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

2. Introduction Strokes occur in ~3.8% of aortic arch operations at HUP 1 Aortic atherosclerosis is a known risk factor for stroke after CABG 3 It is unknown whether aortic atherosclerosis will increase stroke risk in arch operations 1 Appoo, J., et al., Perioperative Outcome in Adults Undergoing Elective Deep Hypothermic Circulatory Arrest With Retrograde Cerebral Perfusion in Proximal Aortic Arch Repair: Evaluation of Protocol-Based Care. J. Cardiothoracic Vascular Anes. 2006; 20:3-7 2 McGarvey, M., et al., Management of Neurologic Complications of Thoracic Aortic Surgery. J. Clinical Neurophysiology. 2007; 24:336-343 3 van der Linden, J., L Hadjinikolaou, P Bergman, D. Lindblom., Postoperative stroke in cardiac surgery is related to the location and extent of atherosclerosis in the ascending aorta. J. Am. Coll. Cardiology. 2001; 38:131-5

3. Objectives To characterize patient and perioperative factors associated with stroke and mortality in ascending aortic repairs –To test whether aortic atheroma is independently predictive of stroke risk

4. Methods Retrospective analysis of 701 consecutive patients undergoing ascending repair under Deep Hypothermic Circulatory Arrest (DHCA) Inclusion criteria: all ascending aortic operations at HUP and Penn-Presbyterian medical center, including emergent cases. Exclusion criteria: operations with concurrent repair of the descending aorta; hybrid procedures Two Primary Endpoints: Intra-operative stroke and in- hospital mortality Factors with p≤0.1 in univariate analysis were included in multivariate analysis.

5. Patient Population % (Number) History of CVD14.0% (98) History of PCI5.3% (37) History of CABG4.6% (32) History of AV Surgery12.0% (84) History of Afib/flutter15.2% (106) History of Dyslipidemia46.7% (327) History of Hypertension73.3% (512) History of Diabetes8.3% (58) History of Aortic Arch Repair 18.1% (127) Male Gender66.6% (467) Average±Std Dev BMI28.1±6.1 Age59.4±14.8

6. Operative Characteristics % (Number) Hemi Arch93.6% (656) Full Arch6.4% (45) Retrograde Perfusion93.3% (654) Anterograde Perfusion6.7% (47) Concurrent CABG16.3% (114) Concurrent Aortic Valve Proc86.6% (607) Ascending Dissection24.9% (168) High Grade Ascending Atheroma 5.9% (41) Descending Dissection11.4% (80) High Grade Descending Atheroma 9.6% (67) Average±Std Dev PRBC Units1.10±0.03 FFP Units1.08±0.03 Platelets Units1.17±0.07 Cryo Units1.46±0.24 Circ Arrest Time 30.4±17.0

7. Results-Univariate Stroke Rate: 5.9% In-hospital Mortality Rate: 7.3%

8. Results - Univariate Intraoperative StrokeIn-Hospital Mortality ORP P RCP Only 0.480.132 0.410.037 Any RCP use0.060.007undef0.692 ACP2.110.1312.430.037 Concurrent CABG2.350.0150.300.037 Concurrent AV Procedure0.510.0820.470.028 CVD3.70<0.0011.160.715 History of AV Surgery0.180.0572.470.008 History of Afib/Flutter0.140.0221.410.353 Redo Arch Repair0.630.3422.450.003 Ascending Dissection3.47<0.0012.400.003 Descending Dissection1.710.2123.35<0.001 Descending Atheroma3.020.0042.190.041 PRBC1.090.0031.11<0.001 FFP1.080.0141.100.001 Platelets1.180.0041.060.354 Cryoprecipitate1.490.0201.98<0.001 Circulatory Arrest Time1.020.0031.020.003 Male Gender0.390.0031.000.994 Age>651.960.0371.530.143 Intraoperative StrokeN/A 3.480.002 Intraoperative StrokeIn-Hospital Mortality FactorORP Any RCP Use0.060.007 Concurrent CABG2.350.015 Concurrent AV Procedure0.510.082 CVD3.70<0.001 History of AV Surgery0.180.057 History of Afib/Flutter0.140.022 Ascending Dissection3.47<0.001 Descending Atheroma3.020.004 PRBC per unit1.090.003 FFP per unit1.080.014 Platelets per unit1.180.004 Cryoprecipitate per unit1.490.020 Circulatory Arrest Time1.020.003 Male Gender0.390.003 Age>651.960.037 FactorORP RCP Only0.410.037 ACP2.430.037 Concurrent CABG0.300.037 Concurrent AV Procedure0.470.028 History of AV Surgery2.470.008 Redo Arch Repair2.450.003 Ascending Dissection2.400.003 Descending Dissection3.35<0.001 Descending Atheroma2.190.041 PRBC per unit1.11<0.001 FFP per unit1.100.001 Cryoprecipitate per unit1.98<0.001 Circulatory Arrest Time1.020.003 Intraoperative Stroke3.480.002 Univariate results with a p<0.1 included in mutlivariate analysis.

9. Results-Multivariate Analysis Stroke FactorOR95% CIP Value Ascending Aortic Dissection3.601.76 - 7.40<0.001 History of Cerebrovascular Disease3.541.67 – 7.490.001 High Grade Descending Atheroma2.691.09 – 6.650.032 Concurrent CABG2.351.07 – 5.170.033 Platelets (per unit)1.201.05 - 1.380.009 FactorOR95% CIP Value Male Gender0.430.22 – 0.870.019 History of Atrial Fibrillation Diagnosis0.070.01 - 0.590.014

10. Results-Multivariate Analysis In-Hospital Mortality FactorOR95% CIP Value Intraoperative Stroke3.471.39-8.640.008 Descending Aortic Dissection3.051.52-6.130.002 High Grade Descending Atheroma2.481.08-5.680.032 History of Aortic Valve Surgery2.161.01-4.600.047 PRBC (per unit)1.111.04-1.180.002 FactorOR95% CIP Value Concurrent CABG0.190.05-0.670.010

11. Discussion Stroke risk is increased by high grade descending atheroma and concurrent CABG. The protective effect of preexisting atrial fibrillation may be due to preoperative prophylaxis Mortality is increased by stroke, high grade atheroma, descending dissection. Concurrent CABG has a protective effect on mortality.

12. Conclusions TEE Grading of atheroma is a useful adjunct to determining the risk of aortic surgery, since high grade descending atheroma is a marker of a “toxic aorta,” increasing the risk of both stroke and mortality. CABG should be attempted cautiously with ascending aortic repair as it significantly increases the risk of intraoperative stroke, however, decreases the risk of mortality.