Association between cardiopulmonary bypass time and 90-day postoperative mortality in patients undergoing arch replacement with the frozen elephant trunk: a retrospective cohort study

Background:The aortic arch replacement and cardiopulmonary bypass(CPB)are both associated with the early mortality after cardiothoracic surgery.This study aimed to investigate the relationship between CPB time and 90-day post-operative mortality in patients undergoing aortic arch surgery using the frozen elephant trunk(FET)technique with selective ante-grade cerebral perfusion(SACP).Methods:We retrospectively reviewed data of 377 adult patients undergoing aortic arch surgery via FET with SACP from July 1,2017 to December 31,2018 at Beijing Anzhen Hospital.The baseline characteristics,intra-operative data,and post-operative data were collected.Univariate and multivariate Cox regression analyses were used to determine independent predictors of 90-day postoperative mortality.Results:The 90-day post-operative mortality was 13.53%.The 78.51%of patients were men.There were 318(84.35%)type A aortic dissections and 28(7.43%)aortic aneurysms.Among those,264(70.03%)were emergency operations.Median CPB time was 202.0(176.0,227.0)min.Multivariate Cox regression analysis revealed that CPB time was independently associated with 90-day post-operative mortality after adjusting confounding factors(hazard ratio:1.21/10 min increase in CPB time,95%confidence interval:1.15–1.27,P<0.001).Kaplan-Meier analysis based on CPB time tertiles revealed that the top tertile(median 236.0 min)was associated with reduced survival rate compared with middle and bottom tertiles(P<0.001).Each sub-group analysis based on the complexity of the underlying disease process showed similar associations between CPB time and 90-day post-operative mortality.Conclusions:CPB time remains a significant factor in determining 90-day post-operative mortality in patients undergoing aortic arch surgery using FET with SACP.Surgeons should be aware of the relationship between CPB time and 90-day post-operative mortality during operative procedures and avoid extended CPB time as far as possible.

Branch-first Sun’s procedure:early experience in patients with aortic dissection and aortic aneurysm

Despite great progress in concepts and surgical technique,arch replacement remains a challenge for most cardiac surgery centers.The classic Sun’s procedure(total arch replacement using four-branched graft with stented elephant trunk implantation)has achieved good results in arch replacement in cases of type A aortic dissection and become the standard treatment for type A aortic dissection in our center.[1,2]The branch-first technique has been reported by some surgeons.In most cases,the three arch branches were reconstructed under cardiopulmonary bypass(CPB)or deep hypothermia circulatory arrest.We began applying the branch-first Sun’s procedure 1 year ago.131 The three arch branches were bypassed without CPB in most patients.The lowest temperature at circulatory arrest was also elevated.Here we report our early experience with branch-first Sun’s procedure in both elective and emergency settings.