Proximal aortic repair in asymptomatic patients

Abstract

Objective: Current guidelines for elective proximal aortic repair are applicable to elective first-time procedures in asymptomatic patients without other primary indications or connective tissue disorders and with specified aortic diameter or growth rate. The objective was to characterize the surgical outcomes in this narrowly defined patient-population.

Methods: Guideline-compliant patients were identified from a recent (2014-2019) single unit consecutive surgical cohort (n = 935) by excluding total arch replacements, redos, acute and symptomatic patients, and genetic syndromes. Remaining patients were included regardless of surgical procedure performed. Early (30-day or in-hospital) and 1-year mortality were primary outcome measures. Major complications (stroke, severe renal or respiratory insufficiency, postcardiotomy shock, deep sternal wound infection, permanent pacemaker, and re-exploration) up to 1 year postoperatively were secondary outcome measures.

Results: In the resulting study population (n = 262), median age was 63 (interquartile range, 52-71) years, and median surgical risk (European System for Cardiac Operative Risk Evaluation II) was 3.2% (2.0%-4.4%). Early mortality was 2 of 262 (0.76%) without additional deaths up to 1-year postoperatively. The occurrence of major complications was low: stroke, 2 (0.76%); renal insufficiency, 2 (0.76%); respiratory insufficiency, 1 (0.38%); postcardiotomy shock, 1 (0.38%); deep sternal wound infection, 0; permanent pacemaker, 3 (1.1%); and re-exploration, 20 (7.6%), all occurring in the immediate (30-day) postoperative period and without additional events up to 1 year postoperatively.

Conclusions: In this recent cohort including the target population referred to by and managed in accordance with current guidelines, mortality and major complications were exceptionally infrequent. Guidelines should adequately weigh risks of conservative management against current surgical outcomes.

Keywords: ATAAD, acute type A aortic dissection; BAV, bicuspid aortic valve; CRRT, continuous renal-replacement therapy; HCA, hypothermic circulatory arrest; PCS, postcardiotomy shock; VSRR, valve-sparing root replacement; aorta; elective operation; guidelines; outcomes.

Graphical abstract

Very few deaths and major complications after prophylactic proximal aortic operations.

Figure 1

Flowchart of all patients (n = 935) and exclusion criteria applied to define a guideline-compliant study population (n = 262) of asymptomatic patients undergoing prophylactic proximal aortic surgery. non-TAA, Non-thoracic aortic aneurysm.

Figure 2

Distribution of aortic diameter (millimeters) at time of proximal aortic repair in asymptomatic patients. Number of patients in each 2-mm interval on top of bars. Red curve, approximated normal distribution.

Figure 3

Number of patients undergoing each type of proximal aortic surgical procedure (supracoronary graft; supracoronary graft and valve replacement; composite aortic root replacement; and valve-sparing root replacement, respectively) with aortic crossclamping or open distal anastomosis. Each category is summarized and each percentage related to the overall study population (n = 262).

Figure 4

Number of each major adverse event occurring at up to 1-year follow-up for each type of proximal aortic surgical procedure (supracoronary graft; supracoronary graft and valve replacement; composite aortic root replacement; and valve-sparing root replacement, respectively) with aortic crossclamping or open distal anastomosis. PCS, Postcardiotomy shock; CRRT, continuous renal-replacement therapy; Trach, tracheostomy; Reexpl; re-exploration for bleeding/tamponade; DSWI, deep sternal wound infection; PPM, permanent pacemaker.

Figure 5

Estimated (Kaplan–Meier) survival with 95% confidence intervals in asymptomatic patients undergoing elective prophylactic surgical repair of the proximal aorta. Estimated 5-year survival was 97% (95% confidence limits, 91%-99%).

Figure 6

Guideline-compliant patients (n = 262) underwent individualized surgical treatment with excellent 1-year outcomes. HCA, Hypothermic circulatory arrest.