Chairman and O. Wayne Isom Professor Department of Cardiothoracic Surgery Weill Cornell Medicine
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1 Leonard N. Girardi, M.D. Chairman and O. Wayne Isom Professor Department of Cardiothoracic Surgery Weill Cornell Medicine New York, New York Houston Aortic Symposium Houston, Texas February 23, 2017 weill.cornell.edu Open Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms in Patients with Preoperative non-dialysis Dependent Renal Failure
2 I Have No Conflicts of Interest to Report Open Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms in Patients with Preoperative non-dialysis Dependent Renal Failure
3 Complex Aortic Arch Reconstruction Total arch Debranching Total arch/et
4 Open Aortic Arch Repair Author n Year % PND % Mortality Leshnower Safi Patel Zierer Iba Ganapathi Ziganshin Girardi Open Repair of Descending Thoracic and Thoracoabdominal Aortic Aneurysms in Patients with Preoperative non-dialysis Dependent Renal Failure
5 Arch Repair Profound Hypothermic Circulatory Arrest 20 Mortality = 12% CVA = 7% 15 % CVA minutes of PHCA
6 490 patients arch repairs with straight DHCA Op Mort: 2.4%, PND 1.6% Mean DHCA duration 30 min 12 pts DHCA > 50mins Stroke: 16.7% DHCA > 50mins vs 1.3% DHCA < 50mins; P =0.014 DHCA > 50mins (OR:5.11; P = 0.038) for worse outcomes Extended Circulatory Arrest DHCA Alone Ziganshin et al. JTCVS 2014
7 148 patients underwent DHCA/RCP for arch repair Mean DHCA duration 49±17 mins, 36 patients (24%) > 60mins PND 4.1%, TND 25%, Mort 4.1% DHCA/RCP time did not correlate with mortality, stroke, or delirium on univariate or MV analysis Extended Circulatory Arrest Retrograde Cerebral Perfusion Ruptured aneurysms and distal arch pathology correlated with PND Okita et al. JTCVS 1998
8 Extended Circulatory Arrest Antegrade Cerebral Perfusion 29 patients total aortic arch repair N = 12, ACP for 90 mins, N = 17, ACP <90mins Operative mortality: 14% (8.3% 90 min vs 18% <90 min, p = 0.62 Grade III - IV neurological damage: 0.0% 90 min vs 33% <90 min, p = TND: 17% 90 min vs 27% <90 min, p = 0.66 Bjurbom et al., SCJ, 2015
9 Extended Circulatory Arrest Antegrade Cerebral Perfusion 34 patients underwent type A dissection repair ACP via right axillary artery, mild hypothermia 28-30oC Mean ACP duration: 79.2 min Operative mortality: 8.8% PND: 0% No difference when ACP was needed for > 60 min Fukunaga et al. Ann Thor CV Surg, 2015
10 Extended Circulatory Arrest Retrograde Cerebral Perfusion Subgroups Procedure Status Total population (n=1043) 50 min (n=50) 49 min (n=993) p value 65.7 ± ± ± Males 639 (61.3) 36 (72) 603 (60.7) Hypertension 992 (95.1) 49 (98) 943 (95) Chronic Pulmonary Disease 213 (20.4) 12 (24) 201 (20.2) Smoking 607 (58.2) 28 (56) 579 (58.3) Dissection 374 (35.9) 30 (60) 344 (34.6) (49.2) 23 (46) 490 (49.3) 2 Variable Age (mean, std. dev.) NYHA Class 238 (22.8) 11 (22) 227 (22.9) (18.0) 12 (24) 176 (17.7) (10.0) 4 (8) 100 (10.1) Previous Revascularization 112 (10.7) 4 (8) 108 (10.8) Previous Cardiac Surgery 235 (22.5) 24 (46) 211 (21.2) Previous Myocardial Infarction 161 (15.4) 6 (12) 155 (15.6) Previous Stroke 151 (14.5) 15 (30) 136 (13.7) Peripheral Vascular Disease 101 (9.7) 6 (12) 95 (9.57) Urgent 157 (15.1) 10 (20) 147 (14.8) Emergent 329 (31.5) 21 (42) 308 (31) 195 (18.7) 13 (26) 182 (18.3) Hemodialysis 24 (2.3) 2 (4) 22 (2.2) Previous renal transplant 1 (0.1) 0 (0) 1 (0.1) Atrial Fibrillation 97 (9.3) 7 (14) 90 (9.1) Ventricular Tachycardia 2 (0.2) 1 (2) 1 (0.1) Ventricular Fibrillation 2 (0.2) 0 (0) 2 (0.2) Pacemaker Dependent 12 (1.2) 0 (0) 12 (1.2) Renal Status CRI, creatinine 1.5 to 3.0 Preoperative Rhythm 0.026
11 Extended Circulatory Arrest Retrograde Cerebral Perfusion Subgroups 50 min (n=50) 49 min (n=993) p value 58.2 ± ± ± ± ± ± ± ± Warming Time (mean, std. dev.) 76.0 ± ± Cardiac Ischemic Time (mean, std. dev.) ± ± 36.4 Total Arch Procedure 47 (94.0) 201 (20.2) Hemi Arch Procedure 2 (4.0) 749 (75.4) Ascending Tube Graft 38 (76.0) 673 (67.8) Aortic Valve Replacement 7 (14.0) 187 (18.8) Aortic Valve Repair 7 (14.0) 244 (24.6) Coronary Artery Bypass Grafting 9 (19.0) 187 (18.8) Composite valve graft 4 (8.0) 196 (19.7) Variable Circulatory Arrest Time (mean, std. dev.) Retrograde Cerebral Perfusion Time (mean, std. dev.) Cardiopulmonary Bypass Time (mean, std. dev.) Cooling Time (mean, std. dev.) Associated Procedure
12 Extended Circulatory Arrest Retrograde Cerebral Perfusion Subgroup 1 Subgroup 2 Total population (n=1043) 50 min (n=50) 49 min (n=993) p value 60 min (n=17) 49 min (n=993) p value 42 (4.0) 4 (8.0) 38 (3.8) (5.9) 38 (3.8) Permanent Neurologic Deficit 13 (1.2) 1 (2.0) 12 (1.2) (0.0) 13 (1.3) Transient Neurologic Deficit 33 (3.2) 4 (8.0) 29 (2.9) (5.9) 32 (3.1) Blood Transfusion (mean, std. dev.) 1.3 ± ± ± ± ± 2.2 Patients without Blood Transfusion 523 (50.1) 14 (28) 509 (51.3) (17.6) 509 (51.3) Myocardial infarction 7 (0.7) 0 (0.0) 7 (0.7) 0 (0.0) 7 (0.7) Tracheostomy 39 (3.7) 4 (8.0) 35 (3.5) 1 (5.9) 35 (3.5) Dialysis 27 (2.6) 1 (2.0) 26 (2.6) 0 (0.0) 26 (2.6) Variable In-hospital death CVA Other major complications:
13 Extended Circulatory Arrest Retrograde Cerebral Perfusion Dependent Variable Variable OR (95% CI) P value Age ( ).007 Previous MI ( ) <.001 Emergent Procedure ( ).026 Pump Time ( ).005 Blood Transfusion ( ).001 Previous CVA ( ).002 Previous Cardiac Surgery ( ).015 Operative Mortality PND
14 Extended Circulatory Arrest Conclusions Extended periods of circulatory arrest are uncommon Mostly associated with complex total arch reconstruction, chronic dissections, reoperations and downstream pathology DHCA alone is inadequate cerebral protection when extended periods of circulatory arrest are anticipated RCP extends safe period of DHCA beyond 50 to 60 minutes,? longer Although large meta-analysis failed to show superiority of a single adjunct, subgroup analysis of those with ECA may yield valuable information
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16 Retrograde 1107 patients underwent ascending and transverse aortic arch repair. RCP was used in 82% (907/1107) of patients Results Overall mortality 10.4% Stroke 2.8% Risk factors for mortality and stroke Estrera et al. Circ 2008
17 Extended DHCA 23 patients underwent aortic surgery with RCP and prolonged HCA. Results Overall early mortality: 4.3% Percent oxygen extraction and pyruvate and lactate levels (26 +/- 2% and / and 45 +/- 16 mg/di) were insignificantly different from those before CA (28 +/- 3% and / and 62 +/- 20 mg/dl, P >.05). Creatine kinase-bb isoenzyme was undetectable Cerebral functional studies performed 3 months after discharge showed no statistically significant difference when compared to a normal cohort of patients. Lin et al. Circ 1996
18 Retrograde 249 patients underwent DHCA with routine RCP for aortic arch surgery Results Overall mortality 10% Stroke 4% Risk factors for mortality and neurological morbidity combined Pump time (p = ) Age (p = ) Urgency of surgery (p = 0.07) RCP time (p = 0.15) Relationship of mortality and RCP time are shown with the estimated logistic curve. Ueda et al. ATS 1999
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