Faculty Bibliography
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143
Prevention and management of spinal cord ischemia following aortic surgery: A survey of contemporary practice
OBJECTIVE:Spinal cord ischemia (SCI) is a devastating complication of thoracoabdominal aortic aneurysm repair. We aim to characterize current practices pertaining to SCI prevention and treatment across Canada. METHODS:Two questionnaires were developed by the Canadian Thoracic Aortic Collaborative and the Canadian Cardiovascular Critical Care Society targeting aortic surgeons and intensivists. A list of experts in the management of patients at risk of SCI was developed, with representation from each of the Canadian centers that perform complex aortic surgery. RESULTS:The response rate was 91% for both intensivists (21/23), and from cardiac and vascular surgeons (39/43). Most surgeons agreed that staging is important during endovascular repair of extent II thoracoabdominal aortic aneurysm (60%) but not for open repair (34%). All of the surgeons felt prophylactic lumbar drains were effective in reducing SCI, whereas only 66.7% of intensivists felt that lumbar drains were effective (P < .001). There was consensus among surgeons over when to employ lumbar drains. A majority of surgeons preferred to keep the hemoglobin over 100 g/L if the patient demonstrated loss of lower-extremity function, whereas most intensivists felt a target of 80 g/L was adequate (P < .001). Management of perioperative antihypertensives, use of intraoperative adjuncts, and management of venous thromboembolism prophylaxis in the presence of a lumbar drain, were highly variable. CONCLUSIONS:We observed some consensus but considerable variability in the approach to SCI prevention and management across Canada. Future studies focused on the areas of variability may lead to more consistent and improved care for this high-risk population.
PMID: 32334886
ISSN: 1097-685x
CID: 5450392
Seminars in thoracic & cardiovascular surgery. 2022:34(2):386-392.DOI: 10.1053/j.semtcvs.2021.03.049
Frozen Elephant Trunk for Aortic Arch Reconstruction is Associated with Reduced Mortality as Compared to Conventional Techniques
To examine the perioperative outcomes following aortic arch repair using frozen elephant trunk (FET) vs conventional elephant trunk (ET) techniques. Between 2002 and 2018, 390 patients underwent aortic repair with elephant trunk reconstruction at 9 centers: 172 patients received a FET (mean age: 65+/-13 years, 30% female, 37% aortic dissection) and 218 patients received an ET (mean age: 63+/-13 years, 37% female, 43% aortic dissection). Outcomes of interest included in-hospital mortality; stroke; and spinal cord injury (SCI). In-hospital mortality rate was 11% (n = 43) overall, 9% (n = 15) for FET and 13% (n = 28) for ET. Post-operative stroke occurred in 13% (n = 49) overall, 13% (n = 22) for FET and 12% (n = 27) for ET. The rate of post-operative SCI was 3% (n = 13) overall, 5.0% (n = 9) for FET and 2.0% (n = 4) for ET. When compared to ET, the propensity score analysis confirmed FET to be associated with lower mortality (adjusted risk difference -7.0% (95% CI -13.0 to -1.0), P = 0.02). There was no significant difference in the propensity score-adjusted risk difference for stroke between FET and ET (-0.7%, 95% CI -7.4% to 6.1%, P = 0.85), nor for SCI (3.3%, 95% CI -0.4% to 7.0%, P = 0.085) On multivariable analysis, FET was associated with lower odds of mortality (OR 0.44, 95% CI 0.21-0.95, P = 0.04), and had similar odds of stroke (OR 0.83, 95% CI 0.41-1.70, P = 0.62) and SCI (OR 2.83, 95% CI 0.83-9.60, P = 0.1). FET repair is associated with lower in-hospital mortality as compared to conventional ET, and results in similar risk of stroke and spinal cord injury. Further investigation is warranted.
PMID: 34089828
ISSN: 1532-9488
CID: 5450562
Journal of thoracic & cardiovascular surgery. 2021:162(6):1769-1778.e7.DOI: 10.1016/j.jtcvs.2020.02.084
Risk for non-home discharge following surgery for ischemic mitral valve disease
OBJECTIVES/OBJECTIVE:To determine the frequency and risk factors for non-home discharge (NHD) and its association with clinical outcomes and quality of life (QOL) at 1 year following cardiac surgery in patients with ischemic mitral regurgitation (IMR). METHODS:Discharge disposition was evaluated in 552 patients enrolled in trials of severe or moderate IMR. Patient and in-hospital factors associated with NHD were identified using logistic regression. Subsequently, association of NHD with 1-year mortality, serious adverse events (SAEs), and QOL was assessed. RESULTS:NHD was observed in 30% (154/522) with 25% (n = 71/289) in moderate and 36% (n = 83/233) in patients with severe IMR (unadjusted P = .006), a difference not significant after including age (5-year change: adjusted odds ratio [adjOR], 1.52; 95% confidence interval [CI], 1.35-1.72; P < .001), diabetes (adjOR, 1.94; 95% CI, 1.27-2.94; P = .002), and previous heart failure (adjOR, 1.64; 95% CI, 1.06-2.52; P = .03). Odds of NHD were increased for patients with postoperative SAEs (adjOR, 1.85; 95% CI, 1.19-2.86; P = .01) but not based on type of cardiac surgery. Greater rates of death and SAEs were observed in NHD patients at 1 year: adjusted hazard ratio, 4.29 (95% CI, 2.14-8.59; P < .001) and adjusted rate ratio, 1.45 (95% CI, 1.03-2.02; P = .03), respectively. QOL did not differ significantly between groups. CONCLUSIONS:NHD is common following surgery for IMR, influenced by older age, diabetes, previous heart failure, and postoperative SAEs. These patients may be at greater risk of death and subsequent SAEs after discharge. Discussion of NHD with patients may have important implications for decision-making and guiding expectations following cardiac surgery.
PMID: 32307181
ISSN: 1097-685x
CID: 5451222
Review of frozen elephant trunk repair with the Thoraflex Hybrid device
The frozen elephant trunk technique has revolutionized aortic arch repair to enable more extensive arch and descending thoracic aortic treatment in a single setting. We review the current evidence supporting the use of the Thoraflex Hybrid (Terumo Aortic, FL, USA) device and discuss advantages, pitfalls and future design considerations.
PMID: 33544641
ISSN: 1744-8298
CID: 5450502
Development of Quality Indicators for the Management of Acute Type A Aortic Dissection
In an effort to further improve surgical outcomes in patients with acute type A aortic dissection (ATAD), the Canadian Thoracic Aortic Collaborative (CTAC), with the support of the Canadian Society of Cardiac Surgeons (CSCS), endeavoured to develop quality indicators (QIs) for the management of patients with ATAD. After 2 successive consultations with the CTAC membership, 11 QIs were selected and separated into 5 broad categories: preoperative (time from presentation to diagnosis, time from presentation to the operating room), intraoperative (use of hypothermic circulatory arrest and antegrade cerebral perfusion), 30-day outcomes (30-day rates of all-cause mortality, 30-day rates of new postoperative stroke), 1-year outcomes (1-year rates of follow-up imaging, 1-year rates of all-cause mortality, and 1-year rates of surgical reintervention), and institutional (institutional surgical volumes, individual surgical volumes, and presence of institutional aortic disease teams). The purpose of this article is to describe the process by which QIs for the management of ATAD were developed and the feasibility by which they may be collected using existing clinical and administrative data sources. Furthermore, we demonstrate how they may be used to evaluate success following surgery for repair of ATAD and ultimately improve clinical outcomes.
PMID: 34090977
ISSN: 1916-7075
CID: 5450572
Does adding an aortic root replacement or sinus repair during arch repair increase postoperative mortality? Evidence from the Canadian Thoracic Aortic Collaborative
OBJECTIVES:The aim of this study was to examine the effect of the addition of an aortic root replacement or sinus repair on mortality and morbidity during aortic arch repair. METHODS:A total of 2472 patients underwent proximal or total aortic arch repair with hypothermic circulatory arrest between 2002 and 2018 at 12 centres. Multivariable logistic regressions (MV) and propensity score (PS) with inverse probability of treatment weighting (IPTW) analyses were performed. RESULTS:A total of 1099 (44.5%) patients had additional aortic root replacement (n = 934) or sinus repair (n = 165). Those with aortic root interventions were younger (61 ± 13 vs 64 ± 13 years, P < 0.001) and had less females (23% vs 35%, P < 0.001), less dissection (31% vs 36%, P = 0.004), less urgent cases (35% vs 39%, P = 0.047), more connective tissue disease (7% vs 3%, P < 0.001) and less total arch replacements (14% vs 22%, P < 0.001). On adjusted analyses, the addition of aortic root procedure was associated with increased mortality [MV: odds ratio (OR) 1.41, 95% confidence interval (CI) 1.03-1.92; PS-IPTW: risk increased by 3.7%, 95% CI 1.2-6.3%, P = 0.004]. Reoperation for bleeding was also increased with the addition of aortic root intervention (MV: OR 1.48, 95% 1.10-1.99; PS-IPTW: risk increased by 3.2%, 95% CI 0.8-5.6%, P = 0.009). The risks of stroke and dialysis-dependent renal failure were similar. When looking only at non-elective cases, the increased risk of mortality was more pronounced (MV: OR 1.60, 95% CI 1.11-2.32, P = 0.013; PS-IPTW: risk increased by 6.8%, 95 CI 1.7-11.8%, P = 0.008, and a number need to harm of 15 patients to cause 1 additional death). CONCLUSIONS:The addition of aortic root replacement or sinus repair during proximal or total aortic arch repair seems to increase postoperative mortality only in non-elective cases.
PMID: 33769490
ISSN: 1873-734x
CID: 5450532
Evolving Surgical Techniques and Improving Outcomes for Aortic Arch Surgery in Canada
BACKGROUND:To explore evolving surgical techniques and outcomes for aortic arch surgery. METHODS:A total of 2435 consecutive patients underwent aortic arch repair with hypothermic circulatory arrest between 2008 and 2018 in 12 institutions across Canada. Trends in patient characteristics, surgical techniques, and in-hospital outcomes, including major morbidity or mortality, were examined. RESULTS: = 0.12). Outcomes remained the same over time for urgent or emergent cases. CONCLUSIONS:Outcomes have improved over the past decade in Canada for elective aortic arch surgery, in the context of operating on smaller aortas, and more frequent use of moderate hypothermia and antegrade cerebral perfusion. Further research is needed to improve stroke rates and outcomes in the emergency setting.
PMCID:8531226
PMID: 34712938
ISSN: 2589-790x
CID: 5450612
Journal of thoracic & cardiovascular surgery. 2021:162(3):759-766.e1.DOI: 10.1016/j.jtcvs.2020.02.032
The impact of age on patients undergoing aortic arch surgery: Evidence from a multicenter national registry
OBJECTIVE:Elderly patients are typically offered aortic surgery at similar diameter thresholds as younger patients, despite limited data quantifying their operative risk. We aim to report the incremental risk experienced by elderly patients undergoing aortic arch surgery. METHODS:In total, 2520 patients underwent aortic arch surgery between 2002 and 2018 in 10 centers. Patients were divided into 3 groups: <65 years (n = 1325), 65 to 74 years (n = 737), and ≥75 years (n = 458). Outcomes of interest were in-hospital mortality, stroke, and the modified Society of Thoracic Surgeons composite for mortality or major morbidity (STS-COMP). Multivariable modeling was performed to determine the association of age with these outcomes. RESULTS:As age increased, there was an increasing rate of comorbidities, including diabetes (P < .001), renal failure (P < .001), and previous stroke (P = .01). Rates of acute aortic syndrome (P = .50) and total arch repair were similar (P = .59) between groups. Older patients had greater mortality (<65: 6.1% vs 65-74: 9.0% vs ≥75: 14%, P < .001), stroke (6.3% vs 7.7% vs 11%, P = .01) and STS-COMP (25% vs 32% vs 38%, P < .001). After multivariable risk-adjustment, a step-wise increase in complications was observed in the older age groups relative to the youngest in terms of in-hospital mortality (65-74: odds ratio [OR] 1.57, P = .04; ≥75: OR, 2.94, P = .001) and STS-COMP (65-74: OR, 1.57, P < .001; ≥75: OR, 1.96, P < .001). CONCLUSIONS:Older patients experienced elevated rates of mortality and morbidity following aortic arch surgery. These results support a more measured approach when evaluating elderly patients. Further research is needed on age-dependent natural history of thoracic aneurysms and size thresholds for intervention.
PMID: 32178917
ISSN: 1097-685x
CID: 5450382
The Ross procedure and valve-sparing root replacement procedures in the adult patient: do guidelines follow the evidence?
Prosthetic aortic valve replacements have long been the mainstay of valvular surgery due to their favorable outcomes and low operative complexity. Yet, mechanical valves require lifelong anticoagulation, whereas bioprosthetic valves increase the risk for earlier and more frequent reoperation. Alternative reconstructive techniques have been proposed to address these challenges. These include valve-sparing root replacement procedures if the native aortic valve can be salvaged, and the Ross procedure, which nearly eliminates prosthetic valve-related thromboembolism, anticoagulation-related hemorrhage and endocarditis. Both procedures are technically more complex and thus subject to surgeons' volume and expertise compared to conventional aortic valve replacements. However, they are associated with more favorable outcomes compared to aortic valve replacements if performed by experienced surgeons, especially in younger patients. Nevertheless, despite the growing high-quality literature supporting both procedures, existing multi-society guidelines fail to acknowledge the strength of evidence in support of valve-sparing root replacement procedures and the Ross procedure. In this review, we summarize the existing long-term evidence for the use of each procedure, describe the current guidelines for the treatment of aortic valve pathology, and propose the reevaluation of guidelines based on the available clinical evidence.
PMCID:8339635
PMID: 34422555
ISSN: 2225-319x
CID: 5450602
Operative techniques in thoracic & cardiovascular surgery. 2021:26(2):210-211. DOI: 10.1053/j.optechstcvs.2021.06.008
Commentary: The Ross Renaissance
SCOPUS:85111336921
ISSN: 1522-2942
CID: 5450972
