Outcomes of circulatory arrest procedures for the treatment of thoracic aortic disease at a veterans facility

Background

The outcomes of thoracic aortic surgery involving hypothermic circulatory arrest at a US Department of Veterans Affairs medical center were evaluated.

Methods

Using the Veterans Affairs Continuous Improvement in Cardiac Surgery Program, all thoracic aortic operations performed with hypothermic circulatory arrest between December 1999 and December 2009 were identified (n = 24). Operative mortality and morbidity were evaluated, and survival was assessed by using the Kaplan-Meier method.

Results

Aortic dissection was the underlying disease in 10 patients (42%). Full or hemiarch aortic repair was performed in 16 patients (67%); of these operations, 3 (13%) involved elephant trunk repair. There was 1 operative death (4%). Four patients (17%) had strokes (all but 1 fully recovered), and 1 (4%) had renal failure. The survival rate was 90% at 1 year and 67% at 3 years.

Conclusions

Despite the magnitude and risk of thoracic aortic surgery involving hypothermic circulatory arrest, good outcomes can be achieved when such surgery is performed at an experienced Veterans Affairs center.     

Diastolic ventricular support with cardiac support devices: an alternative approach to prevent adverse ventricular remodeling

Heart failure is a global epidemic with limited therapy. Abnormal left ventricular wall stress in the diseased myocardium results in a biochemical positive feedback loop that results in global ventricular remodeling and further deterioration of myocardial function. Mechanical myocardial restraints such as the Acorn CorCap and Paracor HeartNet ventricular restraints have attempted to minimize diastolic ventricular wall stress and limit adverse ventricular remodeling. Unfortunately, these therapies have not yielded viable clinical therapies for heart failure. Cellular and novel biopolymer-based therapies aimed at stabilizing pathologic myocardium hold promise for translation to clinical therapy in the future.     

Multiorgan procurement is associated with a survival benefit after heart transplantation

We assessed the impact of donor multiorgan procurement on survival following orthotopic heart transplantation (OHT). From the UNOS STAR database, we included all adult (≥18 Y) heart transplants (OHT) performed since 2000 and used donor IDs to determine how many other organs were procured from the same donor as the recipient's heart allograft (regardless of recipient). The Kaplan-Meier survival functions and risk-adjusted Cox proportional hazards regression models were computed to assess the association of multiorgan procurement with post–heart transplantation mortality. We included 40 336 OHT patients. Including the heart, the median number of donor organs procured was 3 (IQR, 3-4). Heart donors underwent liver procurement in 89.7%; kidney(s) in 98.1% (single 95%, bilateral 5%); lung(s) in 38.0% (single 28%, bilateral 72%); pancreas in 10.4%; and intestine in 1.6%. Following risk adjustment across 16 recipient- and donor-specific variables, an increasing number of organs procured were independently associated with reduced post-OHT mortality (HR 0.98, 95% CI 0.96-0.99, P = .025). Though no significant associations were found examining specific organ types, double lung procurement trended toward a protective effect (HR 0.96, 0.92-1.01, P = .086), with counts of non-lung organs procured still bordering on significance (HR 0.97, 95% CI 0.95-1.00, P = .067). These results likely reflect improved multiorgan donor quality.