nhanced Recovery After Surgery (ERAS) is a multimodal, transdisciplinary care improvement initiative to promote recovery of patients undergoing surgery throughout their entire perioperative journey. 1 These programs aim to reduce complications and promote an earlier return to normal activities. 2,3 The ERAS protocols have been associated with a reduction in overall complications and length of stay of up to 50% compared with conventional perioperative patient management in populations having noncardiac surgery. 4-6 Evidence-based ERAS protocols have been published across multiple surgical specialties. 1 In early studies, the ERAS approach showed promise in cardiac surgery (CS); however, evidence-based protocols have yet to emerge. 7 To address the need for evidence-based ERAS protocols, we formed a registered nonprofit organization (ERAS Cardiac Society) to use an evidence-driven process to develop recommendations for pathways to optimize patient care in CS contexts through collaborative discovery, analysis, expert consensus, and best practices. The ERAS Cardiac Society has a formal collaborative agreement with the ERAS Society. This article reports the first expert-consensus review of evidence-based CS ERAS practices. Methods We followed the 2011 Institute of Medicine Standards for Developing Trustworthy Clinical Practice Guidelines, using a standardized algorithm that included experts, key questions, subject champions, systematic literature reviews, selection and appraisal of evidence quality, and development of clear consensus recommendations. 8 We minimized repetition of existing guidelines and consensus statements and focused on specific information in the framework of ERAS protocols.

Objectives To characterize operative outcomes for ascending aorta and arch replacement on a national scale and develop risk models for mortality and major morbidity. Background Contemporary outcomes for ascending aorta and arch replacement in North America are unknown. Methods We queried the Society of Thoracic Surgeons Database for patients undergoing ascending aorta (+/− root) +/− arch replacement from 2004 to 2009. The database captured 45,894 cases, including 12,702 root, 22,048 supracoronary ascending alone, 6,786 ascending+arch, and 4,358 root+arch. Baseline characteristics and clinical outcomes were analyzed. A parsimonious multivariable logistic regression model was constructed to predict risks of mortality and major morbidity. Results Operative mortality was 3.4% for elective and 15.4% for non-elective cases. A risk model for operative mortality [c-index 0.81] revealed a risk-adjusted odds ratio (OR) for death following emergent vs. elective operation of 5.9 [95% confidence interval (CI) 5.3, 6.6]. Among elective patients, end stage renal disease and re-operative status were the strongest predictors of mortality (adjusted OR 4.0 [95% CI 2.6, 6.4] and 2.3 [95% CI 1.9, 2.7] respectively, p<0.0001). Conclusions Current outcomes for ascending aorta and arch replacement in North America are excellent for elective repair; however, results deteriorate for non-elective status, suggesting that increased screening and/or lowering thresholds for elective intervention could potentially improve outcomes. The predictive models presented may serve clinicians in counseling patients.

Objective: Our enhanced recovery after cardiac surgery (ERAS Cardiac) program is an evidence-based interdisciplinary process, which has not previously been systematically applied to cardiac surgery in the United States.Methods: The Knowledge-to-Action Framework synthesized evidence-based enhanced recovery interventions and implementation of a designated ERAS Cardiac program. Standardized processes included (1) preoperative patient education, (2) carbohydrate loading 2 hours before general anesthesia, (3) multimodal opioid-sparing analgesia, (4) goal-directed perioperative insulin infusion, and (5) a rigorous bowel regimen. All cardiac anesthesiologists and surgeons agreed to follow the standardized pathway for adult cardiac surgery cases. The 1-year outcomes were compared between the 9 months pre-and post-ERAS Cardiac implementation using prospectively collected, retrospectively reviewed data.Results: Comparing the pre-(N ¼ 489) with the post-(N ¼ 443) ERAS Cardiac groups, median postoperative length of stay was decreased from 7 to 6 days (P <.01). Total intensive care unit hours were decreased from a mean of 43 to 28 hours (P <.01). The incidence of gastrointestinal complications was 6.8% pre-ERAS versus 3.6% post-ERAS implementation (P <.05). Opioid use was reduced by a mean of 8 mg of morphine equivalents per patient in the first 24 hours postoperatively (P <.01). Reintubation rate and intensive care unit readmission rate were reduced by 1.2% and 1.5%, respectively (P ¼ not significant). The incidence of hyperglycemic episodes was no different after ERAS Cardiac initiation. Patient satisfaction was 86.3% pre-ERAS versus 91.8% post-ERAS Cardiac implementation and work culture domain scores revealed increases in satisfaction across all measured indices, including patient focus, culture, and engagement.Conclusions: Initial clinical and survey data after the first year of a system-wide ERAS Cardiac program were associated with significantly improved perioperative outcomes. We believe this value-based approach to cardiac surgery can consistently result in earlier recovery, cost reductions, and increased patient/staff satisfaction.

Objective Hybrid repair of the transverse aortic arch may allow for aortic arch repair with reduced morbidity in patients who are suboptimal candidates for conventional open surgery. Here, we present our results with an algorithmic approach to hybrid arch repair, based upon the extent of aortic disease and patient comorbidities. Methods Between August 2005 and January 2012, 87 patients underwent hybrid arch repair by three principal procedures: zone 1 endograft coverage with extra-anatomic left carotid revascularization (zone 1, n=19), zone 0 endograft coverage with aortic arch debranching (zone 0, n=48), or total arch replacement with staged stented elephant trunk completion (stented elephant trunk, n=20). Results The mean patient age was 64 years and the mean expected in-hospital mortality rate was 16.3% as calculated by the EuroSCORE II. 22% (n=19) of operations were non-elective. Sternotomy, cardiopulmonary bypass, and deep hypothermic circulatory arrest were required in 78% (n=68), 45% (n=39), and 31% (n=27) of patients, respectively, to allow for total arch replacement, arch debranching, or other concomitant cardiac procedures, including ascending ± hemi-arch replacement in 17% (n=8) of patients undergoing zone 0 repair. All stented elephant trunk procedures (n=20) and 19% (n=9) of zone 0 procedures were staged, with 41% (n=12) of patients undergoing staged repair during a single hospitalization. The 30-day/in-hospital rates of stroke and permanent paraplegia/paraparesis were 4.6% (n=4) and 1.2% (n=1), respectively. Three of 27 (11.1%) patients with native ascending aorta zone 0 proximal landing zone experienced retrograde type A dissection following endograft placement. The overall in-hospital mortality rate was 5.7% (n=5), however, 30-day/in-hospital mortality increased to 14.9% (n=13) due to eight 30-day out-of-hospital deaths. Native ascending aorta zone 0 endograft placement was found to be the only univariate predictor of 30-day/in-hospital mortality (odds ratio, 4.63; 95% confidence interval, 1.35-15.89; P=0.02). Over a mean follow-up of 28.5 ± 22.2 months, 13% (n=11) of patients required reintervention for type 1A (n=4), type 2 (n=6), or type 3 (n=1) endoleak. Kaplan-Meier estimates of survival at 1, 3, and 5 years were 73%, 60%, and 51%, respectivel. Conclusions Hybrid aortic arch repair can be tailored to patient anatomy and comorbid status to allow complete repair of aortic pathology, frequently in a single stage, with acceptable outcomes. However, endograft placement in the native ascending aorta is associated with high rates of retrograde type A dissection and 30-day/in-hospital mortality and should be approached with caution.

Purpose Retrograde ascending aortic dissection (rAAD) is a potential complication of thoracic endovascular aortic repair (TEVAR) yet little data exists regarding its occurrence. This study examines the incidence, etiology, and outcome of this event. Methods A prospective institutional database was used to identify cases of acute rAAD following TEVAR from a cohort of 309 consecutive procedures from 3/2005 (date of initial FDA approval) to 9/2010. The database was analyzed for the complication of rAAD as well as relevant patient and operative variables. Results The incidence of rAAD was 1.9% (n=6/309); all cases occurred with proximal landing zone in the ascending aorta and/or arch (zones 0–2). All were identified in the perioperative period (range 0–6 days) with 33% (2/6) 30 day/in-hospital mortality. 83% (5/6) underwent emergent repair; 1 patient died without repair. rAAD patients were similar to the non-rAAD group (n=303) across pertinent variables including age, sex, race, and device size (all P>0.1). rAAD incidence by aortic pathology was: 1.0% (2/200) for aneurysm, 4.4% (4/91) for dissection, and 0% (0/18) for transection; p=0.08. rAAD incidence by device was: TAG (Gore) 1.0%, n=2/205; Talent (Medtronic) 4.7%, n=2/43; and Zenith TX2 (Cook) 3.6%, n=2/55. rAAD incidence was observed to be higher among patients with an ascending aortic diameter ≥4.0 cm (4.8% vs. 0.9% for ascending diameter < 4.0 cm), p=0.047. Incidence was also higher with proximal landing zone in native ascending aorta (zone 0) 6.9% (2/29) vs. 1.4% for all others (4/280), p=0.101. For patients with dissection pathology and an ascending aortic diameter ≥4.0 cm, 11% (3/28) suffered rAAD; with the combination of native ascending aorta (zone 0) landing zone measuring ≥4.0 cm the incidence was 25% (2/8). Definitive diagnosis was by CTA (n=1), intraoperative transesophageal echocardiography (TEE) (n=3), intraoperative arteriography (n=1), or postmortem autopsy (n=1). Conclusions rAAD is a lethal early complication of TEVAR, which may be more common when treating dissection, with devices utilizing proximal bare springs or barbs for fixation, with native zone 0 proximal landing zone, and with ascending aortic diameter ≥ 4 cm. Combinations of these risk factors may be particularly high risk. Intraoperative imaging assessment of the ascending aorta should be conducted following TEVAR to avoid under-recognition. National database reporting of this complication is needed to ensure safety and proper application of emerging TEVAR technology.

This study examined the association between patient-reported anxiety and post-cardiac surgery mortality and major morbidity. Frailty ABC'S was a prospective multicenter cohort study of elderly patients undergoing cardiac surgery (coronary artery bypass surgery and/or valve repair or replacement) at 4 tertiary care hospitals between 2008 and 2009. Patients were evaluated a mean of 2 days preoperatively with the Hospital Anxiety and Depression Scale (HADS), a validated questionnaire assessing depression and anxiety in hospitalized patients. The primary predictor variable was high levels of anxiety, defined by HADS score ≥11. The main outcome measure was all-cause mortality or major morbidity (stroke, renal failure, prolonged ventilation, deep sternal wound infection, or reoperation) occurring during the index hospitalization. Multivariable logistic regression examined the association between high preoperative anxiety and all-cause mortality/major morbidity, adjusting for Society of Thoracic Surgeons (STS) predicted risk, age, gender, and depression symptoms. A total of 148 patients (mean age 75.8 ± 4.4 years; 34% women) completed the HADS-A. High levels of preoperative anxiety were present in 7% of patients. There were no differences in type of surgery and STS predicted risk across preoperative levels of anxiety. After adjusting for Society of Thoracic Surgeons predicted risk, age, gender, and symptoms of depression, preoperative anxiety remained independently predictive of postoperative mortality or major morbidity (OR 5.1; 95% CI 1.3, 20.2; p=0.02). In conclusion, although high levels of anxiety were present in a minority of patients anticipating cardiac surgery, this conferred a strong and independent heightened risk of mortality or major morbidity.

Objectives The purpose of this study was to compare the results of acute type A aortic dissection (ATAAD) repair before and after implementation of a multidisciplinary thoracic aortic surgery program (TASP) at our institution, with dedicated high-volume thoracic aortic surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. Background Outcomes of ATAAD repair may be improved when operations are performed at specialized high-volume thoracic aortic surgical centers. Methods Between 1999 and 2011, 128 patients underwent ATAAD repair at our institution. Records of patients who underwent ATAAD repair 6 years before (n = 56) and 6 years after (n = 72) implementation of the TASP were retrospectively compared. Expected operative mortality rates were calculated using the International Registry of Acute Aortic Dissection pre-operative prediction model. Results Baseline risk profiles and expected operative mortality rates were comparable between patients who underwent surgery before and after implementation of the TASP. Operative mortality before TASP implementation was 33.9% and was statistically equivalent to the expected operative mortality rate of 26.0% (observed-to-expected mortality ratio 1.30; p = 0.54). Operative mortality after TASP implementation fell to 2.8% and was statistically improved compared with the expected operative mortality rate of 18.2% (observed-to-expected mortality ratio 0.15; p = 0.005). Differences in survival persisted over long-term follow-up, with 5-year survival rates of 85% observed for TASP patients compared with 55% for pre-TASP patients (p = 0.002). Conclusions ATAAD repair can be performed with results approximating those of elective proximal aortic surgery when operations are performed by a high-volume multidisciplinary thoracic aortic surgery team. Efforts to standardize or centralize care of patients undergoing ATAAD are warranted.

Objective Thoracic endovascular aortic repair for chronic type B aortic dissection with associated descending thoracic aneurysm remains controversial. Concerns include potential ischemic complications due to branch vessel origin from the chronic false lumen and continued retrograde false lumen/aneurysm sac pressurization via fenestrations distal to implanted endografts. The present study examines midterm results with thoracic endovascular aortic repair for chronic (>2 weeks) type B aortic dissection with associated aneurysm to better understand the potential role of thoracic endovascular aortic repair for this condition. Methods Between March 2005 and December 2009, 51 thoracic endovascular aortic repair procedures were performed at a single institution for management of chronic type B dissection. The indication for thoracic endovascular aortic repair was aneurysm in all cases. A subset of 7 patients (14%) underwent placement of the EndoSure wireless pressure measurement system (CardioMEMS, Inc, Atlanta, Ga) in the false lumen adjacent to the primary tear for monitoring aneurysm sac/false lumen pulse pressure after thoracic endovascular aortic repair. Results Mean patient age was 57 ± 12 years (range, 30–82 years); 14 patients (28%) were female. Mean aortic diameter was 6.2 ± 1.4 cm. There were no in-hospital/30-day deaths, strokes, or permanent paraplegia/paresis. There were no complications related to compromise of downstream branch vessels arising from the false lumen. Two patients (3.9%) who had preexisting ascending aortic dilation had retrograde acute type A aortic dissection; both were repaired successfully. Median postoperative length of stay was 4 days. Mean follow-up is 27.0 ± 16.5 months (range, 2–60 months). Actuarial overall survival is 77.7%at 60 months with an actuarial aorta-specific survival of 98%over this same time period. Actuarial freedom from reintervention is 77.3%at 60 months. All patients with the EndoSure wireless pressure measurement system exhibited a decrease in aneurysm sac/false lumen pulse pressure indicating a depressurized false lumen. The aneurysm sac/false lumen pulse pressure ratio decreased from 52% ± 27% at the predischarge measurement to 14% ± 5% at the latest follow-up reading (P = .029). Conclusions Thoracic endovascular aortic repair for chronic type B dissection with associated aneurysm is safe and effective at midterm follow-up. Aneurysm sac/false lumen pulse pressure measurements demonstrate a significant reduction in false lumen endotension, thus ruling out clinically significant persistent retrograde false lumen perfusion and provide proof of concept for a thoracic endovascular aortic repair-based approach. Longer-term follow-up is needed to determine the durability of thoracic endovascular aortic repair for this aortic pathology.