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    <recommendedItem id="20100101_19_295"
                     title="STS: Aorta Repair Done at Warmer Temperatures (CME/CE)"
                     score="0.004"
                     href="http://www.medpagetoday.com/MeetingCoverage/STS/tb/18156?impressionId=1265804073113"
                     
      &lt;p&gt;FORT LAUDERDALE  --  Doctors here suggest it is safe to perform aortic arch surgery using moderate hypothermia  --  cooling the body to about 26 degrees C rather than 18 degrees C  --  without jeopardizing cerebral protection.&lt;/p&gt;
&lt;p&gt;Researchers at Emory University in Atlanta said their aortic arch repair techniques have been evolving over the past decade, including performing the surgery at higher body temperatures.&lt;/p&gt;
&lt;p&gt;&quot;The optimal management during aortic arch surgery is controversial,&quot; Emory&apos;s Bradley Leshnower, MD, noted in his oral presentation at the annual meeting of the Society of Thoracic Surgeons here. &quot;The main issue is cerebral protection during the period of circulatory arrest.&quot;&lt;/p&gt;
&lt;p&gt;Since modern aortic surgery was first performed in 1975, body temperatures have traditionally been lowered to about 18 degrees Celsius (64.4 degrees Fahrenheit) in order to protect organs from damage once circulatory arrest has been achieved.&lt;/p&gt;
&lt;p&gt;&quot;Since that time, two additional methods of surgery with protection have evolved and are used in conjunction with hypothermia: retrograde cerebral perfusion and selective antegrade cerebral perfusion,&quot; Leshnower said.&lt;/p&gt;
&lt;p&gt;&quot;At Emory we use a strategy of cerebral protection that we call unilateral selective antegrade reperfusion,&quot; he explained. &quot;Our hypothesis was that by using adjunctive selective antegrade perfusion, we could safely perform arch reconstruction using more moderate levels of hypothermia and thereby avoid the adverse effects of deep hypothermia.&quot;&lt;/p&gt;
&lt;p&gt;Matthew Williams, MD, of the University of Louisville, noted that temperature is critical because &quot;the deeper the hypothermia, the more problems occur in clotting.&quot;&lt;/p&gt;
&lt;p&gt;&quot;Even the tiniest pinpricks in the aorta that would immediately clot off at normal temperatures will bleed profusely among hypothermia patients,&quot; he said.&lt;/p&gt;
&lt;p&gt;In their retrospective study, Leshnower and colleagues identified 412 aortic arch procedures performed between January 2004 and December 2009.&lt;/p&gt;
&lt;p&gt;All cases involved hypothermia circulatory arrest and unilateral selective antegrade reperfusion. The mean age of the patients was 57, and about two-thirds were male. About 10% had a history of renal failure and the same proportion had a history of stroke. Among the cases were 85 reoperations.&lt;/p&gt;
&lt;p&gt;&quot;About three-fourths of the cases were done electively, and the remaining 24% were done for emergent Type 1 aortic dissections,&quot; Leshnower said.&lt;/p&gt;
&lt;p&gt;The procedures included 344 hemiarch reconstructions and 68 total arch replacements. Among them were 175 aortic root replacements.&lt;/p&gt;
&lt;p&gt;Overall, the average temperature for circulatory arrest was 25.7 degrees Celsius (range 19 - 30). The average circulatory arrest time was 30 minutes.&lt;/p&gt;
&lt;p&gt;In the safety analysis the researchers found: &lt;ul&gt; &lt;li&gt;Overall mortality was 7%, but &quot;as we gained experience with this procedure, our results improved and our mortality was reduced to 4.8% in the latter half of the series,&quot; Leshnower said.&lt;/li&gt; &lt;li&gt;Permanent neurological dysfunction  --  a focal stroke  --  occurred in 3.6%.&lt;/li&gt; &lt;li&gt;Temporary neurological dysfunction  --  cognitive deficits observed postoperatively  --  occurred in 5.1%. &quot;These deficits are considered to be a sign of inadequate cerebral protection,&quot; Leshnower explained.&lt;/li&gt; &lt;li&gt;Renal failure requiring dialysis as a measure of lower body, end organ ischemia occurred in 4.6%&lt;/li&gt; &lt;li&gt;There were no cases of paraplegia.&lt;/li&gt; &lt;/ul&gt;&lt;/p&gt;
&lt;p&gt;In a subgroup analysis, Leshnower and colleagues observed a mortality rate of 14.4% in the emergent cases, compared with 4.8% in the elective group.&lt;/p&gt;
&lt;p&gt;&quot;There was also a significantly higher percentage of permanent neurologic dysfunction and renal failure requiring dialysis in the dissection group. However, there was no difference in our temporary neurologic dysfunction rate,&quot; he said.&lt;/p&gt;
&lt;p&gt;He noted that a multivariate analysis failed to show that higher temperatures were related to adverse outcomes.&lt;/p&gt;
&lt;p&gt;&quot;We feel that the use of moderate hypothermia with selective antegrade cerebral reperfusion is an effective method of cerebral protection as evidenced by our low rate of permanent and temporary neurologic dysfunction,&quot; he said.&lt;/p&gt;
&lt;p&gt;&quot;We feel that the use of this technique avoids the adverse effects of deep hypothermia and is an effective strategy for circulation management in the aortic arch surgery in both the emergent and elective settings.&quot;&lt;/p&gt;
&lt;p&gt;Randall Griepp, MD, of Mount Sinai School of Medicine in New York City, who pioneered the technique back in 1975, praised the report from the floor of the session but added a caution.&lt;/p&gt;
&lt;p&gt;&quot;These are terrific results. But you should do some postoperative cognitive testing. The perfusion of the distal aorta does become an issue somewhere around an hour or so. There have been reports of injury, including paraplegia, when higher temperatures are used. You have not seen it in your series but you are beginning to flirt with the limits of depriving the lower body of blood flow.&quot;&lt;/p&gt;
&lt;p&gt;He said that the estimation of temporary neurologic dysfunction may not appear until six weeks to a year after surgery for those patients who go beyond 25 to 30 minutes with circulatory arrest.&lt;/p&gt;
&lt;p&gt;Leshnower also noted that his study could not prove that bleeding times were reduced, because a proper historical control group using similar surgical and protection techniques is not available.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Leshnower had no disclosures but one of the co-authors revealed financial relationships with Terumo. Williams and Griepp had no disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_284"
                     title="STS: Leg Artery Access Linked to Dissection (CME/CE)"
                     score="0.003"
                     href="http://www.medpagetoday.com/MeetingCoverage/STS/tb/18139?impressionId=1265804073113"
                     
      &lt;p&gt;FORT LAUDERDALE  --  Avoiding femoral artery cannulization during cardiac surgery might eliminate some of the rare but potentially catastrophic aortic dissections that occur during the procedure, researchers said here.&lt;/p&gt;
&lt;p&gt;Doctors identified the femoral location as an increased risk factor in an analysis of records from the Society of Thoracic Surgeons&apos; national database of more than 2.2 million cardiac surgeries. That search yielded 1,294 incidents of aortic dissection.&lt;/p&gt;
&lt;p&gt;&quot;Prevention is the key,&quot; Matthew Williams, MD, of the University of Louisville, said at the annual meeting of the Society of Thoracic Surgeons here.&lt;/p&gt;
&lt;p&gt;Williams and colleagues reported that aortic dissection occurs in only 0.06% of cardiac surgeries but accounts for almost one percent of perioperative deaths.&lt;/p&gt;
&lt;p&gt;&quot;Aortic dissection is a low frequency but catastrophic event,&quot; Williams said, noting that 48% of aortic dissections during surgery prove fatal. Some 9% of the survivors suffer strokes and 14% experience kidney failure.&lt;/p&gt;
&lt;p&gt;He recalled becoming interested in the research after one of his patients, a woman, experienced aortic dissection during a procedure. &quot;She walked out of the hospital,&quot; he said.&lt;/p&gt;
&lt;p&gt;He told &lt;em&gt;MedPage Today&lt;/em&gt; that &quot;the incidence of these aortic dissections is so small that only a large database project such as this one could possibly get at these cases.&quot;&lt;/p&gt;
&lt;p&gt;According to his presentation materials, researchers created a logistic regression model based on 2004-2007 STS data. The analysis turned up nine significant risk factors, including femoral cannulization, preoperative steroids, and Asian race. Diabetes appeared to be protective.&lt;/p&gt;
&lt;p&gt;When aortic dissection occurs during surgery, Williams said, doctors generally stop the operation and attempt to restart it by cannulization in another area.&lt;/p&gt;
&lt;p&gt;He said he has considered femoral access as a last resort and prefers either central aortic cannulization or axial cannulization.&lt;/p&gt;
&lt;p&gt;He said improving outcomes and identifying what causes aortic dissection in these surgical cases may require changes and updates in the information captured by the database. He said a clinical trial would require so many patients that it would not be practical.&lt;/p&gt;
&lt;p&gt;Aubrey Galloway, MD, of the New York University School of Medicine, who was the discussant for Williams&apos; talk, said that the imprecise nature of the way the data are gathered might have misidentified the femoral access point as a culprit procedure.&lt;/p&gt;
&lt;p&gt;&quot;It may be that femoral access was employed in response to another dissection site,&quot; he said.&lt;/p&gt;
&lt;p&gt;Williams responded that by tweaking the information acquired by the database it might be possible to better determine these associations.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;Williams listed no relevant disclosures; Galloway disclosed financial relationships with Medtronic and Edwards Life Sciences and Estech.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_6_133"
                     title="Minimally Invasive Approach Comparable to Open Surgery for Aneurysm Repair"
                     score="-0.005"
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