Aortic Arch Surgery Research Articles

Clinical outcomes of mild versus moderate hypothermic circulatory arrest with antegrade cerebral perfusion in adult aortic arch surgery: A systematic review and meta-analysis.

In adult aortic arch surgery, moderate hypothermic circulatory arrest (HCA) with selective antegrade cerebral perfusion (SACP) (MoHACP) is widely used, but the application of mild HCA with SACP (MiHACP) is still controversial. This meta-analysis aimed to compare clinical outcomes using MiHACP or MoHACP. Studies comparing outcomes of MiHACP or MoHACP in adult aortic arch surgery were searched from four databases from inception through April 2022. Primary outcomes were postoperative permanent neurological deficit (PND), temporary neurological deficit (TND), and mortality. Secondary outcomes included other common complications. Meta-analysis was conducted using a random-effects model in all cases. Eleven comparative studies were included, with 1555 patients in MiHACP group and 1499 patients in MoHACP group, and the mean HCA temperature were 29.4°C and 24.8°C, respectively. Postoperative PND, TND, mortality, paraplegia, dialysis, tracheotomy, reexploration for bleeding, and chest tube drainage volume were comparable in the two groups (p > 0.05). Ventilator time, intensive care unit and in-hospital length of stay were shorter in MiHACP group (p < 0.05). Outcomes were also comparable or had some benefits in MiHACP group when subgroup analyses were conducted according to hemiarch or total arch replacement, unilateral or bilateral SACP, HCA time, emergency aortic dissection surgery, and concomitant procedure. The present meta-analysis showed acceptability of MiHACP in adult aortic arch surgery. Results need to be taken with caution as moderate risk of bias and very low quality of evidence were observed in this meta-analysis. Randomized controlled trials are needed for further analysis.

Bilateral Axillary Artery Perfusion for Aortic Arch Surgery: Worth the Effort?

Bilateral Axillary Artery Perfusion for Aortic Arch Surgery: Worth the Effort?

Arch vessels' switch in frozen elephant trunk: a new technique to facilitate the second-stage endovascular thoraco-abdominal aorta repair.

In patients with extensive thoraco-abdominal aortic disease, staged hybrid repair involving open total aortic arch replacement and endovascular thoraco-abdominal aorta repair with branched stent graft has emerged as a valuable treatment option. However, total arch replacement with the available branched vascular grafts often results in acute angulation between the reimplanted vessels and the aortic arch hampering antegrade catheterization of the thoraco-abdominal aorta during the second endovascular stage. Here, we present our 'switch technique' for arch vessels' reimplantation to facilitate antegrade aortic catheterization of the thoraco-abdominal aorta and visceral vessels.

Total aortic arch repair between endo and hybrid-the Nexus single-branched endograft.

Minimally invasive zone 0 arch procedures have experienced a great evolution from the total zone 0 debranching techniques towards the total endovascular aortic arch procedures in the last decade. This evolution followed the aim of improved perioperative outcomes for patients with substantial comorbidities, who are not candidates for open aortic arch repair. Nowadays, branched endografts are the main endovascular alternative to the frozen elephant trunk technique. In the case of anatomical suitability, branched endovascular repair of the aortic arch offers an excellent treatment option for patients with severe risk profiles for open surgery [1]. The repair is predominantly based on the custom-made inner branch platforms, with 2 or 3 tunnels located in the main graft, which allow for a safe overlap with the bridging stent grafts to the supra-aortic vessels [2]. From the technical point of view, the Nexus single-branched endograft is different. It is bimodular and consists of a branched arch and an anatomically preshaped ascending aorta module. The branch to the brachiocephalic trunk (BCT) is located at the proximal end of the arch module and allows for precise deployment of the BCT branch from the bifurcation to the BCT origin prior to the complete deployment of the aortic arch and descending aorta portion. The implantation is accomplished by the deployment of the ascending module, which lands distally with its locking latches into the docking sleeve of the arch module.

Optimal temperature management in aortic arch surgery: A systematic review and network meta-analysis.

New temperature management concepts of moderate and mild hypothermic circulatory arrest during aortic arch surgery have gained weight over profound cooling. Comparisons of all temperature levels have rarely been performed. We performed direct and indirect comparisons of deep hypothermic circulatory arrest (DHCA) (≤20°C), moderate hypothermic circulatory arrest (MHCA) (20.1-25°C), and mild hypothermic circulatory arrest (mild HCA) (≥25.1°C) in a network meta-analysis. The literature was systematically searched for all papers published through February 2022 reporting on clinical outcomes after aortic arch surgery utilizing DHCA, MHCA and mild HCA. The primary outcome was operative mortality. The secondary outcomes were postoperative stroke and acute kidney failure (AKI). A total of 34 studies were included, with a total of 12,370 patients. DHCA was associated with significantly higher postoperative incidence of stroke when compared with MHCA (odds ratio [OR], 1.46, 95% confidence interval[CI], 1.19-1.78) and mild HCA: (OR, 1.50, 95% CI, 1.14-1.98). Furthermore, DHCA and MHCA were associated with higher operative mortality when compared with mild HCA (OR 1.71, 95% CI, 1.23-2.39 and OR 1.50, 95% CI, 1.12-2.00, respectively). Separate analysis of randomized and propensity score matched studies showed sustained increased risk of stroke with DHCA in contrast to MHCA and mild HCA (OR, 1.61, 95% CI, 1.18-2.20, pvalue = .0029 and OR, 1.74, 95% CI, 1.09-2.77, pvalue = .019). In the included studies, the moderate to mild hypothermia strategies were associated with decreased operative mortality and the risk of postoperative stroke. Large-scale prospective studies are warranted to further explore appropriate temperature management for the treatment of aortic arch pathologies.

Abstract 9865: Acute Infarcts on Brain MRI Following Aortic Arch Repair With Circulatory Arrest: Insights From the ACE Cardiolink-3 Randomized Trial

Introduction: Our objective was to investigate the frequency and distribution of new ischemic brain lesions detected by diffusion-weighted imaging (DWI) on brain MRI after aortic arch surgery. Methods: This was an imaging sub-analysis of the ACE CardioLink-3 randomized controlled trial which compared the safety and efficacy of innominate vs axillary artery cannulation during elective proximal aortic arch surgery. All participants in the trial underwent pre- and post-operative MRI. New ischemic lesions were defined as lesions on post-operative DWI that were not visible on the pre-operative DWI. Results: Of 102 patients who underwent surgery, 71 (70%) had new ischemic lesions on DWI and the total lesion number across all participants was 391. The average lesion number in patients with at least one ischemic lesion was 5.5±4.9, and were similar in the right (3.3±2.7) or left (3.6±2.8) hemispheres (p=0.49). The most common lesion patterns were single or multiple cortical infarcts. Half of the lesions (n=183, 47%) were in the middle cerebral artery territory, while 24% were in the infratentorium. 42% of patients had lesions distributed in both anterior and posterior circulation, 21% in anterior circulation only, and 7% in posterior circulation only. Besides, 20% had lesions in watershed areas. There were no differences in distribution between patients in the innominate vs axillary artery cannulation groups. In multivariable regression models, more severe white matter hyperintensity on pre-operative MRI (odds ratio per 1-score increase of Fazekas scale 1.80; p=0.02) and lower nadir temperature during operation (odds ratio per 1°C decrease, 1.14; p=0.05) were associated with having any new ischemic lesion, while older age (risk ratio per 1-year increase 1.02; p=0.03) and lower nadir temperature (risk ratio per 1°C decrease, 1.06; p=0.06) were associated with higher lesion numbers. Conclusion: In patients who underwent elective proximal aortic arch surgery, new ischemic brain lesions were common, and mostly identified as scattered cortical infarcts in the middle cerebral artery territory. Advanced age, underlying small vessel disease, and lower nadir temperature during operation were risk factors of presence and burden of new ischemic lesions after surgery.

Acute Infarcts on Brain MRI Following Aortic Arch Repair With Circulatory Arrest: Insights From the ACE CardioLink-3 Randomized Trial.

to investigate the frequency and distribution of new ischemic brain lesions detected by diffusion-weighted imaging on brain magnetic resonance imaging after aortic arch surgery. This preplanned secondary analysis of the randomized, controlled ACE (Aortic Surgery Cerebral Protection Evaluation) CardioLink-3 trial compared the safety and efficacy of innominate versus axillary artery cannulation during elective proximal aortic arch surgery. Participants underwent pre and postoperative magnetic resonance imaging. New ischemic lesions were defined as lesions visible on postoperative, but not preoperative diffusion weighted imaging. Of the 111 trial participants, 102 had complete magnetic resonance imaging data. A total of 391 new ischemic lesions were observed on diffusion-weighted imaging in 71 (70%) patients. The average number of lesions in patients with ischemic lesion were 5.5±4.9 with comparable numbers in the right (2.9±2.0) and left (3.0±2.3) hemispheres (P=0.49). Half the new lesions were in the middle cerebral artery territory; 63% of the cohort had ischemic lesions in the anterior circulation, 49% in the posterior circulation, 42% in both, and 20% in watershed areas. A probability mask of all diffusion-weighted imaging lesions revealed that the cerebellum was commonly involved. More severe white matter hyperintensity on preoperative magnetic resonance imaging (odds ratio, 1.80 [95% CI, 1.10-2.95]; P=0.02) and lower nadir nasopharyngeal temperature during surgery (odds ratio per 1°C decrease, 1.15 [95% CI, 1.00-1.32]; P=0.05) were associated with the presentation of new ischemic lesion; older age (risk ratio per 1-year increase, 1.02 [95% CI, 1.00-1.04]; P=0.03) and lower nadir temperature (risk ratio per 1°C decrease, 1.06 [95% CI, 1.00-1.14]; P=0.06) were associated with greater number of lesions. In patients who underwent elective proximal aortic arch surgery, new ischemic brain lesions were common, and predominantly involved the middle cerebral artery territory or cerebellum. Underlying small vessel disease, lower temperature nadir during surgery, and advanced age were risk factors for perioperative ischemic lesions. URL: https://www. gov; Unique identifier: NCT02554032.

Protocol for Guo’s aortIc Arch recoNstrucTion: a prospective, multicentre and single-arm study to evaluate the safety and efficacy of the WeFlow-Arch modular inner branch stent-graft system for aortic arch lesions (GIANT study)

IntroductionEndovascular repair of the entire aortic arch provides treatment opportunities for patients with aortic arch lesions who are intolerant to open surgery. However, the complex anatomical configuration, high-speed blood flow...

Impact of hyperbilirubinemia associated acute kidney injury on chronic kidney disease after aortic arch surgery: a retrospective study with follow-up of 1-year

BackgroundHyperbilirubinemia (HB) is a serious complication in aortic arch surgery, which is associated with acute kidney injury (AKI). The association between HB and chronic kidney disease (CKD) is unknown. The aim of this study was to investigate the impact of HB associated AKI on CKD after aortic arch surgery.MethodsWe reviewed 284 patients who underwent aortic arch surgery from 2016 to 2020 in our hospital. AKI was defined as a 50% increase in sCr from baseline value within the first 7 postoperative days. HB was defined as total bilirubin > 51.3 μmol/L. Patients were divided into 3 groups based on AKI and HB: HB associated AKI (HB-AKI) group (AKI patients suffered HB within the first 7 postoperative days); AKI without HB group and Non-AKI group.ResultsFollow-up for 204 patients ranged from 3 to 12 months. Kaplan–Meier analysis showed that the 1-year cumulative incidence of CKD was highest in HB-AKI (32.6%) than AKI without HB (17.8%) and Non-AKI (7.4%, log-rank test, p < 0.001), and the incidence of CKD was higher in HB group than that in Non-HB group (26.7% vs. 13.9%, log-rank test, p = 0.015). Preoperative sCr (HR 1.010, 95% CI 1.004–1.016, p = 0.001), AKI without HB (HR 2.887, 95% CI 1.133–7.354, p = 0.026) and HB-AKI (HR 4.490, 95% CI 1.59–12.933, p = 0.005) were associated with CKD during 1-year follow-up.ConclusionsPatients suffering HB associated AKI were at more increased odds of CKD than patients suffering AKI without HB after aortic arch surgery.

Safety and efficacy of fibrinogen concentrate in aortic arch surgery involving moderate hypothermic circulatory arrest.

Bleeding is a common complication of cardiac surgery, especially aortic arch surgery involving moderate hypothermic circulatory arrest. Fibrinogen concentrate has been increasingly used to treat coagulopathic bleeding in cardiac surgery, although its effectiveness and safety are unknown. The aim of this prospective study was to investigate the safety and efficacy of fibrinogen concentrate in patients with acute type A aortic dissection. From July 2020 to August 2021, 84 patients with acute type A aortic dissection who underwent emergency aortic arch surgery involving MHCA and whose intraoperative fibrinogen level was less than 1.5g/L were included in this study. Fifty-four patients who were supplemented with fibrinogen concentrate were included in the FC treatment group. Thirty patients were included in the non-FC treatment group. The primary endpoints included the required volumes of individual allogeneic blood products (RBCs, FFP, and PC), volumes of cumulative drainage within 24 and 48h, and total volumes after infusion of FC, as well as reoperation rates due to bleeding. The secondary endpoint for the study was the incidence of serious adverse events from the infusion of FC to day 45. The serious adverse events defined for the evaluation of the safety of FC were death, pulmonary embolism and other thromboembolic or ischaemic events. The clinical data, routine laboratory tests and plasma fibrinogen levels were obtained at 5 time points. We observed rapid increases in the plasma fibrinogen level and subsequent improvement in haemostasis after the administration of fibrinogen concentrate. The mean fibrinogen level increased from 1.36 ± 0.75g/L to 2.91 ± 0.76g/L in the fibrinogen concentrate treatment group. The patients in the fibrinogen concentrate treatment group demonstrated lower volumes of cumulative postoperative drainage and transfused allogeneic blood products than the nonfibrinogen concentrate treatment group. There were no serious adverse events in the fibrinogen concentrate treatment group during hospitalization. Fibrinogen concentrate was effective at increasing the plasma fibrinogen level and significantly reduced the volumes of transfused allogeneic blood products and blood loss in patients with aortic arch surgery. There were no serious adverse events in the patients who received fibrinogen concentrate treatment. The safety and efficacy of fibrinogen concentrate were investigated in acute type A aortic dissection patients with aortic arch surgery. Fibrinogen concentrate was effective at increasing the plasma fibrinogen level and significantly reduced the volumes of transfused allogeneic blood products and blood loss; there were no serious adverse events in the patients who received fibrinogen concentrate treatment.

From the RELAY Family—A Story of Single-Branched International Outcomes

Advances in surgery over the last few decades has led to the development and widespread utilization of thoracic endovascular aortic repair (TEVAR). TEVAR, due to its minimally invasive nature and potential superior outcomes, is now becoming a key focus of interest in treating pathologies of the aortic arch, which has traditionally been treated with open surgical repair. We present our findings of our international multicentre dataset documenting the efficacy of the single-branched RELAY™ endograft in terms of technical success, postoperative outcomes, and reintervention rates. Prospective data were collected and retrospectively analyzed with descriptive and distributive analysis between January 2019 and January 2022 from 17 patients treated with RELAY single-branched endoprostheses from centers across Europe. Follow-up data from 30days and 6 months, 12 months, and 24months postoperatively was included. Patient follow-up was evaluated in terms of postoperative outcomes, target vessel patency, and reintervention rates. Technical success was achieved in all 17 patients (100%) and there were no postoperative disabling or nondisabling strokes in our single-branched RELAY cohort. The target vessel patency remained 100% during the first 30days postoperatively; however, by the end of the follow-up period (24months), target vessel patency was achieved in 93.7% of the patients. There were no reinterventions or deaths during the full study duration using the single-branched RELAY stent-graft. These results with the single-branched RELAY stent graft demonstrate favorable outcomes in comparison to the literature and demonstrate the feasibility of treatment of aortic pathology with this single-branched graft in the future. Further studies with larger patient cohorts will help us to accumulate evidence for the feasibility of the single-branched RELAY stent graft for aortic arch surgery in the future.

Postoperative Dynamic of Leptin and Fibroblast Growth Factor 21 in 123 Patients Recovering from Cardiac Surgery

BackgroundCardiac surgery triggers acute changes in serum leptin and fibroblast growth factor 21 (FGF-21). Considering their pleiotropic role in inflammation and abnormal glucose metabolism, perseverance of their abnormal serum level can have a long-term impact on recovery and end-organ failures. Long-term dynamics after cardiac surgery are unknown.Material/MethodsSerum was collected from 123 patients before cardiac surgery (tbaseline) and 24 h (t24h), 7 days (t7d), and 3 months (t3m) later. Also, interleukin 6 (IL-6) and C-reactive protein (CRP) assessed nonspecific inflammatory responses. Neurodegeneration was gauged with serum amyloid β1–40 and β1–42. Demographic and clinical information, including disposition at 28 days and t3m from admission, were collected.ResultsSerum leptin increased at t24h (leptinbaseline=613±747.9 vs leptin24h=768±718.1; P=0.0083) and decreased at t7d (leptin7d=499.5±540.2; P=0.043). FGF-21 levels increased at t24h and t7d. Cytokines normalized by t3m. Presurgical leptin levels were higher in Asians and were the primary determinant of postoperative leptin changes. Leptin levels were most elevated in patients undergoing aortic valve and arch surgery; the perioperative increase was significant only in patients with mitral valve surgery. Leptin and FGF-21 did not correlate with markers of general inflammation (CRP, IL-6), which partially resolved after t3m. Amyloid β1–42 at t3m correlated with leptin peak at t24h. Low prehospital FGF-21 level correlated with the incidence of perioperative stroke; postoperative FGF-21 correlated with discharge to facility vs home.Conclusions: Leptin and FGF-21 evolve independently from the inflammatory response in the aftermath of cardiac surgery and correlate with cardiac remodeling and neurodegeneration markers.

Post-Operative Kidney Function Using Deep Hypothermic Circulatory Arrest (DHCA) in Aortic Arch Operation.

BackgroundAlthough deep hypothermic circulatory arrest (DHCA) is a useful option to protect the central nervous system during aortic arch operations, the influence of simultaneous renal ischemia remains controversial.Patients and MethodsThis is a retrospective observational study. Sixty-three patients who underwent thoracic aortic surgery with DHCA and 24 patients who underwent cardiac surgery without DHCA were included in this study. The mean age, preoperative serum creatinine (Cr) level, preoperative estimated glomerular filtration rate (eGFR), peak serum Cr level up to 48 hrs post-operative, elevation rate of Cr compared to the preoperative serum Cr, urine volume rate up to 48 hrs post-operative and AKI staging using the KDIGO criteria were estimated for each patient. Clinical parameters for 3 months after the operation and the 3-month post-operative mortality rate were assessed. Mean values indicating kidney function or distribution of the AKI stages were compared between patients with and without DHCA. Patients with DHCA were further divided according to the duration of ischemia to compare the values for the kidney function of each group, distribution of AKI stages and mortality.ResultsThe parameters indicating AKI of the patients with DHCA were significantly more severe than those without DHCA. Patients who had undergone an ischemic state for more than 40 min revealed significantly higher peak serum Cr, elevation rate of serum Cr, less urine volume up to 48 hrs post-operative compared with those without DHCA. Distribution of the AKI stages was related to the duration of ischemia. The 3-month post-operative mortality of the patients with DHCA was significantly higher than those without DHCA.LimitationsThis study had limitations such as its retrospective design and small number patients, and the data will be required confirmation with other prospective studies.ConclusionDHCA is closely related to AKI up to 48 hrs post-operative and death during the 3 months following surgery.

2021 MiECTiS focused update on the 2016 position paper for the use of minimal invasive extracorporeal circulation in cardiac surgery.

The landmark 2016 Minimal Invasive Extracorporeal Technologies International Society (MiECTiS) position paper promoted the creation of a common language between cardiac surgeons, anesthesiologists and perfusionists which led to the development of a stable framework that paved the way for the advancement of minimal invasive perfusion and related technologies. The current expert consensus document offers an update in areas for which new evidence has emerged. In the light of published literature, modular minimal invasive extracorporeal circulation (MiECC) has been established as a safe and effective perfusion technique that increases biocompatibility and ultimately ensures perfusion safety in all adult cardiac surgical procedures, including re-operations, aortic arch and emergency surgery. Moreover, it was recognized that incorporation of MiECC strategies advances minimal invasive cardiac surgery (MICS) by combining reduced surgical trauma with minimal physiologic derangements. Minimal Invasive Extracorporeal Technologies International Society considers MiECC as a physiologically-based multidisciplinary strategy for performing cardiac surgery that is associated with significant evidence-based clinical benefit that has accrued over the years. Widespread adoption of this technology is thus strongly advocated to obtain additional healthcare benefit while advancing patient care.

Perioperative Management of an Adolescent Fontan Patient with Narrowing of the Aortopulmonary Space for Posterior Scoliosis Surgery

Congenital cardiac patients who received neonatal reconstructive aortic arch surgery are at risk of aortopulmonary space narrowing with compression of the left pulmonary artery and left main bronchus (LMB) later in life. We discuss a challenging adolescent single ventricle patient who presented for surgical treatment of a non-idiopathic thoracic scoliosis (posterior spinal fusion) with severe stenosis of the LMB and left pulmonary artery due to a narrow aortopulmonary space. Careful preoperative imaging, evaluation, and decision making resulted in successful surgical treatment and uneventful perioperative course.

Elective aortic arch surgery: cerebral perfusion flows and transient neurological dysfunctions.

Selective antegrade cerebral perfusion technique is a method of cerebral protection used worldwide during aortic arch surgery. This study was designed to identify a potential correlation between perfusion flows and the development of postoperative transient neurological dysfunctions. From January 2015 to May 2020, 175 patients underwent elective surgical replacement of the aortic arch using selective antegrade cerebral perfusion at the Cardiac Surgery Unit of Sant'Orsola Hospital in Bologna. Considering that patients who developed a permanent neurological dysfunction and those who died before a possible evaluation of neurological status were excluded, the study population included 160 patients. The perfusion flows were collected and analyzed. Univariate and multivariate analyses were performed to identify the statistical risk factors involved in the onset of transient neurological dysfunctions. The study population was divided into two groups: 138 patients (86.3%) without and 22 (13.8%) with postoperative transient neurological complications. Among the intra-operative parameters collected in the study, the univariate analysis showed that the indexed medium perfusion flow of selective antegrade cerebral perfusion was significantly lower in the transient neurological dysfunctions group (11.63 ± 2.41 ml/kg/min vs 12.62 ± 2.39 ml/kg/min, P -value = 0.03). The multivariate logistic regression analysis showed that the female gender ( P = 0.004, OR = 4.816, IC = 1.636-14.174) was predictor of transient neurological dysfunctions. The results of the study showed that lower perfusion flows seem to be related to a higher probability of developing transient neurological dysfunctions. However, the analysis of a wider population is required to confirm these preliminary data.

Outcomes of emergency surgery for acute type A aortic dissection complicated by malperfusion syndrome

ObjectiveThe study objective was to determine the impact of malperfusion syndrome on in-hospital mortality and midterm survival after emergency aortic arch reconstruction for acute type A aortic dissection. MethodsThis was an observational study of aortic surgeries from 2010 to 2018. All patients with acute type A aortic dissection undergoing open aortic arch reconstruction were included. Patients were dichotomized by the presence or absence of malperfusion syndrome and were analyzed for differences in short-term postoperative outcomes, including morbidity and in-hospital mortality. Kaplan–Meier survival estimation and multivariable Cox analysis were performed to identify variables associated with survival. ResultsA total of 467 patients undergoing aortic arch reconstruction for acute type A aortic dissection were identified, of whom 332 (71.1%) presented without malperfusion syndrome and 135 (28.9%) presented with malperfusion syndrome. Patients with malperfusion syndrome had higher in-hospital mortality (21.5% vs 5.7%) than patients without malperfusion syndrome. After multivariable adjustment, malperfusion syndrome was associated with worse survival (hazard ratio, 2.43, 95% confidence interval, 1.61-3.66, P < .001) compared with patients without malperfusion syndrome. The predicted risk of mortality increased as the number of malperfused vascular beds increased. Patients with coronary malperfusion syndrome and neuro-malperfusion syndrome had reduced survival compared with the rest of the cohort (P < .05). ConclusionsMalperfusion syndrome is associated with higher in-hospital mortality and reduced survival for patients with acute type A aortic dissection, with the risk of mortality increasing as the number of malperfused vascular beds increases. Coronary malperfusion syndrome and neuro-malperfusion syndrome may represent a high-risk subgroup of patients presenting with acute type A aortic dissection complicated by malperfusion syndrome. Finally, malperfusion syndrome may benefit from immediate surgical intervention to restore true lumen perfusion, as opposed to operative delay.

The 10 Commandments of Open Aortic Arch Repair

The 10 Commandments of Open Aortic Arch Repair

Intravenous landiolol for the prevention of atrial fibrillation after aortic root, ascending aorta, and aortic arch surgery: A propensity score-matched analysis

ObjectivePostoperative atrial fibrillation (POAF) after cardiac surgery is associated with increased mortality. The efficacy of landiolol hydrochloride for POAF prevention after coronary artery bypass grafting procedure and valve surgery has been reported. However, little evidence is available on its role in POAF prevention after aortic root, ascending aorta, and aortic arch surgery. This study aimed to determine the association between intravenous landiolol and the incidence of POAF after these aortic surgeries. MethodsWe included 358 consecutive adult patients without preoperative atrial fibrillation who underwent aortic root, ascending aorta, and aortic arch surgery between January 1, 2011, and December 31, 2018, at our institution. The therapeutic influence of landiolol in preventing POAF was estimated by propensity score-matched analysis (n = 222). The primary end point was the incidence of POAF within 72 hours after surgery. The secondary end points included adverse clinical events such as 30-day mortality and symptomatic cerebral infarction. ResultsThe median age of the cohort was 72 years, 68.5% were men, and 46.4% received postoperative oral or transdermal β-blockers. After minimizing differences in patient background by propensity score matching, the incidence of POAF in the landiolol group was significantly lower than that in the reference group (18.9% vs 38.7%; P = .002). Landiolol use was associated with reduced incidence of POAF (odds ratio, 0.39; 95% CI, 0.21 to −0.72; P = .003). There were no significant differences in secondary end points. ConclusionsIntravenous landiolol was associated with a lower incidence of POAF after aortic root, ascending aorta, and aortic arch surgery.

Risk factors for impaired neurological outcome after thoracic aortic surgery.

BackgroundWe aimed to identify risk factors for an impaired postoperative neurological outcome after thoracic aortic surgery.MethodsData from all patients undergoing thoracic aortic surgery between 2010 and 2020 at our institution were collected and analyzed retrospectively. Logistic regression analysis was used to identify independent risk factors for permanent postoperative neurological deficit (ND) (stroke), which was defined as a ND lasting at least seven days.ResultsThoracic aortic surgery was performed in 1,334 patients. Of these, 286 (21.4%) underwent emergency surgery. The mean EuroSCORE II was 8.6±10.1. A perioperative stroke occurred in 94 patients (7.0%). Of all strokes, 62.8% (n=59) were considered of embolic and 24.5% (n=23) of hemodynamic origin. In elective procedures, stroke rates ranged from 0.5% after valve-sparing root replacement to 8.1% after arch surgery. Adjusted logistic regression identified advanced age [>70 years; odds ratio (OR), 1.83; P=0.009], acute type A dissection (ATAD) (OR, 1.69; P=0.0495), aortic arch surgery (OR, 3.24; P<0.001), concomitant coronary artery bypass grafting (CABG) (OR, 2.19; P=0.005), and high extracorporeal circulation (ECC) time (>230 min; OR, 1.70; P=0.034) as independent risk factors for all strokes. Secondary endpoint analyses revealed that risk factors for hemodynamic stroke were arch surgery, advanced age (>70 years), atherosclerosis, and ATAD. Risk factors for embolic stroke were arch surgery, concomitant CABG and preoperative cerebral malperfusion.ConclusionsIdentified independent risk factors for all strokes were advanced age, ATAD, arch surgery, concomitant CABG, and high ECC time. Hemodynamic and embolic strokes show distinct risk profiles.