Arch Surgery Research Articles

OPEN ARCH: A model of integration for the older person with complex needs

The International Journal of Integrated Care (IJIC) is an online, open-access, peer-reviewed scientific journal that publishes original articles in the field of integrated care on a continuous basis.IJIC has an Impact Factor of 5.120 (2020 JCR, received in June 2021)The IJIC 20th Anniversary Issue was published in 2021.

Does deeper hypothermia reduce the risk of acute kidney injury after circulatory arrest for aortic arch surgery?

The impact of hypothermic circulatory arrest (HCA) temperature on postoperative acute kidney injury (AKI) has not been evaluated. This study examined the association between circulatory arrest temperatures and AKI in patients undergoing proximal aortic surgery with HCA. A total of 759 consecutive patients who underwent proximal aortic surgery (ascending ± valve ± root) including arch replacement requiring HCA between July 2005 and December 2016 were identified from a prospectively maintained institutional aortic surgery database. The primary outcome was AKI as defined by Risk, Injury, Failure, Loss, End Stage Renal Disease (ESRD) criteria. The association between minimum nasopharyngeal (NP) and bladder temperatures during HCA and postoperative AKI was assessed, adjusting for patient-level factors using multivariable logistic regression. A total of 85% (n = 645) of patients underwent deep hypothermia (14.1-20.0°C), 11% (n = 83) low-moderate hypothermia (20.1-24.0°C) and 4% (n = 31) high-moderate hypothermia (24.1-28.0°C) as classified by NP temperature. When analysed by bladder temperature, 59% (n = 447) underwent deep hypothermia, 22% (n = 170) low-moderate, 16% (n = 118) high-moderate and 3% mild (n = 24) (28.1-34.0°C) hypothermia. The median systemic circulatory arrest time was 17 min. The incidence of AKI did not differ between hypothermia groups, whether analysed using minimum NP or bladder temperature. In the multivariable analysis, the association between degree of hypothermia and AKI remained non-significant whether analysed as a categorical variable (hypothermia group) or as a continuous variable (minimum NP or bladder temperature) (all P > 0.05). In patients undergoing proximal aortic surgery including arch replacement requiring HCA, degree of systemic hypothermia was not associated with the risk of AKI. These data suggest that moderate hypothermia does not confer increased risk of AKI for patients requiring circulatory arrest, although additional prospective data are needed.

Using Machine Learning to Predict Postoperative Liver Dysfunction After Aortic Arch Surgery

The study compared machine-learning models with traditional logistic regression to predicting liver outcomes after aortic arch surgery. Retrospective review from January 2013 to May 2017. Fuwai Hospital. The study comprised 672 consecutive patients who had undergone aortic arch surgery. Three machine-learning methods were compared with logistic regression with regard to the prediction of postoperative liver dysfunction (PLD) after aortic arch surgery. The perioperative characteristics, including the patients' baseline medical condition and intraoperative data, were analyzed. The performance of the models was assessed using the area under the receiver operating characteristic curve. Naïve Bayes had the best discriminative ability for the prediction of PLD (area under the receiver operating characteristic curve = 0.77) compared with random forest (0.76), support vector machine (0.73), and logistic regression (0.72). The primary endpoint of PLD was observed in 185 patients (27.5%). The cardiopulmonary bypass time, long surgery time, long aortic clamp time, high preoperative bilirubin value, and low rectal temperature were strongly associated with the development of PLD after aortic arch surgery. The machine-learning method of naïve Bayes predicts PLD after aortic arch surgery significantly better than traditional logistic regression.

Impact of obesity on early postoperative outcomes after frozen elephant trunk procedure

Despite the great interest in the issue of obesity in cardiac surgery patients, its effect on the outcomes surgical treatment of thoracic aortic diseases has hardly been studied. Aim. To assess the effect of obesity on the results of the aortic arch reconstruction using the frozen elephant trunk (FET) technique. Material and methods . In the period from March 2012 to May 2020, 84 patients with thoracic aortic diseases were operated on. All patients underwent surgical aortic arch reconstruction using the FET technique. Interventions were performed under moderate hypothermic circulatory arrest (25-28° C) and unilateral cerebral perfusion via innominate artery. In accordance with the body mass index, all patients were divided into 2 groups: 30 kg/m 2 (group 2, n=28). Results . Neurological complication rates did not differ between the groups. Respiratory failure requiring tracheostomy and dialysis rate due to acute kidney injury occurred in 28,5% vs 35,7% (p=0,626) and 28,5% vs 17,9% (p=0,273), in patients with obesity and normal body weight, respectively. The reoperation rates due to bleeding was nonsignificantly higher in obese patients (14,3% vs 3,6%, p=0,092). The short-term mortality rate was 9,5% without significant differences in studied groups. Conclusion . Aortic arch surgery using FET technique has comparable early results in obese and normal body weight patients.

Mild hypothermic circulatory arrest with selective cerebral perfusion in open arch surgery.

BackgroundThis study aimed to evaluate whether the use of mild hypothermic circulatory arrest (HCA) with selective cerebral perfusion (SCP) in open arch procedure provides comparable perioperative results to moderate HCA for patients with dissected or degenerative arch pathologies.MethodsBetween January 2017 and September 2020, a total of 88 consecutive patients (mean age 47±11 years, 71 males) underwent open arch repair under a single surgeon at our institution with mild or moderate systemic hypothermia assisted by unilateral or bilateral SCP. Patients were divided into groups according to the nasopharyngeal temperature at the beginning of HCA: a moderate HCA group (n=47, 53.4%) and a mild HCA group (n=41, 46.6%). The postoperative mortality, morbidity, and visceral organ functions between these groups were analyzed retrospectively.ResultsCompared to the moderate HCA group, the mild HCA group had a significantly higher core temperature (nasopharynx: 24.4±0.8 vs. 28.5±2, P<0.001; bladder 25.9±0.9 vs. 30±1.2, P<0.001), and the incidence of major adverse events (MAE) in this group was markedly lower (21.3% vs. 4.9%, P=0.031). No differences were identified between the two groups refer to in-hospital mortality, permanent neurological deficit (PND), temporary neurological deficit (TND), and paraplegia (8.5% vs. 2.4%, P=0.366; 8.5% vs. 0, P=0.120; 6.4% vs. 7.3%, P=1.0; 4.3% vs. 2.4%, P=1.0, respectively). In the moderate HCA group, 6 patients (12.8%) developed acute renal failure needing replacement therapy, which did not occur in the mild HCA group (P=0.028). The duration of ventilator support and intensive care unit stay was shorter in the mild HCA group, as well as a decreased volume of drainage during the first 24 h and reduced platelet transfusion.ConclusionsThe preliminary results of the mild HCA group with SCP applied in open arch repair, mainly in total arch replacement (TAR) and stented elephant trunk (SET) implantation for aortic dissection, were satisfactory. Furthermore, comparable inferior outcomes were obtained with mild HCA compared with that of the conventional moderate HCA strategy. These encouraging surgical and postoperative results favor this more aggressive hypothermia strategy in open arch repair.

Femoral artery cannulation as a safe alternative for aortic dissection arch repair in the era of axillary artery cannulation.

BackgroundTo evaluate the safety and efficacy of femoral artery cannulation as an alternative to axillary artery cannulation, we retrospectively compared outcomes between patients with axillary or femoral artery cannulation during open aortic arch repair for type A aortic dissection (TAAD).MethodsBetween January 2014 and January 2019, 646 patients underwent open aortic arch repair with circulatory arrest for TAAD using antegrade selective cerebral perfusion (SACP) and were divided into two groups according to the site of arterial cannulation: an axillary artery group (axillary group, n=558) or a femoral artery group (femoral group, n=88). The axillary artery was considered as the primary cannulation site, and the femoral artery was used as an alternative when axillary artery cannulation was deemed unsuitable or had failed. Propensity score matching was performed to correct baseline differences.ResultsAfter propensity score matching, the patients’ characteristics were comparable between groups (n=85 in each). The incidence of in-hospital mortality (10.6% vs. 14.1%; P=0.642) and stroke (3.5% vs. 5.9%; P=0.720) were comparable between the axillary and femoral groups. The incidence of newly required dialysis was lower in the femoral group, but the difference was not statistically significant (34.1% vs. 20.0%; P=0.050). Other outcomes and major adverse events were comparable.ConclusionsFemoral artery cannulation produced similar perioperative outcomes to axillary cannulation after open arch repair for TAAD. The femoral artery can be used as a safe and effective alternative to the axillary artery for arterial cannulation in TAAD patients undergoing open arch repair.

Aortic arch surgery at 32°C: mild hypothermia and unilateral antegrade cerebral perfusion.

With development of antegrade cerebral perfusion, the necessity of deep hypothermic circulatory arrest (CA) in aortic arch surgery has been called into question. To minimize the adverse effects of hypothermia, surgeons now perform these procedures closer to normothermia. This study examined postoperative outcomes of hemiarch replacement patients using unilateral selective antegrade cerebral perfusion and mild hypothermic CA. Single-centre retrospective review of 66 patients undergoing hemiarch replacement with mild hypothermic CA (32°C) and unilateral selective antegrade cerebral perfusion between 2011 and 2018. Antegrade cerebral perfusion was delivered using right axillary artery cannulation. Postoperative data included death, neurological dysfunction, acute kidney injury and renal failure requiring new dialysis. Additional intraoperative metabolic data and blood transfusions were obtained. Eighty-six percent of patients underwent elective surgery. Mean age was 67 ± 3 years. Lowest mean core body temperature was 32 ± 2°C. Average CA was 17 ± 5 min. No intraoperative or 30-day mortality occurred. Survival was 97% at 1 year, 91% at 3 years and 88% at 5 years. Permanent and temporary neurological dysfunction occurred in 1 (2%) and 2 (3%) patients, respectively. Only 3 (5%) patients suffered postoperative stage 3 acute kidney injury requiring new dialysis. Intraoperative transfusions occurred in 44% of patients and no major metabolic derangements were observed. In patients undergoing hemiarch surgery, mild hypothermia (32°C) with unilateral selective antegrade cerebral perfusion via right axillary cannulation is associated with low mortality and morbidity, offering adequate neurological and renal protection. These findings require validation in larger, prospective clinical trials.

Beyond multimorbidity: primary care and the older person with complex needs.

The aim of this study was to present the health and social characteristics of community-dwelling older people within the Cairns region who were identified by their GP as having complex care needs. This paper reports the subanalysis of baseline data from the Older Persons Enablement and Rehabilitation (OPEN ARCH) stepped wedge randomised controlled trial of an integrated model of care for community-dwelling older people. Data were analysed at the level of the participant and the level of the participant cluster (group of participants from the one GP). Median quality of life, as assessed by the EQ-5D, was higher for females than males (80 vs 70 respectively; P=0.05) and for people living alone than living with family (80 vs 60 respectively; P=0.0940). There was greater functional independence among non-Indigenous than Indigenous participants (median Functional Independence Measure scores of 122 vs 115 respectively; P=0.0937) and the incidence rate (95% confidence intervals) of presentation to the emergency department was sevenfold higher for Indigenous than non-Indigenous participants (11.47 (5.93-20.03) vs 1.65 (0.79-3.04) per 1000 person days respectively). Finally, 61.3% of participants required support to remain living in the community and 44% accessed allied health, with podiatry the most common intervention. The findings indicate that previous hospital utilisation is not a consistent indicator of complexity. Multimorbidity, cultural context and the living and caring situation are considered as matters of complexity, yet variation exists at the participant level.

Open aortic arch surgery: 10 years' single-center experience.

IntroductionOpen aortic arch surgery is a complex cardiac surgical procedure.AimWe reviewed the 10-year outcomes of elective aortic arch aneurysm surgery in a single cardiac surgical center.Material and methodsThe analysis includes all patients who underwent elective aortic arch surgery at our institution between January 2010 and December 2020. The study population was divided into group A consisting of patients operated on during the first 5 years, and group B, including patients operated on during the subsequent 5 years. The groups were compared with regard to baseline characteristics, scope of the surgery, operative and postoperative data as well as morbidity and mortality.ResultsEighty-six elective aortic arch procedures were performed during the analyzed period, including 25 (29%) patients in group A and 61 (71%) patients in group B. The hemiarch procedure was more frequently performed in group A (17 patients, 68%) in comparison to group B (21 patients, 34%) (p = 0.008). Stroke was recorded in 6 (20%) patients from group A and 5 (8.2%) patients from group B (p = 0.002). Five-year survival was 60 ±9.8% for group A, and 81 ±6.2% for group B (log-rank test, p = 0.003).ConclusionsAfter completion of the learning curve, open aortic arch surgery is associated with acceptable early mortality, low incidence of stroke, and a high 5-year survival rate.

Cirugía de arco aórtico con circulación extracorpórea en período neonatal

IntroductionAortic arch repair has shifted from deep hypothermia plus circulatory arrest to cerebral perfusion at tepid temperatures. A step forward is simultaneous brain-coronary perfusion, allowing beating-heart arch surgery. MethodsA “Y” cannula from the arterial line delivers oxigenated blood to brain and heart. The arch is repaired on a beating heart at 25°C. Intracardiac repair is performed after running cardioplegia through the root line. 68 patients are classified into three groups. A: Norwood (9 neonates); B: aortic arch (20 children); C: aortic arch plus intracardiac repair (39 patients). Associated anomalies in group C: ventricular septal defect (15), arterial switch (9), atrial septal defect (6), cor triatriatum (3), aortic commissurotomy (2), comprehensive repair (2), ostium primum (1), Yasui (1). Fourteen lately patients had their descending aorta additionally cannulated to achieve a total body perfusion strategy. ResultsMean by-pass time was 155minutes (range 63-353). Mean brain-coronary perfusion was 36minutes (18-60). Mean coronary ischemia was 34minutes (0-160). The heart was not arrested in group B patients. Follow-up was complete for a mean of 52 months (2-78). Five patients died in the postop. Three requiered angioplasty for recoarctation. ConclusionsSelective brain-coronary perfusion is feasible and easy to switch to conventional cardioplegia delivery. Coronary ischemia can be notably reduced, being even zero minutes in isolated arch surgery. Total body perfusion may reduce morbidity in neonatal arch surgery.

Postoperative hypothermia after total aortic arch replacement in acute type A aortic dissection-multivariate analysis and risk identification for postoperative hypothermia occurrence.

BackgroundPostoperative hypothermia (PH) is a common physiological abnormality associated with increased morbidity and mortality after non-cardiac surgery. The incidence, risk factors of PH and its impact on early outcomes after total aortic arch replacement are not clear.MethodsWe conducted a retrospective cohort study in patients with acute type A aortic dissection who underwent total arch replacement from January 2013 to December 2016 at our institution. Basic variables, procedural and postoperative early outcomes were collected. Univariate and multivariate statistical analysis were performed for statistical interpretation. The early outcomes were compared between patients with or without PH.ResultsA total of 300 patients (age 53.8±11.5 years, female 63, 21.0%) with acute type A aortic dissection underwent total arch replacement. Forty-four patients (14.7%) developed PH. The independent risk factors of PH are age and the intraoperative lowest bladder temperature. There is no significant difference in major postoperative morbidity and mortality between patients with or without PH.ConclusionsThe incidence of PH after total arch replacement in acute type A aortic dissection is relatively low. The independent risk factors of PH in this population include age and the intraoperative lowest bladder temperature. With comprehensive rewarming strategy upon arrival at the ICU, the PH is easy to be corrected, and the adverse effect of transient PH on early outcomes after arch surgery is minimal.

Efficacy of cardiovascular surgery for Marfan syndrome patients: a single-center 15-year follow-up study.

BackgroundMost Marfan syndrome (MFS) patients have thoracic aortic diseases which is the major cause of death. The aim of the study is to analyze the impact of different surgical procedures on prognosis of MFS patients.MethodsWe retrospectively analyzed the results of hospitalization and long-term follow-up of MFS patients who underwent surgical intervention in our center.ResultsOf the 135 MFS patients, 11 died during hospitalization (8.1%). There were no statistical differences in in-hospital mortality between the proximal surgery group and the distal surgery group (P=0.11). Compared to patients who underwent proximal aortic surgery, patients who underwent arch and distal surgery were more likely to have postoperative respiratory dysfunction (P=0.008). The type of surgical procedure was not associated with the incidence of complications during hospitalization. Pre-surgical New York Heart Association (NYHA) Functional Classification IV (P=0.047), EF <50% (P=0.047), pre-surgical atrial fibrillation (P=0.042), and the injury of dissection propagating onto coronary arteries (P=0.02) were independent risk factors for post-surgical mortality. After 15 years of follow-up, there were no deaths in the David group, while the 15-year survival rate for patients in the Bentall group was 73%±13.5%, and 71%±13.9% for patients in the arch surgery group (P=0.42). The probability of patients in the David group not requiring re-surgery after 15 years was 58.9%±20%, while it was 58.7%±12.1% for patients in the Bentall group, 71.5%±10.5% for patients in the Bentall + Arch group, and 12.5%±11.7% for patients in the Arch + Stent group (P=0.007).ConclusionsThe David procedure was the most beneficial and had the highest long-term patient survival rates.

A randomized trial comparing axillary versus innominate artery cannulation for aortic arch surgery

BackgroundCerebral protection remains the cornerstone of successful aortic surgery; however, there is no consensus as to the optimal strategy. ObjectiveTo compare the safety and efficacy of innominate to axillary artery cannulation for delivering antegrade cerebral protection during proximal aortic arch surgery. MethodsThis 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. ResultsOne 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. Conclusionsdiffusion-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.

Propensity score analysis in patients with and without previous isolated coronary artery bypass grafting who require proximal aortic and arch surgery

ObjectiveThe 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. MethodsUsing 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. ResultsThe 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. ConclusionsThis 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.

Arch replacement with collared elephant trunks: The Siena approach.

ObjectiveTo illustrate our experience and results in patients with diffuse aneurysmal disease treated with arch replacement using the Siena collared graft, a device designed in 2002 to improve the elephant trunk technique. Results of the first step surgical implant and the subsequent treatment strategies, with extensive use of endovascular techniques, are reported.MethodsAll aortic arch–replacement procedures using the Siena graft between February 2002 and January 2020 were retrospectively analyzed for early and late clinical outcomes.ResultsOf 146 patients (54 women, 36.9%) with a median age of 69.1 years (interquartile range 58.4-75.0 years), 55 (37.6%) had acute/chronic dissection with false lumen aneurysmal dilatation, 91 (62.3%) had degenerative aneurysms, 45 (30.8%) were redo operations, and 14 (9.5%) had connective tissue disease. First-stage outcomes: 10.9% 30-day mortality (n = 16); 5.4% stroke (n = 8, 6 disabling, 2 nondisabling; 3 fatal); and 0.6% paraplegia. Outcomes for 113 second-stage procedures (77.3%, n = 97 endovascular [66.4%], n = 16 surgical [10.9%]) were 5.3% and 8.8% 30-day and 180-day mortality; no stroke; 10.6% paraplegia. Median follow-up was 5.7 years (range: 0-18.02 years) median survival was 16.65 years (95% lower confidence limit, 10.06 years) with no significant difference between aneurysm and dissection patients. Freedom from further treatment was 87.0% (95% confidence interval, 79.9%-94.7%) at 5 years and 71.4% (95% confidence interval, 71.4%-84.7%) at 10 years; median time to reintervention was 2.59 years (interquartile range, 0.52-5.20 years) with no difference (P = .22) between dissection and aneurysm groups.ConclusionsSiena collared graft represents a reliable platform for the treatment of diffuse aneurysmal disease. This device offers the flexibility required in the treatment of extended aortic lesions and guarantees the choice of the most appropriate approach for treatment completion. In this context, the availability of hybrid grafts has not modified the role of this device in arch surgery.

Preoperative renal function affects outcomes of surgery for aortic arch aneurysm in the elderly.

This study aimed to determine the optimal surgical procedure for arch aneurysm in the elderly based on preoperative comorbidities, especially focusing on renal function. The medical records of 374 patients who experienced arch surgery between 2008 and 2019 were reviewed. Among the 374 patients, 92 who underwent total arch replacement (TAR) were assigned to the TAR group and the remaining 152 who underwent debranching thoracic endovascular aortic repair (DTEVAR) were assigned to the DTEVAR group. Chronic kidney disease (CKD) was an independent risk factor of mortality (hazard ratio, 2.85; p = 0.029) in the TAR group but not in the DTEVAR. In the Grade I/II category CKD (estimated glomerular filtration rate (eGFR) > 60mL/min), freedom from all-cause mortality was significantly higher in the TAR group than in the DTEVAR group (p = 0.0155, log-rank). Freedom from all-cause mortality was comparable between the two groups in the Grade IIIa CKD (eGFR, 45-60) (p = 0.584, log-lank), Grade IIIb (eGFR, 30-45) (p = 0.822), and Grade IV/V (eGFR < 30) (p = 0.548). In elderly patients who underwent TAR, CKD was the independent risk factor of the mortality, but not in the patients who underwent debranching TEVAR. Conversion of surgical strategy from TAR to debranching TEVAR in the treatment of aortic arch aneurysms in the elderly with CKD below Grade IIIa is acceptable considering that less-invasiveness. While, in the elderly with Grade I/II CKD, TAR still remains as a primary choice for the arch repair for better mid-term survival.

Hemoperfusion with HA380 in acute type A aortic dissection patients undergoing aortic arch operation (HPAO): a randomized, controlled, double-blind clinical trial

BackgroundCardiopulmonary bypass (CPB) is an important cause of significant systemic inflammatory response syndrome (SIRS) in the surgical treatment of acute type A aortic dissection (ATAAD). In patients with arch vessel involvement, extensive surgical repairs often necessitate prolonged use of CPB and results in extensive inflammatory responses. Cytokines and chemokines released during CPB contribute to the progression of SIRS, increase perioperative complications, and negatively impact surgical outcomes. A cytokine adsorber (HA380) is expected to reduce the level of cytokines during CPB, which may decrease both intraoperative and postoperative inflammation. The purpose of this study is to investigate if HA380 is able to reduce the levels of inflammatory cytokines and decrease perioperative complications in ATAAD patients undergoing CPB and deep hypothermic circulatory arrest (DHCA).MethodsThis study is a single-center, randomized, controlled, double-blind clinical trial. The study aims to recruit 88 patients with ATAAD and aortic arch involvement who will undergo CPB and DHCA to repair the dissected aorta. Patients will be randomized equally into the CPB/DHCA only group (control group) and the CPB/DHCA + HA380 hemoperfusion group (intervention group), with 44 patients each. Patients in the control group will undergo CPB and DHCA only, while patients in the intervention group will undergo continuous hemoperfusion with HA380, in addition to CPB and DHCA. The primary outcome is a composite of major perioperative complications. The secondary outcomes include related inflammatory markers, coagulation parameters, and minor perioperative complications. To comprehensively evaluate the effect of hemoperfusion on the perioperative outcomes, we will also determine if there are differences in perioperative all-cause mortality, length of ICU stay, and total hospitalization costs.DiscussionIn the current trial, hemoperfusion will be applied in patients undergoing CPB and DHCA for repair of the aorta involving the aortic arch. This trial aims to test the safety and efficacy of our hemoperfusion device (HA380) in such settings. Upon completion of the trial, we will determine if HA380 is effective in reducing perioperative proinflammatory cytokine levels. Further, we will also verify if reduction in the proinflammatory cytokine levels, if present, translates to improvement in patient outcomes.Trial registrationClinicalTrials.gov NCT04007484. Registered on 1 July 2019 (retrospectively registered).

Neurological changes and outcomes of paediatric surgery of the aortic arch using selective cerebral perfusion

IntroductionThe aims of this article are to analyse the neuropsychological changes in the medium–term in children subjected to aortic arch surgery using selective cerebral perfusion (SCP), as well as to detect any modifiable factors in the surgical technique that may contribute to minimising the subsequent neurological involvement. Material and methodsInclusion criteria were established as: aortic arch disease operated on using SCP during the first year of life, between 10 August 2004 and 24 May 2016, biventricular physiology, and gestational age greater than 31 weeks. In the absence of a chromosomal disease, they were classified, from a neurological point of view, using the Rankin score. Children over 4-years of age were subjected to intelligence studies, including attention level, development, and psycho-lingual skills. ResultsThe study included a total of 82 patients with a mean age of 1.8 months. The mean SCP flow was 32ml/kg/min. The mean time of SCP was 31min. The overall mortality of the series was 14.8%. Neurological dysfunction was observed in 35.9% of patients, and the following were detected as risk factors: surgery in patients less than 10-days-old, duration of SCP greater than 40min, and the time required for the cooling down and/or warming-up. Attention deficit was diagnosed in 35.2% of patients greater than 5-years-old. ConclusionsPatients operated on using SCP in in the first year of life required a neuropsychological follow-up, and there are modifiable surgical factors that may have an influence on neurological development.

Minimally Invasive Aortic Arch Repair: Technical Considerations and Mid-Term Outcomes.

Reports of minimal invasive aortic arch surgery are scarce. We reviewed our experience with minimal access aortic arch surgery performed through an upper mini-sternotomy, with emphasis on details of operative technique and early and mid-term outcomes. The medical records of 123 adult patients (mean age 66 ± 12 years), who underwent primary elective minimal access aortic arch surgery in two aortic referral centers, were reviewed. The most common indication was degenerative aortic arch aneurysm in 92 (75%) patients. Standard operative and organ protection techniques used in all patients were upper mini-sternotomy, uninterrupted antegrade cerebral perfusion, and moderate systemic hypothermia (27.4 ± 1°C). Sixty-eight (55%) patients received partial aortic arch replacement; the remaining 55 (45%) patients received total arch replacement, further extended with either a frozen elephant trunk in 43 (35%) patients or a conventional elephant trunk procedure in nine (7%) patients. No conversion to full sternotomy was required. New permanent renal failure occurred in one (0.8%) patient, stroke in two (1.6%), and spinal cord injury in four (3.3%) patients. Early mortality was observed in four (3.3%) patients. At five years, survival was 80 ± 6% and freedom from reoperation was 96 ± 3%. Minimal invasive aortic arch repair through an upper mini-sternotomy can be safely performed, with early and mid-term outcomes well comparable to series performed through a standard median sternotomy.

Outcomes in techniques of valve sparing aortic root replacement: A systematic review and meta-analysis.

To compare clinical outcomes of reimplantation versus remodeling in patients undergoing valve-sparing aortic root replacement (VSRR) surgery. Electronic database search at PubMed, Scopus, Embase, Ovid, and Google scholar was performed from inception to January 2020. Primary outcomes were aortic valve(AV) reintervention and postoperative grade of aortic insufficiency (AI) while secondary outcomes were 30-day mortality, reoperation for bleeding, and operative times. A total of 21 articles met the inclusion criteria. A total of 1283 patients had reimplantation while 1150 had remodeling. No difference in preoperative demographics was noted except reimplantation patients were younger (48 ± 16 vs. 56 ± 15 years; p < .00001). The cardiopulmonary bypass and aortic cross-clamp times were shorter in the remodeling cohort (168 ± 38 vs. 150 ± 37 min; p = .0001 and 133 ± 31 vs. 112 ± 30 min; p = .0002, respectively). No difference in concomitant total arch surgery (14% in reimplantation vs. 15% in remodeling; p = .53). Postoperatively, there were similar stroke rates (3% in both cohorts; p = .54), rates of reoperation for bleeding (9% in reimplantation vs. 12% in remodeling; p = .88), and 30-day mortality (3% in reimplantation vs. 4% in remodeling; p = .96). No difference in early AV reintervention (1% in reimplantation vs. 2% in remodeling; p = .07), and late AV reintervention (4% in reimplantation vs. 7% in remodeling; p = .07). The AI of +2 grade was significantly lower in the reimplantation cohort (5% vs. 8%; p = .01). Our study shows comparable clinical outcomes between both techniques. The practice of each technique is largely center and surgeon dependent. Larger sample size cohorts with minimal confounding factors are required to confirm the above findings.