Probability of Uneventful Recovery After Elective Aortic Root Replacement for Aortic Aneurysm

Utility of structured follow-up imaging after aortic surgery

BACKGROUND

Although postoperative follow-up after aortic surgery is recommended by guidelines, its clinical utility is not well documented. We hypothesized that structured follow-up imaging by an aortic program would improve outcomes. We then documented radiologic findings on asymptomatic postoperative imaging.

METHODS

All patients who survived to discharge after open thoracic aortic surgery between January 2017 and July 2021 were included, excluding endocarditis. Patients who followed at our center and received scheduled imaging were compared with patients who did not. Survival was analyzed by the method of Kaplan-Meier, and reintervention was assessed using the Fine-Gray subhazard function. Routine imaging was reviewed for aortic growth, pseudoaneurysm, and perigraft density.

RESULTS

After aortic surgery, the cumulative incidence of follow-up was 38.6% at 3 years postoperatively. Patients with follow-up were more likely to have a dissection and fewer comorbidities but were similar in regards to socioeconomic factors and distance to hospital. After matching and accounting for immortal time bias, patients with follow-up had a greater reintervention rate (26.0% vs 9.0%) with similar survival (98.7% vs 95.2%, P = .110) at 4 years. The cumulative incidence of pseudoaneurysm, significant perigraft density, and growth ≥3 mm/year on routine imaging was 49.7% at 3 years.

CONCLUSIONS

Implementation of structured follow-up imaging by an aortic program resulted in low clinical compliance. Follow-up was associated with increased rates of aortic reintervention. Clinically relevant radiologic findings were common on asymptomatic imaging and increased throughout 5-year follow-up rather than plateauing in the early postoperative period.

Days alive and out of hospital for adult female and male cardiac surgery patients: a population-based cohort study

BACKGROUND

Research shows women experience higher mortality than men after cardiac surgery but information on sex-differences during postoperative recovery is limited. Days alive and out of hospital (DAH) combines death, readmission and length of stay, and may better quantify sex-differences during recovery. This main objective is to evaluate (i) how DAH at 30-days varies between sex and surgical procedure, (ii) DAH responsiveness to patient and surgical complexity, and (iii) longer-term prognostic value of DAH.

METHODS

We evaluated 111,430 patients (26% female) who underwent one of three types of cardiac surgery (isolated coronary artery bypass [CABG], isolated non-CABG, combination procedures) between 2009 - 2019. Primary outcome was DAH at 30 days (DAH30), secondary outcomes were DAH at 90 days (DAH90) and 180 days (DAH180). Data were stratified by sex and surgical group. Unadjusted and risk-adjusted analyses were conducted to determine the association of DAH with patient-, surgery-, and hospital-level characteristics. Patients were divided into two groups (below and above the 10th percentile) based on the number of days at DAH30. Proportion of patients below the 10th percentile at DAH30 that remained in this group at DAH90 and DAH180 were determined.

RESULTS

DAH30 were lower for women compared to men (22 vs. 23 days), and seen across all surgical groups (isolated CABG 23 vs. 24, isolated non-CABG 22 vs. 23, combined surgeries 19 vs. 21 days). Clinical risk factors including multimorbidity, socioeconomic status and surgical complexity were associated with lower DAH30 values, but women showed lower values of DAH30 compared to men for many factors. Among patients in the lowest 10th percentile at DAH30, 80% of both females and males remained in the lowest 10th percentile at 90 days, while 72% of females and 76% males remained in that percentile at 180 days.

CONCLUSION

DAH is a responsive outcome to differences in patient and surgical risk factors. Further research is needed to identify new care pathways to reduce disparities in outcomes between male and female patients.

Influence of preoperative and intraoperative factors on recovery after aortic root surgery

OBJECTIVE

To determine the influence of intraoperative factors relative to preoperative risk factors on recovery after aortic root replacement (ARR).

METHODS

Retrospective review of baseline and intraoperative characteristics was performed of 822 patients at our Aortic Center from 2005 to 2019. Inclusion criteria were all patients age 18 and older who underwent ARR at our institution from 2005 to 2019. The primary endpoint was the aggregate outcome of "failure to achieve uneventful recovery (FUR)," as previously defined.

RESULTS

In total, 207 (25%) patients experienced FUR. The following preoperative and intraoperative variables were significantly associated with FUR in the multivariable analysis: cardiopulmonary bypass time (OR 1.01, 95% CI 1.01-1.02) open chest management (OR 5.67, 95% CI 2.65-12.1), ejection fraction (OR 1.03, 95% CI 1.01-1.04), chronic kidney disease > stage 3a (OR 2.37, 95% CI 1.54-3.63), bicuspid aortic valve (OR 1.54, 95% CI 1.21-1.96), and female sex (OR 1.30, 95% CI 1.06-1.61). Cardiopulmonary bypass time and open chest management were among the top three partial R2 contributors to the logistic regression model variance.

CONCLUSIONS

These findings suggest efficacy in using intraoperative parameters to predict postoperative outcomes after ARR.

Quantifying the effects of circulatory arrest on acute kidney injury in aortic surgery

OBJECTIVES

We aim to investigate the association between parameters surrounding circulatory arrest and postoperative acute kidney injury in aortic surgery.

METHODS

This is a single-center retrospective study of 1118 adult patients who underwent aortic repair with median sternotomy between January 2010 and May 2019. Acute kidney injury was defined on the basis of a modified version of the 2012 Kidney Disease Improving Global Outcomes Scale that excluded urine output. The primary outcome of interest was any stage of acute kidney injury.

RESULTS

Circulatory arrest was required in 369 patients, and 307 patients (27.5%) developed acute kidney injury: stage 1 in 241 patients, stage 2 in 38 patients, and stage 3 in 28 patients. Lower-body ischemia (the period during circulatory arrest without blood flow to kidneys) duration was not associated with acute kidney injury after multivariable logistic regression (1-40 minutes, odds ratio, 0.67; 95% confidence interval, 0.43-1.04; P = .075; >40 minutes, odds ratio, 0.67; 95% confidence interval, 0.29-1.55; P = .356). Hypertension (odds ratio, 1.65; 95% confidence interval, 1.09-2.54; P = .020), preoperative estimated glomerular filtration rate (odds ratio, 0.99; 95% confidence interval, 0.98-1.00; P = .010), packed red blood cell transfusion volume (odds ratio, 1.00; 95% confidence interval, 1.00-1.00; P = .028), and nadir temperature (odds ratio, 0.93; 95% confidence interval, 0.88-0.99; P = .013) were independently associated with acute kidney injury after multivariable analysis. Although there was a positive association between lower-body ischemia duration and development of acute kidney injury with univariable cubic spline, the positive curve was flattened after adjustment for the described variables.

CONCLUSIONS

Within the range of our clinical practice, prolonged lower-body ischemia duration was not independently associated with postoperative acute kidney injury, whereas nadir temperature was.

Central aortic versus axillary artery cannulation for aortic arch surgery

Objective

Central aortic cannulation for aortic arch surgery has become more popular over the last decade; however, evidence comparing it with axillary artery cannulation remains equivocal. This study compares outcomes of patients who underwent axillary artery and central aortic cannulation for cardiopulmonary bypass during arch surgery.

Methods

A retrospective review of 764 patients who underwent aortic arch surgery at our institution between 2005 and 2020 was performed. The primary outcome was failure to achieve uneventful recovery, defined as having experienced at least 1 of the following: in-hospital mortality, stroke, transient ischemic attack, bleeding requiring reoperation, prolonged ventilation, renal failure, mediastinitis, surgical site infection, and pacemaker or implantable cardiac defibrillator implantation. Propensity score matching was used to account for baseline differences across groups. A subgroup analysis of patients undergoing surgery for aneurysmal disease was performed.

Results

Before matching, the aorta group had more urgent or emergency operations (P = .039), fewer root replacements (P < .001), and more aortic valve replacements (P < .001). After successful matching, there was no difference between the axillary and aorta groups in failure to achieve uneventful recovery, 33% versus 35% (P = .766), in-hospital mortality, 5.3% versus 5.3% (P = 1), or stroke, 8.3% versus 5.3% (P = .264). There were more surgical site infections in the axillary group, 4.8% versus 0.4% (P = .008). Similar results were seen in the aneurysm cohort with no differences in postoperative outcomes between groups.

Conclusions

Aortic cannulation has a safety profile similar to that of axillary arterial cannulation in aortic arch surgery.

Extent of aortic replacement and operative outcome in open proximal thoracic aortic aneurysm repair

Objectives

There are few data to delineate the risk differences among open aortic procedures. We aimed to investigate the influence of the procedural types on the outcomes of proximal thoracic aortic aneurysm repair.

Methods

Among 1900 patients who underwent aortic replacement in our institution between 2005 and 2019, 1132 patients with aortic aneurysm who underwent a graft replacement of proximal thoracic aorta were retrospectively reviewed. Patients were divided into 4 groups based on the extent of the aortic replacement: isolated ascending aortic replacement (n = 52); ascending aortic replacement with distal extension with hemiarch, partial arch, or total arch replacement (n = 126); ascending aortic replacement with proximal extension with aortic valve or root replacement (n = 620); and ascending aortic replacement with distal and proximal extension (n = 334). "Eventful recovery," defined as occurrence of any key complications, was used as the primary end point. Odds ratios for inability to achieve uneventful recovery in each procedure were calculated using ascending aortic replacement as a reference.

Results

Overall, in-hospital mortality and stroke occurred in 16 patients (1.4%) and 24 patients (2.1%). Eventful recovery was observed in 19.7% of patients: 11.5% in those with ascending aortic replacement, 36.5% in those with partial arch or total arch replacement, 16.6% in those with proximal extension with aortic valve or root replacement, and 20.4% in those with distal and proximal extension (P < .001). With ascending aortic replacement as the reference, a multivariable logistic regression revealed partial arch or total arch replacement (odds ratio, 10.0; 95% confidence interval, 1.8-189.5) was an independent risk factor of inability to achieve uneventful recovery.

Conclusions

Open proximal aneurysm repair in the contemporary era resulted in satisfactory in-hospital outcomes. Distal extension was associated with a higher risk for postoperative complications.

A novel dosing strategy of del Nido cardioplegia in aortic surgery

Objective

While del Nido (DN) cardioplegia is increasingly used in cardiac surgery, knowledge is limited in its safety profile for operations with prolonged crossclamp time (CCT). We have introduced a unique redosing strategy for aortic surgery: all operations use DN with a 1000-mL initiation dose (750 mL antegrade, 250 mL retrograde) composed of 1:4 blood:DN crystalloid. At 90 minutes CCT and every 30 minutes thereafter, a 250-mL dose was introduced retrograde in a 4:1 (“reverse”) ratio. Additionally, at 90 minutes CCT and every 90 minutes thereafter, a reverse ratio dose of approximately 100 to 400 mL was introduced via the right coronary artery. Here, we analyze the outcomes of our unique redosing strategy used.

Methods

In total, 440 patients underwent aortic surgery between January 2015 and March 2021 under a single surgeon and received DN. Our primary end points were change in left ventricular ejection fraction (LVEF) and right ventricular systolic function based on echocardiography. Multivariable linear regression was used to analyze the relationship between CCT and outcomes.

Results

The median was 61 years old (interquartile range, 51-69), and 23% were female. Indication was aneurysm in 65% and dissection in 24%. Median preoperative LVEF was 60% (55%-62%). Median CCT and cardiopulmonary bypass times were 135 minutes (93-165 minutes) and 181 minutes (142-218 minutes), respectively. In-hospital mortality occurred in 3%. Multivariable linear regression showed CCT was not associated with change in LVEF or change in right ventricular systolic function.

Conclusions

Our unique method of redosing DN cardioplegia appears to provide safe and effective myocardial protection for aortic surgery.

Proximal aortic repair in asymptomatic patients

Objective

Current guidelines for elective proximal aortic repair are applicable to elective first-time procedures in asymptomatic patients without other primary indications or connective tissue disorders and with specified aortic diameter or growth rate. The objective was to characterize the surgical outcomes in this narrowly defined patient-population.

Methods

Guideline-compliant patients were identified from a recent (2014-2019) single unit consecutive surgical cohort (n = 935) by excluding total arch replacements, redos, acute and symptomatic patients, and genetic syndromes. Remaining patients were included regardless of surgical procedure performed. Early (30-day or in-hospital) and 1-year mortality were primary outcome measures. Major complications (stroke, severe renal or respiratory insufficiency, postcardiotomy shock, deep sternal wound infection, permanent pacemaker, and re-exploration) up to 1 year postoperatively were secondary outcome measures.

Results

In the resulting study population (n = 262), median age was 63 (interquartile range, 52-71) years, and median surgical risk (European System for Cardiac Operative Risk Evaluation II) was 3.2% (2.0%-4.4%). Early mortality was 2 of 262 (0.76%) without additional deaths up to 1-year postoperatively. The occurrence of major complications was low: stroke, 2 (0.76%); renal insufficiency, 2 (0.76%); respiratory insufficiency, 1 (0.38%); postcardiotomy shock, 1 (0.38%); deep sternal wound infection, 0; permanent pacemaker, 3 (1.1%); and re-exploration, 20 (7.6%), all occurring in the immediate (30-day) postoperative period and without additional events up to 1 year postoperatively.

Conclusions

In this recent cohort including the target population referred to by and managed in accordance with current guidelines, mortality and major complications were exceptionally infrequent. Guidelines should adequately weigh risks of conservative management against current surgical outcomes.

Cost-effectiveness analysis of screening for first-degree relatives of patients with bicuspid aortic valve

AIMS

Bicuspid aortic valve (BAV) is the commonest congenital heart valve malformation, and is associated with life-threatening complications. Given the high heritability index of BAV, many experts recommend echocardiography screening for first-degree relatives (FDRs) of an index case. Here we aim to evaluate the cost-effectiveness of such cascade screening for BAV.

METHODS

Using a decision-analytic model, we performed a cost-effectiveness analysis of echocardiographic screening for FDRs of BAV index case. Data on BAV probabilities and complications among FDRs were derived from our institution's BAV familial cohort and from the literature on population-based BAV cohorts with long-term follow-up. Health gain was measured as quality-adjusted life years (QALYs). Cost inputs were based on list prices and literature data. One-way and probabilistic sensitivity analyses were performed to account for uncertainty in the model's variables.

RESULTS

Screening of FDRs was found to be the dominant strategy, being more effective and less costly than no screening, with savings of €644 and gains of 0.3 QALYs. Results were sensitive throughout the rang of the model's variables, including the full range of reported BAV rates among FDRs across the literature. A gradual decrease of the incremental effect was found with the increase in screening age.

CONCLUSIONS

This economic evaluation model found that echocardiographic screening of FDRs of BAV index case is not only clinically important but also cost-effective and cost-saving. Sensitivity analysis supported the model's robustness, suggesting its generalization.

Incidence, Cause, and Outcome of Reinterventions after Aortic Root Replacement

BACKGROUND

This study aims to comprehensively characterize the details of the aortic and aortic valve reinterventions after aortic root replacement (ARR).

METHODS

Between 2005 and 2019, 882 patients underwent ARR. The indication was for aneurysm in 666, aortic valve-related in 116, aortic dissection in 64, and infective endocarditis (IE) in 36. Valve-sparing root replacement was performed in 290 while Bio-Bentall was done in 528. Among them, 52 (5.9%) patients required reintervention. The incidence, cause, and time to reintervention, as well as outcomes after reintervention were investigated. Cause-Specific Cox hazard model was performed to identify predictors for reintervention after ARR.

RESULTS

The 10-year cumulative incidence of aortic and aortic valve reintervention after ARR was 10.3% [95%CI, 7.3%-14.0%]. Age per year decrease was the only independent predictor for reintervention [sHR, 0.97; 95%CI, 0.95-0.99]. The causes for 52 reinterventions were: 29 (55.8%) for aortic valve causes including aortic stenosis/insufficiency, and prosthetic valve dysfunction; 15 (28.9%) for IE; 7 (13.5%) for aortic-related causes including pseudoaneurysm, development of aneurysm, and residual dissection; and 1 (1.9%) for coronary button pseudoaneurysm. Median times to reintervention were 11.0 [IQR, 2.0-20.5] months for IE, 24.0 [IQR, 3.7-46.1] months for aortic-related causes, 77.0 [IQR, 28.4-97.6] months for aortic valve-related causes (p=.005). Overall in-hospital mortality after the reinterventions was 7.7% (4/52) with 20.0% with IE (3/15) .

CONCLUSIONS

Reintervention for IE occurs relatively early after ARR while aortic valve- and aortic-related reinterventions gradually increase over time. In-hospital mortality after the reintervention is low, unless it is for IE.

Chronic kidney disease stage stratifies short- and long-term outcomes after aortic root replacement

OBJECTIVES

Chronic kidney disease (CKD) is prevalent in patients undergoing cardiovascular surgery, and it negatively impacts procedural outcomes; however, its influence on the outcomes of aortic surgery has not been well studied. This study aims to elucidate the importance of CKD on the outcomes of aortic root replacement (ARR).

METHODS

Patients who underwent ARR between 2005 and 2019 were retrospectively reviewed (n = 882). Patients were divided into 3 groups based on the Kidney Disease: Improving Global Outcomes criteria: Group 1 [estimated glomerular filtration rate (eGFR) ≥ 60 ml/min/1.73 m2, n = 421); Group 2 (eGFR = 30-59 ml/min/1.73 m2, n = 424); and Group 3 (eGFR < 30 ml/min/1.73 m2, n = 37). To reduce potential confounding, a propensity score matching was also performed between Group 1 and the combined group of Group 2 and Group 3. The primary end point was 10-year survival. Secondary end points were in-hospital mortality and perioperative morbidity.

RESULTS

Severe CKD patients presented with more advanced overall chronic and acute illnesses. Kaplan-Meier analysis showed a significant correlation between CKD stage and 10-year survival (log-rank P < 0.001). The number of events for Group 1 was 15, Group 2 was 49 and Group 3 was 11 in 10 years. Group 3 had significantly higher in-hospital mortality (13.5% vs 3.5% in Group 2 vs 0.7% in Group 1, P < 0.001) and stroke (8.1% vs 7.1% vs 1.2%, P < 0.001) as well as introduction to new dialysis (27.0% vs 5.4% vs 1.7%, P < 0.001). eGFR was shown to be an independent predictor of mortality (hazard ratio, 0.98; 95% confidence interval, 0.96-0.99). Comparison between propensity matched groups showed similar postoperative outcomes, and eGFR was still identified as a predictor of mortality (hazard ratio, 0.97; 95% confidence interval, 0.95-0.99).

CONCLUSIONS

Higher stage in CKD negatively impacts the long-term survival in patients who are undergoing ARR.