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Objective: Thoracic endovascular aortic repair, although physiologically well tolerated, may fail to confer significant survival benefit in some high-risk patients. In an effort to identify patients most likely to benefit from intervention, the present study sought to determine the risk factors for 1-year mortality after thoracic endovascular aortic repair., Methods: A retrospective review was performed on prospectively collected data from all patients undergoing thoracic endovascular aortic repair from 2002 to 2010 at a single institution. Univariate analysis and multivariate Cox proportional hazards regression analysis were used to identify risk factors associated with mortality within 1 year after thoracic endovascular aortic repair., Results: During the study period, 282 patients underwent at least 1 thoracic endovascular aortic repair; index procedures included descending aortic repair (n = 189), hybrid arch repair (n = 55), and hybrid thoracoabdominal repair (n = 38). The 30-day/in-hospital mortality was 7.4% (n = 21) and the overall 1-year mortality was 19% (n = 54). Cardiopulmonary pathologies were the most common cause of nonperioperative 1-year mortality (22%, n = 12). Multivariate modeling demonstrated 3 variables independently associated with 1-year mortality: age older than 75 years (hazard ratio, 2.26; P = .005), aortic diameter greater than 6.5 cm (hazard ratio, 2.20; P = .007), and American Society of Anesthesiologists class 4 (hazard ratio, 1.85; P = .049). A baseline creatinine greater than 1.5 mg/dL (hazard ratio, 1.79; P = .05) and congestive heart failure (hazard ratio, 1.87; P = .08) were also retained in the final model. These 5 variables explained a large proportion of the risk of 1-year mortality (C statistic = 0.74)., Conclusions: Age older than 75 years, aortic diameter greater than 6.5 cm, and American Society of Anesthesiologists class 4 are independently associated with 1-year mortality after thoracic endovascular aortic repair. These clinical characteristics may help risk-stratify patients undergoing thoracic endovascular aortic repair and identify those unlikely to derive a long-term survival benefit from the procedure., (Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objective: Cardiac catheterization shortly before coronary artery bypass grafting or valve surgery has been associated with increased postoperative acute kidney injury. The relationship between catheterization timing and acute kidney injury after proximal aortic surgery remains unknown., Methods: Between August 2005 and February 2011, a total of 285 consecutive patients underwent cardiac catheterization before elective proximal aortic surgery with cardiopulmonary bypass at a single institution. The association between timing of catheterization and postoperative acute kidney injury (defined as postoperative increase in serum creatinine ≥ 50% of baseline) was assessed using logistic regression analysis., Results: Of 285 patients, 152 (53%) underwent catheterization on preoperative days 1 to 3 and 133 (47%) underwent catheterization on preoperative day 4 or before. Acute kidney injury occurred in 88 (31%) patients, 3 (1.1%) requiring dialysis. Acute kidney injury occurred in 37 (24%) patients catheterized on preoperative days 1 to 3, and 51 (38%) patients catheterized on preoperative day 4 or before. Catheterization on preoperative days 1 to 3 was not associated with an increased risk of acute kidney injury relative to catheterization on preoperative day 4 or before (unadjusted odds ratio, 0.52; 95% confidence interval, 0.31-0.86; P = .01; adjusted odds ratio, 0.35; 95% confidence interval, 0.17-0.73; P = .005)., Conclusions: Cardiac catheterization within 1 to 3 days of elective proximal aortic surgery appears safe and should be considered acceptable practice for patients at low risk of acute kidney injury., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Background: We prospectively applied the Surgical Treatment of Ischemic Cardiomyopathy trial entry criteria to an observational database to determine whether coronary artery bypass grafting (CABG) decreases mortality compared with medical therapy (MED) for patients with coronary artery disease and depressed left ventricular ejection fraction., Methods: This was a retrospective, observational, cohort study of prospectively collected data from the Duke Databank for Cardiovascular Disease. Long-term mortality was the main outcome measure. Between January 1, 1995, and July 31, 2009, 86,874 patients underwent cardiac catheterization for suspected ischemic heart disease and were evaluated for inclusion in the analysis., Results: A total of 2,624 patients were found to have left ventricular ejection fraction less than 0.35, coronary artery disease amenable to CABG, and no left main stenosis of greater than 50%. After exclusions including ongoing Canadian Cardiovascular Society class III angina and acute myocardial infarction, 763 patients were included for propensity score analysis, including 624 who received MED and 139 who underwent CABG. Adjusted mortality curves were constructed for those patients in the three quintiles most likely to receive CABG. The curves diverged early, with risk-adjusted mortality rates at 5 years of 46% for MED versus 29% for CABG, and the survival benefit of CABG over MED continued through 10 years of follow-up (hazard ratio, 0.63; 95% confidence interval, 0.45 to 0.88)., Conclusions: Among a propensity-matched, risk-adjusted, observational cohort of patients with coronary artery disease, left ventricular ejection fraction less than 0.35, and no left main disease of greater than 50%, CABG is associated with a survival advantage over MED through 10 years of follow-up., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Massive perioperative blood product transfusion may be required with thoracic aortic operations and is associated with poor outcomes. We analyzed independent predictors of massive transfusion in thoracic aortic surgical patients undergoing deep hypothermic circulatory arrest., Methods: The study consisted of 168 consecutive patients undergoing open thoracic aortic procedures involving deep hypothermic circulatory arrest between July 2005 and August 2008. We identified 26 preoperative and procedural variables as potentially related to blood product use, tested for association with total blood products transfused by multivariate linear regression model, and constructed logistic regression model for massive transfusion (requiring ≥ 5 units of transfused packed red blood cells between incision and 48 postoperative hours)., Results: Multivariate linear regression determined that 6 significant variables accounted for 42% of variation in total blood products transfused: age (P = .008), preoperative hemoglobin (P = .04), weight (P = .02), cardiopulmonary bypass time (P < .0001), emergency status (P < .0001), and resternotomy (P < .0001). Final predictive logistic regression model included 1-g/dL increase in preoperative hemoglobin (odds ratio, 0.54; 95% confidence interval, 0.43-0.69; P < .0001), 10-minute increase in cardiopulmonary bypass time (odds ratio, 1.15; 95% confidence interval, 1.05-1.26; P = .0026), and emergency status (odds ratio, 4.02; 95% confidence interval, 1.53-10.55; P = .0047., Conclusions: Cardiopulmonary bypass time, emergency status, and preoperative hemoglobin were independent predictors of massive transfusion. These variables, along with weight, age, and resternotomy, were associated with total blood product use in thoracic aortic operations involving deep hypothermic circulatory arrest., (Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)