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Outcomes after Concomitant Arch Replacement at the time of Aortic Root Surgery

Open AccessPublished:January 21, 2023DOI:https://doi.org/10.1016/j.xjon.2022.12.014
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      Abstract

      Introduction

      Contemporary series of aortic arch replacement at the time of aortic root surgery are limited in number of patients and mostly address hemiarch replacement. We describe outcomes after aortic root and concomitant arch replacement, including total arch replacement.

      Methods

      This single institution retrospective review studied 1,196 consecutive patients from May 2004 to September 2020 who underwent first-time aortic root replacement. Patients undergoing surgery for endocarditis were excluded (n=68, 5.7%). Patients undergoing concomitant root and arch replacement were propensity matched with patients undergoing isolated root surgery based on indication, clinical and operative characteristics, demographics, medical history including connective tissue disorders, and urgency. Multivariable Cox proportional hazards and logistic regression modeling were used to assess the primary outcome of all-cause mortality and the secondary outcomes of prolonged ventilator use, post-operative blood transfusion, and debilitating stroke, adjusted for patient and operative characteristics.

      Results

      Among the 1,128 patients who underwent aortic root intervention during the study period, 471 (41.8%) underwent concomitant aortic arch replacement. Most underwent hemiarch replacement (n=411, 87.4%), 59 patients (12.6%) underwent total arch replacement (with elephant trunk: n=23, 4.9%; without elephant trunk: n=36, 7.7%). The mean follow-up time was 4.6 years post-procedure. Operative mortality was 2.2%, and total mortality over the entire study period was 9.2%. Propensity matching generated 348 matches (295 concomitant hemiarch, 53 concomitant total arch). Concomitant hemiarch (HR:1.00,95%CI:0.54-1.86, p=0.99) and total arch replacement (HR:1.60, 95%CI:0.72-3.57, p=0.24) were not significantly associated with increased mortality. Rates of stroke were not significantly different among each group: isolated root (n=11/348, 3.7%), root+hemiarch (n=17/295, 5.8%), and root+total arch (n=3/53, 5.7%) replacement (p=0.50), nor was the adjusted risk of stroke. Both concomitant arch interventions were associated with prolonged ventilator use and use of post-operative blood transfusions.

      Conclusion

      Hemiarch and total arch replacement are safe to perform at the time of aortic root intervention with no significant differences in survival or stroke rates, but increased ventilator and blood product use.

      Key Words

      Glossary of Abbreviations:

      ARR (Aortic Root Replacement), BMI (Body Mass Index), CI (Confidence Interval), ET (Elephant Trunk), HR (Hazard Ratio), OR (Odds Ratio), pRBC (packed Red Blood Cells), RCP (Retrograde Cerebral Perfusion), SACP (Selective Antegrade Cerebral Perfusion), SMD (Standard Mean Difference)