Strokes in Ascending Aortic Repairs: Predictive and Protective Factors Tovy Kamine, BS, Steven R Messé, MD, Elizabeth Leitner, Joseph Bavaria, MD, Michael.

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Presentation transcript:

Strokes in Ascending Aortic Repairs: Predictive and Protective Factors Tovy Kamine, BS, Steven R Messé, MD, Elizabeth Leitner, Joseph Bavaria, MD, Michael McGarvey, MD Departments of Neurology and Cardiovascular Surgery, University of Pennsylvania Health System

Introduction Strokes occur in ~3.8% of aortic arch operations at HUP 1 Aortic atherosclerosis is a known risk factor for stroke after CABG 3 It is unknown whether aortic atherosclerosis will increase stroke risk in 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: 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

Objectives To characterize patient and perioperative factors associated with stroke and mortality in ascending aortic repairs –To test whether aortic atheroma is independently predictive of stroke risk

Methods Retrospective analysis of 701 consecutive patients undergoing ascending repair under Deep Hypothermic Circulatory Arrest (DHCA) Inclusion criteria: all ascending aortic operations at HUP and Penn-Presbyterian medical center, including emergent cases. Exclusion criteria: operations with concurrent repair of the descending aorta; hybrid procedures Two Primary Endpoints: Intra-operative stroke and in- hospital mortality Factors with p≤0.1 in univariate analysis were included in multivariate analysis.

Patient Population % (Number) History of CVD14.0% (98) History of PCI5.3% (37) History of CABG4.6% (32) History of AV Surgery12.0% (84) History of Afib/flutter15.2% (106) History of Dyslipidemia46.7% (327) History of Hypertension73.3% (512) History of Diabetes8.3% (58) History of Aortic Arch Repair 18.1% (127) Male Gender66.6% (467) Average±Std Dev BMI28.1±6.1 Age59.4±14.8

Operative Characteristics % (Number) Hemi Arch93.6% (656) Full Arch6.4% (45) Retrograde Perfusion93.3% (654) Anterograde Perfusion6.7% (47) Concurrent CABG16.3% (114) Concurrent Aortic Valve Proc86.6% (607) Ascending Dissection24.9% (168) High Grade Ascending Atheroma 5.9% (41) Descending Dissection11.4% (80) High Grade Descending Atheroma 9.6% (67) Average±Std Dev PRBC Units1.10±0.03 FFP Units1.08±0.03 Platelets Units1.17±0.07 Cryo Units1.46±0.24 Circ Arrest Time 30.4±17.0

Results-Univariate Stroke Rate: 5.9% In-hospital Mortality Rate: 7.3%

Results - Univariate Intraoperative StrokeIn-Hospital Mortality ORP P RCP Only Any RCP use undef0.692 ACP Concurrent CABG Concurrent AV Procedure CVD3.70< History of AV Surgery History of Afib/Flutter Redo Arch Repair Ascending Dissection3.47< Descending Dissection <0.001 Descending Atheroma PRBC <0.001 FFP Platelets Cryoprecipitate <0.001 Circulatory Arrest Time Male Gender Age> Intraoperative StrokeN/A Intraoperative StrokeIn-Hospital Mortality FactorORP Any RCP Use Concurrent CABG Concurrent AV Procedure CVD3.70<0.001 History of AV Surgery History of Afib/Flutter Ascending Dissection3.47<0.001 Descending Atheroma PRBC per unit FFP per unit Platelets per unit Cryoprecipitate per unit Circulatory Arrest Time Male Gender Age> FactorORP RCP Only ACP Concurrent CABG Concurrent AV Procedure History of AV Surgery Redo Arch Repair Ascending Dissection Descending Dissection3.35<0.001 Descending Atheroma PRBC per unit1.11<0.001 FFP per unit Cryoprecipitate per unit1.98<0.001 Circulatory Arrest Time Intraoperative Stroke Univariate results with a p<0.1 included in mutlivariate analysis.

Results-Multivariate Analysis Stroke FactorOR95% CIP Value Ascending Aortic Dissection <0.001 History of Cerebrovascular Disease – High Grade Descending Atheroma – Concurrent CABG – Platelets (per unit) FactorOR95% CIP Value Male Gender – History of Atrial Fibrillation Diagnosis

Results-Multivariate Analysis In-Hospital Mortality FactorOR95% CIP Value Intraoperative Stroke Descending Aortic Dissection High Grade Descending Atheroma History of Aortic Valve Surgery PRBC (per unit) FactorOR95% CIP Value Concurrent CABG

Discussion Stroke risk is increased by high grade descending atheroma and concurrent CABG. The protective effect of preexisting atrial fibrillation may be due to preoperative prophylaxis Mortality is increased by stroke, high grade atheroma, descending dissection. Concurrent CABG has a protective effect on mortality.

Conclusions TEE Grading of atheroma is a useful adjunct to determining the risk of aortic surgery, since high grade descending atheroma is a marker of a “toxic aorta,” increasing the risk of both stroke and mortality. CABG should be attempted cautiously with ascending aortic repair as it significantly increases the risk of intraoperative stroke, however, decreases the risk of mortality.