Roderick MacArthur

Repair of an acute type A aortic dissection combined with an emergency cesarean section in a pregnant woman

This case report describes a 35-week pregnant woman presenting with an acute type A aortic dissection. She underwent a successful emergency surgical repair and a concomitant cesarean section with a favorable outcome for the mother and the child.

Selective antegrade cerebral perfusion during aortic arch surgery confers survival and neuroprotective advantages

OBJECTIVE To assess the impact of using antegrade cerebral perfusion during aortic arch surgery on postoperative survival and neurologic outcomes. METHODS All operations were performed at the same hospital between January 2001 and January 2009. Patients undergoing aortic arch surgery using antegrade cerebral perfusion during deep hypothermia were compared with patients undergoing aortic arch surgery without antegrade cerebral perfusion during the same study period. Multivariable logistic regression and Cox proportional hazards model were used to identify predictors of postoperative cerebrovascular accidents and midterm survival, respectively. There were 46 patients in the antegrade cerebral perfusion group and 78 patients in the non-antegrade cerebral perfusion group. RESULTS There were no statistically significant differences in age, proportion of emergency operations, or proportion of type A aortic dissection between the 2 groups. There was a statistically significant and clinically important difference in the rates of postoperative cerebrovascular complications (2% antegrade cerebral perfusion vs 13% non-antegrade cerebral perfusion, P = .03), postoperative duration of mechanical ventilation (1.15 ± 0.19 days antegrade cerebral perfusion vs 2.13 ± 0.38 days non-antegrade cerebral perfusion, P = .02), and 3-year survival (93% antegrade cerebral perfusion vs 78% non-antegrade cerebral perfusion, P = .03). Antegrade cerebral perfusion was shown to be a significant predictor of reduced postoperative stroke rates and better survival at 3 years. CONCLUSIONS Antegrade cerebral perfusion was associated with improved survival and neurologic outcomes in patients undergoing aortic arch surgery, especially for cases requiring prolonged aortic arch repair periods.

Association between older age and outcome after cardiac surgery: A population-based cohort study

ObjectiveOctogenarians (aged ≥ 80 years) are increasingly being referred for cardiac surgery. We aimed to describe the morbidity, mortality, and health services utilization of octogenarians undergoing elective cardiac surgery.MethodsRetrospective population-based cohort study of adult patients receiving elective cardiac surgery between January 1 2004 and December 31 2009. Primary exposure was age ≥80 years. Outcomes were 30-day, 1- and 5-year mortality, post-operative complications, and ICU/hospital lengths of stay. Multi-variable logistic and Cox regression analyses were used to explore the association between older age and outcome.ResultsOf 6,843 patients receiving cardiac surgery, 544 (7.9%) were octogenarians. There was an increasing trend in the proportion of octogenarians undergoing surgery during the study period (0.3% per year, P = 0.073). Octogenarians were more likely to have combined procedures (valve plus coronary artery bypass or multiple valves) compared with younger strata (p < 0.001). Crude 30-day, 1-year and 5-year mortality for octogenarians were 3.7%, 10.8% and 29.0%, respectively. Compared to younger strata, octogenarians had higher adjusted 30-day (OR 4.83, 95%CI 1.30-17.92; P = 0.018) and 1-year mortality (OR 4.92; 95% CI, 2.32-10.46. P<0.001). Post-operative complications were more likely among octogenarians. Octogenarians had longer post-operative stays in ICU and hospital, and higher rates of ICU readmission (P < 0.001 for all). After multi-variable adjustment, age ≧ 80 years was an independent predictor of death at 30-days and 1 year.ConclusionsOctogenarians are increasingly referred for elective cardiac surgery with more combined procedures. Compared to younger patients, octogenarians have a higher risk of post-operative complications, consume greater resources, and have worse but acceptable short and long-term survival.

A Systematic Review of the Cost-Effectiveness of Long-Term Mechanical Circulatory Support

BACKGROUND Mechanical circulatory support (MCS) is an option for the treatment of medically intractable end-stage heart failure. MCS therapy, however, is resource intensive. OBJECTIVE The purpose of this report was to systematically review the MCS cost-effectiveness literature as it pertains to the treatment of adult patients in end-stage heart failure. METHODS We conducted a systematic search and narrative review of available cost- effectiveness and cost-utility analyses of MCS in adult patients with end-stage heart failure. RESULTS Eleven studies analyzing the cost-effectiveness or cost-utility of MCS were identified. Seven studies focused on bridge to transplantation, three studies focused on destination therapy, and one study presented analyses of both strategies. Two articles evaluated the cost-effectiveness of the HeartMate II (Thoratec Corp., Pleasanton, CA). Incremental cost-effectiveness ratios between MCS and medical management ranged between

Comparative study on tube-load modeling of arterial hemodynamics in humans.

85,025 and

The Canadian Society of Cardiac Surgeons Perspective on the Cardiac Surgery Workforce in Canada

200,166 for bridge to transplantation and between

Role of preoperative intravenous iron therapy to correct anemia before major surgery: study protocol for systematic review and meta-analysis

87,622 and

Massive Left Atrial Sarcoma Presenting With Severe Congestive Heart Failure

1,257,946 for destination therapy (2012 Canadian dollars per quality-adjusted life-year). Sensitivity analyses indicated that improvements in survival and quality of life and reductions in device and initial hospital-stay costs may improve the cost-effectiveness of MCS. CONCLUSIONS Current studies suggest that MCS is likely not cost-effective with reference to generally accepted or explicitly stated thresholds. Refined patient selection, complication rates, achieved quality of life, and device/surgical costs, however, could modify the cost-effectiveness of MCS.

Midterm Outcomes and Quality of Life of Aortic Root Replacement: Mechanical vs Biological Conduits

In this paper, we assess the validity of two alternative tube-load models for describing the relationship between central aortic and peripheral arterial blood pressure (BP) waveforms in humans. In particular, a single-tube (1-TL) model and a serially connected two-tube (2-TL) model, both terminated with a Windkessel load, are considered as candidate representations of central aortic-peripheral arterial path. Using the central aortic, radial and femoral BP waveform data collected from eight human subjects undergoing coronary artery bypass graft with cardiopulmonary bypass procedure, the fidelity of the tube-load models was quantified and compared with each other. Both models could fit the central aortic-radial and central aortic-femoral BP waveform pairs effectively. Specifically, the models could estimate pulse travel time (PTT) accurately, and the model-derived frequency response was also close to the empirical transfer function estimate obtained directly from the central aortic and peripheral BP waveform data. However, 2-TL model was consistently superior to 1-TL model with statistical significance as far as the accuracy of the central aortic BP waveform was concerned. Indeed, the average waveform RMSE was 2.52 mmHg versus 3.24 mmHg for 2-TL and 1-TL models, respectively (p < 0.05); the r² value between measured and estimated central aortic BP waveforms was 0.96 and 0.93 for 2-TL and 1-TL models, respectively (p < 0.05). We concluded that the tube-load models considered in this paper are valid representations that can accurately reproduce central aortic-radial/femoral BP waveform relationships in humans, although the 2-TL model is preferred if an accurate central aortic BP waveform is highly desired.

Knowledge, attitudes, and practice preferences of Canadian cardiac surgeons toward the management of acute type A aortic dissection

As the professional society representing cardiac surgeons in Canada, the Canadian Society of Cardiac Surgeons (CSCS) recognizes the importance of maintaining a stable cardiac surgical workforce. The current reactive approach to health human resource management in cardiac surgery is inadequate and may result in significant misalignment of cardiac surgeon supply and demand. The availability of forecasting models and high quality, consistent data on productivity, workload, utilization, and demand is a prerequisite for our professions capacity to predict and plan for changes in health human resources. The CSCS recognizes that improved workforce management is a key component to providing optimal cardiac surgical care for Canadians in the future and has developed the recommendations in this document as a call to action to interested stakeholders and policymakers to bring substantial improvements to health human resource management in cardiac surgery.