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Strokes in Ascending Aortic Repairs: Predictive and Protective Factors

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.

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Strokes in Ascending Aortic Repairs: Predictive and Protective Factors

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  1. 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

  2. Introduction • Strokes occur in ~3.8% of aortic arch operations at HUP1 • Aortic atherosclerosis is a known risk factor for stroke after CABG3 • It is unknown whether aortic atherosclerosis will increase stroke risk 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; 20:3-7 2McGarvey, M., et al., Management of Neurologic Complications of Thoracic Aortic Surgery. J. Clinical Neurophysiology. 2007; 24:336-343 3van 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

  3. 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

  4. 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.

  5. Patient Population

  6. Operative Characteristics

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

  8. Results - Univariate Intraoperative Stroke In-Hospital Mortality Univariate results with a p<0.1 included in mutlivariate analysis.

  9. Results-Multivariate AnalysisStroke

  10. Results-Multivariate AnalysisIn-Hospital Mortality

  11. 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.

  12. 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.

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