Proximal aortic repair in asymptomatic patients

Emelie Carlestål; Melih Selcuk Ezer; Anders Franco-Cereceda; Christian Olsson

doi:10.1016/j.xjon.2021.05.001

Proximal aortic repair in asymptomatic patients

JTCVS Open. 2021 May 13:7:1-9. doi: 10.1016/j.xjon.2021.05.001. eCollection 2021 Sep.

Authors

Emelie Carlestål^{1

2}, Melih Selcuk Ezer¹, Anders Franco-Cereceda^{1

2}, Christian Olsson^{1

2}

Affiliations

¹ Department of Molecular Medicine and Surgery, The Karolinska Institutet, Stockholm, Sweden.
² Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden.

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.