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Background: The goal of this study was to compare early postoperative outcomes and actuarial-free survival between patients who underwent repair of acute Type A aortic dissection with axillary or femoral artery cannulation. Methods: A total of 305 patients from five academic medical centers underwent acute Type A aortic dissection repair via axillary (n = 107) or femoral (n = 198) artery cannulation between January 2000 and December 2010. Major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Multivariate logistic regression was used to determine predictors of operative mortality, and Cox regression hazard ratios were calculated to determine predictors of long-term mortality. Results: Operative mortality was not influenced by cannulation site (16% for axillary cannulation vs. 19% for femoral cannulation, p = 0.64). In multivariate logistic regression analysis, hemodynamic instability (p < 0.001) and prolonged cardiopulmonary bypass time (>200 min; p = 0.05) emerged as independent predictors of operative mortality. Stroke rates were comparable between the two techniques (14% for axillary and 17% for femoral cannulation, p = 0.52). Five-year actuarial survival was comparable between the groups (55.1% for axillary and 65.7% for femoral cannulation, p = 0.36). In Cox regression analysis, predictors of long-term mortality were: age (p < 0.001), stroke (p < 0.001), prolonged cardiopulmonary bypass time (p = 0.001), hemodynamic instability (p = 0.002), and renal failure (p = 0.001). Conclusions: The outcomes of femoral versus axillary arterial cannulation in patients with acute Type A aortic dissection are comparable. The choice of arterial cannulation site should be individualized based on different patient risk profiles.

Background: The goal of this study was to compare operative mortality and actuarial survival between patients presenting with and without hemodynamic instability who underwent repair of acute Type A aortic dissection. Previous studies have demonstrated that hemodynamic instability is related to differences in early and late outcomes following acute Type A dissection occurrence. However, it is unknown whether hemodynamic instability at the initial presentation affects early clinical outcomes and survival after repair of Type A aortic dissection. Methods: A total of 251 patients from four academic medical centers underwent repair of acute Type A aortic dissection between January 2000 and October 2010. Of those, 30 presented with hemodynamic instability while 221 patients did not. Median ages were 63 years (range 38-82) and 60 years (range 19-87) for patients presenting with hemodynamic instability compared to patients without hemodynamic instability, respectively (P = 0.595). Major morbidity, operative mortality, and 10-year actuarial survival were compared between groups. Results: Operative mortality was profoundly influenced by hemodynamic instability (patients with hemodynamic instability 47% versus 14% for patients without hemodynamic instability, P < 0.001). Actuarial 10-year survival rates for patients with hemodynamic instability were 44% versus 63% for patients without hemodynamic instability (P = 0.007). Conclusions: Hemodynamic instability has a profoundly negative impact on early outcomes and operative mortality in patients with acute Type A aortic dissection. However, late survival is comparable between hemodynamically unstable and non-hemodynamically unstable patients.

While considered simple and effective, crystalloid antegrade cardioplegia solutions have had few prospective multicentre comparison trials.A commercial intracellular-type histidine-tryptophan-ketoglutarate (HTK) cardioplegia solution (Custodiol HTK; Köhler Chemie GmbH, Germany) designed for 4 h of protection after a single administration was compared with a standard extracellular multidose product (Plegisol [PL]; Hospira Inc, USA) in an open-label, randomized, prospective seven-institution trial. A total of 136 isolated coronary bypass patients were randomly assigned into two groups and stratified by ejection fraction into categories of 40% or greater (n=118) and 20% to 39% (n=18).The mean age of the study cohort was 62 years, of which 94% were men. Seventy per cent of patients had Canadian Cardiovascular Society class III angina and 75% had three-vessel disease anatomy. Cross-clamp times were nearly identical for patients in both cardioplegia groups; however, defibrillation was needed less often for patients who were treated with HTK (64% versus 91%, P0.01). Hospital and intensive care unit stays, creatine kinase isoenzyme MB curves, cardiac outputs, inotrope levels, and deaths or serious adverse events (PL=13, HTK=14) were very similar between groups. Logistic regression showed that myocardial infarction or possible treatment-related adverse events were associated with high cardiac troponin I (cTn-I) levels 6 h after the procedure (P=0.001), and HTK treatment (OR 3.5, P=0.01). The primary study end point (6 h post-ischemia cTn-I) favoured PL (16.7±13.2 μg/L versus 20.3±13.5 μg/L, P=0.01). Patients who underwent circumflex grafting had higher cTn-I levels with HTK (P0.001) and 48% required reinfusions due to cardiac warming. Longer intervals between doses correlated with high cTn-I levels (P=0.02). HTK provided prolonged protection with low cTn-I release (10 μg/L or less), although this occurred less frequently than with PL (17 versus 27 patients, P=0.06).HTK caused more structural protein release and adverse events than PL, even when reinfusion was implemented.