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ASCENDING AORTIC ELONGATION IS A PREDICTOR OF AORTIC DISSECTION
Abstracts CONCLUSIONS:
Overall, participants were much frailer than expected, with over half being considered vulnerable or worse on the FACT scale. This signifies an increase in frailty in the elderly population, which supplies rationale for the current study. This study will analyze a larger sample of elderly cardiac surgery patients in the Atlantic provinces to more thoroughly investigate this relationship. IMPLICATIONS: This study will assist in educating future heart surgery patients about their possible risks. It is hoped that patients who possess more knowledge about their personal risks will be able to make more informed decisions about their surgery. Strategies to address and reduce frailty by increasing mobility and cognitive function and reducing nutritional deficiencies could use this information to inform future work. Canadian Frailty Network
084 SEVERE COAGULOPATHY AFTER CARDIAC SURGERY: IS FEIBA A VIABLE THERAPY? T Murphy, R Forgie, J MacLeod, C Brown, A Hassan, M Pelletier
S113
complex presentation. Group 2 patients were less likely to require emergent or complex procedures, with 47% requiring isolated CABG or valve surgery. Their bypass and cross clamp times were shorter, and bleeding was only problematic after arriving to the ICU. For most, postoperative chest tube hourly output decreased significantly after FEIBA (363 314 ml/hr before FEIBA, 69 61 ml/hr after FEIBA). While 14.2% required re-exploration, CNS and myocardial injuries were low (1.5% and 0%). Mortality was high in both groups, reflecting the complex nature of their diagnoses and procedures. CONCLUSION: This is the largest reported series of FEIBA administration for the treatment of diffuse coagulopathy in cardiac surgery. While deemed clinically effective in controlling perioperative bleeding, high complication rates were observed. Definitive safety and efficacy standards will need to be established through a randomized controlled trial. Table 1 – Characteristics and RESULTS of patients receiving FEIBA Intraop FEIBA Postop FEIBA P Value Group 1 (n=120) Group 2 (n=133) Age
65.7 ± 13.3
66.3 ± 11.6
NS
Male gender
78 (65%)
105 (79%)
NS
Elective procedure
60 (50%)
67 (50%)
NS
Urgent procedure
31 (26%)
57 (43%)
NS
Saint John, New Brunswick
Emergent procedure 29 (24%)
9 (6.7%)
<0.001
Isolated CABG
6 (5%)
44 (33%)
<0.001
BACKGROUND:
Isolated Valve
12 (10%)
FEIBA (Factor VIII Inhibitor Bypassing Activity) is a potentially important therapy for patients with uncontrollable bleeding after cardiac surgery. The objective of this study was to evaluate the safety and efficacy of FEIBA for the treatment of persistent coagulopathy following cardiac surgery. METHODS: From Jan 2008 to June 2015, patients who underwent cardiac surgery and also received either intraoperative or postoperative FEIBA were identified utilizing an institutional database of prospectively gathered data. All patients received tranexamic acid while on cardiopulmonary bypass, followed by protamine administration once weaned from bypass. All patients initially received fresh frozen plasma and platelets for persistent coagulopathy. If bleeding persisted beyond this, FEIBA was used as adjuvant therapy. The intraoperative characteristics and postoperative results of those patients were extracted and analyzed. RESULTS: During the study period, 5551 patients had cardiac surgery, of which 276 (5.0%) received FEIBA for refractory bleeding. Most received FEIBA either intraoperatively (Group 1, n¼120) or postoperatively (Group 2, n¼133), while some received both intra- and postoperative doses (n¼23). All patients received FEIBA only after failure of conventional therapy. Patient characteristics and results are found in Table 1. Group 1 patients were more likely to require an emergent procedure (p<0.001) and 85% underwent complex or combination procedures (p<0.001). Cardiopulmonary bypass and cross clamp times were longer (p<0.001) in Group 1. FEIBA was effective in expediting hemostasis and chest closure. These patients had a low reoperation rate (1.7%) but a high rate of significant complications, including neurological injury and renal failure, partly indicative of their
19 (14%)
NS
Complex procedure 102 (85%)
70 (53%)
<0.001
CPB time (min)
203 ± 83
131 ± 56
<0.001
Cross clamp (min)
144 ± 67
99 ± 46
<0.001
Reoperation
2 (1.7%)
19 (14.2%)
<0.001
CNS injury
10 (8.3%)
2 (1.5%)
0.01
Renal Failure
31 (25.8%)
19 (14.3%)
0.02
Perioperative MI
2 (1.7%)
0
NS
Mortality
13 (10.8%)
9 (6.8%)
NS
085 ASCENDING AORTIC ELONGATION IS A PREDICTOR OF AORTIC DISSECTION A Alsagheir, N Munce, M Patlas, F Farrokhyar, D Parry Hamilton, Ontario INTRODUCTION:
Acute aortic dissection is a life-threatening medical emergency associated with a high rate of morbidity and mortality. Data are limited regarding predicting patients who are at risk of dissection. Aortic diameter is the only parameter that has been extensively studied, and numerous surgical intervention recommendations are based on that. However, the International Registry of Acute Aortic Dissections (IRAD) has demonstrated that diameter is not necessarily a good predictor of aortic dissection. Other parameters, including aortic elongation, curvature, etc., have not been studied and may play a major role in predicting aortic dissection. The aim of this retrospective study is to evaluate those parameters. METHODS: IRB approval was obtained. From January 2008 to January 2016, 51 patients (35 men and 16 women, aged 21 to 87 years) presented with type A aortic dissection. CTA
S114
Canadian Journal of Cardiology Volume 32 2016 RESULTS:
parameters including length of the ascending aorta (AA), maximal AA diameter, diameter of the AA at the ostium, the left ventricular outflow tract angle (the angle between a straight line drawn perpendicular to the plane of the aortic valve and a second line representing the transverse body axis) and the cardiac apex angle were measured (the angle between a straight line drawn from left ventricular apex to the mid point of the aortic valve and a second line representing the transverse body axis). Statistical comparison of age and gender with a matched control group were made with Student’s ttest. RESULTS: The mean length of the ascending aorta in the type A dissection population versus the control group was 12.00 vs 9.27 cm (p < .0001). The maximal aortic diameter mean was 4.97 vs 3.15 cm (p < .0001); similarly, the diameter at the ostium was 4.35 vs 2.89 cm (p < .001). The LVOT angle was statistically significantly less in the type A dissection group, measuring 31.70 vs 44.13 degrees (p < .0001). Similarly, the apex angle was also significantly less in the population with type A dissection, measuring 20.44 vs 30.34 degrees (p < .0001). CONCLUSION: Our study shows, for the first time to our knowledge, that patients with type A aortic dissection have increased AA length and decreased LVOT and CA angles to the ascending aorta in comparison to the control group. These measurement parameters could be as important as diameter in predicting type A dissection.
At discharge and subsequent follow-up echocardiography, 39 patients (8%) had severe PPM and 203 patients (41%) a moderate mismatch. The mean indexed aortic valvular area was respectively 1.08 0.22cm2, 0.74 0.06 cm2 and 0.54 0.05 cm2 in patients without mismatch, with moderate and with severe mismatch (p<0.001). There was no age difference between the 3 groups. There was no difference in left ventricular function between the 3 groups. The median prostheses size was 23 mm, 23 mm and 21 mm in patients without mismatch, with moderate and with severe mismatch (p¼0.04) The 1- , 5- and 10 years survival rates were 100%, 91.7% and 82% for patients with severe PPM; 96.4%, 92.1% and 84.5% for patients with moderate PPM and 97.5%, 94.4% and 90.8% for patients without PPM (p¼0.08). Mid- and longterm were significantly decreased in patients with moderate or severe PPM compared to no PPM (p¼0.026). The rate of cardiac-related deaths was significantly higher in patients with PPM (p¼0.001). CONCLUSION: Prosthesis-patient mismatch after isolated elective mechanical AVR in young adults is associated with a significant decrease in survival at 5 and 10 years, which is in part, driven by a higher rate of cardiac-related deaths. Moderate and severe PPM are equally associated to worse outcomes. Avoidance of PPM in young adults with mechanical AVR may have significant implications for a long-term prognosis.
086 IMPACT OF PROSTHESIS-PATIENT MISMATCH AFTER MECHANICAL AORTIC VALVE REPLACEMENT ON MIDTERM SURVIVAL IN YOUNG ADULTS
087 ASSESSMENT OF FUNCTIONAL RECOVERY IN PATIENTS FOLLOWING CARDIAC SURGERY
M Morgant, I Bouhout, G Amr, N Poirier, D Bouchard, P Demers, R Cartier, M Pellerin, L Perrault, M Carrier, Y Hebert, Y Lamarche, I El-Hamamsy
Saint John, New Brunswick
Montréal, Québec BACKGROUND:
Long-term survival following mechanical aortic valve replacement (AVR) in young adults (<65 years) is lower than the matched general population. The role of patientprosthesis mismatch (PPM) after mechanical AVR remains uncertain. The aim of this study was to evaluate the impact of PPM on long-term survival after mechanical AVR in young adults. METHODS: From 1997 to 2007, 498 consecutive young adults (<65 years; mean age 539 years) underwent elective isolated mechanical AVR at a single center. Surgical indication was aortic stenosis in 75%, aortic regurgitation in 15% and mixed aortic valve disease in 10%. This is a retrospective analysis of prospectively collected data. Echocardiographic examinations were used to calculate the indexed effective orifice area. Severe PPM was defined as an indexed effective orifice area <0.60 cm2/m2 and as moderate between 0.6 and 0.85cm2/m2. The mean follow-up was 9.6 4.7 years. Long-term survival was expressed using Kaplan-Meier actuarial analyses.
A Hameed, JB MacLeod, AM Yip, C Aguiar, A Adisesh, CD Brown, R Forgie, A Hassan BACKGROUND:
It is often assumed by healthcare providers that a patient’s functional status will improve following a successful cardiac surgical procedure and that patients will resume their regular level of activity within 3 months. However, little is known regarding to what extent their functional status actually improves and over what period of time. The purpose of this study was to survey patients who have undergone cardiac surgery and to assess their post-operative functional recovery. METHODS: All patients under the age of 75 who underwent successful, non-emergent cardiac surgery from July 1, 2014 to June 30, 2015 were identified through the New Brunswick Heart Centre cardiac surgery database. These patients were contacted by telephone and consented to participate in a survey designed to assess their pre- and postoperative functional status. Descriptive statistics were used to describe quantitative data. RESULTS: Of the 448 eligible patients, 158 consented to participate (35.3% response rate). At the time of surgery, the average participant’s age was 64.0 6.6 years, and 23.4% of patients were female. 72.9% of the participants were married, 54.4% were retired, and only 26.6% were employed full-time.
Overall, participants were much frailer than expected, with over half being considered vulnerable or worse on the FACT scale. This signifies an increase in frailty in the elderly population, which supplies rationale for the current study. This study will analyze a larger sample of elderly cardiac surgery patients in the Atlantic provinces to more thoroughly investigate this relationship. IMPLICATIONS: This study will assist in educating future heart surgery patients about their possible risks. It is hoped that patients who possess more knowledge about their personal risks will be able to make more informed decisions about their surgery. Strategies to address and reduce frailty by increasing mobility and cognitive function and reducing nutritional deficiencies could use this information to inform future work. Canadian Frailty Network
084 SEVERE COAGULOPATHY AFTER CARDIAC SURGERY: IS FEIBA A VIABLE THERAPY? T Murphy, R Forgie, J MacLeod, C Brown, A Hassan, M Pelletier
S113
complex presentation. Group 2 patients were less likely to require emergent or complex procedures, with 47% requiring isolated CABG or valve surgery. Their bypass and cross clamp times were shorter, and bleeding was only problematic after arriving to the ICU. For most, postoperative chest tube hourly output decreased significantly after FEIBA (363 314 ml/hr before FEIBA, 69 61 ml/hr after FEIBA). While 14.2% required re-exploration, CNS and myocardial injuries were low (1.5% and 0%). Mortality was high in both groups, reflecting the complex nature of their diagnoses and procedures. CONCLUSION: This is the largest reported series of FEIBA administration for the treatment of diffuse coagulopathy in cardiac surgery. While deemed clinically effective in controlling perioperative bleeding, high complication rates were observed. Definitive safety and efficacy standards will need to be established through a randomized controlled trial. Table 1 – Characteristics and RESULTS of patients receiving FEIBA Intraop FEIBA Postop FEIBA P Value Group 1 (n=120) Group 2 (n=133) Age
65.7 ± 13.3
66.3 ± 11.6
NS
Male gender
78 (65%)
105 (79%)
NS
Elective procedure
60 (50%)
67 (50%)
NS
Urgent procedure
31 (26%)
57 (43%)
NS
Saint John, New Brunswick
Emergent procedure 29 (24%)
9 (6.7%)
<0.001
Isolated CABG
6 (5%)
44 (33%)
<0.001
BACKGROUND:
Isolated Valve
12 (10%)
FEIBA (Factor VIII Inhibitor Bypassing Activity) is a potentially important therapy for patients with uncontrollable bleeding after cardiac surgery. The objective of this study was to evaluate the safety and efficacy of FEIBA for the treatment of persistent coagulopathy following cardiac surgery. METHODS: From Jan 2008 to June 2015, patients who underwent cardiac surgery and also received either intraoperative or postoperative FEIBA were identified utilizing an institutional database of prospectively gathered data. All patients received tranexamic acid while on cardiopulmonary bypass, followed by protamine administration once weaned from bypass. All patients initially received fresh frozen plasma and platelets for persistent coagulopathy. If bleeding persisted beyond this, FEIBA was used as adjuvant therapy. The intraoperative characteristics and postoperative results of those patients were extracted and analyzed. RESULTS: During the study period, 5551 patients had cardiac surgery, of which 276 (5.0%) received FEIBA for refractory bleeding. Most received FEIBA either intraoperatively (Group 1, n¼120) or postoperatively (Group 2, n¼133), while some received both intra- and postoperative doses (n¼23). All patients received FEIBA only after failure of conventional therapy. Patient characteristics and results are found in Table 1. Group 1 patients were more likely to require an emergent procedure (p<0.001) and 85% underwent complex or combination procedures (p<0.001). Cardiopulmonary bypass and cross clamp times were longer (p<0.001) in Group 1. FEIBA was effective in expediting hemostasis and chest closure. These patients had a low reoperation rate (1.7%) but a high rate of significant complications, including neurological injury and renal failure, partly indicative of their
19 (14%)
NS
Complex procedure 102 (85%)
70 (53%)
<0.001
CPB time (min)
203 ± 83
131 ± 56
<0.001
Cross clamp (min)
144 ± 67
99 ± 46
<0.001
Reoperation
2 (1.7%)
19 (14.2%)
<0.001
CNS injury
10 (8.3%)
2 (1.5%)
0.01
Renal Failure
31 (25.8%)
19 (14.3%)
0.02
Perioperative MI
2 (1.7%)
0
NS
Mortality
13 (10.8%)
9 (6.8%)
NS
085 ASCENDING AORTIC ELONGATION IS A PREDICTOR OF AORTIC DISSECTION A Alsagheir, N Munce, M Patlas, F Farrokhyar, D Parry Hamilton, Ontario INTRODUCTION:
Acute aortic dissection is a life-threatening medical emergency associated with a high rate of morbidity and mortality. Data are limited regarding predicting patients who are at risk of dissection. Aortic diameter is the only parameter that has been extensively studied, and numerous surgical intervention recommendations are based on that. However, the International Registry of Acute Aortic Dissections (IRAD) has demonstrated that diameter is not necessarily a good predictor of aortic dissection. Other parameters, including aortic elongation, curvature, etc., have not been studied and may play a major role in predicting aortic dissection. The aim of this retrospective study is to evaluate those parameters. METHODS: IRB approval was obtained. From January 2008 to January 2016, 51 patients (35 men and 16 women, aged 21 to 87 years) presented with type A aortic dissection. CTA
S114
Canadian Journal of Cardiology Volume 32 2016 RESULTS:
parameters including length of the ascending aorta (AA), maximal AA diameter, diameter of the AA at the ostium, the left ventricular outflow tract angle (the angle between a straight line drawn perpendicular to the plane of the aortic valve and a second line representing the transverse body axis) and the cardiac apex angle were measured (the angle between a straight line drawn from left ventricular apex to the mid point of the aortic valve and a second line representing the transverse body axis). Statistical comparison of age and gender with a matched control group were made with Student’s ttest. RESULTS: The mean length of the ascending aorta in the type A dissection population versus the control group was 12.00 vs 9.27 cm (p < .0001). The maximal aortic diameter mean was 4.97 vs 3.15 cm (p < .0001); similarly, the diameter at the ostium was 4.35 vs 2.89 cm (p < .001). The LVOT angle was statistically significantly less in the type A dissection group, measuring 31.70 vs 44.13 degrees (p < .0001). Similarly, the apex angle was also significantly less in the population with type A dissection, measuring 20.44 vs 30.34 degrees (p < .0001). CONCLUSION: Our study shows, for the first time to our knowledge, that patients with type A aortic dissection have increased AA length and decreased LVOT and CA angles to the ascending aorta in comparison to the control group. These measurement parameters could be as important as diameter in predicting type A dissection.
At discharge and subsequent follow-up echocardiography, 39 patients (8%) had severe PPM and 203 patients (41%) a moderate mismatch. The mean indexed aortic valvular area was respectively 1.08 0.22cm2, 0.74 0.06 cm2 and 0.54 0.05 cm2 in patients without mismatch, with moderate and with severe mismatch (p<0.001). There was no age difference between the 3 groups. There was no difference in left ventricular function between the 3 groups. The median prostheses size was 23 mm, 23 mm and 21 mm in patients without mismatch, with moderate and with severe mismatch (p¼0.04) The 1- , 5- and 10 years survival rates were 100%, 91.7% and 82% for patients with severe PPM; 96.4%, 92.1% and 84.5% for patients with moderate PPM and 97.5%, 94.4% and 90.8% for patients without PPM (p¼0.08). Mid- and longterm were significantly decreased in patients with moderate or severe PPM compared to no PPM (p¼0.026). The rate of cardiac-related deaths was significantly higher in patients with PPM (p¼0.001). CONCLUSION: Prosthesis-patient mismatch after isolated elective mechanical AVR in young adults is associated with a significant decrease in survival at 5 and 10 years, which is in part, driven by a higher rate of cardiac-related deaths. Moderate and severe PPM are equally associated to worse outcomes. Avoidance of PPM in young adults with mechanical AVR may have significant implications for a long-term prognosis.
086 IMPACT OF PROSTHESIS-PATIENT MISMATCH AFTER MECHANICAL AORTIC VALVE REPLACEMENT ON MIDTERM SURVIVAL IN YOUNG ADULTS
087 ASSESSMENT OF FUNCTIONAL RECOVERY IN PATIENTS FOLLOWING CARDIAC SURGERY
M Morgant, I Bouhout, G Amr, N Poirier, D Bouchard, P Demers, R Cartier, M Pellerin, L Perrault, M Carrier, Y Hebert, Y Lamarche, I El-Hamamsy
Saint John, New Brunswick
Montréal, Québec BACKGROUND:
Long-term survival following mechanical aortic valve replacement (AVR) in young adults (<65 years) is lower than the matched general population. The role of patientprosthesis mismatch (PPM) after mechanical AVR remains uncertain. The aim of this study was to evaluate the impact of PPM on long-term survival after mechanical AVR in young adults. METHODS: From 1997 to 2007, 498 consecutive young adults (<65 years; mean age 539 years) underwent elective isolated mechanical AVR at a single center. Surgical indication was aortic stenosis in 75%, aortic regurgitation in 15% and mixed aortic valve disease in 10%. This is a retrospective analysis of prospectively collected data. Echocardiographic examinations were used to calculate the indexed effective orifice area. Severe PPM was defined as an indexed effective orifice area <0.60 cm2/m2 and as moderate between 0.6 and 0.85cm2/m2. The mean follow-up was 9.6 4.7 years. Long-term survival was expressed using Kaplan-Meier actuarial analyses.
A Hameed, JB MacLeod, AM Yip, C Aguiar, A Adisesh, CD Brown, R Forgie, A Hassan BACKGROUND:
It is often assumed by healthcare providers that a patient’s functional status will improve following a successful cardiac surgical procedure and that patients will resume their regular level of activity within 3 months. However, little is known regarding to what extent their functional status actually improves and over what period of time. The purpose of this study was to survey patients who have undergone cardiac surgery and to assess their post-operative functional recovery. METHODS: All patients under the age of 75 who underwent successful, non-emergent cardiac surgery from July 1, 2014 to June 30, 2015 were identified through the New Brunswick Heart Centre cardiac surgery database. These patients were contacted by telephone and consented to participate in a survey designed to assess their pre- and postoperative functional status. Descriptive statistics were used to describe quantitative data. RESULTS: Of the 448 eligible patients, 158 consented to participate (35.3% response rate). At the time of surgery, the average participant’s age was 64.0 6.6 years, and 23.4% of patients were female. 72.9% of the participants were married, 54.4% were retired, and only 26.6% were employed full-time.