1
|
Chung MM, Pan C, Hayashi H, Kandula V, Zhao Y, Levine D, Childress P, Sutherland L, Raza ST, Kurlansky P, Smith CR, Takayama H. Significance of isolated postoperative atrial fibrillation in thoracic aortic aneurysm repair. J Thorac Cardiovasc Surg 2025; 169:617-626.e7. [PMID: 38191071 DOI: 10.1016/j.jtcvs.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/18/2023] [Accepted: 12/29/2023] [Indexed: 01/10/2024]
Abstract
OBJECTIVE Although postoperative atrial fibrillation has been shown to be associated with worse survival after thoracic aortic surgery, its effect on outcomes independently from other postoperative complications is not well understood. METHODS This is a single-center retrospective study of patients who underwent open thoracic aortic aneurysm repair between March 2005 and March 2021. Postoperative atrial fibrillation was defined as new-onset atrial fibrillation that developed during the index hospital stay. Patients with preoperative atrial fibrillation were excluded. Postoperative major complications included reoperation for bleeding, respiratory failure, acute renal failure, and stroke. Variables associated with postoperative atrial fibrillation were analyzed with multivariable regression. Survival of patients without major complications was compared between patients without atrial fibrillation and patients with postoperative atrial fibrillation after propensity score matching for baseline and intraoperative characteristics. RESULTS Of 1454 patients, 520 (35.8%) were observed to have postoperative atrial fibrillation. Patients with postoperative atrial fibrillation had a higher rate of postoperative major complications than those without atrial fibrillation (20.2% vs 12.2%, P < .001). Ten-year survival was 82.0% in patients with postoperative atrial fibrillation and 87.0% in patients without atrial fibrillation (P = .008). In the cohort of patients without complications, 10-year survival was similar between patients with and without postoperative atrial fibrillation after propensity score matching (83.6% vs 83.8%, P = .75). CONCLUSIONS Postoperative atrial fibrillation is common after open proximal thoracic aortic aneurysm repair. Although development of major postoperative complications is associated with postoperative atrial fibrillation and decreased long-term survival, isolated postoperative atrial fibrillation does not appear to influence long-term survival.
Collapse
Affiliation(s)
- Megan M Chung
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY.
| | - Cheryl Pan
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Hideyuki Hayashi
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Viswajit Kandula
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Yanling Zhao
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Dov Levine
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Patra Childress
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Lauren Sutherland
- Department of Anesthesiology, Columbia University Irving Medical Center, New York, NY
| | - Syed T Raza
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University Irving Medical Center, New York, NY
| | - Craig R Smith
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| | - Hiroo Takayama
- Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, NY
| |
Collapse
|
2
|
Grasty MA, Lawrence K. Advances and Innovation in Acute Type a Aortic Dissection. J Clin Med 2024; 13:7794. [PMID: 39768716 PMCID: PMC11728286 DOI: 10.3390/jcm13247794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2024] [Revised: 11/20/2024] [Accepted: 12/05/2024] [Indexed: 01/16/2025] Open
Abstract
The prompt and appropriate management of acute type A aortic dissections is imperative for patient survival. Advances in medical technology have broadened the adjuncts available to treat the spectrum of pathology within this population. The role of medical management prior to surgical intervention and the components of operative management, including cannulation strategies, neuroprotection, and the extent of aortic intervention, have been explored in-depth within the literature. More recent work has identified novel open and endovascular techniques available to treat acute type A dissections. This review aims to summarize the literature, with a particular focus on innovation in cardiac surgery and its role in the care of this high-risk population.
Collapse
Affiliation(s)
| | - Kendall Lawrence
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, PA 19104, USA
| |
Collapse
|
3
|
Chung M, Rajesh K, Hohri Y, Zhao Y, Wang C, Chan C, Kaku Y, Takeda K, George I, Argenziano M, Smith C, Kurlansky P, Takayama H. Adverse Technical Events During Aortic Root Replacement. Ann Thorac Surg 2024; 118:845-853. [PMID: 38936593 DOI: 10.1016/j.athoracsur.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 05/20/2024] [Accepted: 06/05/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Although adverse technical events during aortic root replacement (ARR) are not uncommon and are extremely challenging, there is scant literature to help surgeons prepare for such situations. We describe our experience of outstanding technical events during ARR. METHODS This is a retrospective study of 830 consecutive ARRs at a single center from 2012 to 2022. Technical events were defined as intraoperative events that led to an unplanned cardiac procedure, need for mechanical circulatory support, or additional aortic cross-clamping. Logistic regression identified factors associated with operative mortality and technical events. RESULTS Technical events occurred in 90 patients (10.8%) and were attributed to bleeding (n = 26), nonischemic ventricular dysfunction (n = 23), residual valve disease (n = 20), myocardial ischemia (n = 19), and iatrogenic dissection (n = 2). Prior sternotomy (odds ratio [OR], 2.38; 95% CI, 1.36-4.19; P = .002) and complex aortic valve disease (OR, 3.09; 95% CI, 1.09-8.75; P = .03) were associated with technical events. Patients with technical events had higher rates of operative mortality (6.7% vs 2.3%, P = .03) and all major postoperative complications. Surgical indications of dissection (OR, 13.57; 95% CI, 4.95-37.23; P < .001) and complex aortic valve disease (OR, 14.09; 95% CI, 3.67-54.02; P < .001) but not adverse technical events (OR, 2.42; 95% CI, 0.81-7.26; P = .11) were associated with operative mortality. CONCLUSIONS Adverse technical events occurred in 10.8% of ARRs and were associated with reoperative sternotomies. Technical events are associated with increased postoperative complications.
Collapse
Affiliation(s)
- Megan Chung
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Kavya Rajesh
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yu Hohri
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yanling Zhao
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York
| | - Chunhui Wang
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York
| | - Christine Chan
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Yuji Kaku
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Koji Takeda
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Isaac George
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Michael Argenziano
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Craig Smith
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, Columbia University Irving Medical Center, New York, New York.
| |
Collapse
|
4
|
Rajesh K, Chung M, Levine D, Norton E, Patel P, Hohri Y, He C, Agarwal P, Zhao Y, Wang P, Kurlansky P, Chen E, Takayama H. Importance of surgeon's experience in practicing valve-sparing aortic root replacement. JTCVS OPEN 2024; 21:19-34. [PMID: 39534352 PMCID: PMC11551295 DOI: 10.1016/j.xjon.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 07/05/2024] [Accepted: 07/08/2024] [Indexed: 11/16/2024]
Abstract
Background Valve-sparing root replacement (VSRR) requires a unique skill set. This study aimed to examine the influence of surgeon's procedural volume on outcomes of VSRR. Methods This retrospective study included 1697 patients from 2 large, high-volume aortic centers who underwent aortic root replacement (ARR) between 2004 and 2021 and were potentially eligible for VSRR. Surgeons were classified as performing <5 ARRs or ≥5 ARRs annually. Multivariable logistic regression was used to examine the independent association of surgeon volume and the decision to perform VSRR. Inverse probability treatment weighting (IPTW) was used to match patients who were operated on by <5 ARR surgeons or ≥5 ARR surgeons and compare long-term survival probability. Cumulative incidence curves with mortality as a competing risk were plotted to compare the rate of aortic valve reoperation. Results Of 1697 patients who met the study inclusion criteria, 944 underwent composite-valve conduit ARR and 753 underwent VSRR. The median age of the cohort was 57 years (interquartile range, 45-66 years), and 268 (15.8%) were female. Aortic insufficiency was present in 1105 patients (65.1%), and 200 of the procedures (11.8%) were reoperations. The indication for surgery was aneurysm in 1496 patients (88.2%) and dissection in 201 (11.8%). Among the 743 patients who underwent VSRR, 691 (92%) were operated on by ≥ 5 ARR surgeons and 62 (8%) were operated on by <5 ARR surgeons. In multivariable logistic regression, ≥5 ARRs (odds ratio, 3.33; 95% confidence interval, 2.34-4.73; P < .001) was associated with VSRR as the procedure of choice. Following IPTW, there was no significant difference between <5 ARR and ≥5 ARR surgeons in survival probability after VSRR (P = .59) or in the rate of aortic valve reoperation (P = .60). Conclusions In the setting of a high-volume aortic center, patients who undergo ARR are less likely to receive VSRR if operated on by a <5 ARR surgeon; however, VSRR may be safely performed by <5 ARR surgeons.
Collapse
Affiliation(s)
- Kavya Rajesh
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Megan Chung
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Dov Levine
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Elizabeth Norton
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Parth Patel
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Yu Hohri
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| | - Chris He
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Paridhi Agarwal
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Yanling Zhao
- Center for Innovation and Outcomes Research, Columbia University, New York, NY
| | - Pengchen Wang
- Center for Innovation and Outcomes Research, Columbia University, New York, NY
| | - Paul Kurlansky
- Center for Innovation and Outcomes Research, Columbia University, New York, NY
| | - Edward Chen
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY
| |
Collapse
|
5
|
Tel Ustunisik C, Yagci L, Arapi B, Balkanay OO, Omeroglu SN, Ipek G, Goksedef D. Aortic versus axillary artery cannulation for hemiarch replacement: single-centre real-world experience. BMC Cardiovasc Disord 2024; 24:462. [PMID: 39198748 PMCID: PMC11351082 DOI: 10.1186/s12872-024-04125-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 08/16/2024] [Indexed: 09/01/2024] Open
Abstract
BACKGROUND Aortic arch disease is a major cause of acute dissections. Surgical replacement is the current curative treatment for aortic arch disease. While traditional aortic cannulation ensures lower body perfusion, axillary cannulation offers optimum cerebral perfusion. AIM To evaluate the outcomes of aortic and axillary cannulation methods in hemiarch replacements, focusing on postoperative perfusion and survival. MATERIALS AND METHODS A retrospective analysis was conducted on 91 patients who underwent hemiarch replacement surgery between February 2007 and October 2016. Patients were divided into two groups based on the cannulation method: aortic cannulation (54 patients) and axillary cannulation (37 patients). Data regarding preoperative, intraoperative, and postoperative parameters were analyzed, including demographics, surgical outcomes, and complications. RESULTS Demographic analysis showed comparable characteristics between the two groups, with notable differences in aortic disease severity and classification. Patients in the axillary group had a larger ascending aorta diameter (57.7 ± 10.8 mm vs. 51.8 ± 5.7 mm, p = 0.002) and a higher prevalence of acute dissections (27.0% (n = 10) vs. 3.7% (n = 2), p = 0.001). Cerebral protection methods varied significantly between the two groups (p < 0.001). Antegrade cerebral perfusion was used in 37.8% (n = 14) of the axillary group compared to 3.7% (n = 2) of the central group. The central cannulation group had a higher proportion of patients with temperatures under 20 °C (98.1% (n = 53) vs. 21.6% (n = 8), p < 0.001), whereas the axillary group maintained higher temperatures (24 -28 °C) in 68.6% (n = 23) of cases. AV repair/replacement was more frequent in the aortic cannulation group (48.2% (n = 26) vs. 18.9% (n = 7), p = 0.013). No significant disparities were observed in operative mortality or intraoperative complications. Statistical analysis showed no significant differences between the two groups in the in-hospital outcomes, but renal complications were more prevalent in the axillary cannulation group with 21.6% (n = 8) experiencing acute kidney injury compared to 9.3% (n = 5) in the central group (p = 0.098). The overall survival rate was slightly higher in the aortic cannulation group at various follow-up periods, yet no statistically significant difference was found between the two groups. CONCLUSION We found no significant differences in safety and efficacy between axillary cannulation and aortic cannulation in hemiarch replacement procedures.
Collapse
Affiliation(s)
- Cigdem Tel Ustunisik
- Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, 34098, Turkey
| | - Lara Yagci
- Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, 34098, Turkey.
| | - Berk Arapi
- Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, 34098, Turkey
| | - Ozan Onur Balkanay
- Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, 34098, Turkey
| | - Suat Nail Omeroglu
- Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, 34098, Turkey
| | - Gokhan Ipek
- Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, 34098, Turkey
| | - Deniz Goksedef
- Cerrahpasa Faculty of Medicine, Istanbul University-Cerrahpasa, Istanbul, 34098, Turkey
| |
Collapse
|
6
|
Rajesh K, Levine D, Murana G, Castagnini S, Bianco E, Childress P, Zhao Y, Kurlansky P, Pacini D, Takayama H. Is surgical risk of aortic arch aneurysm repair underestimated? A novel perspective based on 30-day versus 1-year mortality. Eur J Cardiothorac Surg 2024; 65:ezae041. [PMID: 38318956 DOI: 10.1093/ejcts/ezae041] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 01/11/2024] [Accepted: 02/01/2024] [Indexed: 02/07/2024] Open
Abstract
OBJECTIVES The decision to undergo aortic aneurysm repair balances the risk of operation with the risk of aortic complications. The surgical risk is typically represented by perioperative mortality, while the aneurysmal risk relates to the 1-year risk of aortic events. We investigate the difference in 30-day and 1-year mortality after total arch replacement for aortic aneurysm. METHODS This was an international two-centre study of 456 patients who underwent total aortic arch replacement for aneurysm between 2006 and 2020. Our primary end-point of interest was 1-year mortality. Our secondary analysis determined which variables were associated with 1-year mortality. RESULTS The median age of patients was 65.4 years (interquartile range 55.1-71.1) and 118 (25.9%) were female. Concomitantly, 91 (20.0%) patients had either an aortic root replacement or aortic valve procedure. There was a drop in 1-year (81%, 95% confidence interval (CI) 78-85%) survival probability compared to 30-day (92%, 95% CI 90-95%) survival probability. Risk hazards regression showed the greatest risk of mortality in the first 4 months after discharge. Stroke [hazard ratio (HR) 2.54, 95% CI (1.16-5.58)], renal failure [HR 3.59 (1.78-7.25)], respiratory failure [HR 3.65 (1.79-7.42)] and reoperation for bleeding [HR 2.97 (1.36-6.46)] were associated with 1-year mortality in patients who survived 30 days. CONCLUSIONS There is an increase in mortality up to 1 year after aortic arch replacement. This increase is prominent in the first 4 months and is associated with postoperative complications, implying the influence of surgical insult. Mortality beyond the short term may be considered in assessing surgical risk in patients who are undergoing total arch replacement.
Collapse
Affiliation(s)
- Kavya Rajesh
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Dov Levine
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Giacomo Murana
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sabrina Castagnini
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Edoardo Bianco
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Patra Childress
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - Yanling Zhao
- Center for Innovation and Outcomes Research, Columbia University, New York, NY, USA
| | - Paul Kurlansky
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
- Center for Innovation and Outcomes Research, Columbia University, New York, NY, USA
| | - Davide Pacini
- Division of Cardiac Surgery, Cardiac Surgery Department, IRCCS, Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| |
Collapse
|
7
|
Yadav I, Saifullah H, Mandal AK, I Kh Almadhoun MK, Elsheikh Elabadi HM, Eugene M, Suleman M, Bushra Himedan HO, Fariha F, Ahmed H, Muzammil MA, Varrassi G, Kumar S, Khatri M, Elder M, Mohamad T. Cannulation Strategies in Type A Aortic Dissection: Overlooked Details and Novel Approaches. Cureus 2023; 15:e46821. [PMID: 37954771 PMCID: PMC10636502 DOI: 10.7759/cureus.46821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/10/2023] [Indexed: 11/14/2023] Open
Abstract
Aortic dissection type A is a life-threatening condition that frequently necessitates surgical intervention. This review focuses on central aortic cannulation, arch branch vessel (ABV) cannulation, and proximal arch cannulation as key techniques during aortic surgery. It discusses innovative solutions for addressing these challenges. The review synthesizes findings from recent studies and emphasizes the significance of meticulous planning and execution of cannulation in aortic dissection repair. This review aims to contribute to the advancement of surgical practices and the enhancement of patient outcomes in the management of type A aortic dissection (AAD) by addressing these frequently overlooked details.
Collapse
Affiliation(s)
- Indresh Yadav
- Internal Medicine, Samar Hospital and Research Center Pvt. Ltd., Janakpur, NPL
- Internal Medicine, Community Based Medical College, Bangladesh, Mymensingh, BGD
| | - Hanya Saifullah
- Medicine and Surgery, CMH Lahore Medical College and the Institute of Dentistry, Lahore, PAK
| | - Arun Kumar Mandal
- Internal Medicine, Manipal College of Medical Sciences/Oda Foundation, Pokhara, NPL
| | | | | | | | | | | | - Fnu Fariha
- Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Hanzala Ahmed
- Medicine and Surgery, Islamic International Medical College, Riphah International University, Karachi, PAK
| | | | | | - Satesh Kumar
- Medicine and Surgery, Shaheed Mohtarma Benazir Bhutto Medical University, Karachi, PAK
| | - Mahima Khatri
- Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Mahir Elder
- Interventional Cardiology, Heart and Vascular Institute, Detroit, USA
| | - Tamam Mohamad
- Cardiovascular, Wayne State University, Detroit, USA
| |
Collapse
|