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Optimal Degree of Hypothermia in Total Arch Replacement for Type A Aortic Dissection.

ABSTRACT: Background: We sought to investigate the best degree of hypothermic cardiac arrest (HCA) in type A aortic dissection (TAAD) with a cohort of 1,018 cases receiving total arch replacement from 2013 to 2018 in Fuwai Hospital. Method: The cohort was divided by DHCA (≤24°C, n = 580) vs. MHCA (>24°C, n = 438), and interquartile range (Q1-Q4). Primary endpoints included mortality, stroke, paraplegia, and continuous renal replacement therapy (CRRT), which were summarized as composite major outcomes (CMO). Results: The Odds Ratio (OR) of CMO for MHCA was 0.7 (95% CI: 0.5-1.0, p = 0.06) (unadjusted) and 0.6 (95% CI: 0.4-1.0, p = 0.055) (adjusted). DHCA group tended to have a significantly longer CPB time (175.6 ± 45.6 vs. 166.8 ± 49.8 min, p = 0.003), longer hospital stay (16.0 ± 13.6 vs. 13.5 ± 6.8 days, p < 0.001), and ICU stay [5.0 (3.9-6.6) vs. 3.8 (2.0-5.6) days]. A significantly greater blood loss was observed in DHCA group, with a greater requirement for RBC and platelet transfusion. Of note, MHCA showed a significant protective effect (60% risk reduction) for older patients (above 60 years) (OR 0.4; 95% CI: 0.2-0.8; p = 0.009). By quartering, Q1 had significantly higher mortality (10.9%) than Q4 (5.2%) (p = 0.035). For other comparisons, the gap was significantly widened in quartering between Q1 and Q4, i.e., the lower the temperature, the worse the outcomes, and vice versa. Propensity score matching and sensitivity analyses confirmed the above findings. Conclusions: A paradigm change from DHCA to MHCA may be encouraged in TAAD arch operation, especially for the elderly.

SUBMITTER: Wu J

PROVIDER: S-EPMC8115724 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundStanford type A aortic dissection (TAAD) has a sudden onset and high mortality, and emergency total aortic arch replacement (TAAR) is the main treatment option for TAAD. The mortality rate of patients with postoperative acute kidney injury (AKI) combined with continuous renal replacement therapy (CRRT) is remarkable higher than that of patients without AKI. However, incidence of AKI and risk factors for CRRT following TAAR isn't entirely understood.MethodsFrom October 2018 to March 2021, all patients with Stanford type A dissection who underwent total arch replacement surgery under MHCA were enrolled. According to whether CRRT treatment was performed, participants were divided into a CRRT group (n=49) and control group (n=72). Both groups incorporated the brain protection strategy of moderate hypothermia, and the left common carotid artery and the innominate artery were perfused anteriorly. Relevant medical data was collected.ResultsAge, gender, and a history of smoking and drinking were not significantly different between the 2 groups (P>0.1). There were statistical differences between the 2 groups in aortic sinus diameter and Bentall procedure (P≤0.05). Univariate analysis revealed that fresh frozen plasma was a protective factor (P<0.05) and the intraoperative transfusion volume of red blood cells, platelets, fresh frozen plasma, autologous blood used for intraoperative bleeding, aortic sinus diameter, and Bentall procedure were risk factors (P<0.1). Multivariate analysis showed that the Bentall procedure and intraoperative bleeding were risk factors for CRRT (P<0.05), and the aortic sinus diameter and intraoperative transfusion score were also risk factors for CRRT (P<0.05). Receiver operating characteristic (ROC) analysis demonstrated that the model of aortic sinus diameter and intraoperative transfusion score had more significantly different discriminatory powers.ConclusionsThe Bentall procedure, intraoperative bleeding, aortic sinus diameter, and intraoperative transfusion score were risk factors for postoperative CRRT. The model of aortic sinus diameter and intraoperative transfusion score had more significantly different discriminatory powers.

Project description:BackgroundThis research aimed to evaluate the impacts of transfusing packed red blood cells (pRBCs), fresh frozen plasma (FFP), or platelet concentrate (PC) on postoperative mechanical ventilation time (MVT) in patients with acute Stanford type A aortic dissection (ATAAD) undergoing after total arch replacement (TAR).MethodsThe clinical data of 384 patients with ATAAD after TAR were retrospectively collected from December 2015 to October 2017 to verify whether pRBCs, FFP, or PC transfusion volumes were associated with postoperative MVT. The logistic regression was used to assess whether blood products were risk factors for prolonged mechanical ventilation (PMV) in all three endpoints (PMV ≥24 h, ≥48 h, and ≥72 h).ResultsThe mean age of 384 patients was 47.6 ± 10.689 years, and 301 (78.39%) patients were men. Median MVT was 29.5 (4-574) h (h), and 213 (55.47%), 136 (35.42%), and 96 (25.00%) patients had PMV ≥24 h, ≥48 h, and ≥72 h, respectively. A total of 36 (9.38%) patients did not have any blood product transfusion, the number of patients with transfusion of pRBCs, FFP, and PC were 334 (86.98%), 286 (74.48%), and 189 (49.22%), respectively. According to the multivariate logistic regression of three PMV time-endpoints, age was a risk factor [PMV ≥ 24 h odds ratio (OR PMV≥24) = 1.045, p = 0.005; OR PMV≥48 = 1.060, p = 0.002; OR PMV≥72 = 1.051, p = 0.011]. pRBC transfusion (OR PMV≥24 = 1.156, p = 0.001; OR PMV≥48 = 1.156, p < 0.001; OR PMV≥72 = 1.135, p ≤ 0.001) and PC transfusion (OR PMV≥24 = 1.366, p = 0.029; OR PMV≥48 = 1.226, p = 0.030; OR PMV≥72 = 1.229, p = 0.011) were independent risk factors for PMV. FFP had no noticeable effect on PMV [OR PMV≥48 = 0.999, 95% confidence interval (CI) 0.998-1.000, p = 0.039; OR PMV≥72 = 0.999, 95% CI: 0.998-1.000, p = 0.025].ConclusionsIn patients with ATAAD after TAR, the incidence of PMV was very high. Blood products transfusion was closely related to postoperative mechanical ventilation time. pRBC and PC transfusions and age increased the incidence of PMV at all three endpoints.

Project description:Background Total arch replacement with the frozen elephant trunk (TAR + FET) technique is a challenging approach for acute type A aortic dissection (ATAAD). Severe acute kidney injury (AKI) adversely affects the prognosis of hospitalized patients. The study aims to evaluate the incidence and risk factors of severe AKI. Methods We conducted a retrospective cross-sectional study of the records of ATAAD patients following TAR + FET, admitted between January 2013 and December 2018. A multivariate logistic regression model was used to identify predictors of severe postoperative AKI. Severe postoperative AKI was defined using the Kidney Disease Improving Global Outcomes criteria. Results The whole in-hospital mortality rate was 4.3%. Among 670 patients, major adverse outcomes were present in 169 patients (25.2%), 67 patients (10.0%) required renal replacement therapy (RRT), and 80 (11.9%) developed severe postoperative AKI. In-hospital mortality in the severe AKI group (13.8%) was 4.5 times higher than in the non-severe AKI group (3.1%). Compared with the non-severe AKI patients, the severe AKI patients had a higher incidence of major adverse outcomes (100% vs. 15.1%, P<0.001) and more frequent use of RRT (83.8% vs. 0.0%, P<0.001). Multivariate analysis revealed that severe postoperative AKI was predicted by advanced age [odds ratio (OR) =1.029; 95% confidence interval (CI): 1.002–1.056; P=0.032], lower limb symptoms (OR =4.384; 95% CI: 2.240–8.582; P<0.001), coronary artery involvement (OR =2.478; 95% CI: 1.432–4.288; P=0.001), preoperative postoperative serum creatinine (SCr) (OR =1.008; 95% CI: 1.003–1.013; P=0.001), and prolonged cardiopulmonary bypass (CPB) time (OR =1.011; 95% CI: 1.006–1.015; P<0.001). Conclusions There was a high incidence of severe AKI and high in-hospital mortality after TAR + FET in ATAAD patients. The risk factors for severe AKI in ATAAD patients undergoing TAR + FET were determined to help identify the high-risk patients and make rational treatment decisions.

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Optimal Degree of Hypothermia in Total Arch Replacement for Type A Aortic Dissection.

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