Publications by authors named "Karen Kim"

117 Publications

Differences among sexes in presentation and outcomes in acute type A aortic dissection repair.

J Thorac Cardiovasc Surg 2021 Mar 29. Epub 2021 Mar 29.

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich. Electronic address:

Objective: Female sex is a known risk factor in most cardiac surgery, including coronary and valve surgery, but unknown in acute type A aortic dissection repair.

Methods: From 1996 to 2018, 650 patients underwent acute type A aortic dissection repair; 206 (32%) were female, and 444 (68%) were male. Data were collected through the Cardiac Surgery Data Warehouse, medical record review, and National Death Index database.

Results: Compared with men, women were significantly older (65 vs 57 years, P < .0001). The proportion of women and men inverted with increasing age, with 23% of patients aged less than 50 years and 65% of patients aged 80 years or older being female. Women had significantly less chronic renal failure (2.0% vs 5.4%, P = .04), acute myocardial infarction (1.0% vs 3.8%, P = .04), and severe aortic insufficiency. Women underwent significantly fewer aortic root replacements with similar aortic arch procedures, shorter cardiopulmonary bypass times (211 vs 229 minutes, P = .0001), and aortic crossclamp times (132 vs 164 minutes, P < .0001), but required more intraoperative blood transfusion (4 vs 3 units) compared with men. Women had significantly lower operative mortality (4.9% vs 9.5%, P = .04), especially in those aged more than 70 years (4.4% vs 16%, P = .02). The significant risk factors for operative mortality were male sex (odds ratio, 2.2), chronic renal failure (odds ratio, 3.4), and cardiogenic shock (odds ratio, 6.8). The 10-year survival was similar between sexes.

Conclusions: Physicians and women should be cognizant of the risk of acute type A aortic dissection later in life in women. Surgeons should strongly consider operations for acute type A aortic dissection in women, especially in patients aged 70 years or more.
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http://dx.doi.org/10.1016/j.jtcvs.2021.03.078DOI Listing
March 2021

Multiple Emergency Department Presentations of COVID-19-Related Multisystem Inflammatory Syndrome in Children.

Clin Pediatr (Phila) 2021 05;60(4-5):214-220

Ochsner Medical Center, New Orleans, LA, USA.

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http://dx.doi.org/10.1177/00099228211005289DOI Listing
May 2021

Society of Thoracic Surgeons 2021 Adult Cardiac Surgery Risk Models for Multiple Valve Operations.

Ann Thorac Surg 2021 Apr 9. Epub 2021 Apr 9.

Duke University, Durham, North Carolina.

Background: The STS Quality Measurement Task Force has developed risk models and composite performance measures for isolated coronary artery bypass grafting surgery (CABG), isolated aortic valve replacement (AVR), isolated mitral valve replacement or repair (MVRR), AVR+CABG, and MVRR+CABG. To further enhance its portfolio of risk-adjusted performance metrics, STS has developed new risk models for multiple valve operations +/- CABG procedures.

Methods: Using July 2011 to June 2019 STS Adult Cardiac Surgery Database (ACSD) data, risk models for AVR+MVRR (n=31,968) and AVR+MVRR+CABG (n=12,650) were developed with the following endpoints: operative mortality, major morbidity (any one or more of the following: cardiac reoperation; deep sternal wound infection/mediastinitis; stroke; prolonged ventilation; and renal failure), and combined mortality and/or major morbidity. Data were divided into development (July 2011 - June 2017, n=35,109) and validation (July 2017 - June 2019, n=9,509) samples. Predictors were selected by assessing model performance and clinical face validity of full and progressively more parsimonious models. Performance of the resulting models was evaluated by assessing discrimination and calibration.

Results: C-statistics for the overall population of multiple valve +/- CABG procedures were 0.7086, 0.6734, and 0.6840 for mortality, morbidity, and combined mortality and/or morbidity in the development sample, and 0.6953, 0.6561, and 0.6634 for the same outcomes, respectively, in the validation sample.

Conclusions: New STS-ACSD risk models have been developed for multiple valve +/- CABG operations, and these models will be used in subsequent STS performance metrics.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.089DOI Listing
April 2021

Primary care provider-led group visits for advance care planning in the safety net.

J Am Geriatr Soc 2021 Apr 2. Epub 2021 Apr 2.

Department of Medicine, Olive View-UCLA Medical Center, Los Angeles, California, USA.

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http://dx.doi.org/10.1111/jgs.17098DOI Listing
April 2021

Another Tool in the Toolbox.

Authors:
Karen M Kim

Ann Thorac Surg 2021 Feb 16. Epub 2021 Feb 16.

University of Michigan, Cardiac Surgery, 1500 E Medical Center Drive, 5164 CVC, SPC 5864. Electronic address:

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http://dx.doi.org/10.1016/j.athoracsur.2021.01.056DOI Listing
February 2021

Elective Surgical Delays Due to COVID-19: The Patient Lived Experience.

Med Care 2021 04;59(4):288-294

Center for Healthcare Outcomes and Policy.

Background: This qualitative research explored the lived experiences of patients who experienced postponement of elective cardiac and vascular surgery due to coronavirus disease 2019 (COVID-19). We know very little about patients during the novel coronavirus pandemic. Understanding the patient voice may play an important role in prioritization of postponed cases and triage moving forward.

Methods: Utilizing a hermeneutical phenomenological qualitative design, we interviewed 47 individuals who experienced a postponement of cardiac or vascular surgery due to the COVID-19 pandemic. Data were analyzed and informed by phenomenological research methods.

Results: Patients in our study described 3 key issues around their postponement of elective surgery. Patients described robust narratives about the meanings of their elective surgeries as the chance to "return to normal" and alleviate symptoms that impacted everyday life. Second, because of the meanings most of our patients ascribed to their surgeries, postponement often took a toll on how patients managed physical health and emotional well-being. Finally, paradoxically, many patients in our study were demonstrative that they would "rather die from a heart attack" than be exposed to the coronavirus.

Conclusions: We identified several components of the patient experience, encompassing quality of life and other desired benefits of surgery, the risks of COVID, and difficulty reconciling the 2. Our study provides significant qualitative evidence to inform providers of important considerations when rescheduling the backlog of patients. The emotional and psychological distress that patients experienced due to postponement may also require additional considerations in postoperative recovery.
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http://dx.doi.org/10.1097/MLR.0000000000001503DOI Listing
April 2021

Surgical Explantation of Transcatheter Aortic Bioprostheses: Balloon Versus Self-Expandable Devices.

Ann Thorac Surg 2021 Feb 2. Epub 2021 Feb 2.

Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI.

Background: Despite the rapid adoption of transcatheter aortic replacement (TAVR), surgical TAVR valve explantation (TAVR-explant) and the clinical impact of explanted TAVR device type is not well-described.

Methods: TAVR-explant from 2016 to 2019 was queried using the Society of Thoracic Surgeons (STS) National Database. A total of 483 patients with documented explanted valve type, consisting of 330 (68%) with balloon-expandable and 153 (32%) patients with self-expandable devices, were identified. The primary outcome was 30-day mortality. The secondary outcome was the need for any simultaneous procedures with TAVR-explant.

Results: The mean age was 72.8, 38% were female, and 51% demonstrated NYHA class 3-4 symptoms. During TAVR-explant, 63% required other simultaneous procedures including aortic repair (27%), mitral (22%), coronary artery bypass grafting (15%), and tricuspid (7%) procedures. Patients with a self-expandable device underwent more frequent ascending aortic replacement (22% vs. 9%; p<0.001) than those with a balloon-expandable device, whereas the aortic root replacement rate was similar (19% vs. 24%; p=0.22). The overall 30-day mortality was 18% without difference regarding the mortality or other major complications between groups. Of the 157 patients with isolated surgical aortic valve replacement and available STS predicted risk of mortality score, the observed-to-expected (O/E) mortality ratio was 2.2.

Conclusions: The TAVR-explant outcomes were comparable between patients with balloon-expandable and self-expandable devices, while ascending aortic replacement was observed more frequently with self-expandable devices. Younger patients undergoing a TAVR should be informed of the future TAVR-explant risk which may accompany a higher O/E ratio and frequent morbid concurrent procedures.
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http://dx.doi.org/10.1016/j.athoracsur.2021.01.041DOI Listing
February 2021

Digital Navigation Improves No-Show Rates and Bowel Preparation Quality for Patients Undergoing Colonoscopy: A Randomized Controlled Quality Improvement Study.

J Clin Gastroenterol 2021 Jan 20. Epub 2021 Jan 20.

Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medicine, Chicago, IL Department of Medicine, Section of Gastroenterology, University of Michigan Medicine, Ann Arbor, MI.

Objectives: Because of high historical no-show rates and poor bowel preparation quality in our unit, we sought to evaluate whether text message navigation for patients scheduled for colonoscopy would reduce no-show rates and improve bowel preparation quality compared with usual care.

Methods: We performed a randomized controlled quality improvement study from April to August 2019 in an urban academic endoscopy unit. All patients scheduled for colonoscopy were randomly assigned to a control group that received usual care (paper instructions/nursing precalls) or to the intervention group that received usual care plus the text message program [short message service (SMS)]. The program provided timed-release instructions on dietary modifications and bowel preparation before colonoscopy. The primary outcome was no-shows. Secondary outcomes were no-show/same-day cancellations, no-show/cancellations within 7 days of the procedure, and bowel preparation quality.

Results: A total of 1625 patients were randomized (SMS=833, control=792). No-show rates were significantly lower in the SMS group compared with the control group (8% vs. 14%; P<0.0001). Similar results were found for no-show/same-day cancellations (10% vs. 16%; P=0.0003), and no-show/cancellations within 7 days (18% vs. 26%; P=0.0008). There was no difference in adequate bowel preparation for all colonoscopies between the groups (89% vs. 87%; P=0.47). However, rates of adequate bowel preparation for screening/surveillance colonoscopies were significantly higher in SMS versus control groups (93% vs. 88%; P=0.04).

Conclusions: Text message navigation for patients scheduled for colonoscopy improved the quality of colorectal cancer screening by decreasing no-show rates and increasing adequate bowel preparation rates in patients undergoing screening colonoscopy compared with usual care.
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http://dx.doi.org/10.1097/MCG.0000000000001497DOI Listing
January 2021

Is hemiarch replacement adequate in acute type A aortic dissection repair in patients with arch branch vessel dissection without cerebral malperfusion?

J Thorac Cardiovasc Surg 2021 03 10;161(3):873-884.e2. Epub 2020 Dec 10.

Department of Cardiac Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Mich. Electronic address:

Objective: The study objective was to determine if hemiarch replacement is an adequate arch management strategy for patients with acute type A aortic dissection and arch branch vessel dissection but no cerebral malperfusion.

Methods: From January 2008 to August 2019, 479 patients underwent open acute type A aortic dissection repair. After excluding those with aggressive arch replacement (n = 168), cerebral malperfusion syndrome (n = 34), and indeterminable arch branch vessel dissection (n = 1), 276 patients with an acute type A aortic dissection without cerebral malperfusion syndrome who underwent hemiarch replacement comprised this study. Patients were then divided into those with arch branch vessel dissection (n = 133) and those with no arch branch vessel dissection (n = 143).

Results: The median age of the entire cohort was 62 years, with the arch branch vessel dissection group being younger (60 vs 62 years, P = .048). Both groups had similar aortic arch and descending thoracic aortic diameters, with significantly more DeBakey type I dissections (100% vs 80%) in the arch branch vessel dissection group. The arch branch vessel dissection group had more aortic root replacement (36% vs 27%, P = .0035) and longer aortic crossclamp times (153 vs 128 minutes, P = .007). Postoperative outcomes were similar between the arch branch vessel dissection and no arch branch vessel dissection groups, including stroke (10% vs 5%, P = .12) and operative morality (7% vs 5%, P = .51). The arch branch vessel dissection group had a significantly greater cumulative incidence of reoperation (8-year: 19% vs 4%, P = .04) with a hazard ratio of 2.89 (95% confidence interval, 1.01-8.27; P = .048), which was similar between groups among only DeBakey type I dissections (8-year: 19% vs 5%, P = .11). The 8-year survival was similar between the arch branch vessel dissection and no arch branch vessel dissection groups (76% vs 74%, P = .30).

Conclusions: Hemiarch replacement was adequate for patients with acute type A aortic dissection with arch branch vessel dissection without cerebral malperfusion syndrome, but carried a higher risk of late reoperation.
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http://dx.doi.org/10.1016/j.jtcvs.2020.10.160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935741PMC
March 2021

Establishment and Implementation of Evidence-Based Opioid Prescribing Guidelines in Cardiac Surgery.

Ann Thorac Surg 2020 Dec 4. Epub 2020 Dec 4.

Department of Surgery, University of Michigan, Ann Arbor, MI.

Background: Despite the risk of new persistent opioid use after cardiac surgery, post-discharge opioid use has not been quantified and evidence-based prescribing guidelines have not been established.

Methods: Opioid-naïve patients undergoing primary cardiac surgery via median sternotomy between January-December 2019 at 10 hospitals participating in a statewide collaborative were selected. Clinical data were linked to patient-reported outcomes collected at 30-day follow-up. An opioid prescribing recommendation stratified by inpatient opioid use on the day before discharge (0, 1-3, or ≥4 pills) was implemented in July 2019. Interrupted time-series analyses were performed for prescription size and post-discharge opioid use before (January-June) and after (July-December) guideline implementation.

Results: Among 1495 patients (729 pre- and 766 post-recommendation), median prescription size decreased from 20 to 12 pills after recommendation release (p<0.001), while opioid use decreased from 3 to 0 pills (p<0.001). Change in prescription size over time was +0.6 pills/month before and -0.8 pills/month after the recommendation (difference: -1.4 pills/month, p=0.036). Change in patient use was +0.6 pills/month before and -0.4 pills/month after the recommendation (difference: -1.0 pills/month, p=0.017). Pain levels during the first week after surgery and refills were unchanged. Patients using 0 pills before discharge (n=710) were prescribed a median of 0 pills and used 0, while those using 1-3 pills (n=536) were prescribed 20 and used 7, and those using ≥4 pills (n=249) were prescribed 32 and used 24.

Conclusions: An opioid prescribing recommendation was effective, and prescribing after cardiac surgery should be guided by inpatient use.
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http://dx.doi.org/10.1016/j.athoracsur.2020.11.015DOI Listing
December 2020

Type A Aortic Dissection During COVID-19 Pandemic: Report From Tertiary Aortic Centers in the United States and China.

Semin Thorac Cardiovasc Surg 2020 Nov 7. Epub 2020 Nov 7.

Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan. Electronic address:

Coronavirus disease 2019 (COVID-19) has substantially disrupted many processes of care related to emergency cardiac conditions, while there has been no clinical guidance regarding the management of type A aortic dissection. A retrospective multicenter study involving 52 consecutive patients (mean age 52.3, 28.9% women) with type A aortic dissection during COVID-19 pandemic was conducted at tertiary aortic centers in Michigan, Wuhan and Changsha (China). Twenty-four (46.2%) were considered clinically suspicious for COVID-19 based on radiographic lung lesions (70.8%) followed by dyspnea (25.0%), cough (12.5%), and fever (12.5%). Overall, 47 (90.4%) underwent an operation and 5 (9.6%) managed nonoperatively. All suspected patients underwent a reverse-transcriptase-polymerase-chain-reaction at arrival, whereas 82.1% in the nonsuspected (P = 0.054). Among the 24 patients either nonoperatively managed or whose operation was delayed for >24 hours, only 1 (4.2%) died. A total of 3 (6.4%) operated patients had a positive reverse-transcriptase-polymerase-chain-reaction at various timings, including 1 nonsuspected patient preoperatively and 2 with very recent COVID-19 infection. The first patient died of respiratory failure despite uneventful surgical repair and maximal medical management. The postoperative course of both patients with recent COVID-19 was characterized by severe coagulopathy requiring massive transfusions and prolonged ICU stay. However, both survived to hospital discharge. In light of the possible dismal outcomes associated with dual diagnoses of type A aortic dissection/COVID-19 and the higher-than-expected number of asymptomatic carriers, all type A dissection patients should be immediately tested for COVID-19. Surgical interventions in patients recovered from recent COVID-19 may be safe.
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http://dx.doi.org/10.1053/j.semtcvs.2020.10.034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7648657PMC
November 2020

Type A Aortic Dissection With Cerebral Malperfusion: New Insights.

Ann Thorac Surg 2020 Oct 27. Epub 2020 Oct 27.

Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.

Background: Management of type A aortic dissection with cerebral malperfusion poses a significant challenge. Although involvement of craniocervical vessels is undoubtedly critical, it is not well investigated in the surgical literature.

Methods: Between 1997 and 2019, 775 patients presented with acute type A aortic dissection and 80 (10%) with cerebral malperfusion. All patients were transferred from outside institutions. Medical records and imaging studies were retrospectively reviewed.

Results: Fifty-nine patients (74%) underwent an open repair, 2 (3%) had an endovascular aortic repair, 2 (3%) had carotid stenting, and 18 (23%) received nonoperative management. In-hospital mortality of all comers was 40.0%, and 81.3% were neurology related. Among the 45 patients (56%) in whom cerebrocervical imaging studies were available, 11 (24%) had an internal carotid artery (ICA) occlusion and 28 (62%) had a common carotid artery (CCA) occlusion without ICA involvement as the culprit lesion. Six comatose patients (55%) were in the ICA group and 10 comatose patients (36%) in the CCA group (P = .28). All patients with ICA occlusion developed cerebral edema and herniation syndrome regardless of the management and died. In contrast 79% of patients with unilateral or bilateral CCA occlusion survived to hospital discharge (P < .001), and only 3 (11%) had a neurologic death (P < .001).

Conclusions: ICA occlusion in the presence of type A aortic dissection may be a surrogate marker for dismal neurologic outcomes regardless of the surgical approach, whereas CCA occlusion or comatose state should not preclude surgical candidacy. A prompt neck computed tomography angiography may be warranted in patients with cerebral malperfusion.
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http://dx.doi.org/10.1016/j.athoracsur.2020.08.046DOI Listing
October 2020

Implementing a multilevel intervention to accelerate colorectal cancer screening and follow-up in federally qualified health centers using a stepped wedge design: a study protocol.

Implement Sci 2020 10 29;15(1):96. Epub 2020 Oct 29.

Center for Asian Health Equity, University of Chicago, 5841 S. Maryland Ave, MC1140, Chicago, IL, 60637, USA.

Background: Screening for colorectal cancer (CRC) not only detects disease early when treatment is more effective but also prevents cancer by finding and removing precancerous polyps. Because many of our nation's most disadvantaged and vulnerable individuals obtain health care at federally qualified health centers, these centers play a significant role in increasing CRC screening among the most vulnerable populations. Furthermore, the full benefits of cancer screenings must include timely and appropriate follow-up of abnormal results. Thus, the purpose of this study is to implement a multilevel intervention to increase rates of CRC screening, follow-up, and referral-to-care in federally qualified health centers, as well as simultaneously to observe and to gather information on the implementation process to improve the adoption, implementation, and sustainment of the intervention. The multilevel intervention will target three different levels of influences: organization, provider, and individual. It will have multiple components, including provider and staff education, provider reminder, provider assessment and feedback, patient reminder, and patient navigation.

Methods: This study is a multilevel, three-phase, stepped wedge cluster randomized trial with four clusters of clinics from four different FQHC systems. In the first phase, there will be a 3-month waiting period during which no intervention components will be implemented. After the 3-month waiting period, we will randomize two clusters to cross from the control to the intervention and the remaining two clusters to follow 3 months later. All clusters will stay at the same phase for 9 months, followed by a 3-month transition period, and then cross over to the next phase.

Discussion: There is a pressing need to reduce disparities in CRC outcomes, especially among racial/ethnic minority populations and among populations who live in poverty. Single-level interventions are often insufficient to lead to sustainable changes. Multilevel interventions, which target two or more levels of changes, are needed to address multilevel contextual influences simultaneously. Multilevel interventions with multiple components will affect not only the desired outcomes but also each other. How to take advantage of multilevel interventions and how to implement such interventions and evaluate their effectiveness are the ultimate goals of this study.

Trial Registration: This protocol is registered at clinicaltrials.gov ( NCT04514341 ) on 14 August 2020.
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http://dx.doi.org/10.1186/s13012-020-01045-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7599111PMC
October 2020

Effectiveness and Cost of Implementing Evidence-Based Interventions to Increase Colorectal Cancer Screening Among an Underserved Population in Chicago.

Health Promot Pract 2020 11 29;21(6):884-890. Epub 2020 Sep 29.

RTI International, Waltham, MA, USA.

With funding from the Centers for Disease Control and Prevention's Colorectal Cancer Control Program, The University of Chicago Center for Asian Health Equity partnered with a federally qualified health center (FQHC) to implement multiple evidence-based interventions (EBIs) in order to improve colorectal cancer (CRC) screening uptake. The purpose of this study is to determine the effectiveness and cost of implementing a provider reminder system entered manually and supplemented with patient reminders and provider assessment and feedback. The FQHC collected demographic characteristics of the FQHC and outcome data from January 2015 through December 2015 (preimplementation period) and cost from January 2016 through September 2017 (implementation period). Cost data were collected for the implementation period. We report on the demographics of the eligible population, CRC screening order, completion rates by sociodemographic characteristics, and, overall, the effectiveness and cost of implementation. From the preimplementation phase to the implementation phase, there was a 21.2 percentage point increase in CRC screens completed. The total cost of implementing EBIs was $40908.97. We estimated that an additional 283 screens were completed because of the interventions, and the implementation cost of the interventions was $144.65 per additional screen. With the interventions, CRC screening uptake in Chicago increased for all race/ethnicity and demographic backgrounds at the FQHC, particularly for patients aged 50 to 64 years and for Asian, Hispanic, and uninsured patients.
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http://dx.doi.org/10.1177/1524839920954162DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7894065PMC
November 2020

Treatment of aortic valve endocarditis with stented or stentless valve.

J Thorac Cardiovasc Surg 2020 Aug 26. Epub 2020 Aug 26.

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich. Electronic address:

Objective: The study objective was to provide evidence for choosing a bioprosthesis in treating patients with active aortic valve endocarditis.

Methods: From 1998 to 2017, 265 patients with active aortic valve endocarditis underwent aortic valve replacement with a stented valve (n = 97, 37%) or a stentless valve (n = 168, 63%) with further breakdown into inclusion technique (n = 142, 85%) or total root replacement (n = 26, 15%). Data were obtained from the Society of Thoracic Surgeons database aided with chart review, surveys, and National Death Index data.

Results: The median age of patients was 53 years (43-56) in the stented group and 57 years (44-66) in the stentless group. The stented and stentless groups had high rates of heart failure (54% and 40%), liver disease (16% and 7.7%), prosthetic valve endocarditis (14% and 48%), root abscess (38% and 70%), and concomitant ascending aorta procedures (6.2% and 22%), respectively. The stentless group required permanent pacemakers in 11% of cases. Operative mortality was similar between groups (6.2% and 7.1%). The 5-year survival was 52% and 63% in the stented and stentless groups, respectively. Significant risk factors for long-term mortality included liver disease (hazard ratio, 2.38), previous myocardial infarction (hazard ratio, 1.64), congestive heart failure (hazard ratio, 1.63), and renal failure requiring dialysis (hazard ratio, 4.37). The 10-year cumulative incidence of reoperation was 12% and 3.4% for the stented and stentless groups, respectively. The 10-year freedom from reoccurrence of aortic valve endocarditis was 88% for the stented and 98% for the stentless groups.

Conclusions: Both stented and stentless aortic valves are appropriate conduits for replacement of active aortic valve endocarditis for select patients.
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http://dx.doi.org/10.1016/j.jtcvs.2020.08.068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7907285PMC
August 2020

Cohort profile: the ChicagO Multiethnic Prevention and Surveillance Study (COMPASS).

BMJ Open 2020 09 16;10(9):e038481. Epub 2020 Sep 16.

Department of Public Health Sciences, The University of Chicago, Chicago, Illinois, USA.

Purpose: The ChicagO Multiethnic Prevention and Surveillance Study or 'COMPASS' is a population-based cohort study with a goal to examine the risk and determinants of cancer and chronic disease. COMPASS aims to address factors causing and/or exacerbating health disparities using a precision health approach by recruiting diverse participants in Chicago, with an emphasis on those historically underrepresented in biomedical research.

Participants: Nearly 8000 participants have been recruited from 72 of the 77 Chicago community areas. Enrolment entails the completion of a 1-hour long survey, consenting for past and future medical records from all sources, the collection of clinical and physical measurement data and the on-site collection of biological samples including blood, urine and saliva. Indoor air monitoring data and stool samples are being collected from a subset of participants. On collection, all biological samples are processed and aliquoted within 24 hours before long-term storage and subsequent analysis.

Findings To Date: The cohort reported an average age of 53.7 years, while 80.5% identified as African-American, 5.7% as Hispanic and 47.8% as men. Over 50% reported earning less than US$15 000 yearly, 35% were obese and 47.8% were current smokers. Moreover, 38% self-reported having had a diagnosis of hypertension, while 66.4% were measured as hypertensive at enrolment.

Future Plans: We plan to expand recruitment up to 100 000 participants from the Chicago metropolitan area in the next decade using a hybrid community and clinic-based recruitment framework that incorporates data collection through mobile medical units. Follow-up data collection from current cohort members will include serial samples, as well as longitudinal health, lifestyle and behavioural assessment. We will supplement self-reported data with electronic medical records, expand the collection of biometrics and biosamples to facilitate increasing digital epidemiological study designs and link to state and/or national level databases to ascertain outcomes. The results and findings will inform potential opportunities for precision disease prevention and mitigation in Chicago and other urban areas with a diverse population.

Registration: NA.
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http://dx.doi.org/10.1136/bmjopen-2020-038481DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7497521PMC
September 2020

Impact of Chronic Renal Failure on Surgical Outcomes in Patients With Infective Endocarditis.

Ann Thorac Surg 2021 03 18;111(3):828-835. Epub 2020 Aug 18.

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan. Electronic address:

Background: Patients with chronic renal failure (CRF) who are undergoing hemodialysis are at increased risk for infective endocarditis (IE). However, outcomes of surgical treatment for IE in these patients have not been well studied.

Methods: Between 1997 and 2017, 539 patients underwent surgical treatment for IE. Of these patients, 125 were undergoing hemodialysis for end-stage renal disease (ESRD), and 414 had no history of CRF. Primary end points compared in this study were short-term survival and long-term survival.

Results: Preoperatively, dialysis-treated patients had higher incidences of diabetes (43% vs 18%), hypertension (79% vs 49%), congestive heart failure (63% vs 48%), cardiogenic shock (13% vs 5.3), and sepsis (29% vs 18%) (all P < .05). Postoperatively, they experienced higher rates of prolonged mechanical ventilation (54% vs 22%), pneumonia (17% vs 5.6%), sepsis (6.4% vs 1.0%), cardiac arrest (7.2% vs 1.7%), gastrointestinal events (14% vs 5.1%), and operative mortality (14% vs 5.8%) (all P < .05). The 5- and 10-year survival rates were significantly worse in the dialysis-treated group at 29% and 16%, respectively, compared with 72% and 53% in the patients who did not have CRF (P < .001). ESRD was a risk factor for both short-term mortality (odds ratio, 2.0) and long-term mortality (hazard ratio, 2.7). Rates of reoperation in dialysis-treated patients were very low: 5- and 10-year incidences were 0% and 2.0%, respectively.

Conclusions: In patients with ESRD and IE, poor postoperative outcomes emphasized the importance of prevention and raised the question whether indications for surgical treatment in the general population are appropriate for patients who are dialysis dependent. Additionally, low rates of reoperation supported the use of bioprosthetic valves in these patients.
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http://dx.doi.org/10.1016/j.athoracsur.2020.06.023DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7889771PMC
March 2021

Thoracic Endovascular Aortic Repair in the Setting of Compromised Distal Landing Zones.

Ann Thorac Surg 2021 01 6;111(1):237-245. Epub 2020 Jul 6.

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan.

Background: The short-term and intermediate-term outcomes of two distinct approaches to thoracic endovascular aortic repair (TEVAR) for descending aortic aneurysms in patients with compromised distal landing zones are reported.

Methods: Fifty-one patients (38 female, average age 72 ± 9 years) underwent 55 TEVARs (2008 to 2018) for aneurysmal disease. Inclusion criteria consisted of TEVAR in a compromised distal landing zone, defined as follows: diameter 3.5 cm or greater; cross-sectional thrombus 50% or greater; or 25% or greater circumferential mural calcification in the 2 cm supraceliac aorta; or tortuosity index of 1.1 or more over the 10 cm supraceliac aorta. Treatment cohorts were (1) TEVAR alone (n = 29), and (2) TEVAR with adjunct consisting of visceral snorkel graft with distal stent extension (n = 20) or EndoAnchors (Medtronic, Minneapolis, MN [n = 6]).

Results: Perioperative complication rate was 20%. Thirty-day mortality was 5% including one access-site related intraoperative death and one postoperative death from embolic mesenteric ischemia. Median clinical follow-up was 2.2 years. Intermediate-term outcomes include type 1B endoleaks, 35%; 0.5 cm or more per year maximal aortic diameter growth, 9%; reintervention, 15%; and all-cause mortality, 25%. The distal landing zone diameter increased by 0.3 cm per year in the TEVAR alone cohort; however, it decreased by 0.1 cm per year in the adjunct cohort ( P = .04).

Conclusions: Thoracic endovascular aortic repair is a viable alternative for the treatment of thoracoabdominal aortic aneurysms in patients with compromised distal landing zones, although these patients may benefit significantly from the development of branched thoracoabdominal devices. In the interim, the use of TEVAR adjuncts may limit progressive degeneration of the distal landing zone in this patient population.
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http://dx.doi.org/10.1016/j.athoracsur.2020.05.074DOI Listing
January 2021

Managing Malperfusion Syndrome in Acute Type A Aortic Dissection With Previous Cardiac Surgery.

Ann Thorac Surg 2021 01 20;111(1):52-60. Epub 2020 Jun 20.

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan. Electronic address:

Background: Patients with acute type A aortic dissection with a previous cardiac surgery (PCS) and malperfusion syndrome (MPS) are extremely difficult to manage and have poor outcomes.

Methods: From 1996 to 2018, 668 patients underwent emergent open aortic repair or endovascular fenestration/stenting for MPS for an acute type A aortic dissection, including those with PCS (PCS, n = 64) and those without PCS (No-PCS, n = 604). The groups were further divided into PCS+MPS, PCS+No-MPS, No-PCS+MPS, and No-PCS+No-MPS.

Results: Compared with the No-PCS group, the PCS group had significantly more coronary artery disease, acute renal failure, and mesenteric and renal MPS. Forty-two percent of patients with PCS underwent upfront endovascular fenestration/stenting for endovascular-amendable MPS. The in-hospital mortality was significantly higher in patients with PCS+MPS (40%) compared with PCS+No-MPS (5.9%), No-PCS+MPS (30%), and No-PCS+No-MPS (6.7%). Multivariable logistic regression showed cardiogenic shock (odds ratio, 7.3) and MPS (odds ratio, 6.6) were risk factors for in-hospital mortality (P < .001). After recovering from MPS the PCS group (n = 54) had similar rates of postoperative complications, including 30-day mortality (7.4% vs 6.3%, P = .77), compared with the No-PCS group (n = 557). The 5-year survival was significantly lower in the PCS group compared with the No-PCS group (60% vs 72%, P = .004) and was lowest in those with PCS+MPS (46%). PCS was not a significant risk factor for in-hospital (odds ratio, 1.2; P = .63) or late (hazard ratio, 1.3; P = .27) mortality.

Conclusions: Because of severe preoperative comorbidities and the complexity of open aortic repair, in acute type A aortic dissection patients with PCS and MPS, endovascular fenestration and stenting first with delayed redo sternotomy and central aortic repair was a valid approach.
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http://dx.doi.org/10.1016/j.athoracsur.2020.04.132DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736272PMC
January 2021

Root abscess in the setting of infectious endocarditis: Short- and long-term outcomes.

J Thorac Cardiovasc Surg 2020 Apr 13. Epub 2020 Apr 13.

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich.

Objectives: To evaluate the influence of an aortic root abscess on perioperative outcomes and long-term survival in patients with active infectious endocarditis that was treated surgically.

Methods: From 1996 to 2017, 336 consecutive patients were treated with aortic valve or root replacement for infective endocarditis, including patients with (n = 179) or without (n = 157) a root abscess. Data were obtained from the Society of Thoracic Surgeons data warehouse, through chart review, patient surveys, and National Death Index data.

Results: Demographic characteristics were similar between groups except the root abscess group had a significantly lower prevalence of congestive heart failure and higher rates of prosthetic valve endocarditis. The abscess group had significantly more aortic root replacements as well as longer cardiopulmonary bypass and crossclamp times. Operative mortality was 8.4% and 3.8% (P = .11) for the abscess and no abscess groups, respectively. Nevertheless, the root-abscess group had prolonged ventilation and longer intensive care unit stays. Kaplan-Meier survival was similar between root abscess and no abscess groups (10-year survival 41% vs 43%; P = .35). Significant risk factors for all-time mortality included age greater than 70 (hazard ratio [HR], 2.85; 95% confidence interval [CI], 1.55, 5.24), the presence of a root abscess (HR, 1.42; 95% CI, 1.02, 1.96), intravenous drug use (HR, 1.81; 95% CI, 1.13, 2.89), congestive heart failure (HR, 1.72; 95% CI, 1.22, 2.42), renal failure requiring dialysis (HR, 3.26; 95% CI, 2.30, 4.64), liver disease (HR, 3.04; 95% CI, 1.65, 5.60), and postoperative sepsis (HR, 3.00; 95% CI, 1.30, 6.93). The 10-year rate of reoperation was also similar between groups (5.9% vs 7.9%).

Conclusions: Thorough and extensive debridement is critical for successful treatment of active endocarditis with root abscess. Bioprosthetic stented and stentless valves are valid conduits to treat endocarditis with root abscess.
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http://dx.doi.org/10.1016/j.jtcvs.2019.12.140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7554221PMC
April 2020

Higher admission rates and in-hospital mortality for acute type A aortic dissection during Influenza season: a single center experience.

Sci Rep 2020 03 13;10(1):4723. Epub 2020 Mar 13.

Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.

Triggering events for acute aortic dissections are incompletely understood. We sought to investigate whether there is an association between admission for acute type A aortic dissection (ATAAD) to the University of Michigan Medical Center and the reported annual influenza activity by the Michigan Department of Health and Human Services. From 1996-2019 we had 758 patients admitted for ATAAD with 3.1 admissions per month during November-March and 2.5 admissions per month during April-October (p = 0.01). Influenza reporting data by the Michigan Department of Health and Human Services became available in 2009. ATAAD admissions for the period 2009-2019 (n = 455) were 4.8 cases/month during peak influenza months compared to 3.5 cases/month during non-peak influenza months (p = 0.001). ATAAD patients admitted during influenza season had increased in-hospital mortality (11.0% vs. 5.8%, p = 0.024) and increased 30-day mortality (9.7 vs. 5.4%, p = 0.048). The results point to higher admission rates for ATAAD during months with above average influenza rates. Future studies need to investigate whether influenza virus infection affects susceptibility for aortic dissection, and whether this risk can be attenuated with the annual influenza vaccine in this patient population.
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http://dx.doi.org/10.1038/s41598-020-61717-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7070060PMC
March 2020

Surgical explantation of transcatheter aortic bioprostheses: Results and clinical implications.

J Thorac Cardiovasc Surg 2020 Jan 12. Epub 2020 Jan 12.

Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.

Objective: Despite the rapid adoption of transcatheter aortic valve replacement (TAVR) and worldwide interest in its implantation, TAVR valve explantation has not been well described.

Methods: We retrospectively reviewed 1442 consecutive patients who underwent a TAVR procedure between 2011 and 2019, in which TAVR explantation was performed in 15 patients (1.0%). In addition, 2 patients from outside institutions also underwent TAVR explantation at our institution. We reviewed the clinical details of these 17 patients.

Results: The frequency of TAVR explant increased over time from 0 to 1 during the period from 2011 to 2015 to 6 in 2019. The mean age was 73.0 ± 9.3 years. The majority of patients (88.2%) were in New York Heart Association functional class IV heart failure. The Society of Thoracic Surgeons Predicted Risk of Mortality score was significantly higher at the time of explantation than at the time of the original TAVR (3.5% vs 9.9%; P < .001). The indication for explantation included structural valve degeneration (23.5%), severe paravalvular leak (41.2%), TAVR procedure-related complications (23.5%), endocarditis (5.9%), and bridge-to-definitive surgery (5.9%). Neoendothelialization of the TAVR valve into the aortic wall requiring intense aortic endarterectomy was noted in all 5 of the TAVR valves older than 1 year, in which 2 (40%) required unplanned aortic root repair. There were 2 (11.8%) in-hospital mortalities.

Conclusions: Surgical TAVR valve explant is increasing and may become common in the near future. The clinical effects of explanting chronically implanted valves with the potential need for aortic repair is not negligible. These data should be used to more appropriately select TAVR candidates as TAVR practices expand into younger and lower risk patients.
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http://dx.doi.org/10.1016/j.jtcvs.2019.11.139DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7388726PMC
January 2020

Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) reporting standards for type B aortic dissections.

J Vasc Surg 2020 03 27;71(3):723-747. Epub 2020 Jan 27.

Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pa.

This Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) document illustrates and defines the overall nomenclature associated with type B aortic dissection. The contents describe a new classification system for practical use and reporting that includes the aortic arch. Chronicity of aortic dissection is also defined along with nomenclature in patients with prior aortic repair and other aortic pathologic processes, such as intramural hematoma and penetrating atherosclerotic ulcer. Complicated vs uncomplicated dissections are clearly defined with a new high-risk grouping that will undoubtedly grow in reporting and controversy. Follow-up criteria are also discussed with nomenclature for false lumen status in addition to measurement criteria and definitions of aortic remodeling. Overall, the document provides a facile framework of language that will allow more granular discussions and reporting of aortic dissection in the future.
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http://dx.doi.org/10.1016/j.jvs.2019.11.013DOI Listing
March 2020

Society for Vascular Surgery (SVS) and Society of Thoracic Surgeons (STS) Reporting Standards for Type B Aortic Dissections.

Ann Thorac Surg 2020 03 27;109(3):959-981. Epub 2020 Jan 27.

Division of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.

This Society for Vascular Surgery/Society of Thoracic Surgeons (SVS/STS) document illustrates and defines the overall nomenclature associated with type B aortic dissection. The contents describe a new classification system for practical use and reporting that includes the aortic arch. Chronicity of aortic dissection is also defined along with nomenclature in patients with prior aortic repair and other aortic pathologic processes, such as intramural hematoma and penetrating atherosclerotic ulcer. Complicated vs uncomplicated dissections are clearly defined with a new high-risk grouping that will undoubtedly grow in reporting and controversy. Follow-up criteria are also discussed with nomenclature for false lumen status in addition to measurement criteria and definitions of aortic remodeling. Overall, the document provides a facile framework of language that will allow more granular discussions and reporting of aortic dissection in the future.
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http://dx.doi.org/10.1016/j.athoracsur.2019.10.005DOI Listing
March 2020

Cryoablation of Intercostal Nerves Decreased Narcotic Usage After Thoracic or Thoracoabdominal Aortic Aneurysm Repair.

Semin Thorac Cardiovasc Surg 2020 Autumn;32(3):404-412. Epub 2020 Jan 20.

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Michigan. Electronic address:

To improve surgical pain control through cryoablation of intercostal nerves and reduce narcotic usage in patients undergoing open thoracic or thoracoabdominal aortic aneurysm (TAA or TAAA) repair. From 2012 to 2018, 117 patients underwent open repair of TAA or TAAA. Of those patients, 25 (21%) received cryoablation (2016-2018) of their intercostal nerves and 92 (79%) did not (2012-2018). The primary outcome was pain scores and narcotic usage from extubation day 1 to 10 or the day of discharge. The median age (57 years), demographics, and preoperative comorbidities were not significantly different between the 2 groups. The cryoablation group had significantly more incidences of thoracoabdominal incisions (52% vs 28%), urgent operations (32% vs 11%), and longer duration of chest tubes compared to the noncryoablation group (all P < 0.05). T9-T12 intercostal arteries were selectively reimplanted. Left intercostal nerves were cryoablated from T3 to T9 if 2 thoracotomies were used; or 2 intercostal spaces above and below the thoracotomy if 1 thoracotomy was used. There were no significant differences between the noncryoablation and cryoablation groups in postoperative stroke, paraplegia (5%), pneumonia, and in-hospital mortality (0.9%). However, the average usage of narcotics was significantly reduced in the cryoablation group by 28 measured morphine equivalents (equal to four 5 mg Oxycodone)/patient/day in 10 days after extubation, P = 0.005. With cryoablation of intercostal nerves, the postoperative surgical pain was well controlled and narcotic usage was significantly decreased after TAA or TAAA repair. Cryoablation of intercostal nerves was a safe and effective measure for postoperative pain control in TAA or TAAA repair.
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http://dx.doi.org/10.1053/j.semtcvs.2020.01.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369251PMC
October 2020

Management of acute type B aortic dissection with malperfusion via endovascular fenestration/stenting.

J Thorac Cardiovasc Surg 2020 11 30;160(5):1151-1161.e1. Epub 2019 Sep 30.

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich. Electronic address:

Objective: The study objective was to evaluate the management of malperfusion in acute type B aortic dissection with endovascular fenestration/stenting.

Methods: From 1996 to 2018, 182 patients with an acute type B aortic dissection underwent fenestration/stenting for suspected malperfusion based on imaging, clinical manifestations, and laboratory findings. Data were obtained from medical record review and the National Death Index database.

Results: The median age of patients was 55 years. Signs of malperfusion included abdominal pain (61%), lower-extremity weakness (27%), nonpalpable lower-extremity pulses (24%), and abnormal lactate, creatinine, liver enzymes, and creatine kinase levels. Confirmed hemodynamically significant malperfusion affected the spinal cord (2.7%), celiac (24%), superior mesenteric (40%), renal (51%), and iliofemoral (43%) arterial distributions. Of the 182 patients, 99 (54%) underwent aortic fenestration/stenting, 108 (59%) had 1 or multi-branch vessel fenestration/stenting, 5 (2.7%) had concomitant thoracic endovascular aortic repair, 17 (9.3%) had additional thrombolysis or thromboembolectomy, and 48 (26%) received no intervention. After fenestration/stenting, 24 patients (13%) required additional procedures for necrotic bowel or limb and 9 patients (4.9%) had subsequent aortic repair (thoracic endovascular aortic repair, open repair) before discharge. The new-onset paraplegia was 0%. The in-hospital mortality was 7.7% over 20+ years and 0% in the last 8 years. The 5- and 10-year survivals were 72% and 49%, respectively. The significant risk factors for late mortality were age and acute paralysis (hazard ratio, 3.5; both P < .0001). Given death as a competing factor, the 5- and 10-year cumulative incidence of reintervention was 21% and 31% for distal aortic pathology, respectively.

Conclusions: Patients with acute type B aortic dissection with malperfusion can be managed with endovascular fenestration/stenting with excellent short- and long-term outcomes. This approach is particularly helpful to patients with static malperfusion of aortic branch vessels.
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http://dx.doi.org/10.1016/j.jtcvs.2019.09.065DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7103520PMC
November 2020

Management of malperfusion syndrome in acute type A aortic intramural hematoma.

Ann Cardiothorac Surg 2019 Sep;8(5):540-550

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, MI, USA.

Background: We report the outcomes of acute type A aortic intramural hematoma (ATAAIMH) with malperfusion treated with endovascular intervention and delayed open aortic repair.

Methods: Between April 1998 and April 2018, 644 patients were treated at our institution with an acute type A aortic dissection (ATAAD) or ATAAIMH, 82 (13%) had intramural hematomas (IMHs) including 12 (15%) with malperfusion syndrome (MPS) and 70 (85%) without MPS (no MPS). Data was obtained through medical record review, the Society of Thoracic Surgeons data elements, and the National Death Index database.

Results: Both MPS and No MPS groups had similar comorbidities including coronary artery disease, hypertension, diabetes, and peripheral vascular disease; however, those with MPS were sicker on admission with higher rates of acute renal failure (50% . 1%, P<0.0001) and acute paralysis (17% . 0%, P=0.02). Patients with MPS amenable to endovascular reperfusion (n=10) underwent endovascular fenestration/stenting and delayed aortic repair. Those with cerebral or coronary MPS (n=2) and those without MPS (n=70) underwent emergent open aortic repair. Of the ten patients undergoing fenestration/stenting, seven went on to aortic repair, one survived to discharge without aortic repair, one died from aortic rupture on hospital day 34, and one died from organ failure prior to aortic repair. Following endovascular fenestration/stenting or aortic repair, all patients with MPS had higher in-hospital mortality (17% . 0%), P=0.02. Following aortic repair, patients with MPS had more postoperative sepsis and longer postoperative length of stay (all P<0.05). However, both groups had a 0% operative mortality (including in-hospital and 30-day mortality following aortic repair). The 5-year survival of all ATAAIMH patients was 79%. The 2-year survival was significantly better in the No MPS group (94% . 62%, P=0.006).

Conclusions: ATAAIMH with MPS can be effectively managed with upfront endovascular fenestration/stenting followed by delayed aortic repair.
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http://dx.doi.org/10.21037/acs.2019.07.03DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6785498PMC
September 2019

Unilateral is comparable to bilateral antegrade cerebral perfusion in acute type A aortic dissection repair.

J Thorac Cardiovasc Surg 2020 09 5;160(3):617-625.e5. Epub 2019 Sep 5.

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich. Electronic address:

Objective: To compare the short- and long-term outcomes of unilateral and bilateral antegrade cerebral perfusion (uni-ACP and bi-ACP) in acute type A aortic dissection (ATAAD) repair.

Methods: From 2001 to 2017, 307 patients underwent surgical repair of an ATAAD using uni-ACP (n = 140) and bi-ACP (n = 167). Data were collected through the Department of Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database.

Results: The demographics and preoperative comorbidities were similar between the uni-ACP and bi-ACP groups. Both groups had similar rates of procedures for aortic valve/root, ascending aorta, frozen elephant trunk, and other concomitant procedures. Perioperative outcomes were not significantly different between the 2 groups (30-day mortality: uni-ACP 3.4% vs bi-ACP 7.8%, P = .12) except reoperation for bleeding was significantly lower in uni-ACP (5% vs 12%, P = .03). Between the uni-ACP and bi-ACP groups, overall postoperative stroke rate (6% vs 9%, P = .4) and left brain stroke rate (0.7% vs 3.0%, P = .23) were not significantly different. The odds ratio of uni-ACP versus bi-ACP was 0.87 (P = .80) for postoperative stroke and 0.86 (P = .81) for operative mortality. The mid-term survival was better in the uni-ACP group, P = .027 (5-year: 84% vs 76%). The hazard ratio of all-time mortality for uni-ACP versus bi-ACP was 0.74 (95% confidence interval, 0.33-1.65), P = .46.

Conclusions: In ATAAD, both uni-ACP and bi-ACP are equally effective to protect the brain with low postoperative stroke rates and mortality in hemiarch to zone 3 arch replacement. Uni-ACP is recommended for its simplicity and less manipulation of arch branch vessels.
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http://dx.doi.org/10.1016/j.jtcvs.2019.07.108DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7061338PMC
September 2020

Is previous cardiac surgery a risk factor for open repair of acute type A aortic dissection?

J Thorac Cardiovasc Surg 2020 Jul 25;160(1):8-17.e1. Epub 2019 Aug 25.

Department of Cardiac Surgery, Michigan Medicine, Ann Arbor, Mich. Electronic address:

Objective: The study objective was to determine the optimal treatment for patients with acute type A aortic dissection and previous cardiac surgery.

Methods: A total of 545 patients underwent open repair of an acute type A aortic dissection (July 1996 to January 2017), including patients with (n = 50) and without previous cardiac surgery (n = 495). Data were collected through the University of Michigan Cardiac Surgery Data Warehouse, medical record review, and the National Death Index database.

Results: Compared with patients without previous cardiac surgery, patients with previous cardiac surgery were older (62 vs 59 years, P = .24) and had significantly more coronary artery disease (48% vs 14%, P < .001), peripheral arterial disease (24% vs 11%, P = .01), connective tissue disorders (15% vs 4.5%, P = .004), and acute renal failure on presentation (28% vs 15%, P = .02); and significantly more concomitant mitral or tricuspid procedures, longer cardiopulmonary bypass time, and more intraoperative blood transfusions. There were no statistically significant differences in postoperative major complications between previous cardiac surgery and no previous cardiac surgery groups, including stroke, myocardial infarction, new-onset dialysis, and 30-day mortality (8.9% vs 6.3%, P = .55). Multivariable logistic model showed the significant risk factors for operative mortality were cardiogenic shock (odds ratio, 9.6; P < .0001) and male gender (odds ratio, 3.7; P = .006). The 5- and 10-year unadjusted survivals were significantly lower in the previous cardiac surgery group compared with the no previous cardiac surgery group (66% vs 80% and 42% vs 66%, respectively, P = .02). However, previous cardiac surgery itself was not a significant risk factor for operative mortality (odds ratio, 1.6; P = .36) or all-time mortality (hazard ratio, 1.3; P = .33).

Conclusions: Acute type A aortic dissection in patients with previous cardiac surgery can be repaired with favorable operative mortality and long-term survival, and should be treated surgically.
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http://dx.doi.org/10.1016/j.jtcvs.2019.07.093DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7043015PMC
July 2020