Objective:
Treatment of patients with extensive thoracic aortic disease (TAD) is performed using the different surgical techniques and is associated with higher operative mortality and morbidity as compared to other heart operations. We retrospectively evaluated our 20-years experience in treatment of TAD by analysing the early and late outcomes and identifying the clinical and surgical factors influencing them.
Methods:
Between July 1995 and February 2015, 1004 patients (mean age 61±11 years) underwent elective and urgent aortic arch surgery. Chronic Type A and B aortic dissection were indications for surgery in 61 (6.1%) patients whereas degenerative or atherosclerotic aneurysms accounted for the remaining 943 (93.9%) patients. Circulatory arrest was used in all patients. Antegrade selective cerebral protection (ASCP) was used in 686 (68.3%) patients.
Results:
The overall in-hospital mortality was 5.5 % and was significantly lower in patients who received ASCP (4.4%) compared those who did not (7.9%). Stroke and paraplegia occurred in 8.3% and 1.4% of patients, respectively. Logistic regression analysis revealed age >70 years (OR2.5,p=0.004), coronary artery disease (CAD) (OR 2.4, p=0.002), left ventricle ejection fraction (LVEF) <30% (OR , p=0.05), prior cardiac surgery (OR 2.4, p=0.008), and total arch replacement (OR 3.2, p<0.001) as independent predictors of in-hospital mortality. Use of bilateral ASCP was protective for early survival (OR 0.4, p=0.01). One, five and ten-year survival was 88%, 80% and 61%, respectively. Cox regression analysis revealed that long-term survival was negatively influenced by age, NYHA III-IV, CAD, previously stroke, prior cardiac surgery and total arch replacement and positively influenced by good LVEF and bilateral ASCP. Five and ten-year freedom from aorta-related surgical and endovascular re-intervention was 91% and 86%, respectively.
Conclusions:
Elective aortic arch surgery was associated with low early and late mortality and aorta-related reoperation rate, but increased rate of neurological complications. Use of bilateral ASCP positively influenced survival after surgery. Total aortic arch replacement was associated with worse outcomes compared to partial arch replacement.
EVOLVING SURGICAL TECHNIQUES AND IMPROVING OUTCOMES FOR AORTIC ARCH SURGERY IN CANADA
