Abstract
ObjectiveTo evaluate early and mid-term results in patients undergoing proximal thoracic aortic redo surgery.MethodsWe analyzed 60 patients (median age 60 years, median logistic EuroSCORE 40) who underwent proximal thoracic aortic redo surgery between January 2005 and April 2012. Outcome and risk factors were analyzed.ResultsIn hospital mortality was 13%, perioperative neurologic injury was 7%. Fifty percent of patients underwent redo surgery in an urgent or emergency setting. In 65%, partial or total arch replacement with or without conventional or frozen elephant trunk extension was performed. The preoperative logistic EuroSCORE I confirmed to be a reliable predictor of adverse outcome- (ROC 0.786, 95%CI 0.64–0.93) as did the new EuroSCORE II model: ROC 0.882 95%CI 0.78–0.98. Extensive individual logistic EuroSCORE I levels more than 67 showed an OR of 7.01, 95%CI 1.43–34.27. A EuroSCORE II larger than 28 showed an OR of 4.44 (95%CI 1.4–14.06). Multivariate logistic regression analysis identified a critical preoperative state (OR 7.96, 95%CI 1.51–38.79) but not advanced age (OR 2.46, 95%CI 0.48–12.66) as the strongest independent predictor of in-hospital mortality. Median follow-up was 23 months (1–52 months). One year and five year actuarial survival rates were 83% and 69% respectively. Freedom from reoperation during follow-up was 100%.ConclusionsDespite a substantial early attrition rate in patients presenting with a critical preoperative state, proximal thoracic aortic redo surgery provides excellent early and mid-term results. Higher EuroSCORE I and II levels and a critical preoperative state but not advanced age are independent predictors of in-hospital mortality. As a consequence, age alone should no longer be regarded as a contraindication for surgical treatment in this particular group of patients.
Highlights
Persisting or recurring aortic pathology in a proximal thoracic aortic segment after previous repair of acute or chronic aortic pathology is increasingly observed
Results of the logistic regression model are given as the odds ratio (OR) and the 95% confidence interval (CI) and predictive power was assessed via Receiver-Operating Curve (ROC)
Thirty-eight percent suffered from coronary artery disease, pulmonary hypertension was present in 12%
Summary
The most surprising demographic finding in this cohort was the fact that 27% of patients had already sustained previous neurologic injury This might well be due to the fact that a substantial percentage of patients had undergone surgery at a time (before 2000) where hypothermic circulatory arrest, especially in the acute setting was still associated with a higher risk of side effects, due to the fact that selective antegrade cerebral perfusion was not routinely used [8,9]. Active infective endocarditis (including those with cerebral embolism) was a frequent primary indication for redo-surgery and these two facts might well explain the high percentage of already sustained neurologic injury [9]. This is an important observation as surgeons active in this field do well know the clinical dilemma of decision making in conscious, well-reflected patients asking for treatment or in a situation of a demanding family of an already unconscious patient
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