Re-exploration For Bleeding Research Articles

Analysis of the hemostatic effect of preset wrapping technique for type A aortic dissection with abnormal coagulation.

There are many techniques to reduce anastomotic bleeding for the total arch replacement, but hemostasis is sometimes difficult to achieve after surgery for acute dissection, especially in patients with abnormal coagulation (AC). This study aimed to investigate the hemostatic effect and early efficacy of a pre-set bovine pericardium wrapper in the right heart system shunt for total arch replacement in patients with type A aortic dissection (TAAD) and preoperative AC. A retrospective analysis was conducted on 85 patients with TAAD and AC who underwent total arch replacement between January 2018 and December 2022. The patients were divided into two groups: the preset pericardium group (n=30) and the control group (n=55). There were no significant differences between the two groups in terms of Bentall surgery (ascending aorta replacement with an aortic valve artificial vessel) and cardiac arrest time. However, compared to the control group, the preset pericardium group exhibited a shorter duration of cardiopulmonary bypass (CPB) and operation (P<0.001). Additionally, the preset pericardium group required fewer transfusions of blood products and hemostatic drugs (P<0.05). Moreover, the preset pericardium group had lower 24-hour postoperative mediastinal drainage volume (P<0.001), a lower proportion of bedside hemofiltration (P=0.039), and a shorter duration of mechanical ventilation and stay in the intensive care unit (P=0.014). Although the preset pericardium group showed reductions in in-hospital mortality, re-exploration for bleeding, and neurologic dysfunction, these differences were not statistically significant compared to the control group. This study represents the first investigation into the application of the preset wrapping technique in total arch replacement for TAAD with AC. The results demonstrate that this method can reduce the duration of CPB and operation, decrease postoperative bleeding, and minimize the need for blood transfusion and hemostatic drugs. Consequently, this technique may contribute to early postoperative recovery.

Abstract 11695: Long-Term Clinical Outcomes of Minimally Invasive Aortic Valve Surgery in Patients With Aortic Valve Disease

Introduction: We aim to analyze multicenter long-term clinical outcomes of minimally invasive aortic valve replacement (MI-AVR) in patients with aortic valve disease. Hypothesis: We hypothesize that MI-AVR provides good long-term clinical outcomes in patients undergoing aortic valve surgery. Methods: All consecutive 1,972 patients undergoing MI-AVR with either ministernotomy (n= 986) or right anterior minithoracotomy (RAM, n=986) between 1999 and 2019, were included. Primary outcomes were all-cause mortality and cardiac death. Results: Preoperatively, mean age was 72.1 (±13.7) year-old, and mean STS-PROM risk score was 0.38%. Intraoperatively, mean operative time (min) was 213.97 (± 56.9), while 313 (15.9%) patients were converted to full sternotomy. Postoperatively, 69 (3.5%) patients had prolonged mechanical ventilation (&lt; 24 hours), 59 (3%) patients had re-exploration for bleeding, 10 (0.5%) patients had paravalvular leak (moderate/severe), 22 (1.1%) patients had non-fatal stroke, and 28 (1.4%) patients had non-fatal myocardial infarction. Mean intensive care unit stay was 14.45 (± 10.15) hours, and mean hospital length of stay (LOS) was 7 (± 3.5) days. Thirty-day all-cause mortality occurred in 39 (2%) patients while 30-day cardiac-death occurred in 23 (1.2%) patients. Thirty-day predictors for all-cause mortality included age &lt;75-years, post-operative LOS, peri-operative stroke, and RAM. Mean follow-up time was 10-years. At 20-year follow-up, all-cause death and CV-death incidence were 1156 (60%) and 170 (8.8%) patients, respectively. Valve-related deaths occurred in 33 (1.7%) patients. Long-term predictors for all-cause mortality included age &lt;75-years, chronic kidney failure, mechanical ventilation &lt;12 hours, RAM, and hospital LOS &lt;10 days. Conclusions: MI-AVR is a safe, valid, and reproducible surgical procedure for patients with aortic valve disease. In addition, it provides good long-term outcomes.

The Impact Of Active Chest Tube Clearance Technology On Surgical Outcomes After Cardiac Surgery: An Updated Systematic Review And Meta-Analysis.

Active chest tube clearance technology (ACT) systems were introduced to improve the patency of chest tubes and to reduce the potential complications associated with inadequate mediastinal blood drainage after cardiac surgical procedures. The purpose of this study is to assess the impact of ACT on the incidence of chest tube clogging, retained blood syndromes (RBS), re-exploration for bleeding, and the incidence of postoperative atrial fibrillation (POAF) after cardiac surgical procedures. A database search was conducted using Medline, Embase, Cochrane Library, and Web of Science. Only articles comparing the use of ACT to conventional chest tube drainage after cardiac surgery were screened. Included articles were restricted to adult patients and English language only. Nine of the 841 articles screened were included in this review. Two studies were randomized controlled trials (RCT) and seven were observational studies. Pooled estimates showed RBS, surgical re-exploration rates, and POAF were significantly less common in the ACT group. Our meta-analysis suggests that the use of ACT may be beneficial in reducing the incidence of postoperative complications associated with inadequate drainage of mediastinal blood after cardiac surgery. However, more robust evidence is required to endorse these findings and support the routing use of ACT in clinical practice.

Effect of minimally invasive versus conventional aortic root replacement on transfusion and postoperative wound complications in patients: A meta-analysis.

We examined whether small incision aortic root replacement could reduce the amount of blood transfusion during operation and the risk of postoperative complications. An extensive e-review of the 4 main databases (PubMed, Cochrane, Web of Science and EMBASE) was carried out to determine all the published trials by July 2023. The search terms used were associated with partial versus full sternotomy and aortic root. This analysis only included the study articles that compared partial and full sternotomy. After excluding articles based on titles or abstracts, selected full-text articles had reference lists searched for any potential further articles. We analysed a total of 2167 subjects from 10 comparable trials. The minimally invasive aortic root graft in breastbone decreased the duration of hospitalization (MD, -2.58; 95% CI, -3.15, -2.01, p < 0.0001) and intraoperative red blood cell transfusion (MD, -1.27; 95% CI, -2.34, -0.19, p = 0.02). However, there were no significant differences in wound infection (OR, 0.88; 95% CI, 0.16, 4.93, p = 0.88), re-exploration for bleeding (OR, 0.96; 95% CI, 0.60, 1.53, p = 0.86), intraoperative blood loss (MD, -259.19; 95% CI, -615.11, 96.73, p = 0.15) and operative time (MD, -7.39; 95% CI, -19.10, 4.32, p = 0.22); the results showed that the microsternotomy did not differ significantly from that of the routine approach. Small sternotomy may be an effective and safe substitute for the treatment of the aorta root. Nevertheless, the wide variety of data indicates that larger, well-designed studies are required to back up the current limited literature evidence showing a benefit in terms of complications like postoperative wound infections or the volume of intraoperative red blood cell transfusion.

Temporary venovenous extracorporeal membrane oxygenation after cardiopulmonary bypass in minimally invasive cardiac surgery via right minithoracotomy.

In minimally invasive cardiac surgery, it can be difficult at times to maintain adequate oxygenation with single-lung ventilation after weaning from cardiopulmonary bypass (CPB), and intermittent double-lung ventilation is required during hemostasis. Venovenous extracorporeal membrane oxygenation (VV-ECMO) after weaning from CPB eliminates the necessity of overinflation of the left lung and intermittent double-lung ventilation and enables secure and fast hemostasis. We investigated the effectiveness and safety of temporary VV-ECMO in MICS. Between May 2018 and March 2021, 149 patients underwent temporary VV-ECMO during minimally invasive cardiac surgery in our institutions. After weaning from CPB, the arterial circuit was reconnected to the right internal jugular venous cannula, the femoral venous cannula was pulled down by 20cm, and VV-ECMO was established using the CPB machine and cannulas. After starting VV-ECMO, we administered protamine and performed hemostasis. Operative data and outcomes were retrospectively reviewed. The mean VV-ECMO time and flow were 26 ± 13minutes and 2.38 ± 0.40L/m2, respectively. There was no thrombus in the CPB circuit, including the oxygenator. The trans-oxygenator pressure gradient index at the end of VV-ECMO significantly correlated with that at the start of VV-ECMO (r=0.88; 95% CI, 0.79-0.94; P=.01). The 30-day mortality rate was 2.0%. The incidences of unilateral pulmonary edema, prolonged ventilation, and re-exploration for bleeding were 2.7%, 5.4%, and 2.0%, respectively. Temporary VV-ECMO is safe and useful to maintain single-lung ventilation without overinflation after weaning from CPB for secure and fast hemostasis in minimally invasive cardiac surgery. No thrombotic event was found during temporary VV-ECMO without heparinization.

P63: Preemptive Temporary Right Ventricular Assist Device Implantation For Severe Biventricular Heart Failure: A Case Series

Purpose: We sought to investigate the clinical results of preemptive temporary right ventricular assist device (RVAD) placement with left ventricular assist device (LVAD) implantation for anticipated right ventricular failure. Methods: Patients at risk for right ventricular failure were identified by the heart team. After median sternotomy, Protec-duo (LivaNova, London, UK) dual-stage cannula was inserted from the right internal jugular vein under fluoroscopy guidance, and advanced into the pulmonary artery to the bifurcation of the main pulmonary artery. This was then connected to the venous drainage from the right atrium for cardio pulmonary bypass (CPB). After LVAD implantation, we connected the Protec-duo cannula to the RVAD with oxygenator, and weaned CPB (Figure). Results: A total of 11 patients have received BiVAD implantation with this technique. The median age of patients was 55 years [Interquartile range (IQR): 51 – 63.5] and all patients were male. 63.6 % (7/11) of the patients were INTERMACS profile 1 or 2. Preoperatively, the median pulmonary artery pulsatility index was 4.0 [1.5 – 4.9] and median right ventricular stroke work index was 454.1 g/m/beat/m2 [436.5 – 530.2]. Postoperatively, the oxygenators were removed on median postoperative day (POD) 3.5 [3 – 5]. Patients received mechanical ventilation for a median of 4 days [1.5 – 12] and RVADs were explanted on median POD 8 [7 – 19) with local anesthesia. Perioperative complications included delayed sternal closure [54.5% (6/11)], re-exploration for bleeding [18% (2/11)], acute kidney injury [36% (4/11)], and heparin induced thrombocytopenia [18% (2/11)]. 30-day mortality was 0% (0/11). Conclusion: Preemptive temporary RVAD implantation strategy for right heart failure post-LVAD showed acceptable clinical outcomes without any 30-day mortality.

Postcardiotomy extracorporeal membrane oxygenation in patients with congenital heart disease; the effect of place of initiation.

Postcardiotomy extracorporeal membrane oxygenation (ECMO) in pediatric patients can be affected by the place of initiation, either in the operating room (OR) or the pediatric cardiac intensive care unit (PCICU). This study aimed to characterize and compare patients who had postcardiotomy ECMO initiation in the OR or PCICU and evaluate risk factors for hospital mortality. This retrospective study included 103 patients who required postcardiotomy ECMO support after the repair of congenital cardiac lesions from 2010 to 2022. Patients were grouped according to the place of ECMO insertion into two groups. Group 1 (n = 69) had ECMO insertion in the OR, and Group 2 (n = 34) had ECMO insertion in the PCICU. Cardiac arrest occurred significantly more often in patients with ECMO insertion in the PCICU (21 (61.76%) vs. 13 (18.84%); p < 0.001). Pre-ECMO lactate levels, pH, VIS, base deficit, and PaO2 did not differ between the groups. Re-exploration for bleeding was significantly higher in Group 1 (32 (46.38%) vs. 8 (23.53%); p = 0.03). Cannula repositioning (4 (11.76%) v. 2 (2.90%); p = 0.09) and mechanical ventilation time were nonsignificantly higher in Group 2 (19.5 (10-31) vs. 11 (5-25) days; p = 0.07). No difference in mortality was found between groups (42 (60.87%) vs. 23 (67.65%), p = 0.50). By multivariable analysis, elevated lactate on ECMO and low pH before ECMO were associated with mortality. ECMO insertion in the OR has a comparable mortality rate to PCICU insertion. Pre-ECMO low pH and high lactate during ECMO could predict mortality.

Right-Sided Minimally Invasive Direct Coronary Artery Bypass: Clinical Experience and Perspectives.

Objective: Minimally invasive direct coronary artery bypass grafting (MIDCAB) using the left internal thoracic artery to the left descending artery is a clinical routine in the treatment of coronary artery disease. Far less is known on right-sided MIDCAB (r-MIDCAB) using the right internal thoracic artery (RITA) to the right coronary artery (RCA). We aimed to present our experience in patients with complex coronary artery disease who underwent r-MIDCAB. Materials and Methods: Between October 2019 and January 2023, 11 patients received r-MIDCAB using RITA to RCA bypass in a minimally invasive technique via right anterior minithoracotomy without using a cardiopulmonary bypass. Underlying coronary disease was complex right coronary artery stenosis (n = 7) and anomalous right coronary artery (ARCA; n = 4). All procedure-related and outcome data were evaluated prospectively. Results: Successful minimally invasive revascularization was achieved in all patients (n = 11). There were no conversions to sternotomy and no re-explorations for bleeding. Furthermore, no myocardial infarction, no strokes, and, most importantly, no deaths were observed. During the follow-up period (median 24 months), all patients were alive and 90% were completely angina free. Two patients received a repeated revascularization after surgery but independently from the RITA-RCA bypass, which was fully competent in both patients. Conclusion: Right-sided MIDCAB can be performed safely and effectively in patients with expected technically challenging percutaneous coronary intervention of the RCA and in patients with ARCA. Mid-term results showed high freedom from angina in nearly all patients. Further studies with larger patient cohorts and more evidence are needed to provide the best revascularization strategy for patients suffering from isolated complex RCA stenosis and ARCA.

Predictors and Outcomes of Stroke After Isolated Coronary Artery Bypass Grafting. A Single-Center Experience in 20,582 Patients

Stroke remains a devastating complication after cardiac surgical procedures despite perioperative monitoring and management advances. This study aimed to determine the predictors of stroke in a large, contemporary coronary artery surgery population. Patient data were analyzed retrospectively. This single-center study was performed in the Catharina Hospital (Eindhoven). All patients who underwent isolated coronary artery bypass grafting (CABG) between January 1998 and February 2019 were included. Isolated CABG. The primary endpoint was a postoperative stroke, defined according to the international updated definition for stroke. Logistic regression was performed to retrieve variables associated with postoperative stroke. A total of 20,582 patients underwent CABG during the period of the study. Stroke was observed in 142 patients (0.7%), of which 75 (52.8%) occurred during the first 72 hours. The incidence of postoperative stroke declined over the years. A significantly higher 30-day mortality rate was seen in patients with stroke (20.4%) compared with 1.8% in the rest of the population; p < 0.001. Multivariate logistic regression analysis showed age, peripheral arterial disease, reexploration for bleeding, perioperative myocardial infarction, and year of surgery as independent predictors for stroke. Patients with postoperative stroke had worse long-term survival (log-rank p < 0.001). Cox regression analysis revealed postoperative stroke (odds ratio 2.13 [1.73-2.64)) as an independent predictor of late mortality. Stroke after CABG is associated with high early and late mortality. Age, peripheral vascular disease, and the year of surgery were associated with postoperative stroke.

A modified aortic arch "island anastomosis" with stent graft technique for acute type A aortic dissection: a retrospective analysis.

A modified aortic arch "island anastomosis" with a stent graft technique was used in 33 patients with acute type A aortic dissection. We retrospectively reviewed our experience of this procedure and the short-term follow-up results. This retrospective analysis included 33 patients with acute type A aortic dissection undergoing the modified aortic arch island anastomosis with stent graft procedure. Postoperatively, computed tomography angiography images were obtained before discharge and at 12 months. All patients underwent successful surgery without intraoperative death. Three patients received dialysis because of postoperative renal insufficiency, 1 patient received tracheotomy because of postoperative respiratory insufficiency, and 5 patients had postoperative delirium. Surgery caused stroke in 1 patient. No paraplegia was found, and no re-exploration for bleeding was performed. One patient died in the hospital due to multiple organ failure, and the other patients were discharged as expected. Only 1 patient had a proximal endoleak, and the patient was stable under close follow-up. The diameter of the descending thoracic aorta was smaller at 12 months postoperatively than preoperatively (34.5±2.5 mm versus 36.7±2.9 mm, P<0.05). The average diameter of the true lumen of the descending thoracic aorta was larger at 12 months postoperatively than preoperatively (24.1±3.1 mm versus 14.9±2.3 mm, P<0.05). The modified aortic arch island anastomosis with stent graft technique is a feasible and safety surgical strategy for acute type A aortic dissection. Short-term outcomes are satisfactory.

The Long-Term Impact of Diastolic Dysfunction After Routine Cardiac Surgery

To determine the impact of diastolic dysfunction (DD) on survival after routine cardiac surgery. This was an observational study of consecutive cardiac surgeries from 2010 to 2021. At a single institution. Patients undergoing isolated coronary, isolated valvular, and concomitant coronary and valvular surgery were included. Patients with a transthoracic echocardiogram (TTE) longer than 6 months prior to their index surgery were excluded from the analysis. Patients were categorized via preoperative TTE as having no DD, grade I DD, grade II DD, or grade III DD. A total of 8,682 patients undergoing a coronary and/or valvular surgery were identified, of whom 4,375 (50.4%) had no DD, 3,034 (34.9%) had grade I DD, 1,066 (12.3%) had grade II DD, and 207 (2.4%) had grade III DD. The median (IQR) time of the TTE prior to the index surgery was 6 (2-29) days. Operative mortality was 5.8% in the grade III DD group v 2.4% for grade II DD, 1.9% for grade I DD, and 2.1% for no DD (p=0.001). Atrial fibrillation, prolonged mechanical ventilation (>24 hours), acute kidney injury, any packed red blood cell transfusion, reexploration for bleeding, and length of stay were higher in the grade III DD group compared to the rest of the cohort. The median follow-up was 4.0 (IQR: 1.7-6.5) years. Kaplan-Meier survival estimates were lower in the grade III DD group than in the rest of the cohort. These findings suggested that DD may be associated with poor short-term and long-term outcomes.

Early and midterm outcomes after off pump coronary artery bypass surgery.

There has been debate whether off pump coronary artery bypass surgery (OPCAB) has results comparable to conventional on pump bypass surgery. This has led to the low uptake of OPCAB in the West. In India, OPCAB is the default mode of coronary revascularization. However, there is scarce data on mid-term outcomes of OPCAB in our patients. This study aims to evaluate both short and mid-term mortality and analyze factors associated with mortality. This is a single center study of all consecutive patients undergoing isolated OPCAB from October 2014 to December 2019. Patient data was collected from hospital records and follow-up was from the hospital electronic medical records and telephone interviews. Mortality and factors contributing to survival were analyzed. Operative mortality was 2.3%. Mid-term mortality was 5.5%. Preoperative renal dysfunction, post-operative renal failure, use of the intra-aortic balloon pump (IABP), re-exploration for bleeding, postoperative stroke, ventilation > 24h, and postoperative atrial fibrillation were associated with operative mortality. Factors associated with mid-term mortality were age > 62years, postoperative renal failure, IABP usage, ventilation time > 24h, and postoperative atrial fibrillation. The mean survival time was 2343.55 + / - 15.27days and 6-year survival was 88.7%. OPCAB can safely be performed with satisfactory short and mid-term outcomes. Further corroborative studies from different regions of the country or a multi-center study will help to establish the suitability of the technique in Indian patients.

Hemostatic effects of a dextran-based priming solution for cardiopulmonary bypass: A secondary analysis of a randomized clinical trial

IntroductionIntravascular fluids administered to patients may influence hemostasis. In patients undergoing cardiac surgery with cardiopulmonary bypass, the heart-lung machine is primed with 1300 ml of fluid. We assessed postoperative coagulation and platelet function in patients randomized to two different priming solutions, one colloid-based (dextran 40) and one crystalloid-based. Materials and methodsEighty-four elective cardiac surgery patients were randomized to either a dextran-based prime or Ringer's acetate with added mannitol. Blood samples were collected before, and 2 and 24 h after cardiopulmonary bypass. Coagulation was assessed by standard coagulation tests and rotational thromboelastometry. Platelet function was assessed with impedance aggregometry. Bleeding volumes and transfusion requirements were recorded. ResultsComparing the groups 2 h after bypass, the dextran group showed lower hemoglobin concentration, hematocrit, platelet count, and fibrinogen concentration, and higher INR and aPTT, as well as longer clot formation time (+41 ± 21 % vs. +8 ± 18 %, p < 0.001) and a larger reduction in fibrinogen-dependent clot strength (−37 ± 12 % vs. -7 ± 20 %, p < 0.001). Adenosine diphosphate-dependent platelet activation was reduced in the dextran group but not in the crystalloid group 2 h after bypass (−14 ± 29 % vs. -1 ± 41 %, p = 0.041). No significant between-group differences in hemostatic variables remained after 24 h, and no significant differences in perioperative bleeding volumes, re-explorations for bleeding, or transfusion rates were observed. ConclusionsCompared to a crystalloid solution, a dextran-based prime had measurable negative impact on hemostatic variables but no detectable increase in bleeding volume or transfusion requirements in cardiac surgery patients.

Mortality and reoperation rate of biological versus mechanical Bentall-De Bono operation: a propensity-matched study

Objective: To assess follow-up mortality and reoperation rate in patients undergoing Bentall-De Bono operation according to the type of composite valve graft used. Methods: All consecutive adult patients operated on between May 1997 and December 2019 at our institution were included in the analysis and classified according to the use of a biological or a mechanical composite valve graft (bCVG or mCVG). The primary outcomes were follow-up mortality and reoperation rate. Secondary outcomes were operative mortality and major adverse events (MAEs) including operative mortality, myocardial infarction, cerebrovascular accident, dialysis, tracheostomy, and re-exploration for bleeding. Kaplan-Meier and competing risk analyses were used. Propensity matching analysis was used to balance differences in baseline characteristics between procedures. Results: Of 1,210 included patients, 798 received a bCVG and 412 a mCVG. The mean follow-up was 6.64 ± 0.21 years. The ten-year mortality rate was higher in the mCVG group (25.3% vs. 16.4%, P = 0.023). The ten-year reoperation rate was higher in the bCVG group (7.4% vs. 1.1%, P &lt; 0.001). Overall operative mortality was 0.7%, and MAEs occurred in 6.2% of patients, with no significant differences between groups. Older age (hazard ratio [HR] 1.06, 95% confidence interval [CI: 1.04-1.08], P &lt; 0.01), chronic obstructive pulmonary disease (HR 1.63, 95%CI: [1.01-2.64], P = 0.04), preoperative renal dysfunction (HR 3.08, 95%CI: [1.98-4.78], P &lt; 0.001), New York Heart Association Class III/IV (HR 1.48, 95%CI: [1.04-2.10], P = 0.031), and mCVG (HR 2.15, 95%CI: [1.42-3.26], P &lt; 0.001) were associated with higher risk of follow-up mortality. After propensity matching, the differences in mortality and reoperation remained significant. Conclusions: The Bentall-De Bono operation can be performed with consistently good results in experienced centers. Early outcomes are excellent regardless of the valve choice. In our study, the Bentall-De Bono operation with bCVG was associated with lower 10-year mortality but carried a higher risk of aortic reoperation. While the risk of reoperation is largely tied to valve choice, follow-up mortality is more likely to be influenced by patient comorbidities and risk factors.

Treatment of acute type A aortic dissection with the Ascyrus Medical Dissection Stent in a consecutive series of 57 cases.

The Ascyrus Medical Dissection Stent (AMDS) has been recently introduced as an alternative for total arch replacement in acute aortic dissection type A (AADA). The aim of this study was to evaluate the postoperative outcomes after AMDS treatment in a large contemporary cohort of AADA patients. Data acquisition was performed retrospectively at 2 German aortic centres between 2020 and 2022 and comprised the perioperative parameters and postoperative results of all AADA patients. All patients treated with the AMDS for AADA were included in the study. The primary end point was in-hospital mortality. Secondary end points were defined as early postoperative and AMDS-related complications. Fifty-seven AADA patients treated by AMDS were included in the study group. The mean age was 64.6 ± 10.8 years and 59.7% (n = 34) were males. The actual in-hospital mortality was considerably lower than the predicted mortality risk by the German registry for acute aortic dissection type A score (16% vs 22%). The median ICU and in-hospital stay were 5 (interquartile range: 3-13) and 12 (interquartile range: 10-22) days, respectively. Postoperative complications comprised acute renal insufficiency (37%) with need for temporary (16%) or permanent dialysis (5%), delirium (26%), re-exploration for bleeding (14%), tracheostomy (14%) and new stroke (4%). A new AMDS-related complication (central stent collapse) was observed in 9% (n = 5) by postoperative computed tomography and chest X-ray. The incidence of complete central AMDS collapse did not impact 30-day mortality. The AMDS may be successfully used in AADA with acceptable 30-day mortality in accordance with the German registry for acute aortic dissection type A score. However, careful preoperative evaluation of the patient's individual aortic anatomy regarding potential contraindications and proper device implantation are strongly recommended to avoid complete central AMDS collapse.

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

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

Results of a Multimodal Approach for the Launch of a Ross Program

BackgroundThere has been renewed interest in the Ross procedure in young patients with aortic valve disease. We describe the details and results of a systematic strategy to launch a new Ross program. MethodsOur department developed a multidisciplinary educational program that involved all practitioners involved in the care of potential Ross patients. A core group of surgeons underwent extensive hands-on technical preparation. Selection of patients was reviewed by a multidisciplinary team. Patient characteristics, operative details, and postoperative outcomes were analyzed. ResultsBetween March 2021 and March 2022, 22 consecutive patients underwent Ross procedure at our institution. The mean age of the patients at time of operation was 40.4 ± 10.2 years, and most patients had no medical comorbidities (12/22). The most common indication for operation was aortic stenosis (13/22), followed by mixed aortic stenosis and aortic insufficiency (7/22). There were no deaths. Postoperatively, no patient required blood transfusion or reexploration for hemorrhage. All patients were discharged home on mean hospital day 5.9 ± 1.1. On predischarge echocardiography, there was a significant reduction in mean aortic gradients preoperatively to postoperatively (49 ± 20 mm Hg vs 4 ± 1 mm Hg; P < .01) without aortic insufficiency or a change in left or right ventricular function. ConclusionsWe demonstrate that with multidisciplinary education and extensive hands-on surgical preparation under proctored supervision, a Ross program can be initiated safely with excellent short-term results and perioperative risk that mimics that of conventional surgical aortic valve replacement.

Effect of fibrinogen replacement therapy on bleeding outcomes and 1-year mortality in patients undergoing thoracic aortic surgery: a retrospective cohort study.

This study aimed to examine the effect of fibrinogen replacement therapy with cryoprecipitate or fibrinogen concentrate on bleeding outcomes and 1-year mortality in patients undergoing thoracic aortic surgery. We retrospectively studied 439 consecutive patients who underwent thoracic aortic surgery with cardiopulmonary bypass between January 1st, 2010 and December 31st, 2019 and identified patients who received cryoprecipitate or fibrinogen concentrate (the fibrinogen replacement group) and those who did not (the control group). Multivariate analyses were performed to examine the associations of fibrinogen replacement therapy with perioperative major bleeding (i.e., excessive hemorrhage or blood transfusion), re-exploration for bleeding, and 1-year mortality. There were 285 patients in the fibrinogen replacement group who received 2.2 ± 1.0g of concentrated fibrinogen amount and 154 patients in the control group. The incidence of major bleeding in the fibrinogen replacement group was less than that in the control group in patients with fibrinogen level < 150mg/dL during cardiopulmonary bypass (49.7% versus 74.6%, p = 0.0007, multivariate odds ratio; 0.33, 95% confidence intervals; 0.12-0.91, p = 0.03), but not in patients with fibrinogen level ≥ 150mg/dL (25.0% versus 29.6%, p = 0.51). No significant difference was found in re-exploration for bleeding (1.0% versus 1.3%, p = 1.00) or 1-year mortality (10.4% versus 5.3%, multivariate Cox proportional-hazard ratio; 1.03, 95% confidence intervals; 0.82-1.31, p = 0.74) between the fibrinogen replacement group and the control group. The results of this study indicate that 2-3g of fibrinogen replacement reduces the incidence of major bleeding in patients with hypofibrinogenemia during cardiopulmonary bypass in thoracic aortic surgery.

Acute Kidney Injury in Patients Undergoing Surgery for Type A Acute Aortic Dissection

BackgroundAcute kidney injury (AKI) after repair of type A acute aortic dissection (TAAAD) has been shown to affect both short- and long-term outcomes. This study aimed to validate the impact of postoperative AKI on in-hospital and long-term outcomes in a large population of dissection patients presenting to multinational aortic centers. Additionally, we assessed risk factors for AKI including surgical details. MethodsPatients undergoing surgical repair for TAAAD enrolled in the International Registry of Acute Aortic Dissection database were evaluated to determine the incidence and risk factors for the development of AKI. ResultsA total of 3307 patients were identified. There were 761 (23%) patients with postoperative AKI (AKI group) vs 2546 patients without (77%, non-AKI group). The AKI group had a higher rate of in-hospital mortality (n = 193, 25.4% vs n = 122, 4.8% in the non-AKI group, P < .001). Additional postoperative complications were also more common in the AKI group including postoperative cerebrovascular accident, reexploration for bleeding, and prolonged ventilation. Independent baseline characteristics associated with AKI included a history of hypertension, diabetes, chronic kidney disease, evidence of malperfusion on presentation, distal extent of dissection to abdominal aorta, and longer cardiopulmonary bypass time. Kaplan-Meier survival curves revealed decreased 5-year survival among the AKI group (P < .001). ConclusionsAKI occurs commonly after TAAAD repair and is associated with a significantly increased risk of operative and long-term mortality. In this large study using the International Registry of Acute Aortic Dissection database, several factors were elucidated that may affect risk of AKI.

A robotic-assisted hybrid coronary revascularization program: Establishment and early experience in the Middle East.

Hybrid coronary revascularization (HCR) is a technique that merges coronary artery bypass grafting surgery and percutaneous coronary intervention (PCI) approaches for the treatment of multivessel coronary artery disease. The surgical component of the procedure is minimally invasive and can be done using robotic technology that avoids the need for sternotomy. Our objective is to study all patients who underwent robotic-assisted HCR (RHCR) to evaluate the feasibility and safety of the procedure during the establishment phase. This study is a retrospective chart review conducted at King Faisal Specialist Hospital and Research Centre in Jeddah (KFSRC-J). The study focuses on patients who underwent RHCR between July 2018 to December 2020. The study was approved by the institutional review board #2020-103. Robotic-assisted HCR was performed on 78 patients (mean age, 56 years (range, 43-72 years); 89.75% males) during the study phase. Left internal mammary artery grafting was used in all patients. There was no hospital mortality, and the mean hospital and intensive care unit(ICU) stay were 5.8 and 1.4 days, respectively. We found that 93.6% of the patients had no blood transfusion. There were no major adverse cardiac events (MACE) and perioperative MI recorded. There was a 3.8% rate of postoperative complications. The percentage of surgeries converted to conventional and re-exploration for bleeding were 1.2% and 2.6%, respectively. The average operation time was 164 min. This study emphasizes on the safety and effectiveness of RHCR in treating patients with multivessel coronary artery disease. Moreover, robotic-assisted hybrid coronary revascularization offers an alternative, functionally complete revascularization option to a selected group of patients with minimal surgical trauma, short hospital and ICU length of stay, quick recovery, and little to no blood transfusion requirement.