Richard Mark Kirkner

Failure to achieve a rounded and unobstructed ostia in children who have surgery to repair anomalous coronary arteries can put these children at continued risk for sudden death, but cardiac MRI with virtual angioscopy (VA) before and after the operation can give cardiologists a clear picture of a patient’s risk for sudden death and help direct ongoing management, according to a study in the July issue of the Journal of Thoracic and Cardiovascular Surgery (2016;152:205-10).

“Cardiac MRI with virtual angioscopy is an important tool for evaluating anomalous coronary anatomy, myocardial function, and ischemia and should be considered for initial and postoperative assessment of children with anomalous coronary arteries,” lead author Julie A. Brothers, MD, and her coauthors said in reporting their findings.

Anomalous coronary artery is a rare congenital condition in which the left coronary artery (LCA) originates from the right sinus or the right coronary artery (RCA) originates from the left coronary sinus. Dr. Brothers, a pediatric cardiologist, and her colleagues from the Children’s Hospital of Philadelphia and the University of Pennsylvania, also in Philadelphia, studied nine male patients who had operations for anomalous coronary arteries during Feb. 2009-May 2015 in what they said is the first study to document anomalous coronary artery anatomy both before and after surgery. The patients’ average age was 14.1 years; seven had right anomalous coronary arteries and two had left anomalous arteries. After the operations, MRI-VA revealed that two patients still had narrowing in the neo-orifices.

Previous reports recommend surgical repair for all patients with anomalous LCA and for symptomatic patients with anomalous RCA anatomy (Ann Thorac Surg. 2011;92:691-7; Ann Thorac Surg. 2014;98:941-5). MRI-VA allows the surgical team to survey the ostial stenosis before the operation “as if standing within the vessel itself,” Dr. Brothers and her coauthors wrote. Afterward, MRI-VA lets the surgeon and team see if the operation succeeded in repairing the orifices.

In the study population, VA before surgery confirmed elliptical, slit-like orifices in all patients. The operations involved unroofing procedures; two patients also had detachment and resuspension procedures during surgery. After surgery, VA showed that seven patients had round, patent, unobstructed repaired orifices; but two had orifices that were still narrow and somewhat stenotic, Dr. Brothers and her coauthors said. The study group had postoperative MRI-VA an average of 8.6 months after surgery.

“The significance of these findings is unknown; however, if the proposed mechanism of ischemia is due to a slit-like orifice, a continued stenotic orifice may place subjects at risk for sudden death,” the researchers said. The two study patients with the narrowed, stenotic orifices have remained symptom free, with no evidence of ischemia on exercise stress test or cardiac MRI. “These subjects will need to be followed up in the future to monitor for progression or resolution,” the study authors wrote.

Sudden cardiac death (SCD) is more common in anomalous aortic origin of the LCA than the RCA, Dr. Brothers and her colleagues said. Thus, an elliptical, slit-like neo-orifice is a concern because it can become blocked during exercise, possibly leading to lethal ventricular arrhythmia, they said. Ischemia in patients with anomalous coronary artery seems to result from a cumulative effect of exercise.

Patients who undergo the modified unroofing procedure typically have electrocardiography and echocardiography afterward and then get cleared to return to competitive sports in about 3 months if their stress test indicates it. Dr. Brothers and her colleagues said this activity recommendation may need alteration for those patients who have had a heart attack or sudden cardiac arrest, because they may remain at increased risk of SCD after surgery. “At the very least, additional imaging, such as with MRI-VA, should be used in this population,” the study authors said.

While Dr. Brothers and her colleagues acknowledged the small sample size is a limitation of the study, they also pointed out that anomalous coronary artery is a rare disease. They also noted that high-quality VA images can be difficult to obtain in noncompliant patients or those have arrhythmia or irregular breathing. “The images obtained in this study were acquired at an institution very familiar with pediatric cardiac coronary MRI and would be appropriate for assessing the coronary ostia with VA,” they said.

Dr. Brothers and her coauthors had no financial disclosures.

Failure to achieve a rounded and unobstructed ostia in children who have surgery to repair anomalous coronary arteries can put these children at continued risk for sudden death, but cardiac MRI with virtual angioscopy (VA) before and after the operation can give cardiologists a clear picture of a patient’s risk for sudden death and help direct ongoing management, according to a study in the July issue of the Journal of Thoracic and Cardiovascular Surgery (2016;152:205-10).

“Cardiac MRI with virtual angioscopy is an important tool for evaluating anomalous coronary anatomy, myocardial function, and ischemia and should be considered for initial and postoperative assessment of children with anomalous coronary arteries,” lead author Julie A. Brothers, MD, and her coauthors said in reporting their findings.

Anomalous coronary artery is a rare congenital condition in which the left coronary artery (LCA) originates from the right sinus or the right coronary artery (RCA) originates from the left coronary sinus. Dr. Brothers, a pediatric cardiologist, and her colleagues from the Children’s Hospital of Philadelphia and the University of Pennsylvania, also in Philadelphia, studied nine male patients who had operations for anomalous coronary arteries during Feb. 2009-May 2015 in what they said is the first study to document anomalous coronary artery anatomy both before and after surgery. The patients’ average age was 14.1 years; seven had right anomalous coronary arteries and two had left anomalous arteries. After the operations, MRI-VA revealed that two patients still had narrowing in the neo-orifices.

Previous reports recommend surgical repair for all patients with anomalous LCA and for symptomatic patients with anomalous RCA anatomy (Ann Thorac Surg. 2011;92:691-7; Ann Thorac Surg. 2014;98:941-5). MRI-VA allows the surgical team to survey the ostial stenosis before the operation “as if standing within the vessel itself,” Dr. Brothers and her coauthors wrote. Afterward, MRI-VA lets the surgeon and team see if the operation succeeded in repairing the orifices.

In the study population, VA before surgery confirmed elliptical, slit-like orifices in all patients. The operations involved unroofing procedures; two patients also had detachment and resuspension procedures during surgery. After surgery, VA showed that seven patients had round, patent, unobstructed repaired orifices; but two had orifices that were still narrow and somewhat stenotic, Dr. Brothers and her coauthors said. The study group had postoperative MRI-VA an average of 8.6 months after surgery.

“The significance of these findings is unknown; however, if the proposed mechanism of ischemia is due to a slit-like orifice, a continued stenotic orifice may place subjects at risk for sudden death,” the researchers said. The two study patients with the narrowed, stenotic orifices have remained symptom free, with no evidence of ischemia on exercise stress test or cardiac MRI. “These subjects will need to be followed up in the future to monitor for progression or resolution,” the study authors wrote.

Sudden cardiac death (SCD) is more common in anomalous aortic origin of the LCA than the RCA, Dr. Brothers and her colleagues said. Thus, an elliptical, slit-like neo-orifice is a concern because it can become blocked during exercise, possibly leading to lethal ventricular arrhythmia, they said. Ischemia in patients with anomalous coronary artery seems to result from a cumulative effect of exercise.

Patients who undergo the modified unroofing procedure typically have electrocardiography and echocardiography afterward and then get cleared to return to competitive sports in about 3 months if their stress test indicates it. Dr. Brothers and her colleagues said this activity recommendation may need alteration for those patients who have had a heart attack or sudden cardiac arrest, because they may remain at increased risk of SCD after surgery. “At the very least, additional imaging, such as with MRI-VA, should be used in this population,” the study authors said.

While Dr. Brothers and her colleagues acknowledged the small sample size is a limitation of the study, they also pointed out that anomalous coronary artery is a rare disease. They also noted that high-quality VA images can be difficult to obtain in noncompliant patients or those have arrhythmia or irregular breathing. “The images obtained in this study were acquired at an institution very familiar with pediatric cardiac coronary MRI and would be appropriate for assessing the coronary ostia with VA,” they said.

Dr. Brothers and her coauthors had no financial disclosures.

Failure to achieve a rounded and unobstructed ostia in children who have surgery to repair anomalous coronary arteries can put these children at continued risk for sudden death, but cardiac MRI with virtual angioscopy (VA) before and after the operation can give cardiologists a clear picture of a patient’s risk for sudden death and help direct ongoing management, according to a study in the July issue of the Journal of Thoracic and Cardiovascular Surgery (2016;152:205-10).

“Cardiac MRI with virtual angioscopy is an important tool for evaluating anomalous coronary anatomy, myocardial function, and ischemia and should be considered for initial and postoperative assessment of children with anomalous coronary arteries,” lead author Julie A. Brothers, MD, and her coauthors said in reporting their findings.

Anomalous coronary artery is a rare congenital condition in which the left coronary artery (LCA) originates from the right sinus or the right coronary artery (RCA) originates from the left coronary sinus. Dr. Brothers, a pediatric cardiologist, and her colleagues from the Children’s Hospital of Philadelphia and the University of Pennsylvania, also in Philadelphia, studied nine male patients who had operations for anomalous coronary arteries during Feb. 2009-May 2015 in what they said is the first study to document anomalous coronary artery anatomy both before and after surgery. The patients’ average age was 14.1 years; seven had right anomalous coronary arteries and two had left anomalous arteries. After the operations, MRI-VA revealed that two patients still had narrowing in the neo-orifices.

Previous reports recommend surgical repair for all patients with anomalous LCA and for symptomatic patients with anomalous RCA anatomy (Ann Thorac Surg. 2011;92:691-7; Ann Thorac Surg. 2014;98:941-5). MRI-VA allows the surgical team to survey the ostial stenosis before the operation “as if standing within the vessel itself,” Dr. Brothers and her coauthors wrote. Afterward, MRI-VA lets the surgeon and team see if the operation succeeded in repairing the orifices.

In the study population, VA before surgery confirmed elliptical, slit-like orifices in all patients. The operations involved unroofing procedures; two patients also had detachment and resuspension procedures during surgery. After surgery, VA showed that seven patients had round, patent, unobstructed repaired orifices; but two had orifices that were still narrow and somewhat stenotic, Dr. Brothers and her coauthors said. The study group had postoperative MRI-VA an average of 8.6 months after surgery.

“The significance of these findings is unknown; however, if the proposed mechanism of ischemia is due to a slit-like orifice, a continued stenotic orifice may place subjects at risk for sudden death,” the researchers said. The two study patients with the narrowed, stenotic orifices have remained symptom free, with no evidence of ischemia on exercise stress test or cardiac MRI. “These subjects will need to be followed up in the future to monitor for progression or resolution,” the study authors wrote.

Sudden cardiac death (SCD) is more common in anomalous aortic origin of the LCA than the RCA, Dr. Brothers and her colleagues said. Thus, an elliptical, slit-like neo-orifice is a concern because it can become blocked during exercise, possibly leading to lethal ventricular arrhythmia, they said. Ischemia in patients with anomalous coronary artery seems to result from a cumulative effect of exercise.

Patients who undergo the modified unroofing procedure typically have electrocardiography and echocardiography afterward and then get cleared to return to competitive sports in about 3 months if their stress test indicates it. Dr. Brothers and her colleagues said this activity recommendation may need alteration for those patients who have had a heart attack or sudden cardiac arrest, because they may remain at increased risk of SCD after surgery. “At the very least, additional imaging, such as with MRI-VA, should be used in this population,” the study authors said.

While Dr. Brothers and her colleagues acknowledged the small sample size is a limitation of the study, they also pointed out that anomalous coronary artery is a rare disease. They also noted that high-quality VA images can be difficult to obtain in noncompliant patients or those have arrhythmia or irregular breathing. “The images obtained in this study were acquired at an institution very familiar with pediatric cardiac coronary MRI and would be appropriate for assessing the coronary ostia with VA,” they said.

Dr. Brothers and her coauthors had no financial disclosures.

Acute kidney injury is a common complication after pediatric cardiac surgery, but measuring for a specific genetic protein immediately after cardiac surgery may improve cardiac surgeons’ ability to predict patients at higher risk of AKI, according to researchers from Brazil. The study results are in the July issue of the Journal of Thoracic and Cardiovascular Surgery (2016;152-178-86).

“Plasma syndecan-1 levels measured early in the postoperative period were independently associated with severe acute kidney injury,” wrote Candice Torres de Melo Bezerra Cavalcante, MD, of Heart Hospital of Messejana and Federal University of Ceará.

Their prospective cohort study involved 289 pediatric patients who had cardiac surgery at their institution between September 2013 and December 2014.

©London_England/Thinkstock

Dr. Cavalcante and colleagues acknowledged that the traditional biomarker for renal function, serum creatinine, only increases appreciably after the glomerular filtration rate declines 50%, impairing physicians’ ability to detect AKI early enough to treat it. “This delay can explain, in part the, negative results in AKI therapeutic clinical trials,” they wrote.

They evaluated two different endothelial biomarkers in addition to syndecan-1 with regard to their capacity for predicting severe AKI: plasma ICAM-1, a marker of endothelial cell activation; and E-selectin, an endothelial cell adhesion molecule. Syndecan-1 works as a biomarker of injury to the glycocalyx protein that surrounds endothelial cell membranes that acts as a permeability barrier and prevents the cells from adhering to blood. They found that median syndecan-1 levels soon after surgery were higher in patients with severe AKI, 103.6 vs. 42.3 ng/mL.

“Although syndecan-1 is not a renal-specific biomarker, there has been recent increasing evidence that endothelial injury has an important role in AKI pathophysiology,” the researchers noted.

Study results showed the higher the level of syndecan-1, the greater the adjusted odds ratio (OR) for severe AKI. Levels of less than 17 ng/mL were considered normal; 17.1-46.7 ng/mL carried an adjusted OR of 1.42; 47.4-93.1 ng/mL had an adjusted OR of 2.05; and levels 96.3 or greater had an OR of 8.87.

“Maintenance of endothelial glycocalyx integrity can be a therapeutic target to reduce AKI in this setting,” the researchers wrote.

The authors acknowledged that the study was done at a single center that had dialysis and death rates three and five times higher, respectively, than those of developed countries; and it measured syndecan-1 at only one time point almost immediately after the operation.

“Adding postoperative syndecan-1, even when using a clinical model that already incorporates variables from renal angina index, results in significant improvement in the capacity to predict severe AKI,” Dr. Cavalcante and colleagues concluded.

They had no financial relationships to disclose.

[email protected]

Acute kidney injury is a common complication after pediatric cardiac surgery, but measuring for a specific genetic protein immediately after cardiac surgery may improve cardiac surgeons’ ability to predict patients at higher risk of AKI, according to researchers from Brazil. The study results are in the July issue of the Journal of Thoracic and Cardiovascular Surgery (2016;152-178-86).

“Plasma syndecan-1 levels measured early in the postoperative period were independently associated with severe acute kidney injury,” wrote Candice Torres de Melo Bezerra Cavalcante, MD, of Heart Hospital of Messejana and Federal University of Ceará.

Their prospective cohort study involved 289 pediatric patients who had cardiac surgery at their institution between September 2013 and December 2014.

©London_England/Thinkstock

Dr. Cavalcante and colleagues acknowledged that the traditional biomarker for renal function, serum creatinine, only increases appreciably after the glomerular filtration rate declines 50%, impairing physicians’ ability to detect AKI early enough to treat it. “This delay can explain, in part the, negative results in AKI therapeutic clinical trials,” they wrote.

They evaluated two different endothelial biomarkers in addition to syndecan-1 with regard to their capacity for predicting severe AKI: plasma ICAM-1, a marker of endothelial cell activation; and E-selectin, an endothelial cell adhesion molecule. Syndecan-1 works as a biomarker of injury to the glycocalyx protein that surrounds endothelial cell membranes that acts as a permeability barrier and prevents the cells from adhering to blood. They found that median syndecan-1 levels soon after surgery were higher in patients with severe AKI, 103.6 vs. 42.3 ng/mL.

“Although syndecan-1 is not a renal-specific biomarker, there has been recent increasing evidence that endothelial injury has an important role in AKI pathophysiology,” the researchers noted.

Study results showed the higher the level of syndecan-1, the greater the adjusted odds ratio (OR) for severe AKI. Levels of less than 17 ng/mL were considered normal; 17.1-46.7 ng/mL carried an adjusted OR of 1.42; 47.4-93.1 ng/mL had an adjusted OR of 2.05; and levels 96.3 or greater had an OR of 8.87.

“Maintenance of endothelial glycocalyx integrity can be a therapeutic target to reduce AKI in this setting,” the researchers wrote.

The authors acknowledged that the study was done at a single center that had dialysis and death rates three and five times higher, respectively, than those of developed countries; and it measured syndecan-1 at only one time point almost immediately after the operation.

“Adding postoperative syndecan-1, even when using a clinical model that already incorporates variables from renal angina index, results in significant improvement in the capacity to predict severe AKI,” Dr. Cavalcante and colleagues concluded.

They had no financial relationships to disclose.

[email protected]

Acute kidney injury is a common complication after pediatric cardiac surgery, but measuring for a specific genetic protein immediately after cardiac surgery may improve cardiac surgeons’ ability to predict patients at higher risk of AKI, according to researchers from Brazil. The study results are in the July issue of the Journal of Thoracic and Cardiovascular Surgery (2016;152-178-86).

“Plasma syndecan-1 levels measured early in the postoperative period were independently associated with severe acute kidney injury,” wrote Candice Torres de Melo Bezerra Cavalcante, MD, of Heart Hospital of Messejana and Federal University of Ceará.

Their prospective cohort study involved 289 pediatric patients who had cardiac surgery at their institution between September 2013 and December 2014.

©London_England/Thinkstock

Dr. Cavalcante and colleagues acknowledged that the traditional biomarker for renal function, serum creatinine, only increases appreciably after the glomerular filtration rate declines 50%, impairing physicians’ ability to detect AKI early enough to treat it. “This delay can explain, in part the, negative results in AKI therapeutic clinical trials,” they wrote.

They evaluated two different endothelial biomarkers in addition to syndecan-1 with regard to their capacity for predicting severe AKI: plasma ICAM-1, a marker of endothelial cell activation; and E-selectin, an endothelial cell adhesion molecule. Syndecan-1 works as a biomarker of injury to the glycocalyx protein that surrounds endothelial cell membranes that acts as a permeability barrier and prevents the cells from adhering to blood. They found that median syndecan-1 levels soon after surgery were higher in patients with severe AKI, 103.6 vs. 42.3 ng/mL.

“Although syndecan-1 is not a renal-specific biomarker, there has been recent increasing evidence that endothelial injury has an important role in AKI pathophysiology,” the researchers noted.

Study results showed the higher the level of syndecan-1, the greater the adjusted odds ratio (OR) for severe AKI. Levels of less than 17 ng/mL were considered normal; 17.1-46.7 ng/mL carried an adjusted OR of 1.42; 47.4-93.1 ng/mL had an adjusted OR of 2.05; and levels 96.3 or greater had an OR of 8.87.

“Maintenance of endothelial glycocalyx integrity can be a therapeutic target to reduce AKI in this setting,” the researchers wrote.

The authors acknowledged that the study was done at a single center that had dialysis and death rates three and five times higher, respectively, than those of developed countries; and it measured syndecan-1 at only one time point almost immediately after the operation.

“Adding postoperative syndecan-1, even when using a clinical model that already incorporates variables from renal angina index, results in significant improvement in the capacity to predict severe AKI,” Dr. Cavalcante and colleagues concluded.

They had no financial relationships to disclose.

[email protected]

Cardiac surgeons have been slow to embrace bilateral internal thoracic arteries (ITAs) for coronary artery bypass grafting (CABG) despite accumulating evidence that this technique achieves better long-term survival than the single-artery technique, perhaps because they think the bilateral technique is more difficult. However, investigators from Johns Hopkins University have found no difference in results between four different bilateral ITAs techniques regardless of complexity.

Their single-center study analyzed outcomes from 762 patients at Johns Hopkins who had CABG by way of one of four different bilateral ITA (BITA) techniques between 1997 and 2014. The results are in the July issue of the Journal of Thoracic and Cardiovascular Surgery (2016;152:120-7).

“We found no significant difference in terms of long-term survival or freedom from repeat revascularization between different configurations of BITA use,” wrote J. Trent Magruder, MD, and his colleagues.

Dr. Magruder and his coauthors cited 13 reports that found BITA achieved better graft patency and long-term survival than did single internal thoracic arteries, but they noted the lack of reports comparing different BITA techniques. “Given the paucity of comparative data on long-term outcomes of various BITA configurations, we sought to study differences in mortality and the need for repeat revascularization among patients receiving varying BITA graft configurations at our institution,” they said.

The four groups and types of BITA procedures they analyzed were:

LL/RL group, in situ left ITA (LITA) anastomosed to the left anterior descending artery (LAD) with in situ right ITA (RITA) anastomosed to the left coronary circulation (n = 239).

LL/RR group, in situ LITA-LAD and in situ RITA-right coronary circulation (n = 239 patients).

RL/LL group, in situ RITA-LAD with in situ LITA-left coronary circulation (n = 185 patients).

Y group, in situ LITA-LAD with a free RITA as a composite graft with inflow from the LITA or a saphenous vein graft (n = 99 patients).

BITA cases comprised 5.7% of all 14,502 CABG procedures Johns Hopkins cardiac surgeons performed through the study period (60 BITA cases were dropped from the analysis because of incomplete data). That rate is about in line with a previously reported use rate of 4% of CABG procedures in the United States (Circulation. 2009;120:935-40).

Among the reasons Dr. Magruder and his coauthors cited for the lack of uptake of BITA among cardiac surgeons are discrepancies in survival data, a perceived high risk of complications such as sternal surgical site infections in patients with diabetes or chronic obstructive pulmonary disease or in those who are obese, and increased operative time and risk of bleeding.

With regard to the operation itself, the mean cross-clamp and coronary bypass times and number of bypass grafts were similar among all four groups, the latter ranging from 3.0 for the RL/LL group to 3.4 for the Y group. However, the researchers did find appreciable differences in rates of transfusions during the operation and skeletonization of the RITA at harvest. The Y group had the highest rates for both – 57.6% had transfusions and 72.7% had skeletonized RITA at harvest – followed by the RL/LL with rates of 43.2% for transfusions and 31.4% with skeletonized RITA. Rates for both intraoperative transfusion and RITA skeletonization were 24.7% and 8%, respectively, in the LL/RL group; and 37.7% and 18%, respectively, in the LL/RR group.

In-hospital complications, including reintervention for bleeding, heart attack, stroke, inflammation of the mediastinum, and death, were similar among all four groups. There were no in-hospital heart attacks. The only statistically significant difference was in hospital stay, ranging from an average of 6.1 days for the LL/RL group to 7.4 for both the LL/RR and RL/LL groups.

Through the duration of follow-up, the overall rate for repeat percutaneous coronary intervention was 7.6% – highest among the RL/LL (9.2%) and Y groups (9%). Those in the LL/RR group had the highest rates of repeat CABG: 1.7% vs. 0.8% for LL/RL group, 0.5% for the RL/LL group and 0% for group Y. Rates of late cardiac death were around 5% for the first three groups, but none were reported in group Y.

Dr. Magruder and colleagues acknowledged their study used a limited sample size for each procedure, but that their findings show that cardiac surgeons should choose their BITA configuration based on individual patient factors. “In general, the technically simplest operations should be selected because more complex procedures offer no additional benefit,” they said.

Dr. Magruder and his coauthors had no financial disclosures.

Cardiac surgeons have been slow to embrace bilateral internal thoracic arteries (ITAs) for coronary artery bypass grafting (CABG) despite accumulating evidence that this technique achieves better long-term survival than the single-artery technique, perhaps because they think the bilateral technique is more difficult. However, investigators from Johns Hopkins University have found no difference in results between four different bilateral ITAs techniques regardless of complexity.

Their single-center study analyzed outcomes from 762 patients at Johns Hopkins who had CABG by way of one of four different bilateral ITA (BITA) techniques between 1997 and 2014. The results are in the July issue of the Journal of Thoracic and Cardiovascular Surgery (2016;152:120-7).

“We found no significant difference in terms of long-term survival or freedom from repeat revascularization between different configurations of BITA use,” wrote J. Trent Magruder, MD, and his colleagues.

Dr. Magruder and his coauthors cited 13 reports that found BITA achieved better graft patency and long-term survival than did single internal thoracic arteries, but they noted the lack of reports comparing different BITA techniques. “Given the paucity of comparative data on long-term outcomes of various BITA configurations, we sought to study differences in mortality and the need for repeat revascularization among patients receiving varying BITA graft configurations at our institution,” they said.

The four groups and types of BITA procedures they analyzed were:

LL/RL group, in situ left ITA (LITA) anastomosed to the left anterior descending artery (LAD) with in situ right ITA (RITA) anastomosed to the left coronary circulation (n = 239).

LL/RR group, in situ LITA-LAD and in situ RITA-right coronary circulation (n = 239 patients).

RL/LL group, in situ RITA-LAD with in situ LITA-left coronary circulation (n = 185 patients).

Y group, in situ LITA-LAD with a free RITA as a composite graft with inflow from the LITA or a saphenous vein graft (n = 99 patients).

BITA cases comprised 5.7% of all 14,502 CABG procedures Johns Hopkins cardiac surgeons performed through the study period (60 BITA cases were dropped from the analysis because of incomplete data). That rate is about in line with a previously reported use rate of 4% of CABG procedures in the United States (Circulation. 2009;120:935-40).

Among the reasons Dr. Magruder and his coauthors cited for the lack of uptake of BITA among cardiac surgeons are discrepancies in survival data, a perceived high risk of complications such as sternal surgical site infections in patients with diabetes or chronic obstructive pulmonary disease or in those who are obese, and increased operative time and risk of bleeding.

With regard to the operation itself, the mean cross-clamp and coronary bypass times and number of bypass grafts were similar among all four groups, the latter ranging from 3.0 for the RL/LL group to 3.4 for the Y group. However, the researchers did find appreciable differences in rates of transfusions during the operation and skeletonization of the RITA at harvest. The Y group had the highest rates for both – 57.6% had transfusions and 72.7% had skeletonized RITA at harvest – followed by the RL/LL with rates of 43.2% for transfusions and 31.4% with skeletonized RITA. Rates for both intraoperative transfusion and RITA skeletonization were 24.7% and 8%, respectively, in the LL/RL group; and 37.7% and 18%, respectively, in the LL/RR group.

In-hospital complications, including reintervention for bleeding, heart attack, stroke, inflammation of the mediastinum, and death, were similar among all four groups. There were no in-hospital heart attacks. The only statistically significant difference was in hospital stay, ranging from an average of 6.1 days for the LL/RL group to 7.4 for both the LL/RR and RL/LL groups.

Through the duration of follow-up, the overall rate for repeat percutaneous coronary intervention was 7.6% – highest among the RL/LL (9.2%) and Y groups (9%). Those in the LL/RR group had the highest rates of repeat CABG: 1.7% vs. 0.8% for LL/RL group, 0.5% for the RL/LL group and 0% for group Y. Rates of late cardiac death were around 5% for the first three groups, but none were reported in group Y.

Dr. Magruder and colleagues acknowledged their study used a limited sample size for each procedure, but that their findings show that cardiac surgeons should choose their BITA configuration based on individual patient factors. “In general, the technically simplest operations should be selected because more complex procedures offer no additional benefit,” they said.

Dr. Magruder and his coauthors had no financial disclosures.

Cardiac surgeons have been slow to embrace bilateral internal thoracic arteries (ITAs) for coronary artery bypass grafting (CABG) despite accumulating evidence that this technique achieves better long-term survival than the single-artery technique, perhaps because they think the bilateral technique is more difficult. However, investigators from Johns Hopkins University have found no difference in results between four different bilateral ITAs techniques regardless of complexity.

Their single-center study analyzed outcomes from 762 patients at Johns Hopkins who had CABG by way of one of four different bilateral ITA (BITA) techniques between 1997 and 2014. The results are in the July issue of the Journal of Thoracic and Cardiovascular Surgery (2016;152:120-7).

“We found no significant difference in terms of long-term survival or freedom from repeat revascularization between different configurations of BITA use,” wrote J. Trent Magruder, MD, and his colleagues.

Dr. Magruder and his coauthors cited 13 reports that found BITA achieved better graft patency and long-term survival than did single internal thoracic arteries, but they noted the lack of reports comparing different BITA techniques. “Given the paucity of comparative data on long-term outcomes of various BITA configurations, we sought to study differences in mortality and the need for repeat revascularization among patients receiving varying BITA graft configurations at our institution,” they said.

The four groups and types of BITA procedures they analyzed were:

LL/RL group, in situ left ITA (LITA) anastomosed to the left anterior descending artery (LAD) with in situ right ITA (RITA) anastomosed to the left coronary circulation (n = 239).

LL/RR group, in situ LITA-LAD and in situ RITA-right coronary circulation (n = 239 patients).

RL/LL group, in situ RITA-LAD with in situ LITA-left coronary circulation (n = 185 patients).

Y group, in situ LITA-LAD with a free RITA as a composite graft with inflow from the LITA or a saphenous vein graft (n = 99 patients).

BITA cases comprised 5.7% of all 14,502 CABG procedures Johns Hopkins cardiac surgeons performed through the study period (60 BITA cases were dropped from the analysis because of incomplete data). That rate is about in line with a previously reported use rate of 4% of CABG procedures in the United States (Circulation. 2009;120:935-40).

Among the reasons Dr. Magruder and his coauthors cited for the lack of uptake of BITA among cardiac surgeons are discrepancies in survival data, a perceived high risk of complications such as sternal surgical site infections in patients with diabetes or chronic obstructive pulmonary disease or in those who are obese, and increased operative time and risk of bleeding.

With regard to the operation itself, the mean cross-clamp and coronary bypass times and number of bypass grafts were similar among all four groups, the latter ranging from 3.0 for the RL/LL group to 3.4 for the Y group. However, the researchers did find appreciable differences in rates of transfusions during the operation and skeletonization of the RITA at harvest. The Y group had the highest rates for both – 57.6% had transfusions and 72.7% had skeletonized RITA at harvest – followed by the RL/LL with rates of 43.2% for transfusions and 31.4% with skeletonized RITA. Rates for both intraoperative transfusion and RITA skeletonization were 24.7% and 8%, respectively, in the LL/RL group; and 37.7% and 18%, respectively, in the LL/RR group.

In-hospital complications, including reintervention for bleeding, heart attack, stroke, inflammation of the mediastinum, and death, were similar among all four groups. There were no in-hospital heart attacks. The only statistically significant difference was in hospital stay, ranging from an average of 6.1 days for the LL/RL group to 7.4 for both the LL/RR and RL/LL groups.

Through the duration of follow-up, the overall rate for repeat percutaneous coronary intervention was 7.6% – highest among the RL/LL (9.2%) and Y groups (9%). Those in the LL/RR group had the highest rates of repeat CABG: 1.7% vs. 0.8% for LL/RL group, 0.5% for the RL/LL group and 0% for group Y. Rates of late cardiac death were around 5% for the first three groups, but none were reported in group Y.

Dr. Magruder and colleagues acknowledged their study used a limited sample size for each procedure, but that their findings show that cardiac surgeons should choose their BITA configuration based on individual patient factors. “In general, the technically simplest operations should be selected because more complex procedures offer no additional benefit,” they said.

Dr. Magruder and his coauthors had no financial disclosures.

NEW YORK – A total aortic arch replacement approach that uses a four-branched graft with antegrade cerebral perfusion can be done with low rates of in-hospital death and complications, a large series from two institutions in Japan showed.

Kenji Minatoya, MD, of the National Cerebral and Cardiovascular Center in Osaka, Japan, reported that his institution’s approach for total arch replacement (TAR) had an in-hospital death rate of 5.2%.

Dr. Minatoya and his colleagues started using four-branch TAR in the 1980s, switching from retrograde to antegrade cerebral perfusion to protect the brain later on. “The study purpose was to investigate the results of total arch replacement using the four-branch graft as a benchmark in the endovascular era,” he said at the meeting, sponsored by the American Association for Thoracic Surgery.

The study involved 1,005 cases of total arch replacement performed at Dr. Minatoya’s center and at Tokyo Medical University from 2001 to 2016.

The study population included a cohort of 152 people in their 80s. The in-hospital death rate in this group was 11.8%, Dr. Minatoya said. The over-80 group mostly underwent thoracic endovascular aortic repair (TEVAR) beginning in 2008, he said, but in recent years some had open total arch replacement operations.

The univariate analysis showed that chronic kidney disease, long operation times, long durations for coronary bypass and circulatory arrest, and extended time on mechanical ventilation were risk factors for in-hospital death in octogenarians, Dr. Minatoya said. The multivariate analysis showed that male gender along with extended mechanical ventilation were risk factors for in-hospital death in this group, he said.

The overall population included 252 emergent operations, 224 of which were for acute aortic dissections, Dr. Minatoya said. The in-hospital death rate was 4.5% for elective operations and 7.1% for emergent cases, he said. The death rate for isolated, elective total arch replacement was 3.4%.

Focusing on acute aortic dissections, Dr. Minatoya said, “We have adopted an aggressive strategy for entry-site resection, including total arch replacement, in patients with arch tears.” Almost 50% of patients with acute aortic dissection had total arch replacement, he said, with identical 4.9% rates for in-hospital mortality rate and permanent neurological deficit in this group.

The leading overall causes of in-hospital death were low-output syndrome (38.5%), sepsis (25%), respiratory failure (21%) and rupture of the residual aneurysm (9%), Dr. Minatoya said.

Fifteen patients (1.5%) underwent second operations for arch grafts, he said: 11 for pseudoaneurysm; three for hemolysis and one for infection. Other overall measures in the analysis were a permanent neurological dysfunction rate of 3.6%, a temporary neurological dysfunction rate of 6.4%, and no spinal cord complications. Overall 5-year survival was 80.7% and 10-year survival was 63.1%, Dr. Minatoya said.

A total of 311 patients had concomitant procedures. They included aortic valve operations (64); aortic root replacement (38); mitral valve replacement (13); and coronary artery bypass grafting (196).

The typical operation in the study population took about 8 hours, Dr. Minatoya said (482 minutes). Timing of key operative steps were cardiopulmonary time of 254 minutes, cardiac arrest time of 146 minutes, antegrade cerebral perfusion time of 160 minutes and lower-body circulatory arrest time of 62 minutes.

“Since the mean age was 70 years old, we think the survival rate was acceptable,” Dr. Minatoya said, regarding overall study results. Overall risk factors for in-hospital death were short stature, long pump time, chronic kidney disease, and age of 80 and up, he said. Short stature was a risk factor for permanent neurological deficit, and males over age 80 had a higher risk for total arch replacement.

“Total arch replacement using the four-branched graft with antegrade cerebral perfusion could be accomplished with acceptable early and late results,” Dr. Minatoya said. “The branched-arch TEVAR may be a good option for octogenarians and patients with chronic kidney disease.”

Dr. Minatoya had no financial relationships to disclose.

NEW YORK – A total aortic arch replacement approach that uses a four-branched graft with antegrade cerebral perfusion can be done with low rates of in-hospital death and complications, a large series from two institutions in Japan showed.

Kenji Minatoya, MD, of the National Cerebral and Cardiovascular Center in Osaka, Japan, reported that his institution’s approach for total arch replacement (TAR) had an in-hospital death rate of 5.2%.

Dr. Minatoya and his colleagues started using four-branch TAR in the 1980s, switching from retrograde to antegrade cerebral perfusion to protect the brain later on. “The study purpose was to investigate the results of total arch replacement using the four-branch graft as a benchmark in the endovascular era,” he said at the meeting, sponsored by the American Association for Thoracic Surgery.

The study involved 1,005 cases of total arch replacement performed at Dr. Minatoya’s center and at Tokyo Medical University from 2001 to 2016.

The study population included a cohort of 152 people in their 80s. The in-hospital death rate in this group was 11.8%, Dr. Minatoya said. The over-80 group mostly underwent thoracic endovascular aortic repair (TEVAR) beginning in 2008, he said, but in recent years some had open total arch replacement operations.

The univariate analysis showed that chronic kidney disease, long operation times, long durations for coronary bypass and circulatory arrest, and extended time on mechanical ventilation were risk factors for in-hospital death in octogenarians, Dr. Minatoya said. The multivariate analysis showed that male gender along with extended mechanical ventilation were risk factors for in-hospital death in this group, he said.

The overall population included 252 emergent operations, 224 of which were for acute aortic dissections, Dr. Minatoya said. The in-hospital death rate was 4.5% for elective operations and 7.1% for emergent cases, he said. The death rate for isolated, elective total arch replacement was 3.4%.

Focusing on acute aortic dissections, Dr. Minatoya said, “We have adopted an aggressive strategy for entry-site resection, including total arch replacement, in patients with arch tears.” Almost 50% of patients with acute aortic dissection had total arch replacement, he said, with identical 4.9% rates for in-hospital mortality rate and permanent neurological deficit in this group.

The leading overall causes of in-hospital death were low-output syndrome (38.5%), sepsis (25%), respiratory failure (21%) and rupture of the residual aneurysm (9%), Dr. Minatoya said.

Fifteen patients (1.5%) underwent second operations for arch grafts, he said: 11 for pseudoaneurysm; three for hemolysis and one for infection. Other overall measures in the analysis were a permanent neurological dysfunction rate of 3.6%, a temporary neurological dysfunction rate of 6.4%, and no spinal cord complications. Overall 5-year survival was 80.7% and 10-year survival was 63.1%, Dr. Minatoya said.

A total of 311 patients had concomitant procedures. They included aortic valve operations (64); aortic root replacement (38); mitral valve replacement (13); and coronary artery bypass grafting (196).

The typical operation in the study population took about 8 hours, Dr. Minatoya said (482 minutes). Timing of key operative steps were cardiopulmonary time of 254 minutes, cardiac arrest time of 146 minutes, antegrade cerebral perfusion time of 160 minutes and lower-body circulatory arrest time of 62 minutes.

“Since the mean age was 70 years old, we think the survival rate was acceptable,” Dr. Minatoya said, regarding overall study results. Overall risk factors for in-hospital death were short stature, long pump time, chronic kidney disease, and age of 80 and up, he said. Short stature was a risk factor for permanent neurological deficit, and males over age 80 had a higher risk for total arch replacement.

“Total arch replacement using the four-branched graft with antegrade cerebral perfusion could be accomplished with acceptable early and late results,” Dr. Minatoya said. “The branched-arch TEVAR may be a good option for octogenarians and patients with chronic kidney disease.”

Dr. Minatoya had no financial relationships to disclose.

NEW YORK – A total aortic arch replacement approach that uses a four-branched graft with antegrade cerebral perfusion can be done with low rates of in-hospital death and complications, a large series from two institutions in Japan showed.

Kenji Minatoya, MD, of the National Cerebral and Cardiovascular Center in Osaka, Japan, reported that his institution’s approach for total arch replacement (TAR) had an in-hospital death rate of 5.2%.

Dr. Minatoya and his colleagues started using four-branch TAR in the 1980s, switching from retrograde to antegrade cerebral perfusion to protect the brain later on. “The study purpose was to investigate the results of total arch replacement using the four-branch graft as a benchmark in the endovascular era,” he said at the meeting, sponsored by the American Association for Thoracic Surgery.

The study involved 1,005 cases of total arch replacement performed at Dr. Minatoya’s center and at Tokyo Medical University from 2001 to 2016.

The study population included a cohort of 152 people in their 80s. The in-hospital death rate in this group was 11.8%, Dr. Minatoya said. The over-80 group mostly underwent thoracic endovascular aortic repair (TEVAR) beginning in 2008, he said, but in recent years some had open total arch replacement operations.

The univariate analysis showed that chronic kidney disease, long operation times, long durations for coronary bypass and circulatory arrest, and extended time on mechanical ventilation were risk factors for in-hospital death in octogenarians, Dr. Minatoya said. The multivariate analysis showed that male gender along with extended mechanical ventilation were risk factors for in-hospital death in this group, he said.

The overall population included 252 emergent operations, 224 of which were for acute aortic dissections, Dr. Minatoya said. The in-hospital death rate was 4.5% for elective operations and 7.1% for emergent cases, he said. The death rate for isolated, elective total arch replacement was 3.4%.

Focusing on acute aortic dissections, Dr. Minatoya said, “We have adopted an aggressive strategy for entry-site resection, including total arch replacement, in patients with arch tears.” Almost 50% of patients with acute aortic dissection had total arch replacement, he said, with identical 4.9% rates for in-hospital mortality rate and permanent neurological deficit in this group.

The leading overall causes of in-hospital death were low-output syndrome (38.5%), sepsis (25%), respiratory failure (21%) and rupture of the residual aneurysm (9%), Dr. Minatoya said.

Fifteen patients (1.5%) underwent second operations for arch grafts, he said: 11 for pseudoaneurysm; three for hemolysis and one for infection. Other overall measures in the analysis were a permanent neurological dysfunction rate of 3.6%, a temporary neurological dysfunction rate of 6.4%, and no spinal cord complications. Overall 5-year survival was 80.7% and 10-year survival was 63.1%, Dr. Minatoya said.

A total of 311 patients had concomitant procedures. They included aortic valve operations (64); aortic root replacement (38); mitral valve replacement (13); and coronary artery bypass grafting (196).

The typical operation in the study population took about 8 hours, Dr. Minatoya said (482 minutes). Timing of key operative steps were cardiopulmonary time of 254 minutes, cardiac arrest time of 146 minutes, antegrade cerebral perfusion time of 160 minutes and lower-body circulatory arrest time of 62 minutes.

“Since the mean age was 70 years old, we think the survival rate was acceptable,” Dr. Minatoya said, regarding overall study results. Overall risk factors for in-hospital death were short stature, long pump time, chronic kidney disease, and age of 80 and up, he said. Short stature was a risk factor for permanent neurological deficit, and males over age 80 had a higher risk for total arch replacement.

“Total arch replacement using the four-branched graft with antegrade cerebral perfusion could be accomplished with acceptable early and late results,” Dr. Minatoya said. “The branched-arch TEVAR may be a good option for octogenarians and patients with chronic kidney disease.”

Dr. Minatoya had no financial relationships to disclose.

NEW YORK – With more than 1 million adults living today with congenital aortic disease, cardiovascular surgeons must think of outcomes in terms of decades, not years, when performing aortic arch repair in newborns, infants, and children, according to Charles D. Fraser Jr., M.D.

To that end, an all-autologous approach to aortic arch repair is key in preserving problem-free aortic function in adulthood, said Dr. Fraser, surgeon-in-chief at Texas Children’s Hospital in Houston.

Dr. Fraser reported on his center’s experience with all-autologous aortic arch repair techniques. He reviewed the following five principles that guide aortic arch repair in newborns, infants, and children at Texas Children’s Hospital:

• Use of autologous tissue reconstruction and avoidance of prosthetic material.

• Concomitant intracardiac repair.

• Use of anatomic reconstruction.

• Optimization of ventriculoarterial coupling.

• Preservation of laryngeal nerve function.

“The principles we developed at Texas Children’s Hospital we hope will translate into fewer of these patients that surgeons caring for adults with aortic disease will have to take care of later in life,” Dr. Fraser said at the meeting sponsored by the American Association for Thoracic Surgery. He reviewed cases in which he explained techniques he and his colleagues developed to address long-term outcomes.

The first challenge is to determine when to perform aortic repair in pediatric patients. “A question often asked is how small is too small when assessing the aortic arch in association with significant periductal coarctation?” he said. “Our rule of thumb has been that the arch diameter measured in millimeters should be at least the patient’s weight in kilograms plus one.” In other words, a 3-kg baby should have an aortic arch of at least 4 mm in diameter, he said.

He described the case of a 3.8-kg male baby on prostaglandin E1 who had aortic arch advancement repair and closure of atrial and ventricular septal defects at 8 days of age. The patient had an early origin of the left common carotid artery and a small proximal aortic arch. “This is the kind of patient in which we would do a complete aortic arch reconstruction, again with the autologous technique,” Dr. Fraser said.

In such a patient, Dr. Fraser and his colleagues at Texas Children’s Hospital support the circulation to the brain with antegrade cerebral perfusion, using transcranial Doppler and near-infrared spectroscopy to guide their profusion strategy, before putting the child on cardiac bypass and “profound” hypothermia. Careful planning before cannulation is important to perform the aortic transection at the correct level, he said

He also explained the ascending sliding arch aortoplasty, also known as the “Texas slide,” first described by E. Dean McKenzie, M.D., at Texas Children’s Hospital in 2011 (Ann. Thorac. Surg. 2011;91:805-10) This technique involves sliding a tongue-shaped piece of the ascending aorta underneath the aortic arch to construct an all-autologous repair.

“In patients with bicuspid aortic valves, we often observe that the ascending aorta is extremely elongated,” he said. “The idea is to take advantage of that and slide the ascending aorta completely up underneath the aortic arch and construct an all-autologous arch advancement type of repair.”

He presented the case of a 4-year-old boy with coarctation of the aorta in whom the Texas slide was indicated. “If this patient were treated with a simple coarctectomy, the patient would be subject to a life with a moderately hypoplastic aortic arch, and over the course of time, this could be problematic,” Dr. Fraser said. “The sliding reconstruction has relevance not only to the status of the aortic arch over the long term but it also has a profound effect on ventricular function.”

He noted a single-center, retrospective study from the United Kingdom that demonstrated that the quality of the aortic arch reconstruction, and the related opportunity for ventricular arterial coupling, directly correlate with long-term performance of the aortic arch in patients with hypoplastic left heart syndrome (J Thorac Cardiovasc Surg. 2014;148:1526-33).

“This is very important as part of the growing population of these patients who need long-term management, most of whom we’re anticipating managing not just for years, but for decades,” Dr. Fraser said.

He said he had no relevant financial disclosures.

NEW YORK – With more than 1 million adults living today with congenital aortic disease, cardiovascular surgeons must think of outcomes in terms of decades, not years, when performing aortic arch repair in newborns, infants, and children, according to Charles D. Fraser Jr., M.D.

To that end, an all-autologous approach to aortic arch repair is key in preserving problem-free aortic function in adulthood, said Dr. Fraser, surgeon-in-chief at Texas Children’s Hospital in Houston.

Dr. Fraser reported on his center’s experience with all-autologous aortic arch repair techniques. He reviewed the following five principles that guide aortic arch repair in newborns, infants, and children at Texas Children’s Hospital:

• Use of autologous tissue reconstruction and avoidance of prosthetic material.

• Concomitant intracardiac repair.

• Use of anatomic reconstruction.

• Optimization of ventriculoarterial coupling.

• Preservation of laryngeal nerve function.

“The principles we developed at Texas Children’s Hospital we hope will translate into fewer of these patients that surgeons caring for adults with aortic disease will have to take care of later in life,” Dr. Fraser said at the meeting sponsored by the American Association for Thoracic Surgery. He reviewed cases in which he explained techniques he and his colleagues developed to address long-term outcomes.

The first challenge is to determine when to perform aortic repair in pediatric patients. “A question often asked is how small is too small when assessing the aortic arch in association with significant periductal coarctation?” he said. “Our rule of thumb has been that the arch diameter measured in millimeters should be at least the patient’s weight in kilograms plus one.” In other words, a 3-kg baby should have an aortic arch of at least 4 mm in diameter, he said.

He described the case of a 3.8-kg male baby on prostaglandin E1 who had aortic arch advancement repair and closure of atrial and ventricular septal defects at 8 days of age. The patient had an early origin of the left common carotid artery and a small proximal aortic arch. “This is the kind of patient in which we would do a complete aortic arch reconstruction, again with the autologous technique,” Dr. Fraser said.

In such a patient, Dr. Fraser and his colleagues at Texas Children’s Hospital support the circulation to the brain with antegrade cerebral perfusion, using transcranial Doppler and near-infrared spectroscopy to guide their profusion strategy, before putting the child on cardiac bypass and “profound” hypothermia. Careful planning before cannulation is important to perform the aortic transection at the correct level, he said

He also explained the ascending sliding arch aortoplasty, also known as the “Texas slide,” first described by E. Dean McKenzie, M.D., at Texas Children’s Hospital in 2011 (Ann. Thorac. Surg. 2011;91:805-10) This technique involves sliding a tongue-shaped piece of the ascending aorta underneath the aortic arch to construct an all-autologous repair.

“In patients with bicuspid aortic valves, we often observe that the ascending aorta is extremely elongated,” he said. “The idea is to take advantage of that and slide the ascending aorta completely up underneath the aortic arch and construct an all-autologous arch advancement type of repair.”

He presented the case of a 4-year-old boy with coarctation of the aorta in whom the Texas slide was indicated. “If this patient were treated with a simple coarctectomy, the patient would be subject to a life with a moderately hypoplastic aortic arch, and over the course of time, this could be problematic,” Dr. Fraser said. “The sliding reconstruction has relevance not only to the status of the aortic arch over the long term but it also has a profound effect on ventricular function.”

He noted a single-center, retrospective study from the United Kingdom that demonstrated that the quality of the aortic arch reconstruction, and the related opportunity for ventricular arterial coupling, directly correlate with long-term performance of the aortic arch in patients with hypoplastic left heart syndrome (J Thorac Cardiovasc Surg. 2014;148:1526-33).

“This is very important as part of the growing population of these patients who need long-term management, most of whom we’re anticipating managing not just for years, but for decades,” Dr. Fraser said.

He said he had no relevant financial disclosures.

NEW YORK – With more than 1 million adults living today with congenital aortic disease, cardiovascular surgeons must think of outcomes in terms of decades, not years, when performing aortic arch repair in newborns, infants, and children, according to Charles D. Fraser Jr., M.D.

To that end, an all-autologous approach to aortic arch repair is key in preserving problem-free aortic function in adulthood, said Dr. Fraser, surgeon-in-chief at Texas Children’s Hospital in Houston.

Dr. Fraser reported on his center’s experience with all-autologous aortic arch repair techniques. He reviewed the following five principles that guide aortic arch repair in newborns, infants, and children at Texas Children’s Hospital:

• Use of autologous tissue reconstruction and avoidance of prosthetic material.

• Concomitant intracardiac repair.

• Use of anatomic reconstruction.

• Optimization of ventriculoarterial coupling.

• Preservation of laryngeal nerve function.

“The principles we developed at Texas Children’s Hospital we hope will translate into fewer of these patients that surgeons caring for adults with aortic disease will have to take care of later in life,” Dr. Fraser said at the meeting sponsored by the American Association for Thoracic Surgery. He reviewed cases in which he explained techniques he and his colleagues developed to address long-term outcomes.

The first challenge is to determine when to perform aortic repair in pediatric patients. “A question often asked is how small is too small when assessing the aortic arch in association with significant periductal coarctation?” he said. “Our rule of thumb has been that the arch diameter measured in millimeters should be at least the patient’s weight in kilograms plus one.” In other words, a 3-kg baby should have an aortic arch of at least 4 mm in diameter, he said.

He described the case of a 3.8-kg male baby on prostaglandin E1 who had aortic arch advancement repair and closure of atrial and ventricular septal defects at 8 days of age. The patient had an early origin of the left common carotid artery and a small proximal aortic arch. “This is the kind of patient in which we would do a complete aortic arch reconstruction, again with the autologous technique,” Dr. Fraser said.

In such a patient, Dr. Fraser and his colleagues at Texas Children’s Hospital support the circulation to the brain with antegrade cerebral perfusion, using transcranial Doppler and near-infrared spectroscopy to guide their profusion strategy, before putting the child on cardiac bypass and “profound” hypothermia. Careful planning before cannulation is important to perform the aortic transection at the correct level, he said

He also explained the ascending sliding arch aortoplasty, also known as the “Texas slide,” first described by E. Dean McKenzie, M.D., at Texas Children’s Hospital in 2011 (Ann. Thorac. Surg. 2011;91:805-10) This technique involves sliding a tongue-shaped piece of the ascending aorta underneath the aortic arch to construct an all-autologous repair.

“In patients with bicuspid aortic valves, we often observe that the ascending aorta is extremely elongated,” he said. “The idea is to take advantage of that and slide the ascending aorta completely up underneath the aortic arch and construct an all-autologous arch advancement type of repair.”

He presented the case of a 4-year-old boy with coarctation of the aorta in whom the Texas slide was indicated. “If this patient were treated with a simple coarctectomy, the patient would be subject to a life with a moderately hypoplastic aortic arch, and over the course of time, this could be problematic,” Dr. Fraser said. “The sliding reconstruction has relevance not only to the status of the aortic arch over the long term but it also has a profound effect on ventricular function.”

He noted a single-center, retrospective study from the United Kingdom that demonstrated that the quality of the aortic arch reconstruction, and the related opportunity for ventricular arterial coupling, directly correlate with long-term performance of the aortic arch in patients with hypoplastic left heart syndrome (J Thorac Cardiovasc Surg. 2014;148:1526-33).

“This is very important as part of the growing population of these patients who need long-term management, most of whom we’re anticipating managing not just for years, but for decades,” Dr. Fraser said.

He said he had no relevant financial disclosures.

NEW YORK – Deep hypothermia may affect long-term survival in individuals who have aortic arch surgery with antegrade cerebral perfusion (ACP), but not short-term outcomes in terms of death and major morbidities, according to a Baylor College of Medicine study.

The study evaluated outcomes of 544 consecutive patients who had proximal and total aortic arch surgery and received ACP for more than 30 minutes over a 10-year period, said lead investigator Ourania Preventza, MD, of the division of cardiothoracic surgery at the college in Houston. The researchers compared results of three different hypothermia levels: deep hypothermia at 14.1°-20° C; low-moderate at 20.1°-23.9° C; and high-moderate at 24°-28° C. The study also classified ACP time in two levels: 31-45 minutes for 238 patients (43.8%); and 45 minutes or more in 306 patients (56.3%).

“The different temperature levels did not significantly affect the short-term mortality and major morbidity rates,” Dr. Preventza said. “Reoperation for bleeding was associated with lower temperature (14.1°-20° C). The long-term survival rate in patients who underwent proximal arch surgery involving ACP for more than 30 minutes and use of moderate hypothermia (20.1°-28° C) were actually improved.”

While the outcomes showed small variations between the three groups, with deep hypothermia being associated with a higher percentage of adverse outcomes, Dr. Preventza said the differences were not statistically significant. The overall operative mortality rate was 12.5% (68 patients): 15.5% (18 patients) in the deep-hypothermia group; 11.8% (31 patients) in the low-moderate group; and 11.5% (19 patients) in the high-moderate group (P = 0.54).

The patients who underwent deep hypothermia were more likely to receive unilateral ACP, and those who underwent moderate hypothermia were more likely to have bilateral ACP, Dr. Preventza said at the meeting sponsored by the American Association for Thoracic Surgery. The deep-hypothermia group had higher transfusion rates, but, again, the researchers did not consider this variation to be statistically significant.

In the deep-hypothermia group, 20.9% of patients had a reoperation for bleeding, compared with 11.3% in the overall group and 7.7% and 10.2% in the low- and high-moderate groups, respectively, Dr. Preventza reported. Multivariate analysis revealed that higher temperature was associated with less bleeding, with an odds ratio of 0.61 (P = 0.015).

Deep hypothermia was related to statistically significant differences in the rates of permanent stroke and permanent neurologic events in the univariate analysis only, Dr. Preventza said: 6.3% and 7.2%, respectively, in the overall analysis vs. 12.2% for both events in the deep-hypothermia group. In the propensity score analysis, the rates of permanent stroke and permanent neurologic events in the moderate-hypothermia group were 7.6% and 8.5%, respectively, vs. 11.3% for both events in the deep-hypothermia group, a nonsignificant difference.

“With regard to permanent stoke and permanent neurological events, the multivariate analysis showed that preoperatively a neurologic deficit as well as acute type I aortic dissection were associated with adverse neurological events,” she said.

“However,” Dr. Preventza added, “the surprising thing is that when we looked at long-term survival for the entire cohort, we saw that the patients with moderate hypothermia did better.”

Kaplan-Meier analysis for the propensity pairs showed that the probability of survival at 8 years was 55.3% for the deep-hypothermia group vs. 68.5% for the moderate-hypothermia group.

The approach the Baylor researchers used involved cannulating the axillary or innominate artery in most patients before administering ACP, although a few patients had femoral or direct aortic cannulation, Dr. Preventza said. For bilateral ACP, the researchers delivered cerebral perfusion via a 9-French Pruitt balloon-tip catheter (LeMaitre Vascular) in the left common carotid artery. To protect the brain, they administered perfusion at 8-12 cc/kg per min and maintained a perfusion pressure of 50-70 mm Hg, as measured via the radial arterial line and guided by near-infrared spectroscopy.

Dr. Preventza had no relevant disclosures.

NEW YORK – Deep hypothermia may affect long-term survival in individuals who have aortic arch surgery with antegrade cerebral perfusion (ACP), but not short-term outcomes in terms of death and major morbidities, according to a Baylor College of Medicine study.

The study evaluated outcomes of 544 consecutive patients who had proximal and total aortic arch surgery and received ACP for more than 30 minutes over a 10-year period, said lead investigator Ourania Preventza, MD, of the division of cardiothoracic surgery at the college in Houston. The researchers compared results of three different hypothermia levels: deep hypothermia at 14.1°-20° C; low-moderate at 20.1°-23.9° C; and high-moderate at 24°-28° C. The study also classified ACP time in two levels: 31-45 minutes for 238 patients (43.8%); and 45 minutes or more in 306 patients (56.3%).

“The different temperature levels did not significantly affect the short-term mortality and major morbidity rates,” Dr. Preventza said. “Reoperation for bleeding was associated with lower temperature (14.1°-20° C). The long-term survival rate in patients who underwent proximal arch surgery involving ACP for more than 30 minutes and use of moderate hypothermia (20.1°-28° C) were actually improved.”

While the outcomes showed small variations between the three groups, with deep hypothermia being associated with a higher percentage of adverse outcomes, Dr. Preventza said the differences were not statistically significant. The overall operative mortality rate was 12.5% (68 patients): 15.5% (18 patients) in the deep-hypothermia group; 11.8% (31 patients) in the low-moderate group; and 11.5% (19 patients) in the high-moderate group (P = 0.54).

The patients who underwent deep hypothermia were more likely to receive unilateral ACP, and those who underwent moderate hypothermia were more likely to have bilateral ACP, Dr. Preventza said at the meeting sponsored by the American Association for Thoracic Surgery. The deep-hypothermia group had higher transfusion rates, but, again, the researchers did not consider this variation to be statistically significant.

In the deep-hypothermia group, 20.9% of patients had a reoperation for bleeding, compared with 11.3% in the overall group and 7.7% and 10.2% in the low- and high-moderate groups, respectively, Dr. Preventza reported. Multivariate analysis revealed that higher temperature was associated with less bleeding, with an odds ratio of 0.61 (P = 0.015).

Deep hypothermia was related to statistically significant differences in the rates of permanent stroke and permanent neurologic events in the univariate analysis only, Dr. Preventza said: 6.3% and 7.2%, respectively, in the overall analysis vs. 12.2% for both events in the deep-hypothermia group. In the propensity score analysis, the rates of permanent stroke and permanent neurologic events in the moderate-hypothermia group were 7.6% and 8.5%, respectively, vs. 11.3% for both events in the deep-hypothermia group, a nonsignificant difference.

“With regard to permanent stoke and permanent neurological events, the multivariate analysis showed that preoperatively a neurologic deficit as well as acute type I aortic dissection were associated with adverse neurological events,” she said.

“However,” Dr. Preventza added, “the surprising thing is that when we looked at long-term survival for the entire cohort, we saw that the patients with moderate hypothermia did better.”

Kaplan-Meier analysis for the propensity pairs showed that the probability of survival at 8 years was 55.3% for the deep-hypothermia group vs. 68.5% for the moderate-hypothermia group.

The approach the Baylor researchers used involved cannulating the axillary or innominate artery in most patients before administering ACP, although a few patients had femoral or direct aortic cannulation, Dr. Preventza said. For bilateral ACP, the researchers delivered cerebral perfusion via a 9-French Pruitt balloon-tip catheter (LeMaitre Vascular) in the left common carotid artery. To protect the brain, they administered perfusion at 8-12 cc/kg per min and maintained a perfusion pressure of 50-70 mm Hg, as measured via the radial arterial line and guided by near-infrared spectroscopy.

Dr. Preventza had no relevant disclosures.

NEW YORK – Deep hypothermia may affect long-term survival in individuals who have aortic arch surgery with antegrade cerebral perfusion (ACP), but not short-term outcomes in terms of death and major morbidities, according to a Baylor College of Medicine study.

The study evaluated outcomes of 544 consecutive patients who had proximal and total aortic arch surgery and received ACP for more than 30 minutes over a 10-year period, said lead investigator Ourania Preventza, MD, of the division of cardiothoracic surgery at the college in Houston. The researchers compared results of three different hypothermia levels: deep hypothermia at 14.1°-20° C; low-moderate at 20.1°-23.9° C; and high-moderate at 24°-28° C. The study also classified ACP time in two levels: 31-45 minutes for 238 patients (43.8%); and 45 minutes or more in 306 patients (56.3%).

“The different temperature levels did not significantly affect the short-term mortality and major morbidity rates,” Dr. Preventza said. “Reoperation for bleeding was associated with lower temperature (14.1°-20° C). The long-term survival rate in patients who underwent proximal arch surgery involving ACP for more than 30 minutes and use of moderate hypothermia (20.1°-28° C) were actually improved.”

While the outcomes showed small variations between the three groups, with deep hypothermia being associated with a higher percentage of adverse outcomes, Dr. Preventza said the differences were not statistically significant. The overall operative mortality rate was 12.5% (68 patients): 15.5% (18 patients) in the deep-hypothermia group; 11.8% (31 patients) in the low-moderate group; and 11.5% (19 patients) in the high-moderate group (P = 0.54).

The patients who underwent deep hypothermia were more likely to receive unilateral ACP, and those who underwent moderate hypothermia were more likely to have bilateral ACP, Dr. Preventza said at the meeting sponsored by the American Association for Thoracic Surgery. The deep-hypothermia group had higher transfusion rates, but, again, the researchers did not consider this variation to be statistically significant.

In the deep-hypothermia group, 20.9% of patients had a reoperation for bleeding, compared with 11.3% in the overall group and 7.7% and 10.2% in the low- and high-moderate groups, respectively, Dr. Preventza reported. Multivariate analysis revealed that higher temperature was associated with less bleeding, with an odds ratio of 0.61 (P = 0.015).

Deep hypothermia was related to statistically significant differences in the rates of permanent stroke and permanent neurologic events in the univariate analysis only, Dr. Preventza said: 6.3% and 7.2%, respectively, in the overall analysis vs. 12.2% for both events in the deep-hypothermia group. In the propensity score analysis, the rates of permanent stroke and permanent neurologic events in the moderate-hypothermia group were 7.6% and 8.5%, respectively, vs. 11.3% for both events in the deep-hypothermia group, a nonsignificant difference.

“With regard to permanent stoke and permanent neurological events, the multivariate analysis showed that preoperatively a neurologic deficit as well as acute type I aortic dissection were associated with adverse neurological events,” she said.

“However,” Dr. Preventza added, “the surprising thing is that when we looked at long-term survival for the entire cohort, we saw that the patients with moderate hypothermia did better.”

Kaplan-Meier analysis for the propensity pairs showed that the probability of survival at 8 years was 55.3% for the deep-hypothermia group vs. 68.5% for the moderate-hypothermia group.

The approach the Baylor researchers used involved cannulating the axillary or innominate artery in most patients before administering ACP, although a few patients had femoral or direct aortic cannulation, Dr. Preventza said. For bilateral ACP, the researchers delivered cerebral perfusion via a 9-French Pruitt balloon-tip catheter (LeMaitre Vascular) in the left common carotid artery. To protect the brain, they administered perfusion at 8-12 cc/kg per min and maintained a perfusion pressure of 50-70 mm Hg, as measured via the radial arterial line and guided by near-infrared spectroscopy.

Dr. Preventza had no relevant disclosures.

NEW YORK – A study of an international database of individuals who have had open repair for acute type A aortic dissection (ATAAD) has revealed that in the past 20 years, cardiovascular surgeons have widely embraced valve-sparing procedures, bioprosthetic valves, and cerebral profusion strategies, according to a report here on the latest analysis of the database.

The most telling result is the decline in overall mortality, Santi Trimarchi, MD, PhD, of the University of Milan IRCCS Policlinico San Donato in Italy reported on behalf of the International Registry of Acute Aortic Dissection (IRAD) Interventional Cohort (IVC). The cohort analyzed surgery techniques and outcomes of 1,732 patients who had open repair from 1996 to 2016, clustering results in three time intervals: 1996-2003; 2004-2009; and 2010-2015.

“We noted in the registry that the overall in-hospital mortality rate was 14.3%, and this mortality decreased over time from 17.5% in the first six-year time span to 12.2% in the last six years,” Dr. Trimarchi said.

Among other trends the study identified are greater reliance on biological vs. mechanical valves, an increase in valve-sparing procedures, and steady use of Bentall procedures throughout the study period. “Operative techniques for redo aortic valve repair have been improving over the time, and that’s why we see more frequent use of biologic valves,” he said at the meeting, sponsored by the American Association for Thoracic Surgery.

“Cerebral profusion management has been widely adopted,” Dr. Trimarchi said. “Also there is an important trend showing an increasing utilization of antegrade cerebral profusion while we see a negative trend of the utilization of retrograde brain protection.”

Dr. Trimarchi attributed the detail the study generated to the survey form sent to the 26 IRAD-IVC sites around the world. The form measures 131 different variables, he said.

“Using this new specific surgical data form, we think we can address some surgical issues and report better data from the IRAD registry results on acute dissection,” he said. “These analyses have shown there have been significant changes in operative strategy over time in terms of managing such patients, and more importantly, a significant decrease in in-hospital mortality was observed in a 20-year time period.”

Dr. Trimarchi disclosed that he has received speaking and consulting fees and research support from W.L. Gore & Associates and Medtronic. IRAD is supported by W.L. Gore, Active Sites, Medtronic, Varbedian Aortic Research Fund, the Hewlett Foundation, the Mardigian Foundation, UM Faculty Group Practice, Terumo, and Ann and Bob Aikens.

NEW YORK – A study of an international database of individuals who have had open repair for acute type A aortic dissection (ATAAD) has revealed that in the past 20 years, cardiovascular surgeons have widely embraced valve-sparing procedures, bioprosthetic valves, and cerebral profusion strategies, according to a report here on the latest analysis of the database.

The most telling result is the decline in overall mortality, Santi Trimarchi, MD, PhD, of the University of Milan IRCCS Policlinico San Donato in Italy reported on behalf of the International Registry of Acute Aortic Dissection (IRAD) Interventional Cohort (IVC). The cohort analyzed surgery techniques and outcomes of 1,732 patients who had open repair from 1996 to 2016, clustering results in three time intervals: 1996-2003; 2004-2009; and 2010-2015.

“We noted in the registry that the overall in-hospital mortality rate was 14.3%, and this mortality decreased over time from 17.5% in the first six-year time span to 12.2% in the last six years,” Dr. Trimarchi said.

Among other trends the study identified are greater reliance on biological vs. mechanical valves, an increase in valve-sparing procedures, and steady use of Bentall procedures throughout the study period. “Operative techniques for redo aortic valve repair have been improving over the time, and that’s why we see more frequent use of biologic valves,” he said at the meeting, sponsored by the American Association for Thoracic Surgery.

“Cerebral profusion management has been widely adopted,” Dr. Trimarchi said. “Also there is an important trend showing an increasing utilization of antegrade cerebral profusion while we see a negative trend of the utilization of retrograde brain protection.”

Dr. Trimarchi attributed the detail the study generated to the survey form sent to the 26 IRAD-IVC sites around the world. The form measures 131 different variables, he said.

“Using this new specific surgical data form, we think we can address some surgical issues and report better data from the IRAD registry results on acute dissection,” he said. “These analyses have shown there have been significant changes in operative strategy over time in terms of managing such patients, and more importantly, a significant decrease in in-hospital mortality was observed in a 20-year time period.”

Dr. Trimarchi disclosed that he has received speaking and consulting fees and research support from W.L. Gore & Associates and Medtronic. IRAD is supported by W.L. Gore, Active Sites, Medtronic, Varbedian Aortic Research Fund, the Hewlett Foundation, the Mardigian Foundation, UM Faculty Group Practice, Terumo, and Ann and Bob Aikens.

NEW YORK – A study of an international database of individuals who have had open repair for acute type A aortic dissection (ATAAD) has revealed that in the past 20 years, cardiovascular surgeons have widely embraced valve-sparing procedures, bioprosthetic valves, and cerebral profusion strategies, according to a report here on the latest analysis of the database.

The most telling result is the decline in overall mortality, Santi Trimarchi, MD, PhD, of the University of Milan IRCCS Policlinico San Donato in Italy reported on behalf of the International Registry of Acute Aortic Dissection (IRAD) Interventional Cohort (IVC). The cohort analyzed surgery techniques and outcomes of 1,732 patients who had open repair from 1996 to 2016, clustering results in three time intervals: 1996-2003; 2004-2009; and 2010-2015.

“We noted in the registry that the overall in-hospital mortality rate was 14.3%, and this mortality decreased over time from 17.5% in the first six-year time span to 12.2% in the last six years,” Dr. Trimarchi said.

Among other trends the study identified are greater reliance on biological vs. mechanical valves, an increase in valve-sparing procedures, and steady use of Bentall procedures throughout the study period. “Operative techniques for redo aortic valve repair have been improving over the time, and that’s why we see more frequent use of biologic valves,” he said at the meeting, sponsored by the American Association for Thoracic Surgery.

“Cerebral profusion management has been widely adopted,” Dr. Trimarchi said. “Also there is an important trend showing an increasing utilization of antegrade cerebral profusion while we see a negative trend of the utilization of retrograde brain protection.”

Dr. Trimarchi attributed the detail the study generated to the survey form sent to the 26 IRAD-IVC sites around the world. The form measures 131 different variables, he said.

“Using this new specific surgical data form, we think we can address some surgical issues and report better data from the IRAD registry results on acute dissection,” he said. “These analyses have shown there have been significant changes in operative strategy over time in terms of managing such patients, and more importantly, a significant decrease in in-hospital mortality was observed in a 20-year time period.”

Dr. Trimarchi disclosed that he has received speaking and consulting fees and research support from W.L. Gore & Associates and Medtronic. IRAD is supported by W.L. Gore, Active Sites, Medtronic, Varbedian Aortic Research Fund, the Hewlett Foundation, the Mardigian Foundation, UM Faculty Group Practice, Terumo, and Ann and Bob Aikens.

NEW YORK – Mastery is the product of repetition, and it has long been taken for granted that surgeons and centers that perform a high volume of an operation will have better results than those who don’t do the operation as often, but a study out of the United Kingdom has determined just how much better high-volume centers are when it comes to repair of acute type A aortic dissection (ATAD) – and what the in-hospital mortality odds ratio is for lower-volume surgeons.

Specifically, that odds ratio is 1.64 (P = .030), Mohamad Bashir, MD, PhD, MRCS, a research fellow at Liverpool Heart and Chest Hospital, said in reporting early results of the study here. Lower-volume surgeons had worse outcomes in 12 of 14 different operative metrics the study evaluated, most notably in-hospital mortality: 20.2% for lower-volume surgeons vs. 15.2% for higher-volume surgeons. “There is an initiative in the U.K. to change the trend,” Dr. Bashir said. Full study results will be published in an upcoming issue of BMJ, he said.

“In-hospital mortality for surgeons who operate on 20 or more procedures is very good at 13.2%, and the same follows for 90-day mortality, one-year mortality and three-year mortality,” Dr. Bashir said.

The study evaluated 1,386 ATAD procedures in the National Institute for Cardiovascular Outcomes Research database by 218 different cardiac surgeons at 33 different hospitals in England and Wales from April 2007 to March 2013. That would make the average number of procedures per surgeon 6.4, Dr. Bashir said, but a closer look at each surgeon’s case load reveals some disconcerting trends: almost 80% of the surgeons performed fewer than 10 ATAD repairs in the 6-year span of the study, and 34 surgeons, or about 15%, just did a single procedure in that time. The highest-volume surgeon did 32 procedures. The minimum hospital volume was 8 ATAD operations and the maximum was 103.

The study stratified lower- and higher-volume surgeon groups by characteristics of the patients they operated on. “The differences between these two groups are pretty interesting because we noticed that the lower-volume surgeons are actually operating on patients who are diabetic, who are smokers, who use inotropic support prior to anesthesia and who also have an injection fraction that is significant,” Dr. Bashir said.

In drilling down into those characteristics, people with diabetes made up 6% of the lower-volume surgeons’ cases vs. 3.1% of the higher-volume surgeons’ cases, despite an almost 50-50 split in share of procedures between the two surgeon groups. Current smokers comprised 20.5% of the lower-volume surgeons’ patients vs. 15.5% of their high-volume counterparts’ patients. Operative characteristics in terms of urgency of surgery were similar between the two groups. However Dr. Bashir noted, lower-volume surgeons had longer times for cardiopulmonary bypass, aortic cross-clamping, and circulatory arrest.

The study investigators applied a multivariable logistic regression model to determine predictors of in-hospital mortality for ATAD. “The odds ratio (OR) of mortality for lower-volume surgeons is 1.64, which is statistically significant,” Dr. Bashir said. Odds ratios for other predictors are: previous cardiac surgery, 2.51; peripheral vascular disease, 2.15; preoperative cardiogenic shock, 2.05; salvage operation, 5.57; and concomitant coronary artery bypass procedure, 2.98. For 5-year mortality, the odds ratio was 1.37 for the lower-volume surgeons.

Dr. Bashir laid out how the National Health Service can use the study results. “Concentration of expertise and volume to the appropriate surgeons and centers who perform increasingly more work and more complex aortic cases would be required to change the paradigm of acute type A aortic dissection outcomes in the U.K.,” he said. “It is reasonable to suggest that there should be a national standardization mandate and a quality-improvement framework of acute aortic dissection treatment.”

Dr. Bashir had no financial relationships to disclose.

NEW YORK – Mastery is the product of repetition, and it has long been taken for granted that surgeons and centers that perform a high volume of an operation will have better results than those who don’t do the operation as often, but a study out of the United Kingdom has determined just how much better high-volume centers are when it comes to repair of acute type A aortic dissection (ATAD) – and what the in-hospital mortality odds ratio is for lower-volume surgeons.

Specifically, that odds ratio is 1.64 (P = .030), Mohamad Bashir, MD, PhD, MRCS, a research fellow at Liverpool Heart and Chest Hospital, said in reporting early results of the study here. Lower-volume surgeons had worse outcomes in 12 of 14 different operative metrics the study evaluated, most notably in-hospital mortality: 20.2% for lower-volume surgeons vs. 15.2% for higher-volume surgeons. “There is an initiative in the U.K. to change the trend,” Dr. Bashir said. Full study results will be published in an upcoming issue of BMJ, he said.

“In-hospital mortality for surgeons who operate on 20 or more procedures is very good at 13.2%, and the same follows for 90-day mortality, one-year mortality and three-year mortality,” Dr. Bashir said.

The study evaluated 1,386 ATAD procedures in the National Institute for Cardiovascular Outcomes Research database by 218 different cardiac surgeons at 33 different hospitals in England and Wales from April 2007 to March 2013. That would make the average number of procedures per surgeon 6.4, Dr. Bashir said, but a closer look at each surgeon’s case load reveals some disconcerting trends: almost 80% of the surgeons performed fewer than 10 ATAD repairs in the 6-year span of the study, and 34 surgeons, or about 15%, just did a single procedure in that time. The highest-volume surgeon did 32 procedures. The minimum hospital volume was 8 ATAD operations and the maximum was 103.

The study stratified lower- and higher-volume surgeon groups by characteristics of the patients they operated on. “The differences between these two groups are pretty interesting because we noticed that the lower-volume surgeons are actually operating on patients who are diabetic, who are smokers, who use inotropic support prior to anesthesia and who also have an injection fraction that is significant,” Dr. Bashir said.

In drilling down into those characteristics, people with diabetes made up 6% of the lower-volume surgeons’ cases vs. 3.1% of the higher-volume surgeons’ cases, despite an almost 50-50 split in share of procedures between the two surgeon groups. Current smokers comprised 20.5% of the lower-volume surgeons’ patients vs. 15.5% of their high-volume counterparts’ patients. Operative characteristics in terms of urgency of surgery were similar between the two groups. However Dr. Bashir noted, lower-volume surgeons had longer times for cardiopulmonary bypass, aortic cross-clamping, and circulatory arrest.

The study investigators applied a multivariable logistic regression model to determine predictors of in-hospital mortality for ATAD. “The odds ratio (OR) of mortality for lower-volume surgeons is 1.64, which is statistically significant,” Dr. Bashir said. Odds ratios for other predictors are: previous cardiac surgery, 2.51; peripheral vascular disease, 2.15; preoperative cardiogenic shock, 2.05; salvage operation, 5.57; and concomitant coronary artery bypass procedure, 2.98. For 5-year mortality, the odds ratio was 1.37 for the lower-volume surgeons.

Dr. Bashir laid out how the National Health Service can use the study results. “Concentration of expertise and volume to the appropriate surgeons and centers who perform increasingly more work and more complex aortic cases would be required to change the paradigm of acute type A aortic dissection outcomes in the U.K.,” he said. “It is reasonable to suggest that there should be a national standardization mandate and a quality-improvement framework of acute aortic dissection treatment.”

Dr. Bashir had no financial relationships to disclose.

NEW YORK – Mastery is the product of repetition, and it has long been taken for granted that surgeons and centers that perform a high volume of an operation will have better results than those who don’t do the operation as often, but a study out of the United Kingdom has determined just how much better high-volume centers are when it comes to repair of acute type A aortic dissection (ATAD) – and what the in-hospital mortality odds ratio is for lower-volume surgeons.

Specifically, that odds ratio is 1.64 (P = .030), Mohamad Bashir, MD, PhD, MRCS, a research fellow at Liverpool Heart and Chest Hospital, said in reporting early results of the study here. Lower-volume surgeons had worse outcomes in 12 of 14 different operative metrics the study evaluated, most notably in-hospital mortality: 20.2% for lower-volume surgeons vs. 15.2% for higher-volume surgeons. “There is an initiative in the U.K. to change the trend,” Dr. Bashir said. Full study results will be published in an upcoming issue of BMJ, he said.

“In-hospital mortality for surgeons who operate on 20 or more procedures is very good at 13.2%, and the same follows for 90-day mortality, one-year mortality and three-year mortality,” Dr. Bashir said.

The study evaluated 1,386 ATAD procedures in the National Institute for Cardiovascular Outcomes Research database by 218 different cardiac surgeons at 33 different hospitals in England and Wales from April 2007 to March 2013. That would make the average number of procedures per surgeon 6.4, Dr. Bashir said, but a closer look at each surgeon’s case load reveals some disconcerting trends: almost 80% of the surgeons performed fewer than 10 ATAD repairs in the 6-year span of the study, and 34 surgeons, or about 15%, just did a single procedure in that time. The highest-volume surgeon did 32 procedures. The minimum hospital volume was 8 ATAD operations and the maximum was 103.

The study stratified lower- and higher-volume surgeon groups by characteristics of the patients they operated on. “The differences between these two groups are pretty interesting because we noticed that the lower-volume surgeons are actually operating on patients who are diabetic, who are smokers, who use inotropic support prior to anesthesia and who also have an injection fraction that is significant,” Dr. Bashir said.

In drilling down into those characteristics, people with diabetes made up 6% of the lower-volume surgeons’ cases vs. 3.1% of the higher-volume surgeons’ cases, despite an almost 50-50 split in share of procedures between the two surgeon groups. Current smokers comprised 20.5% of the lower-volume surgeons’ patients vs. 15.5% of their high-volume counterparts’ patients. Operative characteristics in terms of urgency of surgery were similar between the two groups. However Dr. Bashir noted, lower-volume surgeons had longer times for cardiopulmonary bypass, aortic cross-clamping, and circulatory arrest.

The study investigators applied a multivariable logistic regression model to determine predictors of in-hospital mortality for ATAD. “The odds ratio (OR) of mortality for lower-volume surgeons is 1.64, which is statistically significant,” Dr. Bashir said. Odds ratios for other predictors are: previous cardiac surgery, 2.51; peripheral vascular disease, 2.15; preoperative cardiogenic shock, 2.05; salvage operation, 5.57; and concomitant coronary artery bypass procedure, 2.98. For 5-year mortality, the odds ratio was 1.37 for the lower-volume surgeons.

Dr. Bashir laid out how the National Health Service can use the study results. “Concentration of expertise and volume to the appropriate surgeons and centers who perform increasingly more work and more complex aortic cases would be required to change the paradigm of acute type A aortic dissection outcomes in the U.K.,” he said. “It is reasonable to suggest that there should be a national standardization mandate and a quality-improvement framework of acute aortic dissection treatment.”

Dr. Bashir had no financial relationships to disclose.

NEW YORK – While overall guidelines for aortic repair surgery have not changed significantly in the past 5 years, guidelines for the timing of surgery in patients with bicuspid aortic valves and enlarged aortas have undergone some updating in an attempt to clear up disparities in different guidelines on when to operate on those patients.

Lars G. Svensson, MD, PhD, chairman of the Cleveland Clinic Heart and Vascular Institute, coauthor of the clarification statement by the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines (J Thorac Cardiovasc Surg. 2016;151:959-66), reported on the guidelines clarification at the meeting sponsored by the American Association for Thoracic Surgery. He noted that five different clinical guidelines between 2010 and 2014 recommended five different size thresholds for prophylactic aortic root or ascending aortic surgery in the setting of bicuspid aortic valve (BAV), ranging from 4 cm to greater than 5.5 cm. “This created a bit of a quandary and controversy between different guidelines and time periods,” he said.

Dr. Svensson and Loren Hiratzka, MD, medical director of cardiac surgery for TriHealth in Cincinnati, and their colleagues drafted the guideline clarification that makes the following recommendations for aortic root and ascending aorta repair or replacement when patients have BAV (strength of recommendation):

• Surgery is indicated to replace the aortic root or ascending aorta in asymptomatic patients with BAV if the diameter of the aortic root or ascending aorta is 5.5 cm or greater (Class 1).

• Surgical repair is indicated for asymptomatic patients with BAV if the root or ascending aorta diameter is 5 cm or greater in two scenarios: if the patient has an additional risk factor for dissection, such as family history or excessive aortic growth rate; or if the patient is a low surgical risk and has access to an experienced surgeon at a high-volume center (Class IIa).

The guideline update also addresses BAV in patients with Turner syndrome. The 2010 joint guidelines of 10 societies left some questions with regard to surgery in these patients, Dr. Svensson said. The established guidelines included a Class IIb recommendation for imaging of the heart and aorta to help determine the aorta risk in patients with Turner syndrome who had additional risk factors, including BAV, aortic coarctation and/or hypertension, or were planning a pregnancy.

The updated guideline includes Class IIa recommendation that in short-statured patients with Turner syndrome and BAV, measurement of the aortic root or ascending aorta diameter may not predict the dissection risk as well as aortic diameter index greater than 2.5 cm/m². The updated recommendations also draw on one study that reported that in patients with BAV, a maximum aortic cross-sectional area-to-height ratio of 10 cm²/m or greater was also predictive of aortic dissection. (Ann Thorac Surg. 2015;100:1666-73)

The updated recommendations for open surgery for ascending aortic aneurysm include separate valve and ascending aortic replacement in patients without significant aortic root dilatation or in elderly patients, or in younger patients with minimal dilatation who have aortic valve disease; and excision of the sinuses of Valsalva with a modified David reimplantation when technically feasible in patients with connective tissue disease and others with dilatation of the aortic root and sinuses. For patients in whom the latter procedure is not feasible, root replacement with valved graft conduit would be indicated, Dr. Svensson said.

Dr. Svensson also reported on recent studies that validated recommendations in established guidelines.

Studies of circulatory arrest practices in aortic arch surgery as prescribed by established guidelines showed confirmatory results, he said. “The one point I would make about circulatory arrest is that we found in a fairly large study of 1,352 circulatory arrest patients that we reduced the risk of stroke by 40% when we used the axillary artery with a side a graft,” he said (Ann Thorac Surg. 2004;78:1274-84). His own institution’s clinical trial of 121 patients who received antegrade or retrograde brain perfusion showed rates of 0.8% for each stroke and operative death, he said (J Thorac Cardiovasc Surg. 2015;150:1140-7).

“What was also of interest there was no difference in outcomes with antegrade vs. retrograde brain profusion,” he said. “I think protection of the brain is pretty good if you follow the fundamental principles of brain protection.”

He also reported on a recent study at his institution that documented the benefits of intrathecal papaverine (IP) for spinal cord protection during descending open and endovascular aortic repairs. In 398 aortic repairs from 2001-2009, the rates of spinal cord injury were 23% in the non-IP group vs. 7% in the IP group (P = .07) in a matched cohort.

He noted that the clinical guidelines of the American Association for Thoracic Surgery as well as AATS/Society of Thoracic Surgeons joint guidelines are open to input. “If you have areas where you think guideline should be written about, please let me or other members of the committee know,” he said.

Dr. Svensson had no disclosures relevant to his presentation.

NEW YORK – While overall guidelines for aortic repair surgery have not changed significantly in the past 5 years, guidelines for the timing of surgery in patients with bicuspid aortic valves and enlarged aortas have undergone some updating in an attempt to clear up disparities in different guidelines on when to operate on those patients.

Lars G. Svensson, MD, PhD, chairman of the Cleveland Clinic Heart and Vascular Institute, coauthor of the clarification statement by the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines (J Thorac Cardiovasc Surg. 2016;151:959-66), reported on the guidelines clarification at the meeting sponsored by the American Association for Thoracic Surgery. He noted that five different clinical guidelines between 2010 and 2014 recommended five different size thresholds for prophylactic aortic root or ascending aortic surgery in the setting of bicuspid aortic valve (BAV), ranging from 4 cm to greater than 5.5 cm. “This created a bit of a quandary and controversy between different guidelines and time periods,” he said.

Dr. Svensson and Loren Hiratzka, MD, medical director of cardiac surgery for TriHealth in Cincinnati, and their colleagues drafted the guideline clarification that makes the following recommendations for aortic root and ascending aorta repair or replacement when patients have BAV (strength of recommendation):

• Surgery is indicated to replace the aortic root or ascending aorta in asymptomatic patients with BAV if the diameter of the aortic root or ascending aorta is 5.5 cm or greater (Class 1).

• Surgical repair is indicated for asymptomatic patients with BAV if the root or ascending aorta diameter is 5 cm or greater in two scenarios: if the patient has an additional risk factor for dissection, such as family history or excessive aortic growth rate; or if the patient is a low surgical risk and has access to an experienced surgeon at a high-volume center (Class IIa).

The guideline update also addresses BAV in patients with Turner syndrome. The 2010 joint guidelines of 10 societies left some questions with regard to surgery in these patients, Dr. Svensson said. The established guidelines included a Class IIb recommendation for imaging of the heart and aorta to help determine the aorta risk in patients with Turner syndrome who had additional risk factors, including BAV, aortic coarctation and/or hypertension, or were planning a pregnancy.

The updated guideline includes Class IIa recommendation that in short-statured patients with Turner syndrome and BAV, measurement of the aortic root or ascending aorta diameter may not predict the dissection risk as well as aortic diameter index greater than 2.5 cm/m². The updated recommendations also draw on one study that reported that in patients with BAV, a maximum aortic cross-sectional area-to-height ratio of 10 cm²/m or greater was also predictive of aortic dissection. (Ann Thorac Surg. 2015;100:1666-73)

The updated recommendations for open surgery for ascending aortic aneurysm include separate valve and ascending aortic replacement in patients without significant aortic root dilatation or in elderly patients, or in younger patients with minimal dilatation who have aortic valve disease; and excision of the sinuses of Valsalva with a modified David reimplantation when technically feasible in patients with connective tissue disease and others with dilatation of the aortic root and sinuses. For patients in whom the latter procedure is not feasible, root replacement with valved graft conduit would be indicated, Dr. Svensson said.

Dr. Svensson also reported on recent studies that validated recommendations in established guidelines.

Studies of circulatory arrest practices in aortic arch surgery as prescribed by established guidelines showed confirmatory results, he said. “The one point I would make about circulatory arrest is that we found in a fairly large study of 1,352 circulatory arrest patients that we reduced the risk of stroke by 40% when we used the axillary artery with a side a graft,” he said (Ann Thorac Surg. 2004;78:1274-84). His own institution’s clinical trial of 121 patients who received antegrade or retrograde brain perfusion showed rates of 0.8% for each stroke and operative death, he said (J Thorac Cardiovasc Surg. 2015;150:1140-7).

“What was also of interest there was no difference in outcomes with antegrade vs. retrograde brain profusion,” he said. “I think protection of the brain is pretty good if you follow the fundamental principles of brain protection.”

He also reported on a recent study at his institution that documented the benefits of intrathecal papaverine (IP) for spinal cord protection during descending open and endovascular aortic repairs. In 398 aortic repairs from 2001-2009, the rates of spinal cord injury were 23% in the non-IP group vs. 7% in the IP group (P = .07) in a matched cohort.

He noted that the clinical guidelines of the American Association for Thoracic Surgery as well as AATS/Society of Thoracic Surgeons joint guidelines are open to input. “If you have areas where you think guideline should be written about, please let me or other members of the committee know,” he said.

Dr. Svensson had no disclosures relevant to his presentation.

NEW YORK – While overall guidelines for aortic repair surgery have not changed significantly in the past 5 years, guidelines for the timing of surgery in patients with bicuspid aortic valves and enlarged aortas have undergone some updating in an attempt to clear up disparities in different guidelines on when to operate on those patients.

Lars G. Svensson, MD, PhD, chairman of the Cleveland Clinic Heart and Vascular Institute, coauthor of the clarification statement by the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines (J Thorac Cardiovasc Surg. 2016;151:959-66), reported on the guidelines clarification at the meeting sponsored by the American Association for Thoracic Surgery. He noted that five different clinical guidelines between 2010 and 2014 recommended five different size thresholds for prophylactic aortic root or ascending aortic surgery in the setting of bicuspid aortic valve (BAV), ranging from 4 cm to greater than 5.5 cm. “This created a bit of a quandary and controversy between different guidelines and time periods,” he said.

Dr. Svensson and Loren Hiratzka, MD, medical director of cardiac surgery for TriHealth in Cincinnati, and their colleagues drafted the guideline clarification that makes the following recommendations for aortic root and ascending aorta repair or replacement when patients have BAV (strength of recommendation):

• Surgery is indicated to replace the aortic root or ascending aorta in asymptomatic patients with BAV if the diameter of the aortic root or ascending aorta is 5.5 cm or greater (Class 1).

• Surgical repair is indicated for asymptomatic patients with BAV if the root or ascending aorta diameter is 5 cm or greater in two scenarios: if the patient has an additional risk factor for dissection, such as family history or excessive aortic growth rate; or if the patient is a low surgical risk and has access to an experienced surgeon at a high-volume center (Class IIa).

The guideline update also addresses BAV in patients with Turner syndrome. The 2010 joint guidelines of 10 societies left some questions with regard to surgery in these patients, Dr. Svensson said. The established guidelines included a Class IIb recommendation for imaging of the heart and aorta to help determine the aorta risk in patients with Turner syndrome who had additional risk factors, including BAV, aortic coarctation and/or hypertension, or were planning a pregnancy.

The updated guideline includes Class IIa recommendation that in short-statured patients with Turner syndrome and BAV, measurement of the aortic root or ascending aorta diameter may not predict the dissection risk as well as aortic diameter index greater than 2.5 cm/m². The updated recommendations also draw on one study that reported that in patients with BAV, a maximum aortic cross-sectional area-to-height ratio of 10 cm²/m or greater was also predictive of aortic dissection. (Ann Thorac Surg. 2015;100:1666-73)

The updated recommendations for open surgery for ascending aortic aneurysm include separate valve and ascending aortic replacement in patients without significant aortic root dilatation or in elderly patients, or in younger patients with minimal dilatation who have aortic valve disease; and excision of the sinuses of Valsalva with a modified David reimplantation when technically feasible in patients with connective tissue disease and others with dilatation of the aortic root and sinuses. For patients in whom the latter procedure is not feasible, root replacement with valved graft conduit would be indicated, Dr. Svensson said.

Dr. Svensson also reported on recent studies that validated recommendations in established guidelines.

Studies of circulatory arrest practices in aortic arch surgery as prescribed by established guidelines showed confirmatory results, he said. “The one point I would make about circulatory arrest is that we found in a fairly large study of 1,352 circulatory arrest patients that we reduced the risk of stroke by 40% when we used the axillary artery with a side a graft,” he said (Ann Thorac Surg. 2004;78:1274-84). His own institution’s clinical trial of 121 patients who received antegrade or retrograde brain perfusion showed rates of 0.8% for each stroke and operative death, he said (J Thorac Cardiovasc Surg. 2015;150:1140-7).

“What was also of interest there was no difference in outcomes with antegrade vs. retrograde brain profusion,” he said. “I think protection of the brain is pretty good if you follow the fundamental principles of brain protection.”

He also reported on a recent study at his institution that documented the benefits of intrathecal papaverine (IP) for spinal cord protection during descending open and endovascular aortic repairs. In 398 aortic repairs from 2001-2009, the rates of spinal cord injury were 23% in the non-IP group vs. 7% in the IP group (P = .07) in a matched cohort.

He noted that the clinical guidelines of the American Association for Thoracic Surgery as well as AATS/Society of Thoracic Surgeons joint guidelines are open to input. “If you have areas where you think guideline should be written about, please let me or other members of the committee know,” he said.

Dr. Svensson had no disclosures relevant to his presentation.

BALTIMORE – Tumor size and the presence of mutations of the succinate dehydrogenase complex subunit B (SDHB) gene may be reliable indicators of prognosis after surgery for pheochromocytoma and abdominal paraganglioma, investigators in a National Cancer Institute–funded study have reported.

“The staging of pheochromocytoma and abdominal paraganglioma can be difficult, but it is critical for optimal patient care,” Yasmine Assadipour, MD, of the National Cancer Institute, Bethesda, Md., and the George Washington University Hospital, Washington, reported at the annual meeting of the American Association of Endocrine Surgeons.

“Any clinically relevant grading or prognostic system should include SDHB mutation status and primary tumor size as prime features of scoring,” Dr. Assadipour said. “Histologic features such as Ki-67 or mitotic index may not be as useful for prognostic information in patients with pheochromocytoma and abdominal paraganglioma, particularly in the setting of SDHB mutation.”

Dr. Assadipour and her coinvestigators focused their investigation on mutations of the SDHB (succinate dehydrogenase complex subunit B) gene, which codes for one of four subunits comprising a mitochondrial protein.

They also considered primary tumor size, functionality, pathology, surgical approach, and histologic features including Ki-67 index and mitotic index. The study was a retrospective analysis of 84 patients who had surgery for PC [pheochromocytoma] or PGL [paraganglioma] and had germ line genetic testing. Of the 84 patients, 35 patients had sporadic disease and 49 had germ line SDHB mutation. The study analyzed tumor samples for Ki-67/MIB-1 staining and mitotic index.

“In a univariate analysis, SDHB mutation, tumor size and surgical approach were associated with local regional recurrence,” Dr. Assadipour said. “In a multivariate analysis, the only independent risk factors were SDHB mutation status and tumor size; Ki-67 and mitotic index did not have any association with recurrence.”

The researchers found similar results when they looked at distant metastasis. “SDHB mutation, tumor size, abdominal paraganglioma and surgical approach were associated with distant metastasis,” Dr. Assadipour said. “Again, Ki-67 and mitotic index were not.”

In the multivariate analysis, again, only patient SDHB status and tumor size were independently associated with metastasis.”

Dr. Yasmine Assadipour

The incidence of local recurrence in patients with the SDHB mutation was 47.6% vs. 9.1% in those without the gene mutation, Dr. Assadipour said. The rates of distant metastasis showed a similar disparity: 56.5% and 9.1%, respectively.

Patients with the SDHB mutation presented at a younger age than those without the mutation, 33 vs. 49.6 years old. Among the 65 patients who underwent R0 primary tumor resection, those with the SDHB mutation, paraganglioma, and larger tumor size had a shorter disease-free survival, Dr. Assadipour said.

In analyzing tumor size, Dr. Assadipour said two stratifications were studied: evaluating tumors sized 0-3 cm, 3-6 cm and 6 cm and larger; and 0-5 cm and 5 cm and larger. “Tumors over 6 cm had the shortest disease-free survival, and even when we applied the under-5 cm and over-5 cm scale, we clearly saw a difference in disease-free survival,” she said. Ki-67 and mitotic index were not related to disease-free survival.

The presence of a SDHB mutation had a hazard ratio of 16.2, while tumor diameter greater than 6 cm had a HR of 15.4, Dr. Assadipour said. These were the only independent risk factors for local recurrence, distant metastases and shorter disease-free interval found in the study.

During the discussion, Lawrence T. Kim, MD, of the University of North Carolina asked if the researchers found any differences in outcomes related to the surgical approach. “We were unable to identify whether any surgical approach improved or worsened outcomes on multivariate analysis” Dr. Assadipour said.

Thomas J. Fahey, MD, of New York asked what she would recommend for surgical approaches for patients with PC and PGL.

“Our general recommendation is that an adrenal pheochromocytoma that is over 6 cm carries a higher risk of recurrence and distant metastasis so an open approach with lymph node dissection ensuring negative surgical margins should be considered,” Dr. Assadipour said. “For abdominal paragangliomas, unless they are quite small and in a favorable location, we would generally recommend an open approach.”

The study was supported by the intramural program of the Center for Cancer Research, National Cancer Institute, National Institutes of Health. Dr. Assadipour and her coauthors had no financial relationships to disclose.

BALTIMORE – Tumor size and the presence of mutations of the succinate dehydrogenase complex subunit B (SDHB) gene may be reliable indicators of prognosis after surgery for pheochromocytoma and abdominal paraganglioma, investigators in a National Cancer Institute–funded study have reported.

“The staging of pheochromocytoma and abdominal paraganglioma can be difficult, but it is critical for optimal patient care,” Yasmine Assadipour, MD, of the National Cancer Institute, Bethesda, Md., and the George Washington University Hospital, Washington, reported at the annual meeting of the American Association of Endocrine Surgeons.

“Any clinically relevant grading or prognostic system should include SDHB mutation status and primary tumor size as prime features of scoring,” Dr. Assadipour said. “Histologic features such as Ki-67 or mitotic index may not be as useful for prognostic information in patients with pheochromocytoma and abdominal paraganglioma, particularly in the setting of SDHB mutation.”

Dr. Assadipour and her coinvestigators focused their investigation on mutations of the SDHB (succinate dehydrogenase complex subunit B) gene, which codes for one of four subunits comprising a mitochondrial protein.

They also considered primary tumor size, functionality, pathology, surgical approach, and histologic features including Ki-67 index and mitotic index. The study was a retrospective analysis of 84 patients who had surgery for PC [pheochromocytoma] or PGL [paraganglioma] and had germ line genetic testing. Of the 84 patients, 35 patients had sporadic disease and 49 had germ line SDHB mutation. The study analyzed tumor samples for Ki-67/MIB-1 staining and mitotic index.

“In a univariate analysis, SDHB mutation, tumor size and surgical approach were associated with local regional recurrence,” Dr. Assadipour said. “In a multivariate analysis, the only independent risk factors were SDHB mutation status and tumor size; Ki-67 and mitotic index did not have any association with recurrence.”

The researchers found similar results when they looked at distant metastasis. “SDHB mutation, tumor size, abdominal paraganglioma and surgical approach were associated with distant metastasis,” Dr. Assadipour said. “Again, Ki-67 and mitotic index were not.”

In the multivariate analysis, again, only patient SDHB status and tumor size were independently associated with metastasis.”

Dr. Yasmine Assadipour

The incidence of local recurrence in patients with the SDHB mutation was 47.6% vs. 9.1% in those without the gene mutation, Dr. Assadipour said. The rates of distant metastasis showed a similar disparity: 56.5% and 9.1%, respectively.

Patients with the SDHB mutation presented at a younger age than those without the mutation, 33 vs. 49.6 years old. Among the 65 patients who underwent R0 primary tumor resection, those with the SDHB mutation, paraganglioma, and larger tumor size had a shorter disease-free survival, Dr. Assadipour said.

In analyzing tumor size, Dr. Assadipour said two stratifications were studied: evaluating tumors sized 0-3 cm, 3-6 cm and 6 cm and larger; and 0-5 cm and 5 cm and larger. “Tumors over 6 cm had the shortest disease-free survival, and even when we applied the under-5 cm and over-5 cm scale, we clearly saw a difference in disease-free survival,” she said. Ki-67 and mitotic index were not related to disease-free survival.

The presence of a SDHB mutation had a hazard ratio of 16.2, while tumor diameter greater than 6 cm had a HR of 15.4, Dr. Assadipour said. These were the only independent risk factors for local recurrence, distant metastases and shorter disease-free interval found in the study.

During the discussion, Lawrence T. Kim, MD, of the University of North Carolina asked if the researchers found any differences in outcomes related to the surgical approach. “We were unable to identify whether any surgical approach improved or worsened outcomes on multivariate analysis” Dr. Assadipour said.

Thomas J. Fahey, MD, of New York asked what she would recommend for surgical approaches for patients with PC and PGL.

“Our general recommendation is that an adrenal pheochromocytoma that is over 6 cm carries a higher risk of recurrence and distant metastasis so an open approach with lymph node dissection ensuring negative surgical margins should be considered,” Dr. Assadipour said. “For abdominal paragangliomas, unless they are quite small and in a favorable location, we would generally recommend an open approach.”

The study was supported by the intramural program of the Center for Cancer Research, National Cancer Institute, National Institutes of Health. Dr. Assadipour and her coauthors had no financial relationships to disclose.

BALTIMORE – Tumor size and the presence of mutations of the succinate dehydrogenase complex subunit B (SDHB) gene may be reliable indicators of prognosis after surgery for pheochromocytoma and abdominal paraganglioma, investigators in a National Cancer Institute–funded study have reported.

“The staging of pheochromocytoma and abdominal paraganglioma can be difficult, but it is critical for optimal patient care,” Yasmine Assadipour, MD, of the National Cancer Institute, Bethesda, Md., and the George Washington University Hospital, Washington, reported at the annual meeting of the American Association of Endocrine Surgeons.

“Any clinically relevant grading or prognostic system should include SDHB mutation status and primary tumor size as prime features of scoring,” Dr. Assadipour said. “Histologic features such as Ki-67 or mitotic index may not be as useful for prognostic information in patients with pheochromocytoma and abdominal paraganglioma, particularly in the setting of SDHB mutation.”

Dr. Assadipour and her coinvestigators focused their investigation on mutations of the SDHB (succinate dehydrogenase complex subunit B) gene, which codes for one of four subunits comprising a mitochondrial protein.

They also considered primary tumor size, functionality, pathology, surgical approach, and histologic features including Ki-67 index and mitotic index. The study was a retrospective analysis of 84 patients who had surgery for PC [pheochromocytoma] or PGL [paraganglioma] and had germ line genetic testing. Of the 84 patients, 35 patients had sporadic disease and 49 had germ line SDHB mutation. The study analyzed tumor samples for Ki-67/MIB-1 staining and mitotic index.

“In a univariate analysis, SDHB mutation, tumor size and surgical approach were associated with local regional recurrence,” Dr. Assadipour said. “In a multivariate analysis, the only independent risk factors were SDHB mutation status and tumor size; Ki-67 and mitotic index did not have any association with recurrence.”

The researchers found similar results when they looked at distant metastasis. “SDHB mutation, tumor size, abdominal paraganglioma and surgical approach were associated with distant metastasis,” Dr. Assadipour said. “Again, Ki-67 and mitotic index were not.”

In the multivariate analysis, again, only patient SDHB status and tumor size were independently associated with metastasis.”

Dr. Yasmine Assadipour

The incidence of local recurrence in patients with the SDHB mutation was 47.6% vs. 9.1% in those without the gene mutation, Dr. Assadipour said. The rates of distant metastasis showed a similar disparity: 56.5% and 9.1%, respectively.

Patients with the SDHB mutation presented at a younger age than those without the mutation, 33 vs. 49.6 years old. Among the 65 patients who underwent R0 primary tumor resection, those with the SDHB mutation, paraganglioma, and larger tumor size had a shorter disease-free survival, Dr. Assadipour said.

In analyzing tumor size, Dr. Assadipour said two stratifications were studied: evaluating tumors sized 0-3 cm, 3-6 cm and 6 cm and larger; and 0-5 cm and 5 cm and larger. “Tumors over 6 cm had the shortest disease-free survival, and even when we applied the under-5 cm and over-5 cm scale, we clearly saw a difference in disease-free survival,” she said. Ki-67 and mitotic index were not related to disease-free survival.

The presence of a SDHB mutation had a hazard ratio of 16.2, while tumor diameter greater than 6 cm had a HR of 15.4, Dr. Assadipour said. These were the only independent risk factors for local recurrence, distant metastases and shorter disease-free interval found in the study.

During the discussion, Lawrence T. Kim, MD, of the University of North Carolina asked if the researchers found any differences in outcomes related to the surgical approach. “We were unable to identify whether any surgical approach improved or worsened outcomes on multivariate analysis” Dr. Assadipour said.

Thomas J. Fahey, MD, of New York asked what she would recommend for surgical approaches for patients with PC and PGL.

“Our general recommendation is that an adrenal pheochromocytoma that is over 6 cm carries a higher risk of recurrence and distant metastasis so an open approach with lymph node dissection ensuring negative surgical margins should be considered,” Dr. Assadipour said. “For abdominal paragangliomas, unless they are quite small and in a favorable location, we would generally recommend an open approach.”

The study was supported by the intramural program of the Center for Cancer Research, National Cancer Institute, National Institutes of Health. Dr. Assadipour and her coauthors had no financial relationships to disclose.