Safety and efficacy of retrograde cerebral perfusion as an adjunct for cerebral protection during surgery on the aortic arch

ObjectiveThe best adjunct for cerebral protection during aortic arch reconstruction remains controversial. Retrograde cerebral perfusion (RCP) as an adjunct to profound hypothermic circulatory arrest (PHCA) extends the tolerable period of brain ischemia by flushing emboli and air from the cerebral circulation while maintaining hypothermia. We examined our experience with RCP to determine its efficacy in patients undergoing complex arch reconstruction.MethodsWe retrospectively evaluated 879 patients undergoing arch reconstruction using RCP from July 1997 to March 2013. Perioperative risk factors were analyzed as predictors of neurologic injury and mortality. Survival for the type of arch reconstruction and for the interval of PHCA was calculated.ResultsOf the 879 patients, 671 underwent hemiarch and 208 total arch replacement. The mean age was 65 ± 13.3 years, and 61.6% were men. The total arch patients had longer mean periods of PHCA (39 vs 21 minutes, P < .001) and RCP (37 vs 19 minutes, P < .001). However, the incidence of transient neurologic dysfunction (3.0% vs 2.4%, P < .813) and permanent neurologic dysfunction (1.3% vs 1.9%, P < .519) was similar for both techniques. Mortality was greater in the hemiarch group (4.8% vs 0.5%, P < .003). Patients requiring >40 minutes of PHCA had outcomes similar to those requiring less. The 1-, 5-, and 10-year survival was similar, regardless of the procedure performed or interval of PHCA.ConclusionsRCP is a safe and effective adjunct for cerebral protection during arch surgery. Patients requiring more extensive arch reconstruction are not at greater risk of permanent neurologic dysfunction or perioperative mortality

Characteristics of cardiothoracic surgeons practicing at the top-ranked US institutions

BACKGROUND: We aimed to determine which factors distinguish cardiothoracic (CT) surgeons practicing at the top-ranked US institutions from their peers. METHODS: Using online resources, we collected demographics, training information and academic metrics of 694 cardiac (n=489; 70%) and thoracic (n=205; 30%) surgeons practicing at 57 preeminent US institutions, including those with the highest US News & World Report ranking ("top CT centers"). RESULTS: Two hundred and ninety-nine (43.1%) CT surgeons were practicing at the 18 "top CT centers" and had higher academic productivity (publications, citations) than their peers. While there was no difference in the proportion of international medical graduates (IMGs) (21.4% overall) or of surgeons with a PhD degree (9.4% overall) across institutions, the "top CT centers" had a higher proportion of faculty who received their entire CT training abroad (10.4% vs. 5.8%; P=0.038) or at highly-ranked US institutions. Those who published more during their early career years (residency, fellowship and first 5 years as faculty) were more likely to attain academic (professorship) and institutional leadership (division/department chair) positions and to practice at the "top CT centers". Women represented a minority (7.3% overall; 5.1% of cardiac vs. 12.7% of thoracic surgeons, P<0.001), but with growing prevalence among younger faculty and without differences across institutions. CONCLUSIONS: CT surgeons of the best US centers have a more international background and received their training at highly-ranked institutions. Early academic productivity is associated with life-long career achievements, with special importance of the first 5 years as faculty. Women represent a growing proportion of the CT surgical workforce

Biological solutions to aortic root replacement: valve-sparing versus bioprosthetic conduit‡

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Novel insights by 4D Flow imaging on aortic flow physiology after valve-sparing root replacement with or without neosinuses

This study was undertaken to evaluate the flow dynamics in the aortic root after valve-sparing root replacement with and without neosinuses of Valsalva reconstruction, by exploiting the capability of 4D Flow imaging to measure in vivo blood velocity fields and 3D geometric flow patterns

Open radial artery harvesting better preserves endothelial function compared to the endoscopic approach

OBJECTIVES: Both the open and endovascular techniques are commonly used for harvesting the radial artery (ORAH and ERAH, respectively), and yet, very little is known about the effects of these 2 techniques on endothelial integrity and function of the radial artery (RA). The aim of this study was to assess the endothelial integrity and function of RA harvested using the 2 approaches. METHODS: Two independent surgical teams working in the same institution routinely use the RA for coronary artery bypass grafting exclusively employing either ORAH or ERAH. Thirty-nine consecutive patients were enrolled in this comparative study. Endothelial function after ORAH or ERAH was assessed by using the wire myograph system. The integrity of the RA endothelium was evaluated by immunohistochemical staining for erythroblast transformation specific-related gene. RESULTS: The vasodilation in response to acetylcholine was significantly higher in RA harvested with ORAH (P ≤ 0.001 versus ERAH). Endothelial integrity was not different between the 2 groups. CONCLUSIONS: ORAH is associated with a significantly higher endothelium-dependent vasodilation. Further investigation on the potential implications of these findings in terms of graft spasm and patency as well as clinical outcomes are needed