Strokes in ascending aortic repairs predictive and protective factors
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Strokes in Ascending Aortic Repairs: Predictive and Protective Factors. Tovy Kamine, BS, Steven R Messé, MD, Elizabeth Leitner, Joseph Bavaria, MD, Michael McGarvey, MD. Departments of Neurology and Cardiovascular Surgery, University of Pennsylvania Health System. Introduction.

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Strokes in ascending aortic repairs predictive and protective factors l.jpg

Strokes in Ascending Aortic Repairs: Predictive and Protective Factors

Tovy Kamine, BS, Steven R Messé, MD, Elizabeth Leitner, Joseph Bavaria, MD, Michael McGarvey, MD

Departments of Neurology and Cardiovascular Surgery, University of Pennsylvania Health System


Introduction l.jpg
Introduction Protective Factors

  • Strokes occur in ~3.8% of aortic arch operations at HUP1

  • Aortic atherosclerosis is a known risk factor for stroke after CABG3

  • It is unknown whether aortic atherosclerosis will increase stroke risk in arch operations

1Appoo, J., et al., Perioperative Outcome in Adults Undergoing Elective Deep Hypothermic Circulatory Arrest With Retrograde Cerebral Perfusion in Proximal Aortic Arch Repair: Evaluation of Protocol-Based Care. J. Cardiothoracic Vascular Anes. 2006; 20:3-7

2McGarvey, M., et al., Management of Neurologic Complications of Thoracic Aortic Surgery. J. Clinical Neurophysiology. 2007; 24:336-343

3van der Linden, J., L Hadjinikolaou, P Bergman, D. Lindblom., Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerosis in the ascending aorta. J. Am. Coll. Cardiology. 2001; 38:131-5


Objectives l.jpg
Objectives Protective Factors

  • To characterize patient and perioperative factors associated with stroke and mortality in ascending aortic repairs

    • To test whether aortic atheroma is independently predictive of stroke risk


Methods l.jpg
Methods Protective Factors

  • Retrospective analysis of 701 consecutive patients undergoing ascending repair under Deep Hypothermic Circulatory Arrest (DHCA)

  • Inclusion criteria: all ascending aortic operations at HUP and Penn-Presbyterian medical center, including emergent cases.

  • Exclusion criteria: operations with concurrent repair of the descending aorta; hybrid procedures

  • Two Primary Endpoints: Intra-operative stroke and in-hospital mortality

  • Factors with p≤0.1 in univariate analysis were included in multivariate analysis.


Patient population l.jpg
Patient Population Protective Factors


Operative characteristics l.jpg
Operative Characteristics Protective Factors


Results univariate l.jpg
Results- Protective FactorsUnivariate

  • Stroke Rate: 5.9%

  • In-hospital Mortality Rate: 7.3%


Results univariate8 l.jpg
Results - Protective FactorsUnivariate

Intraoperative Stroke

In-Hospital Mortality

Univariate results with a p<0.1 included in mutlivariate analysis.


Results multivariate analysis stroke l.jpg
Results-Multivariate Analysis Protective FactorsStroke


Results multivariate analysis in hospital mortality l.jpg
Results-Multivariate Analysis Protective FactorsIn-Hospital Mortality


Discussion l.jpg
Discussion Protective Factors

  • Stroke risk is increased by high grade descending atheroma and concurrent CABG.

  • The protective effect of preexisting atrial fibrillation may be due to preoperative prophylaxis

  • Mortality is increased by stroke, high grade atheroma, descending dissection. Concurrent CABG has a protective effect on mortality.


Conclusions l.jpg
Conclusions Protective Factors

  • TEE Grading of atheroma is a useful adjunct to determining the risk of aortic surgery, since high grade descending atheroma is a marker of a “toxic aorta,” increasing the risk of both stroke and mortality.

  • CABG should be attempted cautiously with ascending aortic repair as it significantly increases the risk of intraoperative stroke, however, decreases the risk of mortality.


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