Hemiarch Reconstruction Versus Clamped Aortic Anastomosis for Concomitant Ascending Aortic Aneurysm

Abstract

Deep hypothermic circulatory arrest (DHCA) is often avoided in patients with concomitant ascending aortic pathology when treating another cardiac disease to avoid increased risk of morbidity and mortality. We hypothesized that the use of DHCA with retrograde cerebral perfusion (RCP) does not add incremental risk to ascending aortic replacement alone in the setting of concomitant cardiac surgery. A total of 408 ascending aortic ± hemiarch replacements and aortic (root), mitral, or tricuspid valve(s); coronary artery bypass grafting; or MAZE procedures were performed for concomitant cardiac disease. DHCA with RCP was used for all hemiarch replacements or the ascending aorta was replaced with an aortic cross-clamp proximal to the innominate artery. Propensity score matching was used to match similar ascending aorta patients versus hemiarch patients; the final propensity score-matched patients on age, sex, body mass index, previous heart surgery, preoperative aortic insufficiency, preoperative aortic stenosis, preoperative ejection fraction, and operative variables. Propensity score matching yielded 116 pairs of non-hemiarch patients versus 116 hemiarch patients. Within the propensity score-matched cohort, there were no differences in postoperative stroke (1.7% versus 3.4%; p= 0.41), new postoperative dialysis (6.0% versus 5.2%; p= 0.78), postoperative renal insufficiency (27.6% versus 19.8%; p= 0.16), 30-day mortality (2.6% versus 3.4%; p= 0.701), or 1-year mortality (4.3% versus 4.3%; p= 1.00) CONCLUSIONS: Hemiarch replacement using DHCA with RCP does not increase the risk of operative complications compared with a normothermic, clamped-distal aortic anastomosis, and therefore its use should not be limited when planning complex multiprocedural reconstructions during elective ascending thoracic aortic replacement with concomitant cardiac surgery.