
We attempted to determine the true incidence of retrograde ascending aortic dissection (rAAD) and to challenge its reported association with distal aortic dissection or zone 0 deployment.
From ...January 2005 to August 2014, 305 patients who were at risk for rAAD underwent thoracic endovascular aortic repair. We excluded patients with prior ascending, hemiarch, or traditional or frozen elephant trunk grafts, or who required concomitant ascending graft placement. Patients in group A (n = 111, 36.4%) had distal aortic dissection or hematoma (n = 75, 67.6%) or required landing of the endograft in zone 0 of the native ascending aorta (n = 36, 32.4%). Patients in group B (n = 194, 63.6%) had nondissected descending or distal arch aneurysm (n = 172), penetrating ulcer (n = 9), coarctation (n = 6), endoleak not caused by dissection (n = 3), aortobronchial fistula (n = 3), or transection (n = 1).
The incidence of rAAD was 1.3% overall (n = 4), 0.9% in group A (n = 1, Cook Zenith TX2), and 1.5% in group B (n = 3; 1 Talent Captivia, 2 Cook Zenith TX2; p = 0.64). No zone 0-treated patient had rAAD. Two patients from group B died, and 1 was treated nonoperatively. The median interval between thoracic endovascular aortic repair and rAAD was 11 days (range, 0 to 90 days).
Post-thoracic endovascular aortic repair rAAD is a rare but lethal complication. Operator experience is crucial for prompt recognition and prevention. It does not appear that rAAD is specifically associated with distal aortic dissection or landing in zone 0. To our knowledge, this is one of the few studies to report the true incidence of rAAD in at-risk patients.
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