Proximal aortic repair in asymptomatic patients

Emelie Carlestål,Melih Selcuk Ezer,Anders Franco-Cereceda,Christian Olsson

doi:10.1016/j.xjon.2021.05.001

Emelie Carlestål, Melih Selcuk Ezer + Show 2 more

Open Access

https://doi.org/10.1016/j.xjon.2021.05.001

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Abstract

ObjectiveCurrent guidelines for elective proximal aortic repair are applicable to elective first-time procedures in asymptomatic patients without other primary indications or connective tissue disorders and with specified aortic diameter or growth rate. The objective was to characterize the surgical outcomes in this narrowly defined patient-population. MethodsGuideline-compliant patients were identified from a recent (2014-2019) single unit consecutive surgical cohort (n = 935) by excluding total arch replacements, redos, acute and symptomatic patients, and genetic syndromes. Remaining patients were included regardless of surgical procedure performed. Early (30-day or in-hospital) and 1-year mortality were primary outcome measures. Major complications (stroke, severe renal or respiratory insufficiency, postcardiotomy shock, deep sternal wound infection, permanent pacemaker, and re-exploration) up to 1 year postoperatively were secondary outcome measures. ResultsIn the resulting study population (n = 262), median age was 63 (interquartile range, 52-71) years, and median surgical risk (European System for Cardiac Operative Risk Evaluation II) was 3.2% (2.0%-4.4%). Early mortality was 2 of 262 (0.76%) without additional deaths up to 1-year postoperatively. The occurrence of major complications was low: stroke, 2 (0.76%); renal insufficiency, 2 (0.76%); respiratory insufficiency, 1 (0.38%); postcardiotomy shock, 1 (0.38%); deep sternal wound infection, 0; permanent pacemaker, 3 (1.1%); and re-exploration, 20 (7.6%), all occurring in the immediate (30-day) postoperative period and without additional events up to 1 year postoperatively. ConclusionsIn this recent cohort including the target population referred to by and managed in accordance with current guidelines, mortality and major complications were exceptionally infrequent. Guidelines should adequately weigh risks of conservative management against current surgical outcomes.

Highlights

MethodsGuideline-compliant patients were identified from a recent (2014-2019) single unit consecutive surgical cohort (n 1⁄4 935) by excluding total arch replacements, redos, acute and symptomatic patients, and genetic syndromes
PERSPECTIVE The risk of adverse events after prophylactic proximal aortic surgery according to any valid instance covered by current guidelines was extremely low, regardless what type and extent of surgical procedure was performed
It is essential that guidelines adequately weigh the risk of acute aortic events against current surgical outcomes in the target population

Summary

Methods

Guideline-compliant patients were identified from a recent (2014-2019) single unit consecutive surgical cohort (n 1⁄4 935) by excluding total arch replacements, redos, acute and symptomatic patients, and genetic syndromes. To obtain a study population unequivocally corresponding to that with a guideline-compliant indication, a set of exclusion criteria were applied: arch replacement, acute procedures, procedures for symptomatic conditions or with other primary indication, redo procedures, and, Marfan syndrome or other known connective tissue disorders (Figure 1). The proportion of patients undergoing aortic valve procedures (replacement or repair) were essentially asymptomatic (less than New York Heart Association class II), ie, without stand-alone indication for valve surgery. The study population had proximal aortic dilatation as the sole indication for operation at the point in time when the operation was performed.

Results

Discussion

Conclusion