Strokes in Ascending Strokes in Ascending Aortic Repairs: Aortic Repairs: Predictive and Predictive and
Protective FactorsProtective Factors
Tovy Kamine, BS, Steven R Messé, Tovy Kamine, BS, Steven R Messé, MD, Elizabeth Leitner, Joseph MD, Elizabeth Leitner, Joseph
Bavaria, MD, Michael McGarvey, MDBavaria, MD, Michael McGarvey, MDDepartments of Neurology and Cardiovascular Surgery, University of
Pennsylvania Health System
IntroductionIntroduction
Strokes occur in ~3.8% of aortic arch Strokes occur in ~3.8% of aortic arch operations at HUPoperations at HUP11
Aortic atherosclerosis is a known risk Aortic atherosclerosis is a known risk factor for stroke after CABGfactor for stroke after CABG33
It is unknown whether aortic It is unknown whether aortic atherosclerosis will increase stroke atherosclerosis will increase stroke risk in arch operationsrisk in arch operations
1Appoo, 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; 20:3-72McGarvey, M., et al., Management of Neurologic Complications of Thoracic Aortic Surgery. J. Clinical Neurophysiology. 2007; 24:336-3433van 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
ObjectivesObjectives
To characterize patient and To characterize patient and perioperative factors associated perioperative factors associated with stroke and mortality in with stroke and mortality in ascending aortic repairsascending aortic repairs
– To test whether aortic atheroma is To test whether aortic atheroma is independently predictive of stroke independently predictive of stroke risk risk
MethodsMethods
Retrospective analysis of 701 consecutive Retrospective analysis of 701 consecutive patients undergoing ascending repair under Deep patients undergoing ascending repair under Deep Hypothermic Circulatory Arrest (DHCA) Hypothermic Circulatory Arrest (DHCA)
Inclusion criteria: all ascending aortic operations Inclusion criteria: all ascending aortic operations at HUP and Penn-Presbyterian medical center, at HUP and Penn-Presbyterian medical center, including emergent cases.including emergent cases.
Exclusion criteria: operations with concurrent Exclusion criteria: operations with concurrent repair of the descending aorta; hybrid proceduresrepair of the descending aorta; hybrid procedures
Two Primary Endpoints: Intra-operative stroke Two Primary Endpoints: Intra-operative stroke and in-hospital mortality and in-hospital mortality
Factors with p≤0.1 in univariate analysis were Factors with p≤0.1 in univariate analysis were included in multivariate analysis. included in multivariate analysis.
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
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
Results-UnivariateResults-Univariate
Stroke Rate: 5.9%Stroke Rate: 5.9%
In-hospital Mortality Rate: 7.3%In-hospital Mortality Rate: 7.3%
Results - UnivariateResults - UnivariateIntraoperative 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.
Results-Multivariate Results-Multivariate AnalysisAnalysisStrokeStroke
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
Results-Multivariate Results-Multivariate AnalysisAnalysis
In-Hospital MortalityIn-Hospital MortalityFactor 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
DiscussionDiscussion
Stroke risk is increased by high grade Stroke risk is increased by high grade descending atheroma and concurrent CABG. descending atheroma and concurrent CABG.
The protective effect of preexisting atrial The protective effect of preexisting atrial fibrillation may be due to preoperative fibrillation may be due to preoperative prophylaxisprophylaxis
Mortality is increased by stroke, high grade Mortality is increased by stroke, high grade atheroma, descending dissection. atheroma, descending dissection. Concurrent CABG has a protective effect on Concurrent CABG has a protective effect on mortality.mortality.
ConclusionsConclusions
TEE Grading of atheroma is a useful TEE Grading of atheroma is a useful adjunct to determining the risk of aortic adjunct to determining the risk of aortic surgery, since high grade descending surgery, since high grade descending atheroma is a marker of a “toxic aorta,” atheroma is a marker of a “toxic aorta,” increasing the risk of both stroke and increasing the risk of both stroke and mortality.mortality.
CABG should be attempted cautiously with CABG should be attempted cautiously with ascending aortic repair as it significantly ascending 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.