P234. Operative Urgency in Total Arch Replacement: Urgent Patients Benefit from Pre-Operative Optimization
Presented During: POD Abstracts (Available for viewing in the exhibit hall for the duration of the meeting)
University of Colorado Anschutz
Denver, CO
United States - Contact Me
Adam Carroll is a current PGY-3 surgical resident at the University of Colorado. Adam attended medical school at the University of Colorado and has been involved in research with the cardiothoracic surgery department throughout medical school and residency. He has interest specifically in endovascular and transcatheter aortic interventions, as well as neurologic outcomes in aortic research. He is currently in the aortic surgery research labaratory in the Department of Cardiothoracic Surgery at the University of Colorado. He plans to pursue a career in cardiothoracic surgery following his general surgery residency.
Thursday, April 25, 2024: 5:38 PM - 7:00 PM
Sheraton Times Square
Room: Central Park
Description
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.
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
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.
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
Presentation Duration
PODS will be on display in the exhibit hall for the duration of the meeting during exhibit hall hours. PODS will also be available for viewing on the meeting website. There is no formal presentation associated with your POD, but we encourage you to visit the PODS area during breaks to connect with those viewing.