Postoperative Stroke Research Articles

A Retrospective Analysis of 10-year Experience on Branched and Fenestrated Endovascular Aortic Arch Repair.

This study aimed to present the early and mid-term outcomes of fenestrated/branched thoracic endovascular aortic repair (f/bTEVAR) for aortic arch pathologies. f/bTEVAR represents a less invasive treatment option for aortic arch diseases. Previous published series showed decreased early mortality and morbidity compared to open repair. A single-center retrospective analysis of consecutive patients, managed with f/bTEVAR (Cook Medical, Bloomington, IN, USA) between 01.09.11and 30.06.22 was conducted. Primary outcomes were technical success, 30-day mortality and stroke. Data during follow-up and factors affecting early mortality and stroke were analyzed. 209 patients were included (38.3% females; mean age 69.8±3.4years; mean aortic diameter 61±4.7mm); 14.4% were managed urgently. Fenestrations/scallop configuration was used in 39.7%, branched devices in 55.5% and branch/scallop combination in 4.8%. Landing to zone 0 was performed in 65.5% and in zone 1 in 32.1%. Non-native aortas were used for landing in 39.2%. Technical success was 97.1% and 30-day mortality 9.5%. Strokes were identified in 10%; 5.7% major. Non-native proximal aortic landing zone was an independent protective factor for stroke (P=0.002). Post-operative stroke (P<0.001) and pericardial effusion (P<0.001) were independently related to 30-day mortality. The mean follow-up was 21±8 months. The estimated survival and freedom from reintervention rates were 79.5% (standard error; SE3.1%) and 47.1% (SE 4.3%) at 24months, respectively. f/bTEVAR presented high technical success and acceptable 30-day mortality. Non-native proximal landing zone was related to lower stroke rate. Half of patients needed a reintervention within the 24-month follow-up.

Efficacy of mitral valve repair in combination with coronary revascularization for moderate ischaemic mitral regurgitation: a systematic review and meta-analysis of randomized controlled trials.

The efficacy of mitral valve repair (MVR) in combination with coronary artery bypass grafting (CABG) for moderate ischaemic mitral regurgitation (IMR) remains unclear. To evaluate whether MVR + CABG is superior to CABG alone, the authors conducted a systematic review and meta-analysis of existing randomized controlled trials (RCTs). The authors searched PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for eligible RCTs from the date of their inception to October 2023. The primary outcomes were operative (in-hospital or within 30 days) and long-term (≥ 1 year) mortality. The secondary outcomes were postoperative stroke, worsening renal function (WRF), and reoperation for bleeding or tamponade. The authors performed random-effects meta-analyses and reported the results as risk ratios (RRs) with 95% CIs. Six RCTs were eligible for inclusion. Compared with CABG alone, MVR + CABG did not increase the risk of operative mortality (RR, 1.244; 95% CI, 0.514-3.014); however, it was also not associated with a lower risk of long-term mortality (RR, 0.676; 95% CI, 0.417-1.097). Meanwhile, there was no difference between the two groups in terms of postoperative stroke (RR, 2.425; 95% CI, 0.743-7.915), WRF (RR, 1.257; 95% CI, 0.533-2.964), and reoperation for bleeding or tamponade (RR, 1.667; 95% CI, 0.527-5.270). The findings of this meta-analysis suggest that MVR + CABG fails to improve the clinical outcomes of patients with moderate IMR compared to CABG alone.

O163: CABG versus PCI in Heart Failure with Reduced Ejection Fraction Patients: A Systematic Review &amp; Meta-analysis Stratified by Left Ventricular Ejection Fraction

Abstract Background Comparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with heart failure with reduced ejection fraction (HFrEF) remains controversial within the literature. The current meta-analysis aimed to compare CABG and PCI in HFrEF patients regarding mortality and long-term survival, repeat revascularization, new postoperative myocardial infarction (MI) and stroke, stratified by the degree of LVEF reduction. Methods In a systematic review, a comprehensive literature search was conducted on multiple electronic databases using strict search terms. Twenty studies met the set inclusion/exclusion criteria. Meta-analysis of extracted data was conducted using the R-studio and STATA software. Furthermore, the aforementioned study endpoints were stratified by the degree of left ventricular ejection fraction (LVEF) reduction into severe (&amp;lt;35%), moderate (&amp;lt;40%) and mild (&amp;lt;50%). Results Data from 25,031 HFrEF patients was analysed, out of which 12,957 (52%) underwent CABG and 12,074 (48%) received PCI. Long-term survival was significantly higher in the severe (&amp;lt;35%) and mildly (&amp;lt;50%) reduced LVEF groups, with no significant different found in the moderately (&amp;lt;40%) reduced LVEF cohort. However, all 3 groups significantly favoured CABG in terms of need for revascularization, but no difference in stroke incidence was found. As for postoperative MI, this followed the same trend as survival. No evidence of significant heterogeneity or publication bias was found. Conclusion CABG yields more favourable results than PCI in HFrEF patients. Further stratifying the clinical outcomes measured by the degree of LVEF reduction sheds light on the importance of risk stratification of patients to optimise results.

Nonalcoholic fatty liver disease is an independent risk factor for ischemic stroke after revascularization in patients with Moyamoya disease: a prospective cohort study

BackgroundThe study aimed to investigate the association between nonalcoholic fatty liver disease (NAFLD) and ischemic stroke events after revascularization in patients with Moyamoya disease (MMD).MethodsThis study prospectively enrolled 275 MMD patients from September 2020 to December 2021. Patients with alcoholism and other liver diseases were excluded. NAFLD was confirmed by CT imaging or abdominal ultrasonography. Stroke events and modified Rankin Scale (mRS) scores at the latest follow-up were compared between the two groups.ResultsA total of 275 patients were enrolled in the study, among which 65 were diagnosed with NAFLD. Univariate logistic regression analysis showed that NAFLD (P = 0.029) was related to stroke events. Multivariate logistic regression analysis showed that NAFLD is a predictor of postoperative stroke in MMD patients (OR = 27.145, 95% CI = 2.031–362.81, P = 0.013). Kaplan-Meier analysis showed that compared with MMD patients with NAFLD, patients in the control group had a longer stroke-free time (P = 0.004). Univariate Cox analysis showed that NAFLD (P = 0.016) was associated with ischemic stroke during follow-up in patients with MMD. Multivariate Cox analysis showed that NAFLD was an independent risk factor for stroke in patients with MMD (HR = 10.815, 95% CI = 1.259–92.881, P = 0.030). Furthermore, fewer patients in the NAFLD group had good neurologic status (mRS score ≤ 2) than the control group (P = 0.005).ConclusionNAFLD was an independent risk factor for stroke in patients with MMD after revascularization and worse neurological function outcomes.

Impella 5.5 Bridge to Heart Transplant: An Institutional Series and a Closer Look at Device Removal Technique.

Limited donor organ availability often necessitates mechanical circulatory support, and recently the Impella 5.5, as a bridge to heart transplant. Of 175 Impella 5.5-supported patients at our institution, 45 underwent transplantation in the largest series to date, for whom we analyzed outcomes. Two methods of complete device explant were evaluated: central Impella transection and removal via axillary graft. Median Impella days were 25 (16-41); median waitlist days were 21 (9-37). Eighty-nine percent (40/45) of patients had device placement via right axillary artery. Seventy-six percent (34/45) underwent central transection for device removal. Four patients (8.9%) required short-term venoarterial extracorporeal membranous oxygenation (VA ECMO) postoperatively for primary graft dysfunction (PGD). Two patients (4.4%) suffered postoperative stroke. Five patients (11.1%) required new RRT postoperatively. One patient (2.2%) returned to the operating room (OR) for axillary graft bleeding. A higher chance of procedural complications was found with the axillary removal technique ( p = 0.014). Median intensive care unit (ICU) days, length of stay (LOS), and postoperative days to discharge were 46 (35-63), 59 (49-80), and 18 (15-24), respectively. Ninety-eight percent (44/45) survived to discharge. Thirty-day survival was 95.6% (43/45), with 1 year survival at 90.3% (28/31). Eighty-eight percent (37/42) remain without rejection. In our institutional experience, Impella 5.5 is a safe and reliable bridge to transplant.

Meta-analysis of central and peripheral cannulation for type A aortic dissection.

Acute type A aortic dissection necessitates rapid and effective arterial cannulation techniques for optimal outcomes. This meta-analysis compares the safety and effectiveness of direct aortic cannulation (AoC) with peripheral cannulation (PC) via the femoral or axillary arteries in aortic surgery for acute type A aortic dissection. A systematic review following PRISMA guidelines identified 10 retrospective studies encompassing 2518 patients (961 AoC, 1557 PC). Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated to analyze perioperative characteristics, short-term mortality rates, and postoperative complications including stroke and acute kidney injury. Short-term mortality did not significantly differ between AoC and PC (OR [95% CI] = 0.78 [0.61-1.01], p = .06). Likewise, postoperative stroke (OR [95% CI] = 0.86 [0.63-1.17], p = .33) nor acute kidney injury (OR [95% CI] = 1.11 [0.89-1.37], p = .35) showed no significant differences. AoC exhibited shorter operation time whereas there were no significant differences in aortic cross clamp time and cardiopulmonary bypass time between both groups. Our meta-regression analysis, considering the distal extent of aortic replacement, indicated that variations in aortic replacement rates did not significantly impact the observed outcomes. AoC is a viable alternative to PC for acute type A aortic dissection. While both approaches offer comparable outcomes, AoC's advantage in shorter operation time warrants thoughtful consideration in clinical practice.

Nature of Neurological Complications and Outcome After Surgery for Type A Aortic Dissection

Surgery for type A aortic dissection (TAAD) is frequently complicated by neurological complications. The prognostic impact of neurological complications of different nature has been investigated in this study.The subjects of this analysis were 3902 patients who underwent surgery for acute TAAD from the multicenter European Registry of Type A Aortic Dissection (ERTAAD).During the index hospitalization, 722 (18.5%) patients suffered stroke/global brain ischemia. Ischemic stroke was detected in 539 patients (13.8%), hemorrhagic stroke in 76 patients (1.9%) and global brain ischemia in 177 patients (4.5%), with a few patients having had findings of more than one of these conditions. In-hospital mortality was increased significantly among patients with postoperative ischemic stroke (25.6%, adjusted OR 2.422, 95%CI 1.825-3.216), hemorrhagic stroke (48.7%, adjusted OR 4.641, 95%CI 2.524-8.533) and global brain ischemia (74.0%, adjusted OR 22.275, 95%CI 14.537-35.524) compared to patients without neurological complications (13.5%). Similarly, patients who suffered ischemic stroke (46.3%, adjusted HR 1.719, 95%CI 1.434-2.059), hemorrhagic stroke (62.8%, adjusted HR 3.236, 95%CI 2.314-4.525) and global brain ischemia (83.9%, adjusted HR 12.777, 95%CI 10.325-15.810) had significantly higher 5-year mortality compared to patients without postoperative neurological complications (27.5%). The negative prognostic effect of neurological complications on survival vanished about one year after surgery.In conclusion, postoperative ischemic stroke, hemorrhagic stroke, and global cerebral ischemia increased early and mid-term mortality after surgery for acute TAAD. The magnitude of risk of mortality increased with the severity of the neurological complications, with postoperative hemorrhagic stroke and global brain ischemia being highly lethal complications.

Determinants of Mortality and Mid-Term Outcomes After Transcarotid Artery Revascularization and Transfemoral Carotid Artery Stenting.

The potential benefit of transcarotid artery revascularization (TCAR) over transfemoral carotid artery stenting (tfCAS) has been studied in the perioperative period with lower rates of stroke and death; however, data on mid-term outcomes are limited. We aimed to evaluate 3-year outcomes after TCAR and tfCAS and determine the primary predictors of 30-day and 1-year mortality following TCAR. Data from the Vascular Quality Initiative for patients undergoing TCAR or tfCAS from January 2016 to December 2022 were analyzed. 1:1 propensity score matching using the nearest-neighbor method was used to adjust baseline demographics and clinical characteristics. Kaplan-Meier survival analysis and Cox Proportional Hazard Regression were used to evaluate long-term outcomes. Iterative stepwise multiple logistic regression analysis and Cox Proportional Hazard Regression were used to identify predictors of 30-day and 1-year mortality, respectively, based upon preoperative, intraoperative, and postoperative factors. A total of 70 237 patients were included in analysis (TCAR=58.7%, tfCAS=41.3%). Transcarotid artery revascularization patients were older and had higher rates of comorbid conditions and high-risk medical and anatomic features than tfCAS patients. Propensity score matching yielded 22 322 pairs with no major differences between groups except that TCAR patients were older (71.6 years vs 70.8 years). At 3 years, TCAR was associated with a 24% reduction in hazard of death compared with tfCAS (hazard ratio [HR]=0.76, 95% confidence interval [CI]=0.71-0.82, p<0.001), for both symptomatic and asymptomatic patients. This survival advantage was established in the first 6 months (HR=0.59, 95% CI=0.53-0.62, p<0.001), with no difference in mortality risk from 6 months to 36 months (HR=0.95, 95% CI=0.86-1.05, p=0.31). Transcarotid artery revascularization was also associated with decreased hazard for 3-year stroke (HR=0.81, 95% CI=0.66-0.99, p=0.04) and stroke or death (HR=0.81, 95% CI=0.76-0.87, p<0.001) compared with tfCAS. The top predictors for 30-day and 1-year mortality were postoperative complications. The primary independent predictor was the occurrence of postoperative stroke. Transcarotid artery revascularization had a sustained mid-term survival advantage associated over tfCAS, with the benefit being established primarily within the first 6 months. Notably, our findings highlight the importance of postoperative stroke as the primary independent predictor for 30-day and 1-year mortal. The ongoing debate over the superiority of TCAR compared to tfCAS and CEA has been limited by a lack of comparative studies examining the impact of pre-operative symptoms on outcomes. Furthermore, data are scarce on mid-term outcomes for TCAR beyond the perioperative period. As a result, it remains uncertain whether the initial benefits of stroke and death reduction observed with TCAR over tfCAS persist beyond one year. Our study addresses these gaps in the literature, offering evidence to enable clinicians to assess the efficacy of TCAR for up to three years. Additionally, our study seeks to identify risk factors for postoperative mortality following TCAR, facilitating optimal patient stratification.

Examining the Role of Cerebral Embolic Protection Devices in Preventing Postoperative Stroke in Patients with a History of Stroke or Transient Ischemic: Insights from the National Inpatient Sample.

Cerebral embolic protection devices (CEPD) during transcatheter aortic valve replacement (TAVR) have been shown to lower the risk of stroke during the procedure. However, their long-term and clinical effects on neuro-cognition are unknown. Therefore, we hypothesized the benefit of CEPD in TAVR patients with a prior history of stroke or transient ischemic attack (TIA). National Inpatient Sample (2019) and International Classification of Diseases, 10th Revision codes were used to identify patients undergoing TAVR with prior stroke or TIA. Propensity-matched analysis was performed to adjust for baseline characteristics and comorbidities. Primary outcome measures were postoperative stroke and all-cause mortality. Length of stay and hospital cost were secondary outcomes. Of 8450 unmatched TAVR patients with prior stroke or TIA in 2019, 1095 (13%) utilized CEPD. After propensity matching previous myocardial infarction (MI), coronary artery bypass grafting, and drug abuse were higher in the TAVR-only cohort. Postoperative stroke rate (1.4% vs 2.2%; P = 0.081) and odds [adjusted odds ratio (aOR), 0.48; 95% confidence interval (CI), 0.11-2.17; P = 0.341] were lower in the CEPD group. There was no difference in all-cause in-hospital mortality between the 2 groups (0.9% vs 1.0%). Length of stay (3 vs 2 days, P <0.001) and hospital expenditure ($172,711 vs $162,284; P = 0.002) were higher for the TAVR-only cohort. CEPD in TAVR patients with prior stroke or TIA did not show statistically significant postoperative stroke benefits. However, further larger-scale prospective studies are needed to evaluate the long-term neurocognitive benefits of CEPD in these patients. As the use of TAVR continues to expand, optimizing peri-procedural strategies such as the use of CEPD remains a critical area of research to improve patient outcomes.

Early Onset Severe Aortic Stenosis Presenting with Recurrent Ventricular and Supraventricular Arrhythmia and Postoperative Stroke in a 44-year-old Man with Uncontrolled Rheumatoid Arthritis

Calcific aortic stenosis is the most common aetiology of aortic stenosis and is mostly seen in older people. Systemic inflammatory diseases, such as rheumatoid arthritis (RA), are rarely associated with aortic stenosis in the literature. Uncontrolled systemic inflammation related to RA may lead to postoperative complications but this is not well documented. The patient in this case report was a 44-year-old man who had been diagnosed with RA that had been poorly controlled. He had a 7-month history of heart failure symptoms attributed to severe calcific aortic stenosis. He underwent surgical aortic valve replacement, but developed an acute cerebrovascular infarct 2 hours after surgery and recurrent unstable ventricular tachycardia on the first postoperative day warranting 15 synchronised cardioversions. RA is a rare antecedent cause of severe calcific aortic stenosis especially in younger people. Such a valvular complication associated with acute ischaemic stroke and ventricular arrhythmia warrants further study to provide optimal medical management, especially for patients with RA and early cardiovascular complications.

Long-term outcomes after conservative and EDAS treatment for 111 elderly patients with moyamoya disease: longitudinal and cross-sectional study.

This study aimed to explore the clinical features of moyamoya disease (MMD) and the efficacy of encephaloduroarteriosynangiosis (EDAS) in elderly patients with MMD and to identify the risk factors for long-term stroke events. Clinical data were retrospectively collected on elderly patients with MMD (age ≥ 60 years) who had been treated at the authors' center from May 2007 to December 2017. Clinical features, angiographic findings, and long-term outcomes (> 5-year follow-up) were analyzed. Cox regression analysis was performed to determine the risk factors for postoperative stroke events. Long-term stroke events were analyzed using Kaplan-Meier curves. The mean age at symptom onset was 62.9 ± 3.0 years among 111 elderly patients with MMD. Vascular comorbidities were present in 80 (72.1%) patients. The ratio of female to male patients was 1:1.2. Familial MMD was found in 7 (6.3%) patients. Cerebral ischemia was the most common clinical manifestation observed in 82 (73.9%) patients. Most patients (59.5%) presented with Suzuki stages 5 and 6 MMD, and 29 (26.1%) patients presented with stenosis or occlusion of the posterior circulation. Unilateral MMD was present in 17 (15.3%) patients. Among the 58 (52.3%) patients who underwent EDAS, 28 (48.3%) and 30 (51.7%) underwent bilateral and unilateral surgeries, respectively. Overall, 53 (47.7%) patients were treated conservatively using internal medicine. After a median follow-up duration of 8.2 years, stroke incidence in the EDAS and conservative treatment groups was respectively 17.2% (7 and 3 cases of cerebral infarction and hemorrhage, respectively) and 49.1% (22 and 4 cases of cerebral infarction and hemorrhage, respectively). The stroke incidence rate was higher in the conservative group than in the EDAS group, with a statistically significant difference (p = 0.001) according to results of the Kaplan-Meier analysis. The identified predictor of postoperative stroke events was initial hemorrhage in the EDAS group and advanced age, aneurysm, and initial ischemia in the conservative treatment group. The postoperative long-term stroke rate among elderly patients with MMD was lower in the EDAS group than in the conservative treatment group. Long-term stroke events were associated with advanced age, aneurysm, and initial ischemia after conservative treatment and only initial hemorrhage after EDAS.

Surgeon volume and outcomes following thoracic endovascular aortic repair for blunt thoracic aortic injury

ObjectiveThoracic endovascular aortic repair (TEVAR) for blunt thoracic aortic injury (BTAI) at high-volume hospitals has previously been associated with lower perioperative mortality, but the impact of annual surgeon volume on outcomes following TEVAR for BTAI remains unknown. MethodsWe analyzed Vascular Quality Initiative (VQI) data from patients with BTAI that underwent TEVAR between 2013 and 2023. Annual surgeon volumes were computed as the number of TEVARs (for any pathology) performed over a 1-year period preceding each procedure and were further categorized into quintiles. Surgeons in the first volume quintile were categorized as low volume (LV), the highest quintile as high volume (HV), and the middle three quintiles as medium volume (MV). TEVAR procedures performed by surgeons with less than 1-year enrollment in the VQI were excluded. Using multilevel logistic regression models, we evaluated associations between surgeon volume and perioperative outcomes, accounting for annual center volumes and adjusting for potential confounders, including aortic injury grade and severity of coexisting injuries. Multilevel models accounted for the nested clustering of patients and surgeons within the same center. Sensitivity analysis excluding patients with grade IV BTAI was performed. ResultsWe studied 1321 patients who underwent TEVAR for BTAI (28% by LV surgeons [0-1 procedures per year], 52% by MV surgeons [2-8 procedures per year], 20% by HV surgeons [≥9 procedures per year]). With higher surgeon volume, TEVAR was delayed more (in <4 hours: LV: 68%, MV: 54%, HV: 46%; P < .001; elective (>24 hours): LV: 5.1%; MV: 8.9%: HV: 14%), heparin administered more (LV: 80%, MV: 81%, HV: 87%; P = .007), perioperative mortality appears lower (LV: 11%, MV: 7.3%, HV: 6.5%; P = .095), and ischemic/hemorrhagic stroke was lower (LV: 6.5%, MV: 3.6%, HV: 1.5%; P = .006). After adjustment, compared with LV surgeons, higher volume surgeons had lower odds of perioperative mortality (MV: 0.49; 95% confidence interval [CI], 0.25-0.97; P = .039; HV: 0.45; 95% CI, 0.16–1.22; P = .12; MV/HV: 0.50; 95% CI, 0.26-0.96; P = .038) and ischemic/hemorrhagic stroke (MV: 0.38; 95% CI, 0.18-0.81; P = .011; HV: 0.16; 95% CI, 0.04-0.61; P = .008). Sensitivity analysis found lower adjusted odds for perioperative mortality (although not significant) and ischemic/hemorrhagic stroke for higher volume surgeons. ConclusionsIn patients undergoing TEVAR for BTAI, higher surgeon volume is independently associated with lower perioperative mortality and postoperative stroke, regardless of hospital volume. Future studies could elucidate if TEVAR for non-ruptured BTAI might be delayed and allow stabilization, heparinization, and involvement of a higher TEVAR volume surgeon.

Analysis of tranexamic acid usage in adult spinal deformity patients with relative contraindications: does it increase the risk of complications?

Complex spinal deformity surgeries may involve significant blood loss. The use of antifibrinolytic agents such as tranexamic acid (TXA) has been proven to reduce perioperative blood loss. However, for patients with a history of thromboembolic events, there is concern of increased risk when TXA is used during these surgeries. This study aimed to assess whether TXA use in patients undergoing complex spinal deformity correction surgeries increases the risk of thromboembolic complications based on preexisting thromboembolic risk factors. Data were analyzed for adult patients who received TXA during surgical correction for spinal deformity at 21 North American centers between August 2018 and October 2022. Patients with preexisting thromboembolic events and other risk factors (history of deep venous thrombosis [DVT], pulmonary embolism [PE], myocardial infarction [MI], stroke, peripheral vascular disease, or cancer) were identified. Thromboembolic complication rates were assessed during the postoperative 90 days. Univariate and multivariate analyses were performed to assess thromboembolic outcomes in high-risk and low-risk patients who received intravenous TXA. Among 411 consecutive patients who underwent complex spinal deformity surgery and received TXA intraoperatively, 130 (31.6%) were considered high-risk patients. There was no significant difference in thromboembolic complications between patients with and those without preexisting thromboembolic risk factors in univariate analysis (high-risk group vs low-risk group: 8.5% vs 2.8%, p = 0.45). Specifically, there were no significant differences between groups regarding the 90-day postoperative rates of DVT (high-risk group vs low-risk group: 1.5% vs 1.4%, p = 0.98), PE (2.3% vs 1.8%, p = 0.71), acute MI (1.5% vs 0%, p = 0.19), or stroke (0.8% vs 1.1%, p > 0.99). On multivariate analysis, high-risk status was not a significant independent predictor for any of the thromboembolic complications. Administration of intravenous TXA during the correction procedure did not change rates of thromboembolic events, acute MI, or stroke in this cohort of adult spinal deformity surgery patients.

Left atrial dysfunction in bicuspid aortic valve patients with severe aortic stenosis is associated with post-operative atrial fibrillation following aortic valve replacement.

To investigate (i) the association between pre-operative left atrial (LA) reservoir strain and post-operative atrial fibrillation (AF) and (ii) the incidence of post-operative ischaemic stroke events separately in bicuspid aortic valve (BAV) and tricuspid aortic valve (TAV) patients after surgical aortic valve replacement for isolated severe aortic stenosis (AS). We prospectively enrolled 227 patients (n = 133 BAV and n = 94 TAV) with isolated severe AS scheduled for aortic valve replacement. A comprehensive intra- and inter-observer validated pre-operative echocardiogram with an analysis of LA reservoir strain was performed. Post-operative AF was defined as a sustained (>30 s) episode of AF or atrial flutter. The timing of neurological events was defined in accordance with the Valve Academic Research Consortium-3 criteria for stroke. Post-operative AF occurred in 114 of 227 patients (50.2%), with no difference between BAV and TAV patients (48.1 vs. 53.1%, P = 0.452). Persisting post-operative AF at discharge was more frequent in BAV patients (29.7 vs. 8.0%, P = 0.005). Pre-operative LA reservoir strain was independently associated with post-operative AF (odds ratio = 1.064, 95% confidence interval 1.032-1.095, P < 0.001), with a significant interaction between LA reservoir strain and aortic valve morphology (Pinteraction = 0.002). The cumulative transient ischemic attack (TIA)/stroke incidence during follow-up was significantly higher in BAV patients (19.1 vs. 5.8% at 5 years). Pre-operative LA function was associated with post-operative AF after aortic valve replacement in BAV AS patients, while post-operative AF in TAV AS patients likely depends on transient post-operative alterations and traditional cardiovascular risk factors. TIA/stroke during follow-up was more common in BAV AS patients.

Should we operate on patients with acute type A aortic dissection who present with cardiopulmonary resuscitation?

Acute aortic dissection type A (AADA) is a life-threatening medical emergency. Emergent surgical repair is the gold standard but mortality remains high. Mortality is even higher in patients who arrive at the hospital in poor condition, especially after cardiopulmonary resuscitation (CPR). This study was designed to analyse the outcome of patients who underwent surgery for AADA and who require preoperative CPR. Between 2000 and 2023, 810 patients underwent emergent surgery for AADA at our centre. Of these, 63 had preoperative CPR. We performed a retrospective analysis with follow-up. Mean age was 64 ± 13 years and 37 (59%) patients were male. Further, 50 (79%) patients had preoperative intubation, and 54 (86%) had pericardial effusion. Twenty-four (38%) patients had out-of-hospital CPR, 19 (30%) required CPR in hospital and 20 (32%) needed CPR in the operating room. Successful CPR with return of spontaneous circulation was achieved in 41 (65%) patients, and 22 (35%) underwent emergent surgery under ongoing CPR. The median time of CPR was 10 (interquartile range 12) min, and the median time from onset of symptoms to start of the operation was 5.5 (interquartile range 4.8) h. The majority of patients underwent ascending aortic replacement with hemiarch repair (n = 37, 59%). Further, 26 (41%) patients underwent full root replacement. Another 15 (24%) patients underwent total arch repair with or without (frozen) elephant trunk repair. Postoperative stroke was present in 8 (13%) patients. The 30-day mortality was 29 (46%). The 30-day mortality of patients with preoperative intubation was not significantly higher (n = 15/28, 54%, P = 0.446). The 1-, 5- and 10-year survival rates of the entire group were 42, 39 and 36%. Early mortality for patients undergoing surgery for AADA with preoperative CPR is extremely high (almost 50%). However, this means that also ∼50% of patients benefit from surgery despite poor preoperative prognosis. Patients with preoperative intubation after CPR and unknown neurological condition should also undergo surgery. Patients who survive the initial operation for AADA have acceptable long-term survival. Emergent surgery should be offered for all patients with AADA regardless of the preoperative condition, even after CPR.

Early and Midterm Outcomes of Endovascular Aortic Arch Repair Using In Situ Laser Fenestration.

The aim of this study is to present single-center outcomes in patients treated with in situ laser fenestration thoracic endovascular aortic repair (LFTEVAR) for various aortic arch pathologies and assess the impact of increasing experience. The STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) statement was followed. A retrospective analysis of prospectively collected single aortic center data was conducted, including baseline information and peri- and post-operative outcomes of consecutive patients managed with LFTEVAR for aortic arch pathologies. Patients were enrolled from April 1, 2017 to January 31, 2023. The cohort was dichotomized to compare early (2017-2019) and late experience (2020-2023). Primary outcomes were peri-operative mortality and cerebrovascular morbidity. Thirty patients were included (63.3% males, mean age 69.8±9.6 years); 21.4% presented with aortic ruptures. Aortic aneurysm involving the aortic arch was the most frequent pathology (53.3%). Forty target vessels (TVs) were revascularized, including 19 left subclavian arteries (47.5%) and 17 left common carotid arteries (42.5%). Double fenestrations were performed in 10 patients. The proximal landing zone was Ishimaru zone 0 in 5 patients (16.7%) and zone 1 in 13 patients (43.3%). Technical success was 93%. No spinal cord ischemia was recorded, and 3 patients (10%) suffered a post-operative stroke, of which 1 was major (3.3%). The median follow-up was 12 months (range=1-48 months). Thirty-day and follow-up mortality rates were 13.5% and 15.3%, respectively. Target vessel instability was 10%, of which 3.8% required reintervention. There was no statistically significant difference in outcomes between the early and late experience groups. Laser fenestration thoracic endovascular aortic repair of the aortic arch performed in experienced aortic centers is associated with low early mortality and stroke rates. It is a safe and effective therapeutic option in patients considered unfit for open repair. Custom-made devices for arch pathologies requiring urgent repair are not an option because of manufacturing delays. Off-the-shelf devices with single branch arch prostheses, and outside IFU techniques such as parallel-grafts and surgeon-modified endografts have been proposed in this setting. Another off-the-shelf alternative is in situ laser fenestration thoracic endovascular repair (LFTEVAR), which addresses many limitations of the other off-the-shelf options. Our study reports the outcomes of 30 patients treated with LFTEVAR, showing that it is a viable therapeutic option in patients considered unfit for open repair acknowledging that sufficient experience with complex endovascular aortic repair is mandatory to achieve acceptable outcomes in these high-risk patients with challenging aortic anatomies.

Utilizing physician modified fenestration on the castor branched stent technique for reconstruction of an isolated left vertebral artery on the aortic arch

The study aimed to provide physician modified fenestration (PMF) on a single-branched stent for the aortic arch (Castor) to protect the isolated left vertebral artery (ILVA) during thoracic endovascular aortic repair (TEVAR). Patients who underwent TEVAR involving ILVA reconstruction through PMF performing on the Castor branched stent were included in a retrospective, multi-centre study from June 2018 to December 2022. In these patients, all proximal landing zones of "Castor" were positioned in Ishimaru zone 2a. A total of twenty-five patients met the inclusion criteria and the achievement rate showed 25/25 (100%) success in them. The twenty-five patients had a median follow-up length of 28.5 ± 14.6 months. One patient (4.0%) suffered from postoperative ischemic stroke before discharge. One patient (4.0%) died from a hemodialysis-related brain hemorrhage before discharge on the 29th day after the procedure. One patient died of advanced liver cancer in the 33th month after discharge. Aortic rupture, stroke or spinal cord injury did not occur throughout the follow-up period after discharge. Two patients (8.0%) experienced endoleak at the fenestration, however, resulting in only one’s necessity for reintervention. Notably, the procedure effectively maintained ILVAs patency for all patients during follow up. According to our preliminary findings, performing a TEVAR under local anaesthesia using PMF on a Castor branched stent for ILVA preservation appeared practical, secure, and effective.

Early Surgery for Infective Endocarditis Complicated With Neurologic Injury

ObjectivesTo estimate the association between early surgery and the risk of mortality in patients with left-sided infective endocarditis patients in the context of stroke. DesignRetrospective cohort study. SettingThis study was a multi-institution study based on Chang Gung Research Database (CGRD), which contains electronic medical records from 7 hospitals in northern and southern Taiwan; these include 2 medical centers, 2 regional hospitals, and 3 district hospitals. ParticipantsPatients with active left-sided infective endocarditis who underwent valve surgery between September 2002 and December 2018. InterventionsWe divided patients into two groups with versus without preoperative neurologic complications, undergone early (within 7 days) or non-early surgery, and with brain ischemia or hemorrhage. Measurements and Main Results392 patients with the median time from diagnosis to operation 6 days were included. No significant differences in postoperative stroke, in-hospital mortality, or follow-up outcomes were observed between the patients with and without neurological complications. Among the patients with preoperative neurological complications, patients who underwent early surgery had a lower 30-day postoperative mortality rate (13.1% vs 25.8%; hazard ratio, 0.21; 95% CI, 0.07 to 0.67). In the subgroup analysis of comparison between brain ischemia and hemorrhage groups, there was no significant between-group difference on the in-hospital outcomes or outcomes after discharge. ConclusionsEarly cardiac operation may be associated with more favorable clinical outcomes in the patients with preoperative neurological complications. Thus, preoperative neurological complications should not delay operative interventions.

Effect of on-pump vs. off-pump coronary artery bypass grafting in patients with non-dialysis-dependent severe renal impairment: propensity-matched analysis from the UK registry dataset.

On-pump coronary artery bypass (ONCABG) grafting in patients with a pre-existing poor renal reserve is known to carry significant morbidity and mortality. There is limited controversial evidence on the benefit of off-pump coronary artery bypass (OPCABG) grafting in these high-risk groups of patients. We compared early clinical outcomes in propensity-matched cohorts of patients with non-dialysis-dependent pre-operative severe renal impairment undergoing OPCABG vs. ONCABG, captured in a large national registry dataset. All data for patients with a pre-operative creatinine clearance of less than 50 mL/min who underwent elective or urgent isolated OPCABG or ONCABG from 1996 to 2019 were extracted from the UK National Adult Cardiac Surgery Audit (NACSA) database. Propensity score matching was performed using 1:1 nearest neighbor matching without replacement using several baseline characteristics. We investigated the effect of ONCABG vs. OPCABG in the matched cohort using cluster-robust standard error regression. We identified 8,628 patients with severe renal impairment undergoing isolated CABG, of whom 1,142 (13.23%) underwent OPCABG during the study period. We compared 1,141 propensity-matched pairs of patients undergoing OPCABG vs. ONCABG. The median age of the matched population was 78 years in both groups, with no significant imbalance post-matching in the rest of the variables. There was no difference between OPCABG and ONCABG in in-hospital mortality rates, post-operative dialysis, and stroke rates. However, the return to theatre for bleeding or tamponade was higher in ONCABG vs. OPCABG (P > 0.02); however, OPCABG reduced the total length of stay in the hospital by 1 day (P = 0.008). After double adjustment in the matched population using cluster-robust standard regression, ONCABG did not increase mortality compared to OPCABG (OR, 1.05, P = 0.78), postoperative stroke (OR, 1.7, P = 0.12), and dialysis (OR, 0.7, P = 0.09); however, ONCABG was associated with an increased risk of bleeding (OR, 1.53, P = 0.03). In this propensity analysis of a large national registry dataset, we found no difference in early mortality and stroke in patients with pre-operative severe renal impairment undergoing OPCABG or ONCABG surgery; however, ONCABG was associated with an increased risk of return to theatre for bleeding and an increased length of hospital stay.

Determinants of survival following heart transplantation in adults with congenital heart disease

BackgroundAdult patients surviving with congenital heart disease (ACHD) is growing. We examine the factors associated with heart transplant outcomes in this challenging population with complex anatomy requiring redo-surgeries.MethodsWe reviewed the United Network for Organ Sharing-Standard Transplant Analysis and Research database and analyzed 35,952 heart transplants from January 1st, 2000, to September 30th, 2018. We compared transplant characteristics for ischemic cardiomyopathy (ICM) (n = 14,236), nonischemic cardiomyopathy (NICM) (n = 20,676), and ACHD (n = 1040). Mean follow-up was 6.20 ± 4.84 years. Kaplan–Meier survival curves and Cox-proportional hazards analysis were used to analyze survival data.ResultsMultivariable analysis confirmed that ACHD was associated greater in-hospital death compared to ICM (HR = 0.54, P < 0.001) and NICM (HR = 0.46, P < 0.001). Notable factors associated with increased mortality were history of cerebrovascular disease (HR = 1.11, P = 0.026), prior history of malignancy (HR = 1.12, P = 0.006), pre-transplant biventricular support (HR = 1.12, P = 0.069), postoperative stroke (HR = 1.47, P < 0.001) and postoperative dialysis (HR = 1.71, P < 0.001). ACHD transplants had a longer donor heart ischemic time (P < 0.001) and trend towards more deaths from primary graft dysfunction (P = 0.07). In-hospital deaths were more likely with ACHD and use of mechanical support such as use of right ventricular assist device (HR = 2.20, P = 0.049), biventricular support (HR = 1.62, P < 0.001) and extracorporeal membrane oxygenation (HR = 2.36, P < 0.001). Conditional survival after censoring hospital deaths was significantly higher in ACHD (P < 0.001).ConclusionHeart transplant in ACHD is associated with a higher post-operative mortality given anatomical complexity but a better long-term conditional survival. Normothermic donor heart perfusion may improve outcomes in the ACHD population by reducing the impact of longer ischemic times.