Safety of Moderate Hypothermia With Antegrade Cerebral Perfusion in Total Aortic Arch Replacement.

BACKGROUND: Total aortic arch replacement (TOTAL) is a complicated operation and has traditionally required deep hypothermic circulatory arrest. In this study, the impact of moderate hypothermic circulatory arrest (MHCA) and antegrade cerebral perfusion (ACP) for TOTAL were examined. METHODS: The ARCH International aortic database was queried and 3,265 patients undergoing TOTAL using ACP were identified. Patients were divided into groups based on lowest cooling temperature: MHCA (20° to 28°C) or deep hypothermia (DHCA) (12° to 20°C). Propensity-matched scoring using 15 variables was used in 669 matched pairs. Multivariable analyses were performed. RESULTS: In the unmatched cohort, more patients underwent MHCA (2,586; 79.2%) who were also younger (p < 0.001) and more frequently underwent emergent operations (p < 0.001) than DHCA patients. For the propensity-matched patients, there were significant differences in cardiopulmonary bypass (CPB) time (MHCA 200 minutes versus DHCA 243 minutes, p < 0.001), aortic crossclamp time (MHCA 120 minutes versus DHCA 142 minutes, p < 0.001), and cerebral perfusion time (MHCA 63 minutes versus DHCA 58 minutes, p < 0.001). Of note, there was no difference in neurologic outcomes nor in-hospital mortality for the two temperature groups. Multivariable analysis of risk factors for mortality included CPB time (odds ratio [OR] 1.006; p < 0.001), concomitant mitral valve surgery (OR 3.070; p = 0.003), emergent operation (OR 2.924; p < 0.001), and poor ejection fraction (OR 3.133; p = 0.011). Independent risk factors for stroke included coronary artery disease (OR 1.856; p < 0.001), cerebral vascular disease (OR 2.172; p < 0.001), emergent operation (OR 2.109; p < 0.001), and CPB time (OR 1.004; p < 0.001). CONCLUSIONS: In this series, TOTAL with MHCA and ACP can be safely performed with acceptable operative risk. MHCA and ACP represent an effective strategy for TOTAL and may obviate the need for DHCA.

Transcatheter aortic valve replacement has improved short-term but similar midterm outcomes in isolated aortic valve replacement after prior coronary artery bypass grafting.

BACKGROUND: An increasing number of patients with prior coronary artery bypass grafting (CABG) now present with severe aortic stenosis. The proposed benefit of surgical (SAVR) vs transcatheter aortic valve replacement (TAVR) is unknown. The objective of this study was to compare short-term and midterm outcomes of patients undergoing isolated SAVR vs TAVR in those with prior CABG. METHODS: A retrospective analysis was performed of 255 patients who underwent isolated SAVR after prior CABG from January 2002 to February 2013 at Emory University. Outcomes of 148 patients undergoing SAVR (2002 to 2013) and 107 undergoing TAVR (2007 to 2013) were compared using multivariable logistic regression and analysis of variance techniques, adjusting for The Society of Thoracic Surgeons (STS) risk score. Kaplan-Meier plots were used to determine survival rates, and midterm survival between groups was compared using the Cox proportional hazards model. RESULTS: TAVR patients were older (79.8 ± 7.9 years vs 72.5 ± 8.8 years, p < 0.001) but were gender equivalent (female: 24% vs 22%, p = 0.61). The preoperative ejection fraction was similar between groups (TAVR: 0.433 ± 0.131 vs SAVR: 0.469 ± 0.148%, p = 0.60). The TAVR group had a significantly higher the STS risk scores (11.8% vs 7.1%, p < 0.001). All-cause 30-day mortality was 1.9% for TAVR and 4.1% for SAVR (p = 0.32), a result that marginally favors TAVR after risk adjustment (adjusted odds ratio, 0.19; p = 0.07). Postoperative morbidity and resource utilization was significantly higher in the SAVR patients. Midterm survival was similar between the two groups after adjustment (adjusted hazard ratio, 0.78, p = 0.46). CONCLUSIONS: Excellent outcomes can be achieved in SAVR or TAVR after prior CABG. Although TAVR improves short-term outcomes and resource utilization compared with SAVR, midterm mortality outcomes are similar.