Arrest Time Research Articles

Предикторы госпитальной летальности при экстренном хирургическом лечении острейшего расслоения аорты типа А по Стенфорду в условиях искусственного кровообращения: ретроспективное когортное исследование

INTRODUCTION: Acute Stanford type A aortic dissection is one of the most severe cardiovascular diseases with high in-hospital mortality. OBJECTIVE: To establish predictors of in-hospital mortality in the treatment of patients with acute Stanford type A aortic dissection under conditions of artificial circulation and to determine their threshold values. MATERIALS AND METHODS: Study design: retrospective, cohort, single-center. Inclusion criteria: surgical intervention with cardiopulmonary bypass, confirmed diagnosis of acute Stanford type A aortic dissection, age > 18 years. The study included 51 patients: 42 men and 9 women aged from 35 to 77 years, median 59 years [47; 65]. All patients (n = 51) were treated in 2022 and were divided into 2 groups depending on the outcome: group 1 (n = 27) included those who died in the intensive care unit within 30 days, group 2 (n = 24) included survived and discharged patients. The endpoint of trial was 30-day in-hospital mortality. RESULTS: Postoperative Sequential Organ Failure Assessment (SOFA) score > 7, Acute Physiology And Chronic Health Evaluation (APACHE) II score > 19, and Vasoactive-inotropic score (VIS) > 10, cardiopulmonary bypass time > 177 minutes, and total hypothermic circulatory arrest time > 30 minutes were associated with an increased risk of 30-day in-hospital mortality. CONCLUSIONS: Statistically significant predictors of hospital mortality in the treatment of patients with acute Stanford type A aortic dissection under cardiopulmonary bypass are the SOFA index, the APACHE II index and the VIS index after the end of surgery, as well as the time of cardiopulmonary bypass and the time of total hypothermic circulatory arrest.

Cardiovascular etiologies and risk factors of survival outcomes after resuscitation for out-of-hospital cardiac arrest: data from the KoCARC registry

Abstract Background The outcomes and characteristics of out-of-hospital cardiac arrest (OHCA) vary across geographic regions. The etiologies and prognoses of OHCA in Asian populations remain less established. This study aimed to investigate the etiologies and clinical characteristics of patients successfully resuscitated after OHCA and identify predictors of survival outcomes. Methods Data were extracted from a South Korean multicenter prospective registry of OHCA that included 64 tertiary hospitals from 2015 to 2018 (n=7577). The primary outcome was in-hospital mortality, and secondary outcome was the grade-1 cerebral performance category (CPC) score at discharge. Results Of the 7577 patients, 2066 achieved return of spontaneous circulation (ROSC) and were hospitalized and 915 (44·2%) presented with ventricular arrhythmia (VA) as their initial rhythm or on admission. The leading cause was obstructive coronary artery disease (n=413; 20·0%). Sudden unexplained death syndrome (SUDS) accounted for 67·5% of survivors, which were significantly lower with VA (82·7% vs. 48·3%, p<0.001). VA was an independent predictor of in-hospital mortality (adjusted hazard ratio [aHR] 0·72, 95% confidence interval 0·60–0·87) and the grade-1 CPC score at discharge (aHR 3·63, 95% CI 2·56–5·15). Other predictors of the primary outcome included age, ROSC on arrival, total arrest time, alertness on admission, extracorporeal membrane oxygenation use, targeted temperature management, implantable cardioverter defibrillator use, and coronary vasospasm. Conclusions SUDS was common in patients with ROSC after OHCA and thus needs to be evaluated comprehensively. VA was independently associated with favorable survival outcomes at discharge. Further management may improve clinical outcomes in patients with OHCA, particularly those with VA.

NSE and S100β as serum alarmins in predicting neurological outcomes after cardiac arrest

Cardiac arrest (CA) is a serious health concern that often results in mortality or severe neurological dysfunction in the case of survival. Our aim was to explore the neurological prognostic factors in patients with CA. This retrospective observational study included adult patients with CA. We investigated serum neuron-specific enolase (NSE), S100 calcium-binding protein β (S100β), and indices and parameters at 1, 3, 5, 7 and intensive care unit (ICU) discharge days after CA. The primary study endpoint was the Cerebral Performance Category (CPC) scale score at ICU discharge, which was dichotomized as good neurological outcome (CPC 1–2: full recovery or moderate disability) and poor neurological outcome (CPC 3–5: severe disability, vegetative state, or death). Of the 191 adult patients with CA, 42 (22%) had good neurological outcomes, and 149 (78%) had poor neurological outcomes. NSE at 1,3,5,7 and ICU discharge days showed excellent predictive accuracy for neurological outcomes (area under the curve [AUC]: 0.666, 0.716, 0.870, 0.739, and 0.901, respectively). However, S100β exhibited general predictive power (AUC: 0.666, 0.573, 0.607, 0.594, 0.727). Finally, the early warning model, which combined day 1 NSE, day 1 S100β, cardiac arrest time, SOFA scores, APACHE II scores, and age, was used to screen CA patients with poor neurological prognosis at early stages and had an AUC of 0.792. Serum concentrations of NSE and S100β were significantly elevated in CA patients and could be prognostic biomarkers to predict neurological outcomes. Day 1 NSE and S100β combined with multiple indicators could be a decent early warning model for poor neurological prognosis in patients with CA.

A stented elephant trunk procedure with retrograde cerebral perfusion for a rare type of pseudoaneurysm with an aberrant right subclavian artery.

Aberrant right subclavian artery (ARSA) is a rare congenital vascular anomaly that increases the risk of aortic dissection (AD). Although several treatment options for cases of AD with ARSA have been proposed, such as traditional surgery, thoracic endovascular aortic repair, and a hybrid procedure, a consensus regarding the optimal treatment strategy has not yet been established. And there are no reported cases of pseudoaneurysm combined with ARSA. A 44-year-old male was admitted with a 7-days history of chest pain. A physical examination was almost normal. Computed tomography angiography (CTA) showed an ARSA arose from the distal aortic arch and pseudoaneurysm located distal to the origin of the ARSA. The stented elephant trunk (SET) procedure with retrograde cerebral perfusion (RCP) was performed under moderate hypothermic circulatory arrest. The postoperative CTA demonstrated a well-perfused ARSA, left subclavian artery (LSA), left common carotid artery (LCCA), and right common carotid artery (RCCA), and occluded pseudoaneurysm with no endoleaks. He was discharged on postoperative day 9 and was doing well during his 6-months follow-up. With a smaller incision, a simple cannulation method, shorter surgical and circulatory arrest times, fewer blood transfusion requirements, and effective brain protection, the SET procedure with RCP can be a safe and feasible treatment option for complicated aortic arch anomalies with ARSA.

Moderate hypothermia circulatory arrest as a brain-protective strategy for type A aortic dissection.

Brain-protective strategies for acute type A aortic dissection (TAAD) remain controversial. Moderate hypothermia circulatory arrest (MHCA) without cerebral perfusion is not commonly used. However, we aimed to assess its safety and efficacy in 358 patients who underwent hemiarch replacement with MHCA for acute type A aortic dissection at our institution from August 2012 to August 2022. Clinical outcomes were compared according to circulatory arrest time [≤15 min (S group, n = 52) vs ≥16 min (L group, n = 306)]. The primary outcome was postoperative stroke. The S group had more older patients (72.5 vs 68.8 years; P = 0.04), a greater incidence of carotid artery malperfusion (21% vs 11%; P = 0.043) and a lower body mass index (21.7 vs 23.6 kg/m2; P < 0.01) and hemodynamic instability (3.8% vs 16%; P = 0.02) than the L group. The incidence of postoperative stroke (7.7% vs 12%; P = 0.33) and the rate of 30-day mortality (5.8% vs 6.5%; P = 0.83) did not significantly differ between groups. After adjusting for all potential confounding factors pre- and intraoperatively, there was no significant difference in postoperative outcomes between groups. MHCA alone for TAAD had comparable postoperative outcomes with circulatory arrest times under and over 15 min. However, longer arrest times were associated with a higher risk of stroke.

Patients undergoing emergent surgery for type A intramural hematomas or type A aortic dissections have similar outcomes

ObjectiveDespite key differences in pathological processes, both Intramural Hematomas and Aortic Dissections are Acute Aortic Syndromes repaired with similar surgical technique. The objective of this study was to determine differences in surgical outcomes between patients with Intramural Hematoma versus Type A Aortic Dissection undergoing Ascending Aortic Arch repair.MethodsThis retrospective review of prospectively collected data included all patients with acute Intramural Hematoma or Type A Aortic Dissection who underwent emergent Ascending- or Arch Repair from January 2018 to May 2023 at a single academic institution. Primary outcomes included intraoperative mortality, 30-Day mortality, and postoperative stay. Secondary outcomes included postoperative complications. Outcomes were analyzed using Chi-squared, Fisher’s Exact, and t-tests, with significance set at p < 0.05.ResultsA total of 107 patients were included, 27 of whom (25%) had Intramural Hematoma and 80 (75%) had Type A Aortic Dissection. There were no differences in preoperative characteristics such as age, gender, and comorbidities, and no differences in perioperative characteristics such as case length, cardiopulmonary bypass, aortic cross-clamp, and circulatory arrest times. When comparing postoperative outcomes, there was a higher rate of postoperative pericardial effusions requiring pericardial window in the Intramural Hematoma cohort compared to the Aortic Dissection cohort (15% [n = 4] vs. 3% [n = 2]; p = 0.02). There were no differences in other primary outcomes such as intraoperative mortality, 30-Day mortality, and postoperative length of stay. There were also no differences in the rates of postoperative complications such as bleeding requiring reoperation, cerebrovascular accident, atrial fibrillation, pleural effusion requiring thoracentesis, and surgery-related Emergency Department visits.ConclusionsOur analysis demonstrates similar outcomes for patients undergoing Ascending Aortic Arch repair between patients with Intramural Hematoma and Type A Aortic Dissection. Despite the higher rate of required postoperative pericardial windows in the Intramural Hematoma cohort, the overall primary outcomes remained comparable. These findings better elucidate the standard of care for patients with acute Intramural Hematoma undergoing Ascending Aortic Arch repair.

Association between postoperative pain and analgesic use in minimally invasive cardiac surgery.

This study aimed to investigate the effects of surgical methods on pain duration and oral analgesic administration in patients who underwent cardiac surgery using various minimally invasive methods. We included 90 patients who underwent an anterior incision with costal cartilage transection, lateral incision without costal cartilage transection, or total endoscopic cardiac surgery using a lateral incision and no retractor. Oral analgesics were postoperatively administered upon patient request. All the patients were instructed to rate their pain during the daytime 3 and 7 days postoperatively. Between-group differences included surgical method, wound size, operation/cardiopulmonary bypass time/cardiac arrest time, and intraoperative fentanyl dose. No differences were found in sex, age, diabetes status, paravertebral block use, or blood loss. The number of postoperative days, postoperative analgesic use, and pain 3 days postoperatively demonstrated no difference. Pain ratings were most severe for the costal cartilage resection group and least severe for the total endoscopic cardiac surgery group 7 days postoperatively. Similarly, patients who underwent costal cartilage research exhibited the highest rate of analgesic use for 30 days postoperatively, whereas patients who underwent total endoscopic cardiac surgery demonstrated the lowest. We revealed significant between-group differences in pain prevalence and postoperative oral analgesic administration in patients who underwent cardiac surgery relative to the minimally invasive surgical method used.

Goals of Care Discussions Among Patients Who Suffer Cardiac Arrest

Abstract Background Outcomes following in-hospital cardiac arrest remain poor despite advances in resuscitation techniques. Establishing “goals of care” is crucial to optimizing patient care and avoiding burdensome interventions in those who are unlikely to benefit from resuscitation. Doctors often avoid discussions regarding ‘goals of care’ with patients in whom cardiac arrest is not deemed likely at the time of admission. Methods All cardiac arrest team activations for non-pregnant, adult inpatients on medical and surgical wards at our institution from December 2022 – June 2023 were prospectively analysed. Qualitative analysis of inpatient charts was performed to assess; incidence of cardiac arrest, demographic and clinical data, and the degree to which discussions regarding escalation of care had taken place. Results 66 cardiac arrest team activations were screened, of which 23 calls were included for analysis. The estimated incidence of cardiac arrest was 1.11-1.67 events per 1,000 patient discharges. 18 patients (78.2%) were under the care of general medicine or geriatric teams at the time of arrest call. 12 (52%) patients were older than 70 and 4 (17%) were older than 80. Falls were the most common reason for admission (22.7%) among patients for whom the cardiac arrest team was activated. 2 patients (12.5%) with confirmed cardiac arrest survived to hospital discharge. Discussions regarding goals of care were documented for 8/23 patients (34.7%). Conclusion Cardiac arrests were uncommon in our institution. Discussions regarding goals of care were documented in only a third of cases, possibly because many patients presented with issues not typically associated with a risk of subsequent arrest. Given the low survival rates to discharge, routine discussion of goals of care should be considered at the point of admission in all patients who are unlikely to benefit from resuscitation, regardless of the presenting complaint.

Perioperative and Long-Term Outcomes of Acute Stanford Type A Aortic Dissection Repair in Octogenarians.

The aims of this study were to assess the perioperative morbidity, mortality and long-term survival of octogenarians undergoing acute type A aortic dissection repair (ATAAD), and to compare open and closed distal anastomosis techniques. This was a single-centre retrospective study (2007-2021). Open versus closed distal anastomosis were compared. Uni- and multivariable logistic regression analyses were performed to identify independent predictors of in-hospital mortality. Kaplan-Meier and Cox proportional hazards methods were used to compare long-term survival. Fifty octogenarian patients were included (median age-82 years; closed distal-22; open distal-28). Median cardiopulmonary bypass time was 187 min (open distal vs. closed distal group; 219 min vs. 115.5 min, p < 0.01, respectively). Median cross-clamp time was 93 min (IQR; 76-130 min). Median circulatory arrest time was 26 min (IQR; 20-39 min) in the open-distal group. In-hospital mortality was 18% (open distal; 14.2% vs. closed distal; 22.7%, p = 0.44). Stroke was 26% (open distal; 28.6% vs. closed distal; 22.7%, p = 0.64). Median survival was 7.2 years (IQR; 4.5-11.6 years). Survival was comparable between open and closed distal groups (median 10.6 vs. 7.2 years, p = 0.35, respectively). Critical preoperative status (HR; 3.2, p = 0.03) and composite endpoint (renal replacement therapy, new neurological event, length of stay > 30 days or return to theatre; HR; 4.1, p = 0.02) predicted adverse survival. Open distal anastomosis did no impact survival. ATAAD repair in selected octogenarians has acceptable short- and long-term survival. There is no significant difference between open versus closed distal anastomosis strategies.

Bilateral antegrade cerebral perfusion during hypothermic circulatory arrest before sternal reentry for aortic pseudoaneurysm repair.

Sternal reentry for repair of aortic pseudoaneurysms poses a unique technical challenge to prevent exsanguination. Initiation of peripheral cardiopulmonary bypass and deep hypothermic circulatory arrest prior to reentry are the cornerstones of a successful surgical approach. Adjunctive bilateral antegrade cerebral perfusion increases safe arrest time and reduces neurologic morbidity. Herein, we describe our safe reentry technique for aortic pseudoaneurysm repair in two patients.

Hematocrit and Renal Failure in Aortic Arch Surgery: A Society of Thoracic Surgeons Database Study

BackgroundThis study examined the association between cardiopulmonary bypass (CPB) hematocrit and postoperative acute renal failure (ARF) in patients undergoing aortic arch surgery with hypothermic circulatory arrest. MethodsThe Society of Thoracic Surgeons Adult Cardiac Surgery Database was queried from 2011 to 2019 for patients undergoing aortic arch surgery with hypothermic circulatory arrest. A multivariable logistic regression model estimated the adjusted odds of postoperative ARF on the basis of CPB hematocrit. Effects were stratified by preoperative kidney function and the duration of hypothermic circulatory arrest by using interaction terms. The study also investigated the association between postoperative ARF and major postoperative outcomes by using multivariable regression models. ResultsOn adjusted analysis, higher CPB hematocrit (>20%-25%, >25%-30%, >30%) was associated with lower odds of ARF as compared with lower CPB hematocrit (≤20%) (>20-25%, aOR, 0.78; 95% CI, 0.65-0.93; P = .006; >25%-30%, aOR, 0.65; 95% CI, 0.50-0.84; P = .0007; >30%, aOR, 0.45; 95% CI, 0.28-0.72; P = .0008). The predicted probability of postoperative ARF by CPB hematocrit was higher in patients with lower preoperative renal function (estimated glomerular filtration rate, <60 mL/min/1.73 m2) (interaction P = .03). The association between hematocrit and postoperative ARF was not significantly modified by hypothermic circulatory arrest time (interaction P = .74). All postoperative outcomes were significantly worse in patients with postoperative ARF (all P < .0001). ConclusionsAmong patients undergoing aortic arch surgery, a higher CPB hematocrit level is associated with reduced likelihood of postoperative ARF. Preoperative renal function, but not hypothermic circulatory arrest duration, significantly modified this association. The maintenance of higher CPB hematocrit may reduce the incidence of postoperative ARF, especially for patients with poor preoperative renal function.

A comparison between direct true lumen versus conventional cannulation for management of acute type- aortic dissection patients.

Objective: To compare the postoperative outcomes while using direct true lumen approach versus conventional cannulation approach in management of acute type-A aortic dissection patients. Study Design: Randomized Clinical Trial. Setting: Department of Vascular Surgery, Combined Military Hospital, Rawalpindi. Period: 1st June 2022 to 31st December 2022. Methods: A total of 22 patients age more than 18 years who presented in CMH Emergency Department with acute type A aortic dissection were included in this study. In group A (11 patients) were managed with direct true lumen cannulation while in group B (11 patients) were managed with conventional (axillary/femoral) cannulation. In both groups intra-operative parameters like procedure time, mean time of cardiopulmonary bypass, cross clamp and circulatory arrest time were measured. In both groups, outcome was measured in terms of occurrence of multi-organ failure, acute kidney injury, arrhythmias on ECG and in-hospital mortality. Data was analyzed using SPSS 26. Results: Mean age of our patients were 43.36±2.16yrs in group A while 43.36±2.94yrs in group B. Male gender predominates in both groups (gp A- 81.8% &amp; gp B-90.9%). We found no difference of statistical significance between two groups in terms of various intra-operative parameters like mean duration of procedure in group A was 428.15min and in group B was 427.36 min. Similarly mean circulatory arrest time was 31 min in group A and 29.09 min in group B. Patients in “direct true lumen cannulation” group had significantly shorter duration of intubation. In terms of post-operative outcomes, multi-organ failure occurred in 1 (9.09%) patient in group A while it occurred in 3(27.27%) patients in group B. In hospital mortality occurred in 2(18%) patients in group A as compared to 4(36%) in group B. So better results were observed in “direct true lumen cannulation” group as compared to “conventional (axillary/femoral) cannulation” group. Conclusion: In our study, acute type-A aortic dissection patients who had undergone direct true lumen cannulation during operative management showed better post-operative outcomes.

Early outcomes of total arch replacement in the treatment of aortic dissection

Abstract: Overview: Aortic dissection are severe pathologies with high mortality and complication rates post-surgery despite significant advancements in both diagnosis and surgical treatment. Aortic arch replacement surgery is a classic and highly effective treatment method at Cho Ray Hospital. Objectives: Describe clinical, paraclinical characteristics, postoperative results, general complications and early hospital mortality. Methods: Descriptive cross sectional study. Results: 102 patients underwent aortic arch replacement surgery due to aortic dissection. Males predominated at 72.5%. The male:female ratio was 2.5:1. The average age was 56.45 ± 11.79 years. A history of hypertension was present in 81.4% of cases. Most patients with aortic dissection were admitted in an acute condition, accounting for 95%. Patients with type A aortic dissection accounted for 87.3%, with the entry tear in the ascending aorta at 27.5%. Isolated aortic arch replacement was performed in 46.1% of patients, while 53.9% underwent aortic arch replacement with frozen elephant trunk technique. 7 patients required aortic root replacement, 7 needed aortic valve surgery, and 10 required CABG. Most patients were cooled to 25 degrees C with cerebral perfusion to three branches. Ascending aorta cannulation was established in 45.2% of cases. The average cardiopulmonary bypass time was 257.7 minutes, with selective cerebral perfusion time at 115.9 minutes and lower body circulatory arrest time averaging 57.2 minutes. Postoperative neurological complications occurred in 10.8%, and the rate of renal failure requiring dialysis was 17.8%. The mortality rate was 9.6%. Longer cardiopulmonary bypass times and body temperatures above 25 degrees significantly increased the rate of postoperative renal failure requiring dialysis. Patients with postoperative renal failure requiring dialysis had a statistically significant increase in postoperative mortality rates. Aortic root intervention surgery combined with arch replacement did not affect the rate of postoperative complications. Aortic arch replacement with frozen elephant trunk technique did not affect cardiopulmonary bypass time, clamping time, or the rate of postoperative complications. Conclusions: Total arch replacement at Cho Ray Hospital initially showed a safe and effective with acceptable mortality rate.

Timing Matters: Exploring the Age-Graded Effects of Juvenile Arrest on Educational Attainment

Scholars have spent considerable time studying barriers to educational attainment. This work has highlighted the deleterious effects of juvenile arrest on educational attainment but has overlooked the importance of timing of first arrest in this age-graded process. Using data from the National Longitudinal Survey of Youth (NLSY97), this study examines the age-graded nature of arrest experiences on educational attainment. The analysis reveals that age at first arrest is a predictor of educational outcomes, emphasizing the detrimental effects of early arrests. These findings highlight the importance of addressing juvenile delinquency through supportive interventions rather than punitive measures. Given the current educational and juvenile justice landscape, the implications of this study are even more relevant.

The safety and prognostic evaluation of subsequent aortic surgery after thoracic endovascular aortic repair: a retrospective cohort study.

Thoracic endovascular aortic repair (TEVAR) is a widely employed clinical procedure for treating various aortic pathologies. However, some patients require subsequent surgical interventions post-TEVAR, particularly due to life-threatening complications such as aortic dissection. This study aimed to evaluate the safety and prognosis associated with additional aortic surgeries following TEVAR. A retrospective analysis was conducted on 21 patients who underwent aortic surgery after TEVAR at Guangdong Provincial People's Hospital between September 2016 and August 2020. By compiling and reviewing perioperative data, we assessed surgical-related complications and survival rates. Among the 21 patients, 95.2% were male, with an average age of 53 years. Preoperative comorbidities included hypertension in 15 individuals, abdominal aortic aneurysm in one patient, and coronary heart disease in two patients. The primary complications of TEVAR were stent leakage and retrograde aortic dissection, with the latter being the predominant type in subsequent aortic surgeries. The mean duration of aortic clamping during surgery was 130.0 minutes, with a deep hypothermic circulatory arrest time of 8.5 minutes. Postoperatively, two patients suffered in-hospital mortality, one developed renal dysfunction, four required re-entry into the operating room for further treatment, and the average length of hospital stay was 20 days. Following discharge, 14.3% of patients experienced complications, with central nervous system symptoms being the most prevalent. Kaplan-Meier survival analysis indicated a 5-year survival rate of 85.7%. Aortic surgical intervention following TEVAR is a safe therapeutic approach that can improve patient prognosis. However, meticulous management of the perioperative period is crucial for reducing the risk of complications and improving survival rates. This study provides valuable insights into aortic surgery post-TEVAR, but large-scale research is needed to validate these findings.

The impact of injuries at the time of cardiac arrest on the prognosis of extracorporeal cardiopulmonary resuscitation (ECPR) in out-of-hospital cardiac arrest patients

AimExtracorporeal cardiopulmonary resuscitation (ECPR) is an effective treatment for out-of-hospital cardiac arrest and refractory ventricular fibrillation. Despite the success of this intervention, trauma is a potential complication that may adversely impact patient outcomes. This study assessed the incidence and impact of trauma in patients who underwent ECPR. We hypothesized that all trauma incurred until the conclusion of ECPR would have a significant negative effect on survival and neurological outcomes. MethodsThis retrospective observational study examined all ECPR patients admitted to a tertiary emergency medical center between January 2015 and December 2021. All patients underwent pan-scan computed tomography (CT) before admission to the intensive care unit. The head and body trauma were assessed from CT images taken after ECPR. Trauma was defined as all trauma affecting post-ECPR management. In other words, all trauma caused by collapse, trauma caused by resuscitative actions such as chest compressions, and vascular injuries associated with ECPR were included. Univariate analysis of neurological prognosis and 30-day survival due to complicated trauma was performed. ResultsA total of 189 patients (mean age 55.2 ± 13.4 years; 85.2% male) were included in this study. Four patients (2.1%) had head trauma, and 31 patients (16.4%) had torso trauma. All patients with head trauma died during extracorporeal membrane oxygenation management. In patients with torso trauma, 30-day survival was not significantly different compared with that in those without trauma (31.5% vs. 41.9%, P = 0.60); good neurological outcomes were almost the same (26.0% vs. 25.8%, P = 1.00). Approximately half of the patients with torso trauma (48%) underwent transarterial embolization. ConclusionPatients treated with ECPR can suffer a variety of traumatic injuries from the time of collapse to the establishment of ECMO. Head trauma may be lethal and warrants caution. With appropriate treatment, patients with torso trauma may have an equivalent prognosis to those without traumatic complications.

Long-term outcomes of total arch replacement with bilateral antegrade cerebral perfusion using the "arch first" approach.

To report outcomes of total arch replacement (TAR) with hypothermic circulatory arrest and bilateral antegrade cerebral perfusion (bACP) using an "arch first" approach for acute Type A aortic dissection (ATAAD). The "arch first" approach involved revascularization of the aortic arch branch vessels with uninterrupted ACP, before lower body circulatory arrest, while the patient was cooling. This was an observational study of aortic surgeries from 2010 to 2021. All patients who underwent TAR with bACP for ATAAD were included. Short-term and long-term outcomes were reported utilizing descriptive statistics and Kaplan-Meier survival estimation. A total of 215 patients were identified who underwent TAR + bACP for ATAAD. Age was 59.0 [49.0-67.0] years and 35.3% were female. 73 patients (34.0%) underwent a concomitant aortic root replacement, 188 (87.4%) had aortic cannulation, circulatory arrest time was 37.0 [26.0-52.0] minutes, and nadir temperature was 20.8 [19.4-22.5] degrees Celsius. 35 patients (16.3%) had operative mortality (STS definition), 17 (7.9%) had a new stroke, 79 (36.7%) had prolonged mechanical ventilation (>24h), 35 (16.3%) had acute renal failure (by RIFLE criteria), and 128 (59.5%) had blood product transfusions. One-year survival was 77.1%, while 5-years survival was 67.1%. During follow-up, there were 23 (10.7%) reinterventions involving the descending thoracic aorta - either thoracic endovascular aortic repair or open thoracoabdominal aortic replacement. Among patients with ATAAD, short-term postoperative outcomes after TAR + bACP using the "arch first" approach are acceptable. Moreover, this operative strategy may furnish long-term durability, with a reasonably low reintervention rate and satisfactory overall survival.

The association of early naloxone use with outcomes in non-shockable out-of-hospital cardiac arrest

Study ObjectiveEvaluate the association between early naloxone use and outcomes after out-of-hospital cardiac arrest (OHCA) with initial non-shockable rhythms. MethodsThis study was a secondary analysis of data collected in the Portland Cardiac Arrest Epidemiologic Registry, a database containing details of emergency medical services (EMS)-treated OHCA cases in the Portland, Oregon metropolitan region. Eligible patients had non-traumatic OHCA with an initial non-shockable rhythm and received naloxone by EMS or law enforcement prior to IV/IO access (exposure group). The primary outcome was ROSC at emergency department (ED) arrival. Secondary outcomes included survival to admission, survival to hospital discharge, and cerebral performance category score ≤2 at discharge (good neurologic outcome). We performed multivariable logistic regressions adjusting for age, sex, arrest location, witness status, bystander interventions, dispatch to EMS arrival time, initial rhythm, and county of arrest. ResultsThere were 1807 OHCA cases from 2018 to 2021 meeting eligibility criteria, with 57 receiving naloxone before vascular access. Patients receiving naloxone prior to vascular access attempts had higher adjusted odds (aOR [95% CI]) of ROSC at any time (2.14 [1.20–3.81]), ROSC at ED arrival (2.14 [1.18–3.88]), survival to admission (2.86 [1.60–5.09]), survival to discharge (4.41 [1.78–10.97]), and good neurologic outcome (4.61 [1.74–12.19]). ConclusionsPatients with initial non-shockable OHCA who received law enforcement or EMS naloxone prior to IV/IO access attempts had higher adjusted odds of ROSC at any time, ROSC at ED arrival, survival to admission, survival to discharge, and good neurologic outcome.

Management of Anomalous Left Vertebral Artery During Open Total Arch Replacement

BackgroundAn anomalous left vertebral artery (aLVA) can complicate aortic arch surgery. We examined the safety of various aLVA revascularization strategies during open total arch replacement. MethodsWe retrospectively evaluated 92 patients undergoing total arch replacement from January 2018 to May 2023 and identified 11 patients with aLVA. A comparison group (n = 31) with conventional 3-branched anatomy was selected by 3:1 matching on age, sex, circulatory arrest time, and operative mortality. Forty-two patients were selected for analysis. The primary outcome was perioperative stroke within 30 days. Secondary outcomes included spinal cord ischemia and long-term stroke. ResultsPatients with aLVA had an average age of 53 ±16 years. Indications included Stanford type A dissection (n = 4), chronic dissection with aneurysmal degeneration (n = 4), and primary aneurysmal disease (n = 3). The aLVA was reconstructed by transposition to the left carotid (n = 2) or subclavian (n = 8). In 1 case, partial zone 2 arch replacement was performed proximal to the aLVA and manipulation was not required. Total arch replacement with frozen elephant trunk was performed in 8 of 11 cases. No postoperative mortality was observed. One patient experienced transient postoperative stroke (9% vs 9%, P = 1.00). One patient received lumbar drain for suspected spinal cord ischemia (9% vs 7%, P = 0.59). One patient experienced stroke 6 months post operation. One-year patency of transposition was 100%. ConclusionsThe presence of aLVA does not impact outcomes of open arch surgery. Our strategy to preserve the aLVA may be preferable to simple ligation. We describe several safe and feasible approaches for reimplantation of this anomalous variant.

Comparison between Zone 2 and Zone 3 distal anastomoses for aortic arch replacement in terms of invasiveness.

Zone 2 anastomosis with total cervical branch reconstruction for acute type A aortic dissection and aortic arch aneurysms became possible after stent-graft introduction. This may be an easier procedure and reduce the risk of recurrent laryngeal nerve palsy. Therefore, this study aimed to compare the outcomes between Zone 2 and Zone 3 distal anastomoses. After evaluating the patient data in our institute between April 2016 and April 2022, the patients in whom distal anastomosis was performed at Zone 2 with a stent-graft were defined as the Zone 2 group (n = 70). The patients in whom distal anastomosis was performed at Zone 3 were defined as the Zone 3 group (n = 24). The incidence of new-onset recurrent nerve palsy was one patient (1.4%) in the Zone 2 group and six patients (25.0%) in the Zone 3 group (p < 0.001). The lower body perfusion arrest time was 44.3 ± 9.1min in the Zone 2 group and 52.9 ± 12.8min in the Zone 3 group (p = 0.005). There were no significant differences in in-hospital mortality and morbidities. Multivariable analysis showed that only age was an independent predictor of overall mortality. Performing distal anastomosis at Zone 2 with a frozen elephant trunk or stent-graft reduced the lower body perfusion arrest time and possibly prevented recurrent nerve palsy.