Postoperative Stroke Research Articles

The Importance of the Circle of Willis in Carotid Interventions Outcomes: A Real-Life Study

ObjectiveThe main objective of this study is to evaluate and compare the outcomes regarding operative mortality rate, ipsilateral stroke and overall survival rate among patients with internal carotid artery (ICA) stenosis submitted to carotid endarterectomy or stenting regarding the completeness of Circle of Willis (CoW). MethodsProspective, consecutive cohort study of patients submitted to carotid interventions (carotid endarterectomy – CEA - and carotid stenting - CAS) for ICA stenosis diagnosis evaluated according complete or incomplete CoW. The patients were divided into two groups: group I - the patients with complete CoW and group II - the patients with incomplete CoW, with the disruption of anterior and/ or ipsilateral posterior circulation, regarding the ipsilateral significant carotid stenosis. ResultsOverall, 98 patients submitted to carotid intervention were evaluated. Two groups of patients were identified: group CoW complete with 54 patients and group CoW incomplete with 44 patients. Regarding the type of intervention, the prevalence of CAS in CoW complete group and CoW incomplete group were statistically similar (54.1% versus 55.1%, p = 0.22). Notwithstanding, CEA was also statistically similar in CoW incomplete group and CoW complete group (44.2% versus 45.9%, p = 0.22). The perioperative mortality rate was 2% in total cohort (2 patients), with no differences among CoW complete and incomplete groups (3.7% versus 0%, p = 0.50, respectively). Furthermore, the incidence of post-operative stroke was 3.1% (asymptomatic 2%, symptomatic 1.1%), with no differences among CoW complete and incomplete groups (3.7% versus 2.3%, p = 0.68, respectively). A univariate and multivariate linear regression showed that among the factors evaluated, only chronic kidney failure was related with HR = 1.89, p = 0.003, CI 1.058-2.850. ConclusionThe completeness of the CoW, independently of the type of carotid intervention (CEA and CAS), did not interfere in the results regarding postoperative outcomes for stroke and death. Chronic Kidney disease was associated to increased risk of perioperative stroke.

Discovery of plasma proteome markers associated with clinical outcome and immunological stress after cardiac surgery.

Molecular mechanisms underlying perioperative acute phase reactions in cardiac surgery are largely unknown. We aimed to characterise perioperative alterations of the acute phase plasma proteome in a cohort of adult patients undergoing on-pump cardiac surgery using high-throughput mass spectrometry and to identify candidate proteins potentially relevant to postoperative clinical outcome through a novel, multi-step approach. This study is an analysis of the Bern Perioperative Biobank, a prospective cohort of adults who underwent cardiac surgery with the use of cardiopulmonary bypass (CPB) at Bern University Hospital between January and December 2019. Blood samples were taken before induction of anaesthesia and on postoperative day one. Proteomic analyses were performed by mass spectrometry. Through a multi-step, exploratory approach, hit-proteins were first identified according to their perioperative prevalence and dynamics. The set of hit-proteins were associated with predefined clinical outcome measures (all-cause one-year mortality, length of hospital stay, postoperative myocardial infarction and stroke until hospital discharge). 192 patients [75.5% male, median age 67.0 (IQR 60.0-73.0)] undergoing cardiac surgery with the use of CPB were included in this analysis. In total, we identified and quantified 402 proteins across all samples, whereof 30/402 (7%) proteins were identified as hit-proteins. Three hit-proteins-LDHB, VCAM1 and IGFBP2-demonstrated the strongest associations with clinical outcomes. After adjustment both for age, sex, BMI and for multiple comparisons, the scaled preoperative levels of IGFBP2 were associated with 1-year all-cause mortality (OR 10.63; 95% CI: 2.93-64.00; p = 0.046). Additionally, scaled preoperative levels of LDHB (OR 5.58; 95% CI: 2.58-8.57; p = 0.009) and VCAM1 (OR 2.32; 95% CI: 0.88-3.77; p = 0.05) were found to be associated with length of hospital stay. We identified a subset of promising candidate plasma proteins relevant to outcome after on-pump cardiac surgery. IGFBP2 showed a strong association with clinical outcome measures and a significant association of preoperative levels with 1-year all-cause mortality. Other proteins strongly associated with outcome were LDHB and VCAM1, reflecting the dynamics in the acute phase response, inflammation and myocardial injury. We recommend further investigation of these proteins as potential outcome markers after cardiac surgery. ClinicalTrials.gov; NCT04767685, data are available via ProteomeXchange with identifier PXD046496.

Detrimental effect of anemia after mechanical thrombectomy on functional outcome in patients with ischemic stroke.

Anemia can occur due to an aspiration maneuver of blood with thrombi during mechanical thrombectomy (MT) for stroke. However, the association between postoperative anemia and stroke outcomes is unknown. In a registry-based hospital cohort, consecutive patients with acute ischemic stroke who underwent MT were retrospectively recruited. Patients were divided into the following three groups according to their hemoglobin (Hb) concentrations within 24 h after MT; no anemia (Hb concentrations ≥13 g/dL for men and ≥ 12 g/dL for women), mild anemia (Hb concentrations of 11-13 g/dL and 10-12 g/dL, respectively), and moderate-to-severe anemia (Hb concentrations <11 g/dL and < 10 g/dL, respectively). A 3-month modified Rankin Scale score of 0-2 indicated a favorable outcome. Of 470 patients, 166 were classified into the no anemia group, 168 into the mild anemia group, and 136 into the moderate-to-severe anemia group. Patients in the moderate-to-severe anemia group were older and more commonly had congestive heart failure than those in the other groups. Patients in the moderate-to-severe anemia group also had more device passes than those in the other groups (p < 0.001). However, no difference was observed in the rate of final extended thrombolysis in cerebral infarction ≥2b reperfusion or intracranial hemorrhage among the groups. A favorable outcome was less frequently achieved in the moderate-to-severe anemia group than in the no anemia group (adjusted odds ratio, 0.46; 95% confidence interval, 0.26-0.81) independent of the baseline Hb concentration. A restricted cubic spline model with three knots showed that the adjusted odds ratio for a favorable outcome was lower in patients with lower Hb concentrations within 24 h after MT. Moderate-to-severe anemia within 24 h after MT is independently associated with a reduced likelihood of a favorable outcome. https://www.clinicaltrials.gov, NCT02251665.

Risk of Postoperative Ischemic Stroke and Myocardial Infarction in Patients Operated for Cancer.

Risk assessment for ischemic stroke (IS) and myocardial infarction (MI) is done routinely before surgery, but the increase in risks associated with surgery is not known. The aim of this study is to assess the risk of arterial ischemic events during the first year after oncological surgery. We used Swedish healthcare databases to identify 443,300 patients who underwent cancer surgery between 1987 and 2016 and 4,127,761 matched comparison subjects. We estimated odds ratios (ORs) for myocardial infarction and ischemic stroke during the hospitalization with logistic regression and calculated 1-year cumulative incidences and hazard ratios (HRs) with 95% confidence intervals (CIs) for the outcomes after discharge. The cumulative incidences of myocardial infarction and ischemic stroke during the first postoperative year were 1.33% and 1.25%, respectively. In the comparison cohort, the corresponding 1-year cumulative incidences were 1.04% and 1.00%. During the hospitalization, the OR for myocardial infarction was 8.81 (95% CI 8.24-9.42) and the OR for ischemic stroke was 6.71 (95% CI 6.22-7.23). After discharge, the average HR during follow-up for 365 days was 0.90 (95% CI 0.87-0.93) for myocardial infarction and 1.02 (95% CI 0.99-1.05) for ischemic stroke. We found an overall increased risk of IS and MI during the first year after cancer surgery that was attributable to events occurring during the hospitalization period. After discharge from the hospital, the overall risk of myocardial infarction was lower among the cancer surgery patients than among matched comparison subjects.

Managing post-operative stroke following cardiac surgery

Managing post-operative stroke following cardiac surgery

Stroke After Acute Type A Dissection Repair Using Right Axillary Cannulation First Approach

BackgroundThis study sought to analyze the details of strokes after acute type A dissection repair (ATAD) using a right axillary artery (RAX) first approach. MethodsA total of 356 consecutive ATAD repairs from 2005 to 2022 were analyzed on the basis of arterial cannulation site. Strokes were evaluated by head computed tomography. ResultsThe rate of RAX cannulation was 82.6% (n = 294), with a 38.2% rate of antegrade cerebral perfusion use, both of which had increased over the years. The non-RAX group had more cardiogenic shock (RAX, 16.3% vs non-RAX, 37.1%; P < .001), cerebral malperfusion (8.8% vs 25.8%, respectively; P < .001), and innominate artery dissection (45.9% vs 69.2%, respectively; P = .007). Eight patients died before undergoing a full neurologic assessment. The overall stroke rate was 8.4% (n = 30), and it was lower in the RAX group (5.1% vs 24.2%; P < .001). All strokes were ischemic, with concomitant hemorrhagic strokes occurring in 6 patients. Strokes diagnosed immediately after surgery (perioperative stroke) accounted for 70% (n = 21 of 30) of cases. Strokes predominantly affected the right anterior circulation (right anterior, 80% vs left anterior, 46.7% vs left posterior, 26.7%; P = .013), independent of arterial cannulation site. The proposed mechanism of perioperative strokes was not uniform (embolism, 33.3%; hypoperfusion, 42.8%; embolism and hypoperfusion, 14.3%; lacunar infarct, 10%), whereas most postoperative strokes were embolic (77.8%). The mean National Institutes of Health Stroke Scale score was 20.6 ± 9.9, and the modified Rankin score at discharge was 4.1±2.2. ConclusionsMost strokes in ATAD occurred perioperatively from various mechanisms predominantly affecting the right anterior circulation irrespective of the arterial cannulation site. This complication is most likely the result of unstable hemodynamics and dissection of the innominate artery (IA) or its downstream vessels.

Clinical Features and Risk Factors of Postoperative Stroke in Adult Moyamoya Disease.

The clinical features of and risk factors for postoperative stroke after surgical revascularization in adult moyamoya disease (MMD) have not been fully elucidated. To this end, the baseline clinical features were hereby described, and the risk factors for postoperative stroke were determined. Data of 4078 MMD inpatients were collected retrospectively across all secondary- and higher-level hospitals of Hubei Province from January 2019 to December 2020. In accordance with inclusion and exclusion criteria, 559 adult MMD inpatients were finally enrolled. The associated characteristics and potential risk factors were analyzed, and the Kaplan-Meier risk of stroke was also calculated. The patients consisted of 286 females and 273 males, with a mean age of 49.1 ± 10.0 years, all of whom had at least 1 year of follow-up (median 25.1 months). There were 356 cases of preoperative ischemic symptoms and 203 cases of preoperative hemorrhage symptoms. Indirect, direct, and combined revascularization were conducted on 97, 105 and 357 patients, respectively. Among these patients, 17 had postoperative hemorrhagic stroke (PHS), and 43 had postoperative ischemic stroke (PIS). A comparison between PHS/PIS group and control group (patients without postoperative stroke events) showed that preoperative hemorrhage was significantly associated with PHS (p = 0.003), while hypertension (p = 0.003), diabetes mellitus (p = 0.003) and modified Rankin scale (mRS) (p = 0.034) at admission were associated with a higher rate of PIS. Furthermore, preoperative hemorrhagic stroke was identified as a risk factor for PHS (odds ratio [OR], 4.229 [95% CI, 1.244-14.376]; p = 0.021), while hypertension (odds ratio [OR], 0.424 [95% CI, 0.210-0.855]; p = 0.017), diabetes mellitus (odds ratio [OR], 0.368 [95% CI, 0.163-0.827]; p = 0.016) and admission mRS (odds ratio [OR], 2.301 [95% CI, 1.157-4.575]; p = 0.017) were found to be risk factors for PIS. The age distribution of adult MMD patients with revascularization was predominantly concentrated within the range from 46 to 55 years. Preoperative hemorrhage events were considered the risk factor for PHS. Hypertension, diabetes and admission mRS were correlated with PIS, and were also the risk factors for PIS. These results indicated the possible contribution of enhancing systematic disease management to the prevention of postoperative cerebrovascular accidents.

The role of carotid artery stenosis in predicting stroke after coronary artery bypass grafting in a Chinese cohort study

Current guidelines give priority to surgical treatment of carotid artery stenosis (CAS) before coronary artery bypass grafting (CABG), especially in symptomatic patients. Carotid artery stenting is an alternative treatment for narrowing of the carotid arteries. This study sought to demonstrate the role of severe CAS in predicting stroke after CABG and assess the efficacy of carotid artery stenting in preventing postoperative stroke in a Chinese cohort. From 2015 to 2021, 1799 consecutive patients undergoing isolated CABG surgery were retrospectively recruited in a Chinese cohort. The predictive value of severe CAS in postoperative stroke and carotid stenting in preventing postoperative stroke was statistically analyzed. The incidence of postoperative stroke was 1.67%. The incidence of CAS with stenosis ≥ 50% and ≥ 70% was 19.2% and 6.9%. After propensity matching, the incidence of stroke was 8.0% in the severe CAS group and 0% in the non-severe CAS group. We successfully established an optimal predictive nomogram for predicting severe CAS in patients undergoing CABG. Carotid artery stenting was found ineffective in preventing postoperative stroke. The present study provides the incidence of CAS and postoperative stroke in a Chinese cohort, identifies severe CAS as an independent risk factor for postoperative stroke after CABG, constructs a nomogram predicting the incidence of severe CAS, and evaluates the effectiveness of carotid artery stenting in preventing postoperative stroke after CABG.

Predictors associated with stroke after coronary artery bypass grafting in Turkish population

Background Objective: Postoperative stroke is a serious adverse event, a major cause of morbidity and mortality after coronary artery bypass grafting (CABG). This study is designed to determine the incidence of stroke after CABG and to identify the preoperative, intraoperative and postoperative risk factors associated with the development of a stroke. Methods: Between January 2019 and December 2022, 1.555 CABG were performed. Retrospective analysis of the patient files revealed that 24 (1.48%) patients had stroke in the postoperative period. Variables were compared with patients without neurological deficits (n=50) who had undergone CABG. Predictors of preoperative, intraoperative and postoperative stroke were identified. Results: The incidence of postoperative stroke was 1.48% (n=24). Mean age of these patients was 63.86 ± 8.58 years, and 59 (79.7%) were males. Chronic renal failure (p= 0.011), previous CABG (p=0.009), carotid artery disease (p=0.009), CRP levels (p=0.004) and Monocyte/Lymphocyte ratio (p=0.019) were identified as important preoperative risk factors for stroke development but there were no diffirence prevalence of age, sex, diabetes, hypertension, congestive heart failure and atrial fibrillation. Conclusion: Five variables (chronic renal failure, prior CABD, prior carotid artery disease, preoperative CRP levels and Monocyte/Lymphocyte ratio were found as risk factors for stroke after CABG. The development of postoperative stroke is associated with multiple morbidities and increased mortality. Careful assessment and management of risk factors should be implemented to reduce this important complication after CABG.

Incidence, risk factors, and outcomes of postoperative stroke in combined heart-lung transplantation: A retrospective cohort study of the UNOS registry.

Stroke is a well-characterized complication of isolated heart and lung transplantation, but has not been described in combined heart-lung transplantation (HLTx). We retrospectively reviewed national U.S. data to describe the incidence, risk factors, and impact of postoperative stroke in HLTx recipients. Of 871 heart-lung recipients between 1994-2022, 35 (4.0%) experienced stroke, and the incidence increased over time, trending toward significance (p-trend=.07). After adjustment, extracorporeal membrane oxygenation (ECMO) (Adjusted odds ratio [aOR]=2.63, 95%CI=[1.13-6.11]) and pre-transplant implantable defibrillator (aOR=2.86, 95%CI=[1.20-6.81]) were independent risk factors for stroke. Postoperative stroke is common and is increasing in an era where organ allocation is driven by mechanical circulatory support (MCS) bridging.

Off-pump vs. on-pump bypass surgery grafting in diabetic patients with three-vessel disease: a propensity score matching study

BackgroundControversy exists regarding the advantages and risks of off-pump vs. on-pump coronary artery bypass grafting (CABG) for patients with diabetes. We therefore compare the early clinical outcomes of off-pump vs. on-pump procedures for diabetic patients with three-vessel disease.Materials and methodsWe conducted a retrospective analysis of clinical data obtained from 548 diabetic patients with three-vessel coronary artery disease who underwent isolated CABG between January 2016 and June 2020. To adjust the differences of baseline characteristics between the off-pump CABG (OPCAB) and on-pump CABG (ONCAB) groups, propensity score matching (PSM) was used. Following 1:1 matching, we selected 187 pairs of patients for further comparison of outcomes within the first 30 days after surgery.ResultsThe preoperative characteristics of the patients between the two groups were clinically comparable after PSM. The OPCAB group exhibited a significantly higher incidence of incomplete revascularization (27.3% vs. 14.4%; P = 0.002) compared with the ONCAB group. No differences were seen in mortality within 30 days between the matched groups (1.1% vs. 3.7%; P = 0.174). Notably, the OPCAB group had a lower risk of respiratory failure or infection (2.1% vs. 7.0%; P = 0.025), less postoperative stroke (1.1% vs. 4.8%; P = 0.032), and reduced postoperative ventilator assistance time (35.8 ± 33.7 vs. 50.9 ± 64.8; P = 0.005).ConclusionOPCAB in diabetic patients with three-vessel disease is a safe procedure with reduced early stroke and respiratory complications and similar mortality rate, myocardial infarction, and renal failure requiring dialysis to conventional on-pump revascularization.

Bicuspid Morphology and Rapid Deployment Valve Replacement: Is This Still a Contraindication?

When using rapid deployment surgical aortic valve replacement (RD SAVR) in treating bicuspid aortic valve morphology (BAV), several challenges are faced due to annular asymmetry. The Sievers classification has been traditionally used for the description of BAV morphology. In this study, we aimed to conduct a retrospective feasibility analysis of RD SAVR in relation to the Sievers classification. From January 2014 to March 2022, 31 patients with BAV morphology (15 patients with Sievers type 0 BAV and 16 with Sievers type 1 BAV) underwent RD SAVR. Specific surgical techniques were applied depending on the BAV morphology. Comparable clinical outcomes were observed. No paravalvular leaks and no valvular re-interventions occurred in either group. CPB and cross-clamping times, as well as the prosthesis sizes used, were also not significantly different. Postoperative mean gradients were comparable in both groups. No significant distinction was found between the groups in terms of postoperative pacemaker indication, postoperative stroke, or death. Annular symmetry can be adequately restored through precise prosthesis sizing and placement according to an individual’s valve morphology regardless of the Sievers classification of BAV by choosing a different landmark for the initial suture. RD SAVR seems to be a safe approach for any bicuspid morphology, with good hemodynamic results and time-saving potential in experienced hands.

Prevalence and adverse outcomes of pre-operative frailty in patients undergoing carotid artery revascularization: a meta-analysis

IntroductionFrailty can lead to a decrease in the patient's resistance to interference such as injury and disease, and cause a series of complications. An increasing number of studies have found that pre-operative frailty exacerbates the occurrence of adverse events after carotid artery revascularization, but an integrated quantitative analysis is currently lacking. Therefore, we conducted a meta-analysis to evaluate the impact of pre-operative frailty on patients undergoing carotid artery revascularization.MethodAccording to the PRISMA guidelines, we systematically searched for relevant studies on Medline, Embase, Ovid, CINAHL, Web Of Science, and Cochrane Library from establishment until June 2023. Summarize the risk of adverse outcome events through OR and 95% CI.ResultsA total of 16 cohort studies were included, including 1692338 patients. Among patients who underwent carotid artery revascularization surgery, the prevalence of pre-operative frailty was 36% (95% CI = 0.18–0.53, P &amp;lt; 0.001). Compared with non frail individuals, frail individuals have an increased risk of mortality (OR = 2.35, 95% CI = 1.40–3.92, P = 0.001, I2 = 94%), stroke (OR = 1.33, 95% CI = 1.10–1.61, P = 0.003, I2 = 71%), myocardial infarction (OR = 1.86, 95% CI = 1.51–2.30, P &amp;lt; 0.001, I2 = 61%), and non-home discharge (OR = 2.39, 95% CI = 1.85–3.09, P &amp;lt; 0.001, I2 = 63%).ConclusionThe results of this article show that patients undergoing carotid artery revascularization have a higher prevalence of pre-operative frailty, which can lead to an increased risk of postoperative death, stroke, myocardial infarction, and non-home discharge. Strengthening the assessment and management of frailty is of great significance for patient prognosis.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=416234, identifier: CRD42023416234.

Operative Repair of Type A Aortic Dissection in Jehovah’s Witnesses: Insights From a Case Series

BackgroundJehovah’s Witnesses are known to refuse allogeneic blood products. Consequently, many surgeons will decline to perform aortic surgery on this patient group, given their higher risk. We present here a case series describing operative repair of type A aortic dissection without the use of allogeneic blood products. MethodsFrom 2018 to 2021, 6 Jehovah’s Witness patients underwent open repair of type A aortic dissection. We reviewed preoperative characteristics, diagnostic workup, operative technique, and postoperative outcomes. We also looked specifically at use of autologous whole blood, Cell Saver (Haemonetics) transfusion, synthetic clotting factors (recombinant factor VIIa), and albumin and prothrombin complex concentrate when allowed. ResultsModified hemiarch replacement was performed with the branched single-anastomosis frozen elephant trunk repair (B-SAFER) technique in 4 patients; 2 patients received a standard hemiarch replacement. Aortic valve replacement was performed in 2 patients; root replacement was performed in 1 patient. There were no immediate postoperative coronary complications, strokes, or instances of renal failure. Average decrease in hemoglobin concentration after surgery was 2.3 ± 1.5 g/dL (mean ± SD). Thirty-day mortality was 0. Five of 6 patients survived to discharge, and all survivors to discharge were still alive at the time of submission. ConclusionsBloodless aortic dissection repair in these rare patients can be performed safely in specialized centers using the techniques described. Furthermore, we believe that these techniques can be applied to the general population of patients undergoing emergent cardiac operation to avoid allogeneic transfusions.

Perioperative Right Ventricular Dysfunction and Abnormalities of the Tricuspid Valve Apparatus in Patients Undergoing Cardiac Surgery.

Right ventricular (RV) dysfunction frequently occurs after cardiac surgery and is linked to adverse postoperative outcomes, including mortality, reintubation, stroke, and prolonged ICU stays. While various criteria using echocardiography and hemodynamic parameters have been proposed, a consensus remains elusive. Distinctive RV anatomical features include its thin wall, which presents a triangular shape in a lateral view and a crescent shape in a cross-sectional view. Principal causes of RV dysfunction after cardiac surgery encompass ischemic reperfusion injury, prolonged ischemic time, choice of cardioplegia and its administration, cardiopulmonary bypass weaning characteristics, and preoperative risk factors. Post-left ventricular assist device (LVAD) implantation RV dysfunction is common but often transient, with a favorable prognosis upon resolution. There is an ongoing debate regarding the benefits of concomitant surgical repair of the RV in the presence of regurgitation. According to the literature, the gold standard techniques for assessing RV function are cardiac magnetic resonance imaging and hemodynamic assessment using thermodilution. Echocardiography is widely favored for perioperative RV function evaluation due to its accessibility, reproducibility, non-invasiveness, and cost-effectiveness. Although other techniques exist for RV function assessment, they are less common in clinical practice. Clinical management strategies focus on early detection and include intravenous drugs (inotropes and vasodilators), inhalation drugs (pulmonary vasodilators), ventilator strategies, volume management, and mechanical support. Bridging research gaps in this field is crucial to improving clinical outcomes associated with RV dysfunction in the near future.

Tranexamic Acid Is Safe in Patients with a History of Venous Thromboembolism Undergoing Total Joint Arthroplasty.

Tranexamic acid (TXA) is increasingly utilized during total knee arthroplasty (TKA) and total hip arthroplasty (THA) to decrease blood loss; however, there are concerns with regard to potential thromboembolic complications, particularly in high-risk patients. This study sought to define a subset of patients at elevated risk for thromboembolic complications following total joint arthroplasty (TJA) and to compare postoperative outcomes between patients who received TXA and those who did not. Patients who underwent primary, elective TJA from 2015 to 2021 were identified in the Premier Healthcare Database. Patients with a history of venous thromboembolism, defined as a history of pulmonary embolism or deep vein thrombosis, were identified and formed the high-risk cohort. Patient demographic characteristics, hospital factors, patient comorbidities, antithrombotic medication use, perioperative blood transfusion, and 90-day complications were assessed and compared between patients who received TXA and those who did not. Univariate regression and multivariable regression were performed to account for potential confounders. The high-risk cohort comprised 70,759 patients who underwent TJA, of whom 46,074 (65.1%) received TXA and 24,685 (34.9%) did not. After controlling for confounding factors, patients in the TXA cohort had similar risks of pulmonary embolism (adjusted odds ratio [OR], 0.90 [95% confidence interval (CI), 0.79 to 1.02]; p = 0.097), stroke (adjusted OR, 0.97 [95% CI, 0.69 to 1.37]; p = 0.867), and myocardial infarction (adjusted OR, 0.93 [95% CI, 0.69 to 1.24]; p = 0.614) compared with patients who did not receive TXA. Patients who received TXA demonstrated decreased risks of transfusion (adjusted OR, 0.42 [95% CI, 0.38 to 0.46]; p < 0.001) and 90-day readmission (adjusted OR, 0.87 [95% CI, 0.80 to 0.94]; p < 0.001). TXA utilization was not associated with an increased risk of postoperative pulmonary embolism, stroke, or myocardial infarction in patients with a history of venous thromboembolism. Furthermore, patients who received TXA had a decreased risk of transfusion and readmission. This evidence suggests that TXA may be safely utilized among select high-risk patients. Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

The anemia conundrum in contemporary redo cardiac surgery

Abstract Aims Preoperative anemia has been associated with increased morbidity and mortality after cardiac surgery, but little is known on its prognostic value in the setting of redo procedure. This study aimed to investigate whether preoperative anemia is an independent determinant of adverse events in this augmented risk patients subset. Methods A retrospective, observational, cohort study of prospectively collected data was undertaken on 409 consecutive patients referred for redo cardiac procedures between January 2011 and December 2020 (mean age of 62 ± 12.7 years, octogenarians 5.6%, female sex 52.8%, diabetes 19.5%, chronic kidney disease 30%, urgent/emergent status 34.8%, third-time sternotomy 9.8%). The EuroSCORE II calculated an average mortality risk of 25.7 ± 15.4%. The prevalence of preoperative anemia (according to World Health Organization definition) and its relationships with postoperative morbidity were obtained. Selection bias was assessed with propensity-adjustment method. Results The prevalence of preoperative anemia was 41%. In unmatched analysis, significant differences between the anemic and non-anemic group emerged in the risk of postoperative stroke (0.6% vs 4.4%, p = 0.023), postoperative renal dysfunction (29,7% vs 15.6%, p = 0.001), need for prolonged ventilation (18.1% vs 7.2%, p = 0.002), high dosage inotropes (53.1% vs 32.9%, p &amp;lt; 0.001) along with both length of ICU and hospital stay (8.2±15.9 vs 4.3±5.4 days, p=0.003 and 18.8±17.4 vs 14.9±11.1, p=0.012 ). After propensity matching (143 pairs), preoperative anemia was still significantly associated with postoperative renal dysfunction, stroke and need for high dosage inotropes cardiac morbidity. Anemia proved also a significant predictor of acute kidney injury at univariate analysis. Conclusions Preoperative anemia is significantly associated with acute kidney injury, stroke and need for high dosage inotropes in patients referred for redo procedures. Further studies are warranted to determine whether preoperative low hemoglobin concentration is a marker of severity of illness or a modifiable risk factor.

Acute Aortic Dissection Type A in Younger Patients (< 60 Years Old) - Does Full Arch Replacement Provide Benefits Compared to Limited Approach?

Acute aortic dissection Stanford type A (AADA) is a surgical emergency associated with high morbidity and mortality. Although surgical management has improved, the optimal therapy is a matter of debate. Different surgical strategies have been proposed for patients under 60 years old. This paper evaluates the postoperative outcome and the need for secondary aortic operation after a limited surgical approach (proximal arch replacement) vs. extended arch repair. Between January 2000 and January 2018, 530 patients received surgical treatment for AADA at our hospital; 182 were under 60 years old and were enrolled in this study - Group A (n=68), limited arch repair (proximal arch replacement), and group B (n=114), extended arch repair (> proximal arch replacement). More pericardial tamponade (P=0.005) and preoperative mechanical resuscitation (P=0.014) were seen in Group A. More need for renal replacement therapy (P=0.047) was seen in the full arch group. Mechanical ventilation time (P=0.022) and intensive care unit stay (P<0.001) were shorter in the limited repair group. Thirty-day mortality was comparable (P=0.117). New onset of postoperative stroke was comparable (Group A four patients [5.9%] vs. Group B 15 patients [13.2%]; P=0.120). Long-term follow-up did not differ significantly for secondary aortic surgery. Even though young patients received only limited arch repair, the outcome was comparable. Full-arch replacement was not beneficial in the long-time follow-up. A limited approach is justified in the cohort of young AADA patients. Exemptions, like known Marfan syndrome and the presence of an intimal tear in the arch, should be considered.

Abstract 16591: Surgical vs Non-surgical Repair of Aortic Arch in Type A Aortic Dissection: An Inverse Probability Treatment Weighting Propensity Score

Introduction: Several surgical techniques are used in acute type A aortic dissection (TAAAD). Most are treated with hemiarch or limited replacement of the ascending aorta with interposition graft while total aortic arch replacement is less frequently performed. The research question/hypothesis: Is total arch replacement justified by the favourable late outcomes despite early complications? Aims: To evaluate if conservative approaches (root-sparing and hemiarch) can improve the early and late outcomes compared to total arch replacement. Methods: From 2005 and 2021, 633 patients underwent TAAAD repair of which 192(30.0%) were women. The ascending aorta replacement with/without root-sparing (group 1) were compared to the partial or total arch replacement cohort (group 2) using propensity score matching. A regression model with inverse probability treatment weighting by propensity score (IPTW) was built to generate a weighted cohort. Results: Patients undergoing aortic arch surgery were significantly younger (mean age 61.0 vs 66.5years; p&lt;0.001), frequently male (70%) or with a family history of aortic dissection or aneurysm (P=0.005). Antegrade cerebral perfusion was preferred when arch surgery was performed (83.5% vs33.8%, P&lt;0.001). Post-IPTW by propensity score analysis revealed that aortic arch surgery was associated with thirty-day mortality (odds ratio 1.60; 95% CI, 1.00-2.55, p=0.05), postoperative stroke (odds ratio 2.19; 95% CI, 1.29-3.73, P=0.004), postoperative sepsis (odds ratio 1.76; 95% CI,1.08-2.87, P=0.02) and mid-term mortality (hazard ratio 1.44, 95% CI, 1.05-1.99, p=0.03). Conclusions: A tailored approach deploying ascending aorta replacement with or without root-sparing in TAAAD prompted to useful outcomes without compromising durability.

Endovascular Embolization for Epistaxis: A Single Center Experience and Meta-Analysis.

The optimal treatment for intractable epistaxis is still controversial. Various studies have demonstrated high success rates and low complication rates for endovascular embolization. Herein, the authors report an institutional experience and meta-analysis in terms of efficacy and safety of endovascular embolization of intractable epistaxis. This was a retrospective observational study of 35 patients with epistaxis who underwent 40 embolization procedures between 2010 and 2023. The primary outcome was immediate success defined by immediate cessation of epistaxis at the end of the procedure. Immediate success was achieved in most of the procedures (39, 97.5%). During follow-up, three (7.5%) patients experienced a rebleed. Forty-one studies from 3595 articles were identified for inclusion in the meta-analysis and comprised 1632 patients. The mean pooled age was 57.5 years (95% CI: 57.2-57.8) and most patients were males (mean: 70.4, 95% CI: 69.8-71.0). Immediate success was achieved at a pooled mean of 90.9% (95% CI: 90.4-91.4) and rebleeding was observed at a pooled mean of 17% (95% CI: 16.5-17.5). In conclusion, endovascular embolization proved to be both safe and effective in treating intractable epistaxis carrying a low risk of post-operative stroke.