Strokes in Ascending Aortic Repairs: Predictive and ...


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  • Grade 1 is an aortic wall intima with no or minimal thickening; grade 2, extensive aortic wall intimal thickening but no protruding atheroma; grade 3, atheroma raised less than 5 mm into the aortic lumen; grade 4, sessile atheroma protruding at least 5 mm into the aortic lumen; and grade 5, mobile protruding atheroma
  • STS database
    Noted baseline and perioperative data, including: Age, Sex, BMI, Prior Cerebrovascular Disease, Prior Arrythmia, Prior MI or PCI, Dyslipidemia, Hypertension, Diabetes, Prior Cardiac and Aortic Surgery, Anterograde v. Retrograde Perfusion, Time on DHCA, Atherosclerosis Grade by TEE, Number of Interop Transfusions, Postop Neuro Outcomes.
  • Describe composite endpoint
  • 100th only
  • 100th only
  • Evidence in the EP literature that in Afib ablations, pre and peri-procedure anticoagulation decreases the risk of. Stroke
    Mortada et al., “Periprocedural Anticoagulation for Atrial Fibrilation Ablation” J Cardiovasc Electrophys 2008 19(4) 362-6
    DiBiase et al., “Periprocedural Stroke in Patients Undergoing Catheter Ablation of Atrial FibrillationL the Impact of Periprocedural Therapeutic INR” Circulation 2009:120:S658
  • Strokes in Ascending Aortic Repairs: Predictive and ...

    1. 1. Strokes in Ascending AorticStrokes in Ascending Aortic Repairs: Predictive andRepairs: Predictive and Protective FactorsProtective Factors Tovy Kamine, BS, Steven R Messé, MD,Tovy Kamine, BS, Steven R Messé, MD, Elizabeth Leitner, Joseph Bavaria, MD,Elizabeth Leitner, Joseph Bavaria, MD, Michael McGarvey, MDMichael McGarvey, MD Departments of Neurology and Cardiovascular Surgery, University of Pennsylvania Health System
    2. 2. IntroductionIntroduction Strokes occur in ~3.8% of aortic archStrokes occur in ~3.8% of aortic arch operations at HUPoperations at HUP11 Aortic atherosclerosis is a known riskAortic atherosclerosis is a known risk factor for stroke after CABGfactor for stroke after CABG33 It is unknown whether aorticIt is unknown whether aortic atherosclerosis will increase stroke riskatherosclerosis will increase stroke risk in arch operationsin arch operations 1 Appoo, J., et al., Perioperative Outcome in Adults Undergoing Elective Deep Hypothermic Circulatory Arrest With Retrograde Cerebral Perfusion in Proximal Aortic Arch Repair: Evaluation of Protocol-Based Care. J. Cardiothoracic Vascular Anes. 2006; 20:3-7 2 McGarvey, M., et al., Management of Neurologic Complications of Thoracic Aortic Surgery. J. Clinical Neurophysiology. 2007; 24:336-343 3 van der Linden, J., L Hadjinikolaou, P Bergman, D. Lindblom., Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerosis in the ascending aorta. J. Am. Coll. Cardiology. 2001; 38:131-5
    3. 3. ObjectivesObjectives To characterize patient andTo characterize patient and perioperative factors associatedperioperative factors associated with stroke and mortality inwith stroke and mortality in ascending aortic repairsascending aortic repairs – To test whether aortic atheroma isTo test whether aortic atheroma is independently predictive of stroke riskindependently predictive of stroke risk
    4. 4. MethodsMethods Retrospective analysis of 701 consecutive patientsRetrospective analysis of 701 consecutive patients undergoing ascending repair under Deepundergoing ascending repair under Deep Hypothermic Circulatory Arrest (DHCA)Hypothermic Circulatory Arrest (DHCA) Inclusion criteria: all ascending aortic operations atInclusion criteria: all ascending aortic operations at HUP and Penn-Presbyterian medical center,HUP and Penn-Presbyterian medical center, including emergent cases.including emergent cases. Exclusion criteria: operations with concurrent repairExclusion criteria: operations with concurrent repair of the descending aorta; hybrid proceduresof the descending aorta; hybrid procedures Two Primary Endpoints: Intra-operative stroke and in-Two Primary Endpoints: Intra-operative stroke and in- hospital mortalityhospital mortality Factors with p≤0.1 in univariate analysis wereFactors with p≤0.1 in univariate analysis were included in multivariate analysis.included in multivariate analysis.
    5. 5. Patient PopulationPatient Population % (Number) History of CVD 14.0% (98) History of PCI 5.3% (37) History of CABG 4.6% (32) History of AV Surgery 12.0% (84) History of Afib/flutter 15.2% (106) History of Dyslipidemia 46.7% (327) History of Hypertension 73.3% (512) History of Diabetes 8.3% (58) History of Aortic Arch Repair 18.1% (127) Male Gender 66.6% (467) Average±Std Dev BMI 28.1±6.1 Age 59.4±14.8
    6. 6. Operative CharacteristicsOperative Characteristics % (Number) Hemi Arch 93.6% (656) Full Arch 6.4% (45) Retrograde Perfusion 93.3% (654) Anterograde Perfusion 6.7% (47) Concurrent CABG 16.3% (114) Concurrent Aortic Valve Proc 86.6% (607) Ascending Dissection 24.9% (168) High Grade Ascending Atheroma 5.9% (41) Descending Dissection 11.4% (80) High Grade Descending Atheroma 9.6% (67) Average±Std Dev PRBC Units 1.10±0.03 FFP Units 1.08±0.03 Platelets Units 1.17±0.07 Cryo Units 1.46±0.24 Circ Arrest Time 30.4±17.0
    7. 7. Results-UnivariateResults-Univariate Stroke Rate: 5.9%Stroke Rate: 5.9% In-hospital Mortality Rate: 7.3%In-hospital Mortality Rate: 7.3%
    8. 8. Results - UnivariateResults - Univariate Intraoperative Stroke In-Hospital Mortality Factor OR P Any RCP Use 0.06 0.007 Concurrent CABG 2.35 0.015 Concurrent AV Procedure 0.51 0.082 CVD 3.70 <0.001 History of AV Surgery 0.18 0.057 History of Afib/Flutter 0.14 0.022 Ascending Dissection 3.47 <0.001 Descending Atheroma 3.02 0.004 PRBC per unit 1.09 0.003 FFP per unit 1.08 0.014 Platelets per unit 1.18 0.004 Cryoprecipitate per unit 1.49 0.020 Circulatory Arrest Time 1.02 0.003 Male Gender 0.39 0.003 Age>65 1.96 0.037 Factor OR P RCP Only 0.41 0.037 ACP 2.43 0.037 Concurrent CABG 0.30 0.037 Concurrent AV Procedure 0.47 0.028 History of AV Surgery 2.47 0.008 Redo Arch Repair 2.45 0.003 Ascending Dissection 2.40 0.003 Descending Dissection 3.35 <0.001 Descending Atheroma 2.19 0.041 PRBC per unit 1.11 <0.001 FFP per unit 1.10 0.001 Cryoprecipitate per unit 1.98 <0.001 Circulatory Arrest Time 1.02 0.003 Intraoperative Stroke 3.48 0.002 Univariate results with a p<0.1 included in mutlivariate analysis.
    9. 9. Results-Multivariate AnalysisResults-Multivariate Analysis StrokeStroke Factor OR 95% CI P Value Ascending Aortic Dissection 3.60 1.76 - 7.40 <0.001 History of Cerebrovascular Disease 3.54 1.67 – 7.49 0.001 High Grade Descending Atheroma 2.69 1.09 – 6.65 0.032 Concurrent CABG 2.35 1.07 – 5.17 0.033 Platelets (per unit) 1.20 1.05 - 1.38 0.009 Factor OR 95% CI P Value Male Gender 0.43 0.22 – 0.87 0.019 History of Atrial Fibrillation Diagnosis 0.07 0.01 - 0.59 0.014
    10. 10. Results-Multivariate AnalysisResults-Multivariate Analysis In-Hospital MortalityIn-Hospital Mortality Factor OR 95% CI P Value Intraoperative Stroke 3.47 1.39-8.64 0.008 Descending Aortic Dissection 3.05 1.52-6.13 0.002 High Grade Descending Atheroma 2.48 1.08-5.68 0.032 History of Aortic Valve Surgery 2.16 1.01-4.60 0.047 PRBC (per unit) 1.11 1.04-1.18 0.002 Factor OR 95% CI P Value Concurrent CABG 0.19 0.05-0.67 0.010
    11. 11. DiscussionDiscussion Stroke risk is increased by high gradeStroke risk is increased by high grade descending atheroma and concurrentdescending atheroma and concurrent CABG.CABG. The protective effect of preexisting atrialThe protective effect of preexisting atrial fibrillation may be due to preoperativefibrillation may be due to preoperative prophylaxisprophylaxis Mortality is increased by stroke, highMortality is increased by stroke, high grade atheroma, descending dissection.grade atheroma, descending dissection. Concurrent CABG has a protective effectConcurrent CABG has a protective effect on mortality.on mortality.
    12. 12. ConclusionsConclusions TEE Grading of atheroma is a useful adjunctTEE Grading of atheroma is a useful adjunct to determining the risk of aortic surgery,to determining the risk of aortic surgery, since high grade descending atheroma is asince high grade descending atheroma is a marker of a “toxic aorta,” increasing the riskmarker of a “toxic aorta,” increasing the risk of both stroke and mortality.of both stroke and mortality. CABG should be attempted cautiously withCABG should be attempted cautiously with ascending aortic repair as it significantlyascending aortic repair as it significantly increases the risk of intraoperative stroke,increases the risk of intraoperative stroke, however, decreases the risk of mortality.however, decreases the risk of mortality.