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695 Protocol for Antegrade Cerebral Perfusion Reduces Mortality
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The primary complication of rFVIIa is thromboembolism–an important concern for VAD patients. We present our centre’s experience with rFVIIa in patients receiving VAD therapy. METHODS: Between June 2009 and June 2011, 9 of 24 VAD patients required rFVIIa to control refractory hemorrhage. Retrospective chart review and statistical analyses were conducted within and between these two groups. RESULTS: Average patient ages were 50 ⫹/⫺ 14.2 years (rFVIIa group) and 47.8 ⫹/⫺ 11.9 years (control group; p ⫽ 0.22). Cardiopulmonary bypass (CPB) time and operative (OR) times were greater in the rFVIIa group (CPB 190.3 ⫾ 81.2 min, p⫽0.007; OR 407.4 ⫾ 140.3, p⫽0.005), compared to the control group patients (CPB 123.3 ⫾ 46.3 min; OR 280.6 ⫾ 61.6 min). Packed red blood cell (pRBC) requirements were greater in the rFVIIa group (11.2 ⫾ 6.6 units; control: 2.6 ⫾ 4.9 units, p ⬍0.001), and were reduced following rFVIIa administration (2.9 ⫾ 2.1 units, p⫽0.003). Both platelet and fresh frozen plasma (FFP) requirements were reduced following administration of rFVIIa (platelets: 2.2 ⫾ 1.0 units, 0.9 ⫾ 0.8 units, p⫽0.02; FFP: 9.6 ⫾ 6.5 units, 2.4 ⫾ 1.9 units, p⫽0.001). There were no significant differences in blood product requirements between the rFVIIa group and control group in the 24 hours postoperatively (or post-rFVIIa administration). Following rFVIIa delivery, patients’ international normalized ratios (INR) were reduced (1.43 ⫾ 0.29, to 0.77 ⫾ 0.11, p⫽0.003), and were lower than those in the control group (1.4 ⫾ 0.2; p ⫽ 0.002). Platelet and partial thromboplastin times remained unchanged between measures, within both groups. No complication but mediastinal reexploration (rFVIIa: 56%; control: 10%, p⫽0.01), varied significantly between groups; neither length of hospital stay nor patient survival were significantly different between groups. CONCLUSION: In our experience, rFVIIa has safely achieved hemostasis in patients with VADs at dosages ⬎40 ìg/kg. To our knowledge no highly powered studies have yet been conducted, and represent meaningful future directions for this area of research.
694 REGIONAL CARDIAC RHYTHM PROGRAM: A NEW APPROACH TO DEVICE IMPLANTATION M Downey, S Karim, J Bonet, J Reimer-Kent, S Lochan New Westminster, British Columbia BACKGROUND: The Fraser Health Cardiac Service program is accountable for the delivery of cardiac care to the 1.67 million people we serve. The implantation of 1400 cardiac electrical devices was fragmented in its approach and not aligned with the cardiac services strategic direction and plan. The increase in demand for service was placing pressure on the system. Wait times were above benchmarks both for inpatients and outpatients. With wait times greater than 48 hours 61% of the time, and greater than six weeks 78% of the time for inpatient and outpatient pacemaker implantations respectively. Additionally, the ICD and CRTs did not have dedicated procedure or operating room time resulting in delayed access.
Canadian Journal of Cardiology Volume 28 2012
The implantable cardiac electrical device (ICED) project was initiated to design and implement a program that would meet both current and future demand for service. The ICED project used research-based evidence to support the development of an integrated regional model and action plans to develop a system of service delivery in a more coordinated manner. The use of consolidation, integration, and standardization concepts were applied to provide optimization including: improved quality of care and safety, enhanced access to services, improved clinical and administrative information, enhanced reporting capabilities, and a sustainable, efficient and cost-effective system. Methods include; a literature review, current state analysis, one on one interviews with subject matter experts, cross country survey of current practices, and stakeholder engagement on working groups and project teams. RESULTS: Research and background findings identified the opportunity to move from a four site model to one enhanced regional structure, consolidating all pacemaker implants at two regional sites and ICD and CRT at a single site, and standardize practices. CONCLUSION: The design and implementation of a regional service delivery model for a cardiac rhythm program to meet the demand of the 30 communities serviced by Fraser Health occurred over an 18 month period. Model includes: METHODS:
1. Consistent implanter clinical competency and coverage, and service quality. 2. Optimizes the skill of the implant team by triaging patients for cases that may be performed without the use of an anesthetist. 3. Regionalization and standardization of pre and post implant patient care and order sets. 4. Decreased inpatient wait-times for implant procedures and improve access to scheduled outpatient implant services.
695 PROTOCOL FOR ANTEGRADE CEREBRAL PERFUSION REDUCES MORTALITY K Sharma Sacramento, California BACKGROUND: Antegrade cerebral perfusion (ACP) during circulatory arrest procedures is managed variably. We developed goal directed approach to delivering ACP. We wanted to establish whether ACP reduced stroke and mortality. METHODS: 87 patients underwent procedures that required circulatory arrest by 6 different surgeons. One surgeon performed 51 of these cases and employed ACP. ACP was delivered through the right axillary artery at 22-24°C. The right radial arterial pressure was maintained at 50-60 by varying ACP flow. The left carotid artery was clamped when cerebral oximetry dropped on the left side. 33% of these ACP patients underwent total arch reconstruction. RESULTS: Operative mortality was 5.4% and the incidence of permanent stroke was 3.2%. There were no operative mortalities in the ACP group vs 13.5% in the non-ACP group (p⬍0.05). There were no permanent strokes in the ACP group vs 8% in the
S365
Abstracts
non-ACP group (p⫽0.08). Note that the mean circulatory arrest time was significantly greater in the ACP group (44 ⫾ 28.0 min ACP vs 29 ⫾ 18.0 min non-ACP; p⬍0.05). CONCLUSION: A goal directed ACP protocol resulted in significantly less operative mortality in circulatory arrest cases. ACP also trended toward reducing the incidence of permanent stroke.
696 OUTCOMES OF TRAUMATIC AORTIC INJURY PATIENTS ACCORDING TO CT GRADE OF INJURY J Forcillo, M Philie, A Ojanguren, S LeGuillan, A Verdant, P Demers, Y Lamarche Montréal, Québec BACKGROUND: Blunt aortic injury (BAI) occurs in less than 1%
of motor vehicle crashes but is responsible for 16% of deaths. Computed tomography (CT) is the test of choice to diagnose blunt aortic injury. There are multiple classifications in order to diagnose and manage aortic injury. The Vancouver classification is a new simplified computed tomography with angiography (CTA) -based Blunt Aortic Injury (BAI) grading system linked to clinical outcomes. The objectives of this study are to 1) describe the severity of aortic trauma according to new grading system in a single center, 2) correlate the severity of aortic trauma to the hospital survival and to the adverse events during hospital length of stay 3) to verify the inter-observer agreement for the CT scan interpretation of severity of injury. METHODS: All patients presenting to the Hôpital Sacré-Coeur de Montréal, a level 1 trauma Center from August 1998 to April 2011 for management of BAI were identified by searching the hospital trauma database. Two radiologists reviewed all the single and multi detector CT scans imaging individually and classified the aortic injuries using the Vancouver classification. RESULTS: Out of 112 patients total with BAI, 2 radiologists rated 39 CT-scans according to the Vancouver Classification of aortic injury. From the 39 cases, 7 grade I (Flap or thrombus of less than 1cm) (18%), 6 grade II (flap or thrombus more than 1cm) (15%) and 26 grade III (pseudoaneurysm) (67%) were identified. No aortic rupture with contrast extravasation (grade IV) was identified in this series. For patients with grade I injury, 57% of patients was treated surgically and 43% treated medically for a survival of 100%. For patients with grade II injury, 67% of patients had surgery and one third had medical treatment for a survival of 100%. For grade III injuries, 85% of patients had surgery, 7% were treated with EVAR and 8% were treated medically. Survival in these patient groups were 95%, 95% and 50% respectively. There were no significant differences according to grade of injury between groups for the ICU, intubation and hospitalization length of stay neither for major adverse events during the hospitalization. The inter-rater reliability was calculated as 0.81. CONCLUSION: Surgical management of patients with blunt aortic injury, especially with pseudoaneurysm is safe and resulted in good clinical outcomes. Medical treatment of patients with grade 1 and 2 was safe. Inter-rater reliability using the Vancouver classification scoring system was excellent.
697 CEREBRAL PROTECTION AND LONG-TERM OUTCOMES IN AORTIC ARCH SURGERY J Higgins, C Co, MT Janusz Vancouver, British Columbia BACKGROUND: Hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and retrograde cerebral perfusion (RCP) are three well-described techniques for cerebral protection in aortic arch surgery. However, the associated peri-operative outcomes in the currently published are conflicting. Furthermore, long-term survival remains largely unexplored in this population. Therefore, the objective of this study is to review the populationbased experience in British Columbia with three techniques of cerebral protection in aortic arch surgery, with an emphasis on long-term survival. METHODS: The prospectively maintained provincial cardiac surgery database was retrospectively interrogated. All patients undergoing aortic arch surgery requiring HCA, ACP⫹/⫺ HCA, or RCP⫹/⫺HCA between 1993-2010 were identified and baseline characteristics were summarized for the three groups of patients. The in-hospital rate of stroke, 30-day mortality, and successful discharge home were compared across the three cerebral protection groups using the Chi-squared test. Kaplan-Meier analysis was performed to determine long-term survival at 17 years, and results were compared across the three groups using the Log Rank test. RESULTS: From 1993-2010, 599 patients underwent aortic arch surgery at 4 hospitals in British Columbia. The mean age was 63 years and the majority of patients (63%) were male. Twenty-two percent of patients received HCA alone, 62% of patients received ACP⫹/⫺HCA, and 16% of patients received RCP⫹/⫺HCA. Baseline characteristics were similar across the three groups, except patients receiving ACP were less likely to have undergone emergent surgery and were more likely to have received surgery after 2001. Peri-operative outcomes and survival rates are listed in the Table. CONCLUSIONS: Antegrade and retrograde cerebral perfusion are associated with improved in-hospital outcomes and midterm survival, compared to hypothermic circulatory arrest alone following aortic arch surgery. However, long-term survival is superior among patients receiving antegrade cerebral perfusion, compared to the other two modes of cerebral protection.
The primary complication of rFVIIa is thromboembolism–an important concern for VAD patients. We present our centre’s experience with rFVIIa in patients receiving VAD therapy. METHODS: Between June 2009 and June 2011, 9 of 24 VAD patients required rFVIIa to control refractory hemorrhage. Retrospective chart review and statistical analyses were conducted within and between these two groups. RESULTS: Average patient ages were 50 ⫹/⫺ 14.2 years (rFVIIa group) and 47.8 ⫹/⫺ 11.9 years (control group; p ⫽ 0.22). Cardiopulmonary bypass (CPB) time and operative (OR) times were greater in the rFVIIa group (CPB 190.3 ⫾ 81.2 min, p⫽0.007; OR 407.4 ⫾ 140.3, p⫽0.005), compared to the control group patients (CPB 123.3 ⫾ 46.3 min; OR 280.6 ⫾ 61.6 min). Packed red blood cell (pRBC) requirements were greater in the rFVIIa group (11.2 ⫾ 6.6 units; control: 2.6 ⫾ 4.9 units, p ⬍0.001), and were reduced following rFVIIa administration (2.9 ⫾ 2.1 units, p⫽0.003). Both platelet and fresh frozen plasma (FFP) requirements were reduced following administration of rFVIIa (platelets: 2.2 ⫾ 1.0 units, 0.9 ⫾ 0.8 units, p⫽0.02; FFP: 9.6 ⫾ 6.5 units, 2.4 ⫾ 1.9 units, p⫽0.001). There were no significant differences in blood product requirements between the rFVIIa group and control group in the 24 hours postoperatively (or post-rFVIIa administration). Following rFVIIa delivery, patients’ international normalized ratios (INR) were reduced (1.43 ⫾ 0.29, to 0.77 ⫾ 0.11, p⫽0.003), and were lower than those in the control group (1.4 ⫾ 0.2; p ⫽ 0.002). Platelet and partial thromboplastin times remained unchanged between measures, within both groups. No complication but mediastinal reexploration (rFVIIa: 56%; control: 10%, p⫽0.01), varied significantly between groups; neither length of hospital stay nor patient survival were significantly different between groups. CONCLUSION: In our experience, rFVIIa has safely achieved hemostasis in patients with VADs at dosages ⬎40 ìg/kg. To our knowledge no highly powered studies have yet been conducted, and represent meaningful future directions for this area of research.
694 REGIONAL CARDIAC RHYTHM PROGRAM: A NEW APPROACH TO DEVICE IMPLANTATION M Downey, S Karim, J Bonet, J Reimer-Kent, S Lochan New Westminster, British Columbia BACKGROUND: The Fraser Health Cardiac Service program is accountable for the delivery of cardiac care to the 1.67 million people we serve. The implantation of 1400 cardiac electrical devices was fragmented in its approach and not aligned with the cardiac services strategic direction and plan. The increase in demand for service was placing pressure on the system. Wait times were above benchmarks both for inpatients and outpatients. With wait times greater than 48 hours 61% of the time, and greater than six weeks 78% of the time for inpatient and outpatient pacemaker implantations respectively. Additionally, the ICD and CRTs did not have dedicated procedure or operating room time resulting in delayed access.
Canadian Journal of Cardiology Volume 28 2012
The implantable cardiac electrical device (ICED) project was initiated to design and implement a program that would meet both current and future demand for service. The ICED project used research-based evidence to support the development of an integrated regional model and action plans to develop a system of service delivery in a more coordinated manner. The use of consolidation, integration, and standardization concepts were applied to provide optimization including: improved quality of care and safety, enhanced access to services, improved clinical and administrative information, enhanced reporting capabilities, and a sustainable, efficient and cost-effective system. Methods include; a literature review, current state analysis, one on one interviews with subject matter experts, cross country survey of current practices, and stakeholder engagement on working groups and project teams. RESULTS: Research and background findings identified the opportunity to move from a four site model to one enhanced regional structure, consolidating all pacemaker implants at two regional sites and ICD and CRT at a single site, and standardize practices. CONCLUSION: The design and implementation of a regional service delivery model for a cardiac rhythm program to meet the demand of the 30 communities serviced by Fraser Health occurred over an 18 month period. Model includes: METHODS:
1. Consistent implanter clinical competency and coverage, and service quality. 2. Optimizes the skill of the implant team by triaging patients for cases that may be performed without the use of an anesthetist. 3. Regionalization and standardization of pre and post implant patient care and order sets. 4. Decreased inpatient wait-times for implant procedures and improve access to scheduled outpatient implant services.
695 PROTOCOL FOR ANTEGRADE CEREBRAL PERFUSION REDUCES MORTALITY K Sharma Sacramento, California BACKGROUND: Antegrade cerebral perfusion (ACP) during circulatory arrest procedures is managed variably. We developed goal directed approach to delivering ACP. We wanted to establish whether ACP reduced stroke and mortality. METHODS: 87 patients underwent procedures that required circulatory arrest by 6 different surgeons. One surgeon performed 51 of these cases and employed ACP. ACP was delivered through the right axillary artery at 22-24°C. The right radial arterial pressure was maintained at 50-60 by varying ACP flow. The left carotid artery was clamped when cerebral oximetry dropped on the left side. 33% of these ACP patients underwent total arch reconstruction. RESULTS: Operative mortality was 5.4% and the incidence of permanent stroke was 3.2%. There were no operative mortalities in the ACP group vs 13.5% in the non-ACP group (p⬍0.05). There were no permanent strokes in the ACP group vs 8% in the
S365
Abstracts
non-ACP group (p⫽0.08). Note that the mean circulatory arrest time was significantly greater in the ACP group (44 ⫾ 28.0 min ACP vs 29 ⫾ 18.0 min non-ACP; p⬍0.05). CONCLUSION: A goal directed ACP protocol resulted in significantly less operative mortality in circulatory arrest cases. ACP also trended toward reducing the incidence of permanent stroke.
696 OUTCOMES OF TRAUMATIC AORTIC INJURY PATIENTS ACCORDING TO CT GRADE OF INJURY J Forcillo, M Philie, A Ojanguren, S LeGuillan, A Verdant, P Demers, Y Lamarche Montréal, Québec BACKGROUND: Blunt aortic injury (BAI) occurs in less than 1%
of motor vehicle crashes but is responsible for 16% of deaths. Computed tomography (CT) is the test of choice to diagnose blunt aortic injury. There are multiple classifications in order to diagnose and manage aortic injury. The Vancouver classification is a new simplified computed tomography with angiography (CTA) -based Blunt Aortic Injury (BAI) grading system linked to clinical outcomes. The objectives of this study are to 1) describe the severity of aortic trauma according to new grading system in a single center, 2) correlate the severity of aortic trauma to the hospital survival and to the adverse events during hospital length of stay 3) to verify the inter-observer agreement for the CT scan interpretation of severity of injury. METHODS: All patients presenting to the Hôpital Sacré-Coeur de Montréal, a level 1 trauma Center from August 1998 to April 2011 for management of BAI were identified by searching the hospital trauma database. Two radiologists reviewed all the single and multi detector CT scans imaging individually and classified the aortic injuries using the Vancouver classification. RESULTS: Out of 112 patients total with BAI, 2 radiologists rated 39 CT-scans according to the Vancouver Classification of aortic injury. From the 39 cases, 7 grade I (Flap or thrombus of less than 1cm) (18%), 6 grade II (flap or thrombus more than 1cm) (15%) and 26 grade III (pseudoaneurysm) (67%) were identified. No aortic rupture with contrast extravasation (grade IV) was identified in this series. For patients with grade I injury, 57% of patients was treated surgically and 43% treated medically for a survival of 100%. For patients with grade II injury, 67% of patients had surgery and one third had medical treatment for a survival of 100%. For grade III injuries, 85% of patients had surgery, 7% were treated with EVAR and 8% were treated medically. Survival in these patient groups were 95%, 95% and 50% respectively. There were no significant differences according to grade of injury between groups for the ICU, intubation and hospitalization length of stay neither for major adverse events during the hospitalization. The inter-rater reliability was calculated as 0.81. CONCLUSION: Surgical management of patients with blunt aortic injury, especially with pseudoaneurysm is safe and resulted in good clinical outcomes. Medical treatment of patients with grade 1 and 2 was safe. Inter-rater reliability using the Vancouver classification scoring system was excellent.
697 CEREBRAL PROTECTION AND LONG-TERM OUTCOMES IN AORTIC ARCH SURGERY J Higgins, C Co, MT Janusz Vancouver, British Columbia BACKGROUND: Hypothermic circulatory arrest (HCA), antegrade cerebral perfusion (ACP), and retrograde cerebral perfusion (RCP) are three well-described techniques for cerebral protection in aortic arch surgery. However, the associated peri-operative outcomes in the currently published are conflicting. Furthermore, long-term survival remains largely unexplored in this population. Therefore, the objective of this study is to review the populationbased experience in British Columbia with three techniques of cerebral protection in aortic arch surgery, with an emphasis on long-term survival. METHODS: The prospectively maintained provincial cardiac surgery database was retrospectively interrogated. All patients undergoing aortic arch surgery requiring HCA, ACP⫹/⫺ HCA, or RCP⫹/⫺HCA between 1993-2010 were identified and baseline characteristics were summarized for the three groups of patients. The in-hospital rate of stroke, 30-day mortality, and successful discharge home were compared across the three cerebral protection groups using the Chi-squared test. Kaplan-Meier analysis was performed to determine long-term survival at 17 years, and results were compared across the three groups using the Log Rank test. RESULTS: From 1993-2010, 599 patients underwent aortic arch surgery at 4 hospitals in British Columbia. The mean age was 63 years and the majority of patients (63%) were male. Twenty-two percent of patients received HCA alone, 62% of patients received ACP⫹/⫺HCA, and 16% of patients received RCP⫹/⫺HCA. Baseline characteristics were similar across the three groups, except patients receiving ACP were less likely to have undergone emergent surgery and were more likely to have received surgery after 2001. Peri-operative outcomes and survival rates are listed in the Table. CONCLUSIONS: Antegrade and retrograde cerebral perfusion are associated with improved in-hospital outcomes and midterm survival, compared to hypothermic circulatory arrest alone following aortic arch surgery. However, long-term survival is superior among patients receiving antegrade cerebral perfusion, compared to the other two modes of cerebral protection.