Nimesh D. Desai

Off-pump surgery decreases postoperative complications and resource utilization in the elderly

BACKGROUND Bypass surgery in the elderly (age >70 years) has increased mortality and morbidity, which may be a consequence of cardiopulmonary bypass. We compare the outcomes of a cohort of elderly off-pump coronary artery bypass (OPCAB) patients with elderly conventional coronary artery bypass grafting (CABG) patients. METHODS Chart and provincial cardiac care registry data were reviewed for 30 consecutive elderly OPCAB patients (age 74.7 +/- 4.2 years) and 60 consecutive CABG patients (age 74.9 +/- 4.1 years, p = 0.82) with similar risk factor profiles: Parsonnet score 17.2 +/- 8.1 (OPCAB) versus 15.6 +/- 6.5 (CABG), p = 0.31; and Ontario provincial acuity index 4.5 +/- 1.9 (OPCAB) versus 4.3 +/- 2.0 (CABG), p = 0.65. RESULTS Mean hospital stay was 6.3 +/- 1.8 days for OPCAB patients and 7.7 +/- 3.9 days for CABG patients (p < 0.05). Average intensive care unit stay was 24.0 +/- 10.9 h for OPCAB patients versus 36.6 +/- 33.5 h for CABG patients (p < 0.05). Atrial fibrillation occurred in 10.0% of OPCAB patients and 28.3% of CABG patients (p < 0.05). Low output syndrome was observed in 10% of OPCAB patients and 31.7% of CABG patients (p < 0.05). Cost was reduced by

Impact of Patient and Target-Vessel Characteristics on Arterial and Venous Bypass Graft Patency Insight From a Randomized Trial

1,082 (Canadian) per patient in the OPCAB group. Postoperative OPCAB graft analysis showed 100% patency. CONCLUSIONS OPCAB is safe in the geriatric population and significantly reduces postoperative morbidity and cost.

Presentation, complications, and natural history of penetrating atherosclerotic ulcer disease

Background— The purpose of this investigation was to determine optimal patient and target-vessel characteristics to maximize arterial and venous graft patency on the basis of data from a large clinical trial. Methods and Results— Angiographic data on 440 radial artery grafts and 440 saphenous vein grafts were analyzed with methodology to account for within-patient clustering. Multivariable models that incorporated patient demographic, operative, anatomic, and postdischarge medical management were constructed to determine predictors of graft occlusion. Radial artery use was strongly protective against graft occlusion at 1 year after adjustment for all covariates, with a larger protective effect seen in women (P=0.05 for a subgroup-by-treatment interaction). Among all grafts, diabetes and small target-vessel diameter were associated with an increased risk of graft occlusion, and grafting to a target vessel with more severe proximal stenosis was associated with a decreased risk of graft occlusion. With regard to gender, radial artery graft occlusion at 1 year occurred in similar proportions of men (8.6%) and women (5.3%, P=0.6), whereas, for saphenous vein grafts the comparable occlusion rates were 12.0% and 23.3% respectively (P=0.02). A history of peripheral vascular disease was associated with an elevated risk of radial artery occlusion but was not associated with early vein graft occlusion (P=0.02 for a subgroup-by-treatment interaction). Conclusions— Patients benefit from radial artery–coronary artery bypass conduits as opposed to saphenous vein conduits, and this effect is especially strong in women. Small target-vessel size adversely affected graft patency, and grafting to a target vessel with more severe proximal stenosis improved graft patency.

Thoracic endovascular aortic repair for acute complicated type B aortic dissection: superiority relative to conventional open surgical and medical therapy.

OBJECTIVES Increased utilization of computed tomography angiography (CTA) has increased the radiologic diagnosis of penetrating atherosclerotic ulcers (PAUs), which are defined as the ulceration of atherosclerotic plaque through the internal elastic lamina into the aortic media. However, the presentation, treatment indications, and natural history of this disease process remain unclear. METHODS The radiology database at a single university hospital was searched retrospectively for the CTA diagnosis of PAU from January 2003 to June 2009. All scans were interpreted by a cardiovascular radiologist. Information on PAU characteristics and need for surgical repair due to PAU disease was collected. PAU stability or progression was assessed by follow-up CTA, if available. Only PAUs in the aortic arch, descending thoracic aorta, and abdominal aorta were included. RESULTS Three hundred eighty-eight PAUs were diagnosed by CTA interpretation. PAU location was in the aortic arch in 27 (6.8%) cases, the descending thoracic aorta in 243 (61.2%) cases, and the abdominal aorta in 118 (29.7%) cases. Two hundred twenty-four (57.7%) PAUs were isolated (without saccular aneurysm or intramural hematoma); 108 (27.8%) PAUs had associated saccular aneurysms; and 56 (14.4%) PAUs had associated intramural hematoma. Rupture was present in 16 (4.1%) cases. Fifty (12.9%) PAUs underwent repair with thoracic endovascular aortic repair (TEVAR) (n = 30), endovascular aneurysm repair (EVAR) (n = 10), or open surgery (n = 10); primary indications for repair were saccular aneurysm (n = 26), rupture (n = 16), and persistent or recurrent symptoms (n = 8). Even if initially treated conservatively with resolution of pain, symptomatic PAU disease was more likely to require repair than asymptomatic PAU disease (36.2% vs 7.8%, P < .001). Follow-up CTA was available for 87 PAUs, 20 (23.0%) of which demonstrated radiographic disease progression at a mean follow-up of 8.4 ± 10.3 months. Symptomatic PAU disease was more likely to progress than asymptomatic disease (42.9% vs 16.7%, P = .029). CONCLUSIONS For PAUs diagnosed on CTA at a single institution, 4.1% were ruptured and 12.9% underwent repair. Close follow-up imaging appears to be indicated for PAUs, particularly in the case of symptomatic disease, which is more likely to require repair and to undergo radiographic progression.

The St Jude Medical Trifecta aortic pericardial valve: Results from a global, multicenter, prospective clinical study

OBJECTIVE This study compared outcomes between thoracic endovascular aortic repair and conventional open surgical and medical therapies for acute complicated type B aortic dissection. METHODS From 2002 to 2010, a total of 170 patients with type B aortic dissections were retrospectively identified from the University of Pennsylvania aortic database. Of these 170 patients, 147 had acute type B aortic dissections (uncomplicated 70, complicated 77). For patients with acute complicated type B aortic dissections, management included thoracic endovascular aortic repair (group A) or conventional open surgical and medical therapies (group B). RESULTS In the 77 patients with acute complicated type B aortic dissections, thoracic endovascular aortic repair (group A) was performed in 45 patients (59%). In group B, 20 patients (26%) underwent open surgical repair and 12 (15%) had their conditions managed with medical therapy. Thoracic endovascular aortic repair was associated with lower in-hospital or 30-day mortality (n = 2, 4%) than conventional therapy (open surgical repair n = 8, 40%, medical therapy, n = 4, 33%, P = .006). Patients in group A (thoracic endovascular aortic repair) continued to show significantly improved survival at 1, 3, and 5 years (group A: 82%, 79%, and 79% vs group B: 58%, 52%, and 44%, P = .008). CONCLUSIONS Thoracic endovascular aortic repair for acute complicated type B dissection is associated with superior early outcome and improved midterm survival relative to conventional therapy. Longer follow-up demonstrating survival benefit is needed before definitive conclusion can be made.

Stroke After Aortic Valve Surgery Results From a Prospective Cohort

BACKGROUND The St Jude Medical Inc (St Paul, Minn) Trifecta valve is a novel aortic biological prosthesis that incorporates several design features, including a true supra-annular sewing cuff, a stent design that maximizes valve hemodynamics while minimizing leaflet stresses, and an ethanol-based anticalcification technology. This study establishes the safety and early clinical and hemodynamic performance of the Trifecta valve. METHODS The Trifecta bioprosthesis was implanted in 1014 eligible patients between 2007 and 2009 at 31 centers. The mean age of the population was 72.5 ± 9.0 years, of whom 650 (64.1%) were male and 364 (35.9%) were female. Eighty-two subjects (8.1%) had undergone previous open surgery. Indications for aortic valve replacement surgery included stenosis in 556 patients (54.8%), regurgitation in 61 patients (6.0%), and mixed pathology in 397 patients (39.2%). RESULTS The overall follow-up included 844.3 late patient-years. Early (≤ 30 day) mortality occurred in 18 patients (1.8%), and there were 23 late (≥ 31 days) deaths yielding a linearized mortality rate of 2.72% per late patient-year. There were 27 early thromboembolic events, including 8 (0.8%) strokes, 17 (1.7%) reversible neurologic events, and 2 (0.2%) systemic embolic events. There were no instances of early valve thrombosis, endocarditis, or clinically significant hemolysis. There were 16 late thromboembolic events (linearized rate of 1.90% per year of follow-up), including 4 strokes and 12 reversible neurologic events. In total, there were 5 late valve explants, including 1 structural deterioration and 4 prosthetic valve endocarditis cases. Overall, freedom from valve explant was 99.4% at 2 years. At the time of discharge, average mean gradients ranged from 9.3 to 4.1 mm Hg and effective orifice area ranged from 1.58 to 2.50 cm(2) for valve sizes 19 to 29 mm, respectively. CONCLUSIONS The St Jude Medical Trifecta valve is a unique pericardial bioprosthesis with design elements that provide excellent hemodynamic performance while providing ease of implantation. Long-term follow-up continues to confirm the promising results of this innovative bioprosthesis.

Hybrid approaches in the treatment of aortic arch aneurysms: Postoperative and midterm outcomes

Background— The incidence and impact of clinical stroke and silent radiographic cerebral infarction complicating open surgical aortic valve replacement (AVR) are poorly characterized. Methods and Results— We performed a prospective cohort study of subjects ≥65 years of age who were undergoing AVR for calcific aortic stenosis. Subjects were evaluated by neurologists preoperatively and postoperatively and underwent postoperative magnetic resonance imaging. Over a 4-year period, 196 subjects were enrolled at 2 sites (mean age, 75.8±6.2 years; 36% women; 6% nonwhite). Clinical strokes were detected in 17%, transient ischemic attack in 2%, and in-hospital mortality was 5%. The frequency of stroke in the Society for Thoracic Surgery database in this cohort was 7%. Most strokes were mild; the median National Institutes of Health Stroke Scale was 3 (interquartile range, 1–9). Clinical stroke was associated with increased length of stay (median, 12 versus 10 days; P=0.02). Moderate or severe stroke (National Institutes of Health Stroke Scale ≥10) occurred in 8 (4%) and was strongly associated with in-hospital mortality (38% versus 4%; P=0.005). Of the 109 stroke-free subjects with postoperative magnetic resonance imaging, silent infarct was identified in 59 (54%). Silent infarct was not associated with in-hospital mortality or increased length of stay. Conclusions— Clinical stroke after AVR was more common than reported previously, more than double for this same cohort in the Society for Thoracic Surgery database, and silent cerebral infarctions were detected in more than half of the patients undergoing AVR. Clinical stroke complicating AVR is associated with increased length of stay and mortality.Background— The incidence and impact of clinical stroke and silent radiographic cerebral infarction complicating open surgical aortic valve replacement (AVR) are poorly characterized. Methods and Results— We performed a prospective cohort study of subjects ≥65 years of age who were undergoing AVR for calcific aortic stenosis. Subjects were evaluated by neurologists preoperatively and postoperatively and underwent postoperative magnetic resonance imaging. Over a 4-year period, 196 subjects were enrolled at 2 sites (mean age, 75.8±6.2 years; 36% women; 6% nonwhite). Clinical strokes were detected in 17%, transient ischemic attack in 2%, and in-hospital mortality was 5%. The frequency of stroke in the Society for Thoracic Surgery database in this cohort was 7%. Most strokes were mild; the median National Institutes of Health Stroke Scale was 3 (interquartile range, 1–9). Clinical stroke was associated with increased length of stay (median, 12 versus 10 days; P =0.02). Moderate or severe stroke (National Institutes of Health Stroke Scale ≥10) occurred in 8 (4%) and was strongly associated with in-hospital mortality (38% versus 4%; P =0.005). Of the 109 stroke-free subjects with postoperative magnetic resonance imaging, silent infarct was identified in 59 (54%). Silent infarct was not associated with in-hospital mortality or increased length of stay. Conclusions— Clinical stroke after AVR was more common than reported previously, more than double for this same cohort in the Society for Thoracic Surgery database, and silent cerebral infarctions were detected in more than half of the patients undergoing AVR. Clinical stroke complicating AVR is associated with increased length of stay and mortality. # CLINICAL PERSPECTIVE {#article-title-47}

Long-term comparison of thoracic endovascular aortic repair (TEVAR) to open surgery for the treatment of thoracic aortic aneurysms

BACKGROUND The combined open surgical and endovascular approach for the treatment of aortic arch aneurysms has emerged as a safe treatment modality. This platform may have an especially important role in treating patients of old age and with a greater comorbid burden. We describe our institutional experience with the hybrid aortic arch approach, with midterm outcomes. METHODS From 2005 to the present, 685 patients have undergone thoracic endovascular repair (TEVAR); 104 had a hybrid arch repair (open plus endovascular approach). Of these, 47 patients had treatment for an aortic arch aneurysm with or without a proximal ascending aortic aneurysm. All these patients had a median sternotomy approach for arch vessel debranching and antegrade with or without retrograde TEVAR stent grafting of the arch. Results from a prospectively maintained database are reported. RESULTS Twenty-eight patients had type I repair, 8 patients had type II repair, and 11 patients had type III arch hybrid repair. Those with type III repair were excluded from the analysis. Stent graft deployment rate was 100% after arch vessel debranching. Mean age was 71 ± 8 years. Fourteen percent of cases involved a redo sternotomy. Average cardiopulmonary bypass time was 215 ± 64 minutes, with a crossclamp time of 70 ± 55 minutes and a circulatory arrest time of 19 ± 10 minutes. The paraplegia rate was 5.5% (n = 2), with a stroke rate of 8% (n = 3). In-hospital mortality was 8% (n = 3). There were no postoperative endoleaks. The mean length of stay was 17.2 ± 14 days. The median follow-up was 30 ± 21 months. Freedom from all-cause mortality was 71%, 60%, and 48% at 1, 3, and 5 years, respectively. The aortic reoperation rate was 2.7% (n = 1). No patient has a type 1 or 3 endoleak at latest follow-up. CONCLUSIONS The hybrid approach to aortic arch aneurysm involving a zone 0 stent graft landing can be safely adopted with good midterm results in a cohort of old patients with significant comorbidity. This procedure can be performed with no type 1 or 3 endoleaks and may represent a technical advancement in the field of aortic arch surgery.

Retrograde and antegrade cerebral perfusion: results in short elective arch reconstructive times.

OBJECTIVE Thoracic endovascular aortic repair (TEVAR) has become a widely established treatment for a variety of thoracic aortic pathologic diseases despite limited long-term data to support its use. We compared the long-term outcomes of TEVAR with the 3 commercially available stents grafts for thoracic aortic aneurysms to results in control subjects undergoing open surgery. METHODS Demographic, clinical radiographic parameters were collected prospectively on patients enrolled in trials assessing the Gore TAG (55), Medtronic Talent (36) and Cook TX2 (15) devices. Outcomes were compared with 45 contemporaneous open controls. Detailed clinical and radiographic information was available for analysis. Standard univariate, survival, and regression methods were used. RESULTS During the study period (1995-2007) 106 patients were enrolled in TEVAR trials and there were 45 open controls. TEVAR patients were older and had significantly more comorbidities including diabetes and renal failure. TEVAR patients had 2.3 ± 1.3 devices implanted. Mortality (2.6% TEVAR, 6.7% open; P = .1), paralysis/paraparesis (3.9% TEVAR, 7.1% open; P = .2), and prolonged intubation more than 24 hours (9% TEVAR, 24% open; P = .02) tended to be more common in the open controls. Overall survival at 10 years was similar between groups (log rank P = .5). Multivariate predictors of late mortality included age, chronic obstructive pulmonary disease, diabetes, and chronic renal failure. Use of TEVAR versus open surgery did not influence mortality (hazard ratio, 0.9 95% confidence interval, 0.4-1.6). Over 5 years of radiographic follow-up in the TEVAR group, mean aortic diameter decreased from 61 to 55 mm. Freedom from reintervention on the treated segment was 85% in TEVAR patients at 10 years. CONCLUSIONS TEVAR is a safe and effective procedure to treat thoracic aortic aneurysms with improved perioperative and similar long-term results as open thoracic aortic repair. TEVAR-treated aneurysm diameters initially decrease and then stabilize over time.

One-year clinical outcomes with SAPIEN 3 transcatheter aortic valve replacement in high-risk and inoperable patients with severe aortic stenosis

BACKGROUND Debate remains regarding optimal cerebral circulatory management during relatively noncomplex, short arch reconstructive times. Both retrograde cerebral perfusion with deep hypothermic circulatory arrest (RCP/DHCA) and antegrade cerebral perfusion with moderate hypothermic circulatory arrest (ACP/MHCA) have emerged as established techniques. The aim of the study was to evaluate perioperative outcomes between antegrade and retrograde cerebral perfusion techniques for elective arch reconstruction times less than 45 minutes. METHODS Between 1997 and September 2008, 776 cases from two institutions were reviewed to compare RCP/DHCA and ACP/MHCA perfusion techniques. At the University of Pennsylvania, 682 were treated utilizing RCP/DHCA cerebral protection. At the University of Bologna, 94 were treated with ACP/MHCA and bilateral cerebral perfusion. RESULTS Mean cerebral ischemic time and visceral ischemic time differed between RCP/DHCA and ACP/MHCA (p < 0.001). Multivariate analysis showed age more than 65 years, atherosclerotic aneurysm, and cross-clamp time as predictors of the composite endpoint of mortality, neurologic event, and acute myocardial infarction. There was no significant difference in permanent neurologic deficit, temporary neurologic dysfunction, or renal failure, between RCP/DHCA and ACP/MHCA. Mortality was comparable across both techniques. CONCLUSIONS Both RCP/DHCA and ACP/MHCA have emerged as effective techniques for selected aortic arch operations with low morbidity and mortality. Univariate analysis revealed no statistically significant differences in primary or secondary outcomes between techniques for aortic reconstruction times less than 45 minutes. Data from this study demonstrate that selective use of either RCP/DHCA or ACP/MHCA provides excellent cerebral and visceral outcomes for elective open aortic surgery with short arch reconstructive times.