Operative Urgency in Total Arch Replacement: Urgent Patients Benefit from Pre-Operative Optimization
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0234
Submission Type:
Abstract Submission
Authors:
Adam Carroll (1), Michal Schafer (1), Nicolas Chanes (1), Michael Kirsch (1), Ananya Shah (1), Zihan Feng (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions:
(1) University of Colorado Anschutz, Denver, CO
Submitting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Co-Author(s):
Michal Schafer
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University of Colorado Anschutz
University of Colorado Anschutz
Nicolas Chanes
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University of Colorado Anschutz
University of Colorado Anschutz
Michael Kirsch
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University of Colorado Anschutz
University of Colorado Anschutz
Ananya Shah
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University of Colorado Anschutz
University of Colorado Anschutz
Zihan Feng
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University of Colorado Anschutz
University of Colorado Anschutz
*Muhammad Aftab
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University of Colorado Anschutz
University of Colorado Anschutz
*T. Brett Reece
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University of Colorado Anschutz
University of Colorado Anschutz
Presenting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Abstract:
Objective
Despite advances in technique and post-operative management, total arch replacement remains a procedure with significant clinical risk. It has been repeatedly demonstrated that elective patients have significantly lower rates of morbidity and mortality relative to emergent patients. However, it is unclear how "urgent" patients, patients who present acutely, but can undergo some degree of pre-operative resuscitation and optimization, fare compared to the other groups. Our goal was to clarify total arch outcomes in urgent patients compared to elective and emergent cases. We hypothesized that given the similar severity in pathology of urgent patients, often to the point of being symptomatic, they would have similar outcomes to emergent total arch replacements, despite pre-operative resuscitation.
Methods
We performed a retrospective review of our database for patients who underwent total arch replacement at our institution from 2009-2023. Patients were categorized based on operative urgency: elective, urgent (admitted due to pathology, operation occurred during same admission), and emergent (admitted and taken immediately to operating room due to pathology and/or hemodynamic instability). Between groups comparisons were performed for pre-operative, operative and post-operative variables, as dictated by distribution of data, and nature of variable. An adjusted cox proportional hazard model was performed with the primary endpoint of mortality, with cumulative survival stratified by procedure urgency.
Results
A total 243 patients from 2011-2023 were included in the analysis (Table 1). There was a higher incidence in coronary artery disease (p=0.011) among the elective and urgent group, otherwise, there were no differences in pre-operative characteristics. Cardiopulmonary bypass and cross-clamp time was significantly longer for emergent compared to elective and urgent procedures (p<0.001), but not circulatory arrest times (p=0.205). Usage of packed red blood cells (pRBC, p=0.001), and coagulation products (FFP, plasma, cryo, p=0.003), was significantly higher in emergent compared to elective and urgent procedures.
Length of stay between the urgent and emergent group were similar and higher than elective cases (p=0.003), however, this included the pre-operative optimization period, and ICU length of stay was significantly higher comparatively in the emergent cohort (p=0.001). Significant differences were found between groups for prolonged ventilation (p=0.025), new renal replacement therapy (p<0.001), stroke (p<0.001), and mortality (p=0.001), with higher rates in the emergent group. Adjusted cox proportional hazard with baseline as elective procedure demonstrated no significant difference in mortality compared to urgent (p=0.653), and a significant difference compared to emergent (p=0.010).
Conclusions
Our results did not support our hypothesis, as urgent total arch outcomes were significantly better than emergent cases and were similar to elective outcomes. Emergent procedures were associated with longer intraoperative CPB and XC times, more use of blood and coagulation products, and significant morbidity and mortality. Urgent cases did not have any significant difference in any operative or post-operative variables compared to elective cases. These results suggest that even during urgent aortic admissions, patients benefit from pre-operative optimization.
Despite advances in technique and post-operative management, total arch replacement remains a procedure with significant clinical risk. It has been repeatedly demonstrated that elective patients have significantly lower rates of morbidity and mortality relative to emergent patients. However, it is unclear how "urgent" patients, patients who present acutely, but can undergo some degree of pre-operative resuscitation and optimization, fare compared to the other groups. Our goal was to clarify total arch outcomes in urgent patients compared to elective and emergent cases. We hypothesized that given the similar severity in pathology of urgent patients, often to the point of being symptomatic, they would have similar outcomes to emergent total arch replacements, despite pre-operative resuscitation.
Methods
We performed a retrospective review of our database for patients who underwent total arch replacement at our institution from 2009-2023. Patients were categorized based on operative urgency: elective, urgent (admitted due to pathology, operation occurred during same admission), and emergent (admitted and taken immediately to operating room due to pathology and/or hemodynamic instability). Between groups comparisons were performed for pre-operative, operative and post-operative variables, as dictated by distribution of data, and nature of variable. An adjusted cox proportional hazard model was performed with the primary endpoint of mortality, with cumulative survival stratified by procedure urgency.
Results
A total 243 patients from 2011-2023 were included in the analysis (Table 1). There was a higher incidence in coronary artery disease (p=0.011) among the elective and urgent group, otherwise, there were no differences in pre-operative characteristics. Cardiopulmonary bypass and cross-clamp time was significantly longer for emergent compared to elective and urgent procedures (p<0.001), but not circulatory arrest times (p=0.205). Usage of packed red blood cells (pRBC, p=0.001), and coagulation products (FFP, plasma, cryo, p=0.003), was significantly higher in emergent compared to elective and urgent procedures.
Length of stay between the urgent and emergent group were similar and higher than elective cases (p=0.003), however, this included the pre-operative optimization period, and ICU length of stay was significantly higher comparatively in the emergent cohort (p=0.001). Significant differences were found between groups for prolonged ventilation (p=0.025), new renal replacement therapy (p<0.001), stroke (p<0.001), and mortality (p=0.001), with higher rates in the emergent group. Adjusted cox proportional hazard with baseline as elective procedure demonstrated no significant difference in mortality compared to urgent (p=0.653), and a significant difference compared to emergent (p=0.010).
Conclusions
Our results did not support our hypothesis, as urgent total arch outcomes were significantly better than emergent cases and were similar to elective outcomes. Emergent procedures were associated with longer intraoperative CPB and XC times, more use of blood and coagulation products, and significant morbidity and mortality. Urgent cases did not have any significant difference in any operative or post-operative variables compared to elective cases. These results suggest that even during urgent aortic admissions, patients benefit from pre-operative optimization.
Aortic Symposium:
Aortic Arch
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