Invited Commentary

Abstract

This study by Okada and colleagues [1Okada K. Omura A. Kano H. et al.Short and midterm outcomes of elective total aortic arch replacement combined with coronary artery bypass grafting.Ann Thorac Surg. 2012; 94: 530-536Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar] presents a large (n = 200) institutional experience with total aortic arch replacement (TAR) performed to treat nondissecting aneurysm. The 30-day mortality for the entire cohort was remarkably low at 0.5%, and hospital mortality was 3.5%. The authors examined the surgical outcomes of TAR with and without coronary artery bypass grafting (CABG). Unadjusted outcomes for the patients who underwent both TAR and CABG included higher operative mortality, lower survival, and a higher incidence of major cardiac and cerebrovascular events. Although CABG was associated with prolonged operative times—reflecting the greater complexity of a combined procedure—only operative time emerged as an important independent predictor of both perioperative and mid-term mortality. In established cardiac risk models, including the STS model and the Veterans Affairs Continuous Improvement in Cardiac Surgery Program, the addition of CABG to valve procedures increases risk independently of other patient-related comorbidities. In fact, in the Japanese thoracic aortic surgery model (cited by the authors as reference 9), the addition of unexpected CABG to a thoracic aortic procedure was independently associated with increased 30-day mortality, and the addition of any CABG was associated with an increased rate of the composite outcome of major morbidity and mortality. Beyond the immediate perioperative risk posed by CABG, coronary artery disease is a clearly an additional life-limiting disease that is palliated by CABG but perhaps not cured. Therefore, one would expect the TAR-plus-CABG cohort to have worse long-term survival than the TAR-only cohort. Although this study had an impressive sample size for a single-center TAR series, the number of patients and events is small; therefore, the study might not have had enough power to detect any increase in risk caused by the addition of CABG to TAR. The confidence intervals in some instances are wide and in others approach or encompass 1.0. Regardless of how concomitant CABG might affect TAR outcomes, this study serves as a good example of the excellent short- and mid-term outcomes achieved in modern-day TAR performed at an experienced center. These results set the bar high for emerging endovascular and hybrid approaches to treating aortic arch aneurysms. Short and Midterm Outcomes of Elective Total Aortic Arch Replacement Combined With Coronary Artery Bypass GraftingThe Annals of Thoracic SurgeryVol. 94Issue 2PreviewThis study was performed to investigate the early and late outcomes of total aortic arch replacement (TAR) with or without coronary artery bypass grafting (CABG). Full-Text PDF