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Roberto Di Bartolomeo - One of the best experts on this subject based on the ideXlab platform.
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Multicentre analysis of current strategies and outcomes in open Aortic Arch Surgery: heterogeneity is still an issue.
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, 2016Co-Authors: Paul P. Urbanski, Roberto Di Bartolomeo, Anno Diegeler, Maximilian Luehr, Ruggero De Paulis, Giampiero Esposito, Robert S. Bonser, Christian D. Etz, Klaus Kallenbach, Bartosz RylskiAbstract:Objectives The study was conducted to evaluate, on the basis of a multicentre analysis, current results of elective open Aortic Arch Surgery performed during the last decade. Methods Data of 1232 consecutive patients who underwent Aortic Arch repair with reimplantation of at least one supra-Aortic artery between 2004 and 2013 were collected from 11 European cardiovascular centres, and retrospective statistical examination was performed using uni- and multi-variable analyses to identify predictors for 30-day mortality. Acute Aortic dissections and Arch surgeries not involving the supra-Aortic arteries were not included. Results Arch repair involving all 3 Arch arteries (total), 2 Arch arteries (subtotal) or 1 Arch artery (partial) was performed in 956 (77.6%), 155 (12.6%) and 121 (9.8%) patients, respectively. The patients' characteristics as well as the surgical techniques, including the method of cannulation, perfusion and protection, varied considerably between the clinics participating in the study. The in-hospital and 30-day mortality rates were 11.4 and 8.8% for the entire cohort, respectively, ranging between 1.7 and 19.0% in the surgical centres. Multivariable logistic regression analysis identified surgical centre, patient's age, number of previous surgeries with sternotomy and concomitant surgeries as independent risk factors of 30-day mortality. The follow-up of the study group was 96.5% complete with an overall follow-up duration of 3.3 ± 2.9 years, resulting in 4020 patient-years. After hospital discharge, 176 (14.3%) patients died, yielding an overall mortality rate of 25.6%. The actuarial survival after 5 and 8 years was 72.0 ± 1.5% and 64.0 ± 2.0, respectively. Conclusions The surgical risk in elective Aortic Arch Surgery has remained high during the last decade despite the advance in surgical techniques. However, the patients' characteristics, numbers of surgeries, the techniques and the results varied considerably among the centres. The incompleteness of data gathered retrospectively was not effective enough to determine advantages of particular cannulation, perfusion, protection or surgical techniques; and therefore, we strongly recommend further prospective multicentre studies, preferably registries, in which all relevant data have to be clearly defined and collected.
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Long-term outcomes after Aortic Arch Surgery: results of a study involving 623 patients
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, 2014Co-Authors: Marco Di Eusanio, Antonio Pantaleo, Gianluca Folesani, Mariano Cefarelli, Paolo Berretta, Giacomo Murana, Sebastiano Castrovinci, Jacopo Alfonsi, Roberto Di BartolomeoAbstract:OBJECTIVES: To assess early and long-term outcomes in a large cohort of patients undergoing open Aortic Arch Surgery. METHODS: From 1996 to 2012, 623 consecutive patients (mean age: 62.8 years) underwent Aortic Arch interventions in our institution. Of these, 208 (33.4%) presented with an acute Aortic syndrome (AAS) and 415 (66.6%) with a chronic Aortic pathology (CAP). During the study period, our surgical strategy involved extensive resections of the diseased Aortic tissue at elective interventions, and a tear-oriented Aortic replacement in patients with acute dissection. More extensive interventions were often performed in younger patients, and in those with connective tissue diseases and bicuspid Aortic valves. A total Arch replacement was frequently performed (53.3%). Antegrade selective cerebral perfusion was used in all cases. RESULTS: Overall in-hospital mortality was 23.1% in patients with AAS and 11.1% in patients with a CAP; in the same groups, postoperative permanent neurological dysfunction (PND) occurred in 9.6 and 5.6%, respectively. The follow-up was 94.4% complete. For in-hospital survivors, 5- and 10-year survival (%) were 79.4 ± 2.1 and 60.9 ± 3.2, respectively, not influenced by the underlying Aortic disease. Cox regression identified age (hazard ratio [HR]: 1.048; P< 0.001), preoperative renal failure (HR: 2.3; P= 0.003), diabetes (HR: 1.805; P= 0.005) and PND(HR:2.4;P= 0.03)tobeindependentpredictorsforthefollow-upmortality.Overall,109(59%endovascular)Aorticreinterventionswere performed: 18.3% were proximal and 81.7% distal to the Aortic Arch. Five- and 10-year freedom from Aortic redo (%) were 82.8 ± 1.9 and 77.7 ± 2.6, respectively. Aortic dissection (HR: 1.7; P= 0.03) was the only independent predictor of reoperative Surgery at the follow-up. CONCLUSIONS: Aortic Arch Surgery was associated with satisfactory early and long-term outcomes. Survival was largely determined by patient comorbidities and postoperative PND. While the underlying Aortic disease did not affect long-term mortality, chronic dissection was associated with increased need for Aortic reinterventions.
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visceral organ protection in Aortic Arch Surgery safety of moderate hypothermia
European Journal of Cardio-Thoracic Surgery, 2014Co-Authors: Davide Pacini, Antonio Pantaleo, Luca Di Marco, Alessandro Leone, Giuseppe Barberio, Giacomo Murana, Sebastiano Castrovinci, S. Sottili, Roberto Di BartolomeoAbstract:OBJECTIVES: Although antegrade selective cerebral perfusion (ASCP) provides good brain protection during Aortic Arch Surgery, the issue of distal organ protection during circulatory arrest remains to be clarified. The aim of the study was to retrospectively evaluate the outcome of Aortic Arch Surgery using ASCP at different temperatures, focusing on visceral functions (VFs). METHODS: Three hundred and thirty-four patients underwent elective Aortic Arch Surgery using ASCP from November 1996 to MArch 2011. Those patients without early postoperative low cardiac output syndrome were included. VFs were evaluated by comparing preoperative and postoperative creatinine, aspartate amino transferase, alanine amino transferase and bilirubin. Univariate and multivariate analysis were performed. RESULTS: Three hundred and four patients represent the cohort of the study. Deeper systemic hypothermia (≤25°C) (Group A) was used in 194 patients (63.8%) and moderate hypothermia (>25°C) (Group B) in 110 patients (36.2%). The 30-day mortality rate was 3.6% in Group B and 5.2% in Group A (P= NS). Permanent neurological deficits occurred in 4 (3.6%) and in 14 patients (7.2%) of Group A and Group B, respectively (P= NS). Postoperative renal insufficiency requiring dialysis occurred in 6 patients (5.4%) in Group A and in 15 patients (7.7%) in Group B, the differences were not statistically significant. Biochemical markers of VFs increased in the postoperative period without differences between groups. At the multivariate analysis, cardiopulmonary bypass time >180 min (odds ratio (OR) = 2.16) was the only significant risk factor for renal dysfunction with or without liver dysfunction, while cardiopulmonary bypass time longer than 180 min (OR = 2.28) and hypothermia higher than 25°C (OR = 0.54) were found to be independently related to liver dysfunction. CONCLUSION: Our results confirmed that ASCP with moderate hypothermia at 26°C is a safe method for brain protection. Moreover, during circulatory arrest, moderate hypothermia also offers good protection of visceral organs and it should be preferred for limited periods (<60 min) of visceral ischaemia because it may reduce the systemic inflammatory response and the reperfusion organ injury.
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Visceral organ protection in Aortic Arch Surgery: safety of moderate hypothermia
European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, 2014Co-Authors: Davide Pacini, Antonio Pantaleo, Luca Di Marco, Alessandro Leone, Giuseppe Barberio, Giacomo Murana, Sebastiano Castrovinci, S. Sottili, Roberto Di BartolomeoAbstract:OBJECTIVES: Although antegrade selective cerebral perfusion (ASCP) provides good brain protection during Aortic Arch Surgery, the issue of distal organ protection during circulatory arrest remains to be clarified. The aim of the study was to retrospectively evaluate the outcome of Aortic Arch Surgery using ASCP at different temperatures, focusing on visceral functions (VFs). METHODS: Three hundred and thirty-four patients underwent elective Aortic Arch Surgery using ASCP from November 1996 to MArch 2011. Those patients without early postoperative low cardiac output syndrome were included. VFs were evaluated by comparing preoperative and postoperative creatinine, aspartate amino transferase, alanine amino transferase and bilirubin. Univariate and multivariate analysis were performed. RESULTS: Three hundred and four patients represent the cohort of the study. Deeper systemic hypothermia (≤25°C) (Group A) was used in 194 patients (63.8%) and moderate hypothermia (>25°C) (Group B) in 110 patients (36.2%). The 30-day mortality rate was 3.6% in Group B and 5.2% in Group A (P= NS). Permanent neurological deficits occurred in 4 (3.6%) and in 14 patients (7.2%) of Group A and Group B, respectively (P= NS). Postoperative renal insufficiency requiring dialysis occurred in 6 patients (5.4%) in Group A and in 15 patients (7.7%) in Group B, the differences were not statistically significant. Biochemical markers of VFs increased in the postoperative period without differences between groups. At the multivariate analysis, cardiopulmonary bypass time >180 min (odds ratio (OR) = 2.16) was the only significant risk factor for renal dysfunction with or without liver dysfunction, while cardiopulmonary bypass time longer than 180 min (OR = 2.28) and hypothermia higher than 25°C (OR = 0.54) were found to be independently related to liver dysfunction. CONCLUSION: Our results confirmed that ASCP with moderate hypothermia at 26°C is a safe method for brain protection. Moreover, during circulatory arrest, moderate hypothermia also offers good protection of visceral organs and it should be preferred for limited periods (
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Impact of different cannulation strategies on in-hospital outcomes of Aortic Arch Surgery: a propensity-score analysis.
The Annals of thoracic surgery, 2013Co-Authors: Marco Di Eusanio, Antonio Pantaleo, Francesco Dimitri Petridis, Gianluca Folesani, Mariano Cefarelli, Paolo Berretta, Roberto Di BartolomeoAbstract:Background The impact of different cannulation strategies on outcomes of Aortic Arch Surgery remains controversial. This retrospective study sought to evaluate central cannulation (ascending aorta, right axillary, and innominate artery) compared with femoral artery cannulation for Aortic Arch Surgery, and to identify among preoperative and intraoperative variables the independent predictors of death and permanent neurologic dysfunction (PND) in Aortic Arch Surgery. Methods All patients were operated through a median sternotomy using antegrade selective cerebral perfusion with moderate hypothermia as a method of brain protection. Treatment bias was addressed by use of propensity-score matching and multivariate regression analysis. Logistic regression models were used to identify the independent predictors of hospital mortality and PND. Results Of the 473 patients undergoing Aortic Arch Surgery, 273 (57.7%) underwent femoral cannulation (FC), and 200 (42.3%) underwent central cannulation (CC). The CC and FC cannulation were associated with similar risk of in-hospital death (absolute risk reduction [ARR]: 0.7%; p = 0.880) and PND (ARR:-2.6%, p = 0.361) in the overall cohort and after adjusting for propensity-based matching (ARR for hospital mortality: 2.2%, p = 0.589; ARR for PND: 3.4%, p = 0.271). Female gender (odds ratio [OR]:2.1, p = 0.030), type A acute dissection or intramural hematoma (OR: 2.2; p = 0.041), and CPB time (OR: 1.010/minute, p = 0.015) were independent predictors of in-hospital death. Female gender (OR: 2.4; p = 0.033), type A acute dissection or intramural hematoma (OR: 4.2; p = 0.005), and diabetes (OR: 6.6, p = 0.007) were independent predictors of PND. Conclusions During Aortic Arch Surgery, CC and FC are associated with a similar risk of postoperative death and PND. Type A acute Aortic dissection and cardiopulmonary bypass time remain strong risk factors for mortality and PND.
Xiaotong Hou - One of the best experts on this subject based on the ideXlab platform.
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Safety of Hypothermic Circulatory Arrest During Unilateral Antegrade Cerebral Perfusion for Aortic Arch Surgery
The Canadian journal of cardiology, 2019Co-Authors: Xiaomeng Wang, Feng Yang, Jun-ming Zhu, Yong-min Liu, Li-zhong Sun, Liangshan Wang, Dengbang Hou, Xiaotong HouAbstract:Abstract Background Hypothermic circulatory arrest (HCA) with adjunctive unilateral antegrade cerebral perfusion (UACP) is widely used as a cerebral protection strategy during Aortic Arch Surgery. However, the ideal temperature for HCA during UACP remains unknown. The study compared clinical outcomes of patients in different temperature groups for HCA during UACP. Methods From January 2009 to January 2016, 1691 patients who underwent Aortic Arch Surgery for HCA during UACP in Beijing Anzhen Hospital were categorized into 2 groups according to nasopharyngeal temperature before initiating systemic circulatory arrest: the low temperature group (≤ 24°C, 22.9°C; 22.0°C-23.5°C; n = 1207) and the high temperature group (24.1°C-28.0°C, 24.6°C; 24.3°C-24.9°C; n = 484). After balancing the differences of baseline conditions by propensity score matching, 473 pairs of patients were matched, and the prognosis was compared with matched patients. Results The multivariable Cox regression analysis shows the high temperature group was an independent predictor for 30-day mortality (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.33-0.93; P = 0.03). After matching, the high temperature group was still an independent predictor of 30-day mortality (HR, 0.55; 95% CI, 0.32-0.98; P = 0.04). In subgroup analyses, there was an interaction between the high temperature group and UACP > 40 minutes for 30-day mortality (P for interaction 40 minutes subgroup (HR, 1.00; 95% CI, 0.46-2.20; P = 0.99). Conclusions This study shows that the high temperature (24.1°C-28.0°C) management strategy for HCA during UACP is safer for UACP ≤ 40 minutes. High temperature benefits were not found in patients for UACP > 40 minutes.
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Aortic Arch Surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion: Perioperative outcomes.
The Journal of thoracic and cardiovascular surgery, 2019Co-Authors: Xiaomeng Wang, Feng Yang, Jun-ming Zhu, Yong-min Liu, Li-zhong Sun, Xiaotong HouAbstract:Abstract Objective The study objective was to determine the effects of surgical procedures, circulatory management strategies, and cerebral protection strategies on the short-term outcomes of Aortic Arch Surgery based on the 7-year clinical experience of a single center. Methods We analyzed the data of 1708 patients who underwent Aortic Arch Surgery with definite hypothermic circulatory arrest and unilateral antegrade cerebral perfusion at Beijing Anzhen Hospital between 2009 and 2015. Logistic regression and random Forest regression analyses were used to determine predictors and their effects on outcomes. Results Thirty-day mortality was 6.1%. Permanent neurologic dysfunction incidence was 4.8%. The proportion of patients requiring continuous renal replacement therapy was 7.9%. In multivariable analyses, age, DeBakey type I dissection, New York Heart Association score, coma, coronary artery bypass grafting, extra-anatomic bypass, and cardiopulmonary bypass time were independent risk factors for mortality. Age, DeBakey type I dissection, and cardiopulmonary bypass time were independent risk factors for permanent neurologic dysfunction. In the random Forest regression, the risk for permanent neurologic dysfunction and mortality increased when unilateral antegrade cerebral perfusion time was more than 38 minutes and decreased with an increase in nasopharyngeal temperature when temperature was lower than approximately 24°C. The risk for permanent neurologic dysfunction, continuous renal replacement therapy, and paraplegia increased when temperature was greater than approximately 24°C. Conclusions The study showed that the largest reported cohort of patients undergoing Aortic Arch Surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion had reasonable morbidity and mortality rates. As a cerebral protection strategy, unilateral antegrade cerebral perfusion may have a 38-minute safety threshold. Moderate hypothermia should be maintained below 24°C to reduce the risk for permanent neurologic dysfunction, paraplegia, and acute renal dysfunction requiring continuous renal replacement therapy.
Yasuhiko Terai - One of the best experts on this subject based on the ideXlab platform.
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Insights of stroke in Aortic Arch Surgery: identification of significant risk factors and surgical implication
General Thoracic and Cardiovascular Surgery, 2012Co-Authors: Tatsuji Okada, Mitsuomi Shimamoto, Fumio Yamazaki, Masanao Nakai, Yujiro Miura, Tatsuya Itonaga, Daisuke Takahashi, Ryota Nomura, Noriyuki Abe, Yasuhiko TeraiAbstract:Purpose Although the outcomes of Aortic Arch Surgery have improved, stroke remains one of the most devastating complications. Therefore, identification of true risk factors and understanding the pathogenesis of intraoperative stroke are necessary to decrease its occurrence. Methods From January 2002 to December 2010, a total of 251 consecutive patients underwent Aortic Arch Surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion in our hospital. HemiArch replacement cases were excluded. Of the remaining patients, 190 elective cases that could be reviewed with full perioperative clinical data were analyzed. Strokes were classified into three subtypes according to their distribution on imaging studies: multiple-embolism type, hypoperfusion type, and solitary-embolism type. Results Operative death occurred in 1.1% of patients (2/190), and Aortic Arch Surgery-related in-hospital death occurred in 5.3%. Among the 188 survivors, intraoperative strokes occurred in 5.9%. Multiple-embolism, hypoperfusion type, and solitary-embolism stroke occurred in 2.7%, 2.1%, and 1.6%, respectively. Multivariate analysis revealed that the risk factor for multiple-embolism stroke was high-grade atheroma in the ascending aorta [ P < 0.001, odds ratio (OR) 118.0], and that for hypoperfusion type stroke was prolonged brain ischemia time over 120 min ( P = 0.004, OR 31.5). No significant risk factor was found for solitary-embolism stroke. Conclusion Intraoperative strokes during elective Aortic Arch Surgery under deep hypothermic circulatory arrest and antegrade selective cerebral perfusion are strongly influenced by the presence of a high-grade atheroma in the ascending aorta and prolonged brain ischemia time. The results suggest that these are key issues to reduce stroke in Aortic Arch Surgery.
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Insights of stroke in Aortic Arch Surgery: identification of significant risk factors and surgical implication.
General thoracic and cardiovascular surgery, 2012Co-Authors: Tatsuji Okada, Mitsuomi Shimamoto, Fumio Yamazaki, Masanao Nakai, Yujiro Miura, Tatsuya Itonaga, Daisuke Takahashi, Ryota Nomura, Noriyuki Abe, Yasuhiko TeraiAbstract:Purpose Although the outcomes of Aortic Arch Surgery have improved, stroke remains one of the most devastating complications. Therefore, identification of true risk factors and understanding the pathogenesis of intraoperative stroke are necessary to decrease its occurrence.
Jun-ming Zhu - One of the best experts on this subject based on the ideXlab platform.
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Safety of Hypothermic Circulatory Arrest During Unilateral Antegrade Cerebral Perfusion for Aortic Arch Surgery
The Canadian journal of cardiology, 2019Co-Authors: Xiaomeng Wang, Feng Yang, Jun-ming Zhu, Yong-min Liu, Li-zhong Sun, Liangshan Wang, Dengbang Hou, Xiaotong HouAbstract:Abstract Background Hypothermic circulatory arrest (HCA) with adjunctive unilateral antegrade cerebral perfusion (UACP) is widely used as a cerebral protection strategy during Aortic Arch Surgery. However, the ideal temperature for HCA during UACP remains unknown. The study compared clinical outcomes of patients in different temperature groups for HCA during UACP. Methods From January 2009 to January 2016, 1691 patients who underwent Aortic Arch Surgery for HCA during UACP in Beijing Anzhen Hospital were categorized into 2 groups according to nasopharyngeal temperature before initiating systemic circulatory arrest: the low temperature group (≤ 24°C, 22.9°C; 22.0°C-23.5°C; n = 1207) and the high temperature group (24.1°C-28.0°C, 24.6°C; 24.3°C-24.9°C; n = 484). After balancing the differences of baseline conditions by propensity score matching, 473 pairs of patients were matched, and the prognosis was compared with matched patients. Results The multivariable Cox regression analysis shows the high temperature group was an independent predictor for 30-day mortality (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.33-0.93; P = 0.03). After matching, the high temperature group was still an independent predictor of 30-day mortality (HR, 0.55; 95% CI, 0.32-0.98; P = 0.04). In subgroup analyses, there was an interaction between the high temperature group and UACP > 40 minutes for 30-day mortality (P for interaction 40 minutes subgroup (HR, 1.00; 95% CI, 0.46-2.20; P = 0.99). Conclusions This study shows that the high temperature (24.1°C-28.0°C) management strategy for HCA during UACP is safer for UACP ≤ 40 minutes. High temperature benefits were not found in patients for UACP > 40 minutes.
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Aortic Arch Surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion: Perioperative outcomes.
The Journal of thoracic and cardiovascular surgery, 2019Co-Authors: Xiaomeng Wang, Feng Yang, Jun-ming Zhu, Yong-min Liu, Li-zhong Sun, Xiaotong HouAbstract:Abstract Objective The study objective was to determine the effects of surgical procedures, circulatory management strategies, and cerebral protection strategies on the short-term outcomes of Aortic Arch Surgery based on the 7-year clinical experience of a single center. Methods We analyzed the data of 1708 patients who underwent Aortic Arch Surgery with definite hypothermic circulatory arrest and unilateral antegrade cerebral perfusion at Beijing Anzhen Hospital between 2009 and 2015. Logistic regression and random Forest regression analyses were used to determine predictors and their effects on outcomes. Results Thirty-day mortality was 6.1%. Permanent neurologic dysfunction incidence was 4.8%. The proportion of patients requiring continuous renal replacement therapy was 7.9%. In multivariable analyses, age, DeBakey type I dissection, New York Heart Association score, coma, coronary artery bypass grafting, extra-anatomic bypass, and cardiopulmonary bypass time were independent risk factors for mortality. Age, DeBakey type I dissection, and cardiopulmonary bypass time were independent risk factors for permanent neurologic dysfunction. In the random Forest regression, the risk for permanent neurologic dysfunction and mortality increased when unilateral antegrade cerebral perfusion time was more than 38 minutes and decreased with an increase in nasopharyngeal temperature when temperature was lower than approximately 24°C. The risk for permanent neurologic dysfunction, continuous renal replacement therapy, and paraplegia increased when temperature was greater than approximately 24°C. Conclusions The study showed that the largest reported cohort of patients undergoing Aortic Arch Surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion had reasonable morbidity and mortality rates. As a cerebral protection strategy, unilateral antegrade cerebral perfusion may have a 38-minute safety threshold. Moderate hypothermia should be maintained below 24°C to reduce the risk for permanent neurologic dysfunction, paraplegia, and acute renal dysfunction requiring continuous renal replacement therapy.
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Changes in the Hemostatic System of Patients With Acute Aortic Dissection Undergoing Aortic Arch Surgery
The Annals of thoracic surgery, 2015Co-Authors: Xin Liang Guan, Yong-min Liu, Xiaolong Wang, Yu Yong Liu, Feng Lan, Ming Gong, Ou Liu, Wen Jian Jiang, Jun-ming ZhuAbstract:Background Aortic Arch Surgery for patients with acute Aortic dissection is frequently complicated by excessive bleeding and transfusion of allogeneic blood products. However, the physiopathology of acute Aortic dissection and Surgery-induced coagulopathy has never been precisely studied. The aim of the present study is to describe the changes of the perioperative hemostatic system in patients with acute Aortic dissection undergoing Aortic Arch Surgery. Methods Sixty-two patients undergoing emergent Aortic Arch Surgery for Stanford type A acute Aortic dissection were enrolled in this study from January 2013 to September 2014. The hemostatic system was evaluated using standard laboratory tests, plasma fibrinogen levels, and thromboelastogragh at 5 time points: anesthesia induction (T0), lowest nasopharyngeal temperature (T1), protamine reversal (T2), 4 h after Surgery (T3), and on the first postoperative day (T4). Results The study results revealed that clotting factors had a tendency to be consumed in the preoperative period. Surgery and hypothermia resulted in a progressive reduction in clotting factors, platelet counts, and function, as well as fibrinogen concentration and function. After hemostatic therapy, although platelet counts were constantly low, clotting factors and platelet function returned to nearly preoperative levels. In contrast, fibrinogen concentration and function were still significantly lower than preoperative levels. Conclusions The results of this prospective analysis showed that acute Aortic dissection itself activated the hemostatic system even before Surgery. After hemostatic therapy, fibrin formation was more impaired than platelet function. In this setting, we proposed that hemostatic therapy should focus on rapid and sufficient supplementation of fibrinogen. Thus, we recommend further increases in fibrinogen concentration to improve coagulopathy in patients with acute Aortic dissection.
Xiaomeng Wang - One of the best experts on this subject based on the ideXlab platform.
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Safety of Hypothermic Circulatory Arrest During Unilateral Antegrade Cerebral Perfusion for Aortic Arch Surgery
The Canadian journal of cardiology, 2019Co-Authors: Xiaomeng Wang, Feng Yang, Jun-ming Zhu, Yong-min Liu, Li-zhong Sun, Liangshan Wang, Dengbang Hou, Xiaotong HouAbstract:Abstract Background Hypothermic circulatory arrest (HCA) with adjunctive unilateral antegrade cerebral perfusion (UACP) is widely used as a cerebral protection strategy during Aortic Arch Surgery. However, the ideal temperature for HCA during UACP remains unknown. The study compared clinical outcomes of patients in different temperature groups for HCA during UACP. Methods From January 2009 to January 2016, 1691 patients who underwent Aortic Arch Surgery for HCA during UACP in Beijing Anzhen Hospital were categorized into 2 groups according to nasopharyngeal temperature before initiating systemic circulatory arrest: the low temperature group (≤ 24°C, 22.9°C; 22.0°C-23.5°C; n = 1207) and the high temperature group (24.1°C-28.0°C, 24.6°C; 24.3°C-24.9°C; n = 484). After balancing the differences of baseline conditions by propensity score matching, 473 pairs of patients were matched, and the prognosis was compared with matched patients. Results The multivariable Cox regression analysis shows the high temperature group was an independent predictor for 30-day mortality (hazard ratio [HR], 0.55; 95% confidence interval [CI], 0.33-0.93; P = 0.03). After matching, the high temperature group was still an independent predictor of 30-day mortality (HR, 0.55; 95% CI, 0.32-0.98; P = 0.04). In subgroup analyses, there was an interaction between the high temperature group and UACP > 40 minutes for 30-day mortality (P for interaction 40 minutes subgroup (HR, 1.00; 95% CI, 0.46-2.20; P = 0.99). Conclusions This study shows that the high temperature (24.1°C-28.0°C) management strategy for HCA during UACP is safer for UACP ≤ 40 minutes. High temperature benefits were not found in patients for UACP > 40 minutes.
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Aortic Arch Surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion: Perioperative outcomes.
The Journal of thoracic and cardiovascular surgery, 2019Co-Authors: Xiaomeng Wang, Feng Yang, Jun-ming Zhu, Yong-min Liu, Li-zhong Sun, Xiaotong HouAbstract:Abstract Objective The study objective was to determine the effects of surgical procedures, circulatory management strategies, and cerebral protection strategies on the short-term outcomes of Aortic Arch Surgery based on the 7-year clinical experience of a single center. Methods We analyzed the data of 1708 patients who underwent Aortic Arch Surgery with definite hypothermic circulatory arrest and unilateral antegrade cerebral perfusion at Beijing Anzhen Hospital between 2009 and 2015. Logistic regression and random Forest regression analyses were used to determine predictors and their effects on outcomes. Results Thirty-day mortality was 6.1%. Permanent neurologic dysfunction incidence was 4.8%. The proportion of patients requiring continuous renal replacement therapy was 7.9%. In multivariable analyses, age, DeBakey type I dissection, New York Heart Association score, coma, coronary artery bypass grafting, extra-anatomic bypass, and cardiopulmonary bypass time were independent risk factors for mortality. Age, DeBakey type I dissection, and cardiopulmonary bypass time were independent risk factors for permanent neurologic dysfunction. In the random Forest regression, the risk for permanent neurologic dysfunction and mortality increased when unilateral antegrade cerebral perfusion time was more than 38 minutes and decreased with an increase in nasopharyngeal temperature when temperature was lower than approximately 24°C. The risk for permanent neurologic dysfunction, continuous renal replacement therapy, and paraplegia increased when temperature was greater than approximately 24°C. Conclusions The study showed that the largest reported cohort of patients undergoing Aortic Arch Surgery with hypothermic circulatory arrest and unilateral antegrade cerebral perfusion had reasonable morbidity and mortality rates. As a cerebral protection strategy, unilateral antegrade cerebral perfusion may have a 38-minute safety threshold. Moderate hypothermia should be maintained below 24°C to reduce the risk for permanent neurologic dysfunction, paraplegia, and acute renal dysfunction requiring continuous renal replacement therapy.