Andrea Garcia

Total aortic arch replacement: A comparative study of zone 0 hybrid arch exclusion versus traditional open repair

OBJECTIVE We attempted to identify predictors of adverse outcomes after traditional open and hybrid zone 0 total aortic arch replacement. METHODS We performed multivariable analysis using 16 variables to identify predictors of adverse outcomes (mortality, permanent neurologic events, and permanent renal failure necessitating hemodialysis) in 319 consecutive patients who underwent total aortic arch replacement in the past 8.5 years and a subgroup analysis in 25 propensity-matched pairs. A total of 274 patients (85.9%) had traditional open repair, and 45 patients (14.1%) had hybrid zone 0 total arch exclusion. RESULTS Operative mortality was 10.3% (n = 33): 11.1% (n = 5) in the hybrid group and 10.2% (n = 28) in the traditional group (P = .79). A total of 19 patients (5.9%) had permanent stroke (15 traditional [5.5%] vs 4 hybrid [8.9%]; P = .32), and 2 patients (both traditional) had permanent paraplegia (P = 1.00). The hybrid group had more total neurologic events (P = .051) but not more permanent strokes (P = .32). Prior cardiac disease unrelated to the aorta (P = .0033) and congestive heart failure (P = .0053) independently predicted permanent adverse outcome (operative mortality, permanent neurologic event, or permanent renal failure). Concomitant coronary artery bypass grafting independently predicted permanent stroke (P = .032), as did previous cerebrovascular disease (P = .032). In multivariable analysis, procedure type (hybrid or traditional) was not an independent predictor of stroke (P = .09). During a median follow-up of 4.5 years (95% confidence interval, 3.9-4.9), survival was 78.7%, with no intergroup difference (P = .14). CONCLUSIONS Among contemporary cases, both traditional and hybrid total aortic arch replacement had acceptable results. Comparing these 2 different surgical treatment options is challenging, and an individualized approach offers the best results. Permanent adverse outcome was not significantly different between the 2 groups. Procedure type is not an independent predictor of permanent stroke. Prior cardiac disease, past or current smoking, and congestive heart failure predict adverse outcomes for total aortic arch replacement.

Innominate artery cannulation for proximal aortic surgery: outcomes and neurological events in 263 patients

OBJECTIVES To determine whether innominate artery cannulation is the ideal perfusion strategy for delivering antegrade cerebral perfusion (ACP) during surgery on the proximal ascending aorta and transverse aortic arch. METHODS A total of 263 patients underwent innominate artery cannulation with a side graft for surgery on the proximal aorta. Operations performed were ascending and proximal arch replacement (n = 213, 81.0%), ascending and total arch replacement (n = 33, 12.6%) and ascending aortic replacement (n = 12, 4.6%). Concomitant or other procedures included aortic root replacement and repair (n = 113, 43.0%), aortic valve replacement or repair (n = 118, 44.9%), coronary artery bypass (n = 40, 15.2%), antegrade stent graft delivery to the proximal descending thoracic aorta for aneurysm or dissection (n = 28, 10.7%), mitral valve repair (n = 11, 4.2%), patent foramen ovale repair (n = 3, 1.1%) and tricuspid valve repair (n = 2, 0.8%). Twenty-seven patients (10.3%) presented with acute or subacute Type I aortic dissection, and 45 (17.1%) had a previous sternotomy. Median cardiopulmonary bypass (CPB), cardiac ischaemia and ACP times were 126.0 [95-163 interquartile range (IQR)], 91.0 (73-121 IQR) and 21.0 (16-32 IQR) min. Bilateral ACP was delivered in 235 patients (90.7%). RESULTS The operative mortality rate was 4.9% (n = 13). Nine patients (3.4%) had postoperative stroke, which was permanent in 5 (1.9%) of them. Multivariate analysis associated risk of stroke or temporary neurological deficit with acute or subacute Type I aortic dissection (P = 0.028) and age (P = 0.015). Renal disease (P = 0.036) and CPB time (P = 0.011) were independent risk factors for operative mortality. Circulatory arrest time was identified as a risk factor for mortality (P = 0.038). CONCLUSIONS Innominate artery cannulation can be performed safely and poses a low risk of neurological events in procedures requiring hypothermic circulatory arrest. The technique for cannulating this artery should be part of the routine armamentarium of cardiac and aortic surgeons, and the innominate artery is among the preferred perfusion sites for delivering ACP.

Mesh shift following laparoscopic ventral hernia repair

INTRODUCTION Traditionally, laparoscopic ventral hernia repair (LVHR) is performed by placing the trocars on one side of the abdomen. Tacking the mesh on the operative side can be challenging. We hypothesized that mesh shift may occur as a result of this approach. We define mesh shift as any mesh off-center, where the center is the hernia defect. Our objectives were to evaluate whether mesh shift occurs after LVHR, and to develop a grading system to describe this phenomenon. METHODS We conducted a retrospective review of patients who underwent LVHR from 2000 to 2010. We examined patient demographics, comorbidities, radiographic data, surgical data, and outcomes. Using analysis of variance, we analyzed continuous data; we used Chi squared to analyze categorical data. Of the 201 patients, we reviewed 78 postoperative computed tomography (CT) scans. Two surgeons measured mesh overlap of the fascia bilaterally at the level of the hernia defect. We compared a ratio of the two sides of overlap (least overlap/greatest overlap) and classified patients into four grades: grade I, no mesh shift (ratio of 0.5-1.00); grade II, mild mesh shift (ratio of 0.20-0.49); grade III, moderate mesh shift (>0-0.19); and grade IV, major mesh shift with recurrence (<0). Any recurrence was classified as a grade IV shift. RESULTS A total of 48% of patients had mesh shift (grade II = 23%; grade III = 10%; and grade IV = 17%). In 92% of the patients with mesh shift, the mesh migrated away from the port placement site, resulting in decreased mesh/fascial overlap. Patients in the four groups had similar demographics, comorbid conditions, hernia characteristics, operative technique, and outcomes (excluding recurrences, which were all grade IV by definition). Whereas differences in time to follow-up CT scan in the different grades were not statistically significant, there was a trend toward increasing shift with time (mean: grade I, 20 mo; grade II, 38 mo; grade III, 50 mo; and grade IV, 26 mo; P = 0.07). A total of 26 patients (33%) had multiple postoperative CT scans. With time, it appears that mesh tended to shift with time (grade I, 68%-46%; grade II, 12%-19%; grade III, 12%-8%, and grade 4, 8%-23%). CONCLUSIONS Mesh can shift from the ideal central placement after LVHR. Mesh tends to shift away from the operative side and recurrences tend to occur on the operative side. Mesh shift may be a precursor to hernia recurrence. Recurrence may be a two-step process, beginning first with intra-operative mesh shift followed by additional factors (such mesh contraction) that may accentuate the shift and lead to recurrence. Potential solutions include increasing mesh overlap (≥ 6 cm), performing transcutaneous closure of central defect, securing trans-fascial sutures before tacking, placing operative side tacks first, and consider placing contralateral ports to secure the mesh.

Reoperations on the total aortic arch in 119 patients: short- and mid-term outcomes, focusing on composite adverse outcomes and survival analysis.

OBJECTIVES To determine the preoperative and perioperative risk factors that significantly predict adverse outcomes after total arch replacement in patients with previous proximal aortic surgery and to analyze patient survival. METHODS We performed univariate analysis and logistic regression on data extracted from a prospectively maintained database for 119 patients who had undergone total arch operations during a 7.5-year period. All patients had undergone previous proximal aortic surgery. The adverse outcome was defined as a single composite endpoint comprising operative mortality, permanent neurologic deficit, and renal failure necessitating permanent hemodialysis. RESULTS The incidence of the composite endpoint was 13.5% (16 of 119 patients). The univariate predictors were preoperative pulmonary disease (P = .010), cardiac ischemia time (P = .032), and cardiopulmonary bypass (CPB) time (P = .073). On multivariate analysis, the following were predictors of the composite endpoint: preoperative pulmonary disease (P = .036), CPB time (P = .039), concomitant coronary artery bypass (P = .0057), previous aortic valve replacement (P = .027), and previous thoracoabdominal aortic aneurysm surgery (P = .057). Multivariate analysis showed that the CPB time predicted mortality (P = .0044), and previous thoracoabdominal aortic aneurysm surgery predicted stroke (P = .034). The overall survival was 85.3% during a median follow-up of 4.76 years (95% confidence interval, 4.2-5.1). CONCLUSIONS Aortic arch reoperations, although technically demanding, can produce acceptable results. Preoperative pulmonary disease, CPB time, and concomitant coronary artery bypass predicted an adverse outcome. The CPB time predicted mortality, and previous thoracoabdominal aortic surgery predicted stroke.

Impact of cumulative intravascular contrast exposure on renal function in patients with occlusive and aneurysmal vascular disease

OBJECTIVE Patients with occlusive or aneurysmal vascular disease are repeatedly exposed to intravascular (IV) contrast for diagnostic or therapeutic purposes. We sought to determine the long-term impact of cumulative iodinated IV contrast exposure (CIVCE) on renal function; the latter was defined by means of National Kidney Foundation (NKF) criteria. METHODS We performed a longitudinal study of consecutive patients without renal insufficiency at baseline (NFK stage I or II) who underwent interventions for arterial occlusive or aneurysmal disease. We collected detailed data on any IV iodinated contrast exposure (including diagnostic or therapeutic angiography, cardiac catheterization, IV pyelography, computed tomography with IV contrast, computed tomographic angiography); medication exposure throughout the observation period; comorbidities; and demographics. The primary end point was the development of renal failure (RF) (defined as NFK stage 4 or 5). Analysis was performed with the use of a shared frailty model with clustering at the patient level. RESULTS Patients (n = 1274) had a mean follow-up of 5.8 (range, 2.2-14) years. In the multivariate model with RF as the dependent variable and after adjusting for the statistically significant covariates of baseline renal function (hazard ratio [HR], 0.95; P < .001), diabetes (HR, 1.8; P = .007), use of an angiotensin-converting enzyme inhibitor (HR, 0.63; P = .03), use of antiplatelets (HR, 0.5; P = .01), cumulative number of open vascular operations performed (HR, 1.2; P = .001), and congestive heart failure (HR, 3.2; P < .001), CIVCE remained an independent predictor for RF development (HR, 1.1; P < .001). In the multivariate survival analysis model and after adjusting for the statistically significant covariates of perioperative myocardial infarction (HR, 3.9; P < .001), age at entry in the cohort (HR, 1.05; P = .035), total number of open operations (HR, 1.51; P < .001), and serum albumin (HR, 0.47; P < .001), CIVCE was an independent predictor of death (HR, 1.07; P < .001). CONCLUSIONS Cumulative IV contrast exposure is an independent predictor of RF and death in patients with occlusive and aneurysmal vascular disease.

Moderate hypothermia at warmer temperatures is safe in elective proximal and total arch surgery: Results in 665 patients

Objective: To evaluate adverse outcomes after elective aortic arch surgery performed at higher or lower temperatures (24.0°C‐28.0°C vs 20.1°C‐23.9°C) within the wide range of moderate hypothermia. Methods: Over a 9‐year period, a total of 665 patients underwent elective proximal (n = 479) or total (n = 186) arch replacement with moderate hypothermia and antegrade cerebral perfusion. Circulatory arrest was initiated at an actual temperature of 20.1°C to 23.9°C in the lower‐temperature group (n = 334; 223 proximal, 111 total) and at 24.0°C to 28.0°C in the higher‐temperature group (n = 331; 256 proximal, 75 total). Composite adverse outcome was defined as operative mortality or persistent neurologic event or persistent hemodialysis at discharge. Multivariate logistic regression analysis was used to model adverse outcome. In addition to the actual temperature, a new, balanced variable, “predicted temperature,” was analyzed to eliminate surgeon bias. We used this variable in a propensity score–matching analysis to validate the multivariate analysis results. Results: A composite adverse outcome occurred in 7.2% of cases. Operative mortality was 5.1%. The rate of postoperative persistent neurologic deficits was 2.4%. No significant differences were found between the lower– and higher–predicted temperature groups within the moderate hypothermia range in the propensity score–matching analysis. The higher–actual temperature group had a lower rate of ventilator support at >48 hours (P = .036) and less need for tracheostomy (P = .023). Packed red blood cell transfusion and previous coronary artery bypass independently predicted composite adverse outcome (P = .0053 and .0002, respectively), operative mortality (P = .0051 and .0041), and postoperative stroke (P = .045 and .048). Cardiopulmonary bypass time independently predicted composite outcome (P = .0005), operative mortality (P < .0001), ventilatory support for >48 hours (P < .0001), and renal dysfunction (P = .0005). Conclusions: In elective proximal or total arch surgery, higher temperatures (≥24.0°C‐28.0°C) within the wide range of moderate hypothermia (20.1°C‐28°C) are safe and, compared with colder temperatures, not associated with significantly different rates of composite and adverse outcomes.

The impact of temperature in aortic arch surgery patients receiving antegrade cerebral perfusion for >30 minutes: How relevant is it really?

Objective: We examined the early outcomes and the long‐term survival associated with different degrees of hypothermia in patients who received antegrade cerebral perfusion (ACP) for >30 minutes. Methods: During a 10‐year period, 544 consecutive patients underwent proximal and total aortic arch surgery and received ACP for >30 minutes and 1 of 3 levels of hypothermia: deep (14.1°C‐20°C; n = 116 [21.3%]), low‐moderate (20.1°C‐23.9°C; n = 262 [48.2%]), and high‐moderate (24°C‐28°C; n = 166 [30.5%]). A variable called “predicted temperature” was used in propensity‐score analysis. Multivariate analysis was done to evaluate the effect of actual temperature on outcomes. Results: The operative mortality rate was 12.5% (n = 68) overall and was 15.5%, 11.8%, and 11.5% in the deep, low‐moderate, and high‐moderate hypothermia patients, respectively (P = .54). The persistent stroke rate was 6.6% overall and 12.2%, 4.6%, and 6.0% in these 3 groups, respectively (P = .024 on univariate analysis). On multivariate analysis, actual temperature was not associated with mortality, but lower temperatures predicted persistent stroke and reoperation for bleeding. In the propensity‐matched subgroups, the patients with predicted deep hypothermia had (nonsignificantly) greater rates of persistent stroke (12.2% vs 4.9%; relative risk, 1.08; 95% CI, 0.87–1.15) and reoperation for bleeding (14.6% vs 2.4%; relative risk, 1.14; 95% CI, 0.87–1.15) than the patients with predicted moderate hypothermia. On long‐term follow‐up (mean duration, 5.12 years), 4‐ and 8‐year survival rates were 62.3% and 55.7% in the deep hypothermia group and 75.4% and 74.2% in the moderate hypothermia group (P = .0015). Conclusions: In proximal and arch operations involving ACP for >30 minutes, greater actual temperatures were associated with less stroke and reoperation for bleeding. There were no significant differences among the predicted hypothermia levels, although a trend toward a higher rate of adverse events was noticed in the deep hypothermia group. Long‐term survival was better in the moderate hypothermia group.

Aortic root surgery with circulatory arrest: Predictors of prolonged postoperative hospital stay

Objective: Little is known about the outcomes of aortic root operations that involve inducing hypothermic circulatory arrest for relatively extensive proximal aortic surgery. We attempted to identify predictors of postoperative hospital length of stay (LOS) and factors that affect postoperative recovery. Methods: During 2006‐2014, 247 of 265 patients (93.2%) with disease extending into the aortic arch survived aortic root operations (206 elective, 41 urgent/emergent) in which hypothermic circulatory arrest with moderate hypothermia was used. Stepwise multivariate regression analysis was performed to identify predictors of LOS (as a continuous variable) and prolonged LOS (defined as LOS >9 days, the median for the cohort). By this definition, 111 patients (45%) had prolonged LOS and 136 (55%) did not. Results: Preoperative factors that independently predicted longer LOS in the entire cohort included age (P = .0014), redo sternotomy (P = .0047), and intraoperative packed red blood cell (PRBC) transfusion (P = .0007). Redo sternotomy and intraoperative PRBC transfusion also predicted longer LOS in 3 subgroup analyses: one of elective cases, one from which total arch replacement procedures were excluded, and one limited to patients who were discharged home. Age predicted longer LOS in the non‐total arch (hemiarch) replacement patients. Ventilator support >48 hours (P < .0001) was associated with longer LOS. Elective aortic valve−sparing root replacement predicted a shorter LOS than valve replacement in multivariate regression analysis (P = .028). Conclusions: In patients undergoing aortic root surgery with hypothermic circulatory arrest for disease extending into the aortic arch, reducing intraoperative PRBC transfusion except when absolutely necessary may reduce postoperative LOS and expedite recovery. Performing aortic valve–sparing root replacement, when feasible, may also reduce LOS.

Implications of Clinical Documentation (In)Accuracy: A Pilot Study Among General Surgery Residents

ABSTRACT Accurate and reliable medical records are necessary for assessing, improving, and reimbursing healthcare services. Clear and concise physician documentation is essential to assuring accurate and reliable medical records. Yet, prior literature reveals surgery residents do not receive adequate, beneficial education on medical record documentation and coding. This is concerning because the evaluation of and reimbursement for healthcare service delivery relies on the physicians ability to produce appropriate medical records, which then get translated into billable codes. This pilot study suggests hospitals may incur significant financial loss in revenue due to inaccurate clinical documentation by residents. Thus, educational training for medical residents in the area of clinical documentation and hospital-specific coding practices may prove financially advantageous.