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.