Yuya Tanaka, MD, Akihito Mikamo, MD, PhD, Ryo Suzuki, MD, PhD, Hiroshi Kurazumi, MD, PhD, Tomoaki Kudo, MD, Masaya Takahashi, MD, PhD, Shigeru Ikenaga, MD, PhD, Bungo Shirasawa, MD, PhD, and Kimikazu Hamano, MD, PhD Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, Yamaguchi, Japan

Background. Total aortic arch replacement is associated with considerable mortality and morbidity. Although operative death is the most extreme adverse clinical end point, postoperative morbidity can also be devastating for survivors. Methods. We examined the short-term and long-term outcomes of 146 patients who underwent total aortic arch replacements between September 2003 and September 2011. Results. The overall in-hospital mortality was 4.8%, and major postoperative morbidity during hospitalization occurred in 29 patients (19.9%). Multivariate analyses demonstrated that risk factors for hospital death were left thoracotomy (odds ratio [OR], 51.92; p [ 0.01), high preoperative serum creatinine values (OR, 3.88; p [ 0.02), and intraoperative blood loss (OR, 1.01; p [ 0.04). Ruptured aorta (OR, 7.13; p [ 0.02) and previous myocardial infarction (OR, 5.13; p [ 0.04) were identified as independent risk factors for major postoperative

morbidity. The postoperative survival of all patients at 5 years was 76.7% ± 5%. After hospital discharge, the standardized mortality ratios showed no significant difference between hospital survivors and a comparable Japanese population and were 1.09 (p [ 0.41) among patients without major morbidity and 1.82 (p [ 0.12) among those with major morbidity. The development of renal failure requiring hemodialysis increased the risk of long-term death (hazard ratio, 5.59; p [ 0.03), even among hospital survivors. Conclusions. Our approach for total arch replacement resulted in low in-hospital mortality and morbidity. Long-term outcomes are stable in hospital survivors, especially in the absence of a postoperative requirement for dialysis.

A

STS-NCD [3]. These major morbidities may be life threatening or result in permanent functional disability. Although the occurrence of a postoperative stroke was reported to adversely affect long-term survival after aortic arch operations [4], the effect of other major morbidities on long-term outcomes it is unclear. The purpose of this study was to investigate the incidence of postoperative mortality and morbidity and to determine the influence of major morbidities (defined by STS-NCD or JACVSD) on long-term death after TAR.

lthough the short-term and long-term outcomes of total aortic arch replacement (TAR) have improved during the past decade, the procedure is still associated with life-threatening morbidities, such as stroke, prolonged ventilation, renal failure, and graft infection [1, 2]. The incidence of postoperative morbidities resulting from thoracic aortic operations is thought to be high relative to other types of cardiac operations [3]. The effect of postoperative morbidities on long-term outcome is not fully understood. In Japan, the JapanSCORE (Japanese System for Cardiac Operative Risk Evaluation), devised by the Japan Adult Cardiovascular Surgery Database (JACVSD) in reference to The Society of Thoracic Surgeons National Adult Cardiac Surgery Database (STS-NCD), exists as Japan’s own nationwide risk model [3]. This risk model defines major postoperative morbidities, and the variables and definitions are almost identical to those in the

Accepted for publication Jan 6, 2014. Address correspondence to Dr Mikamo, Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine, 1-1-1 Minami-Kogushi, Ube, Yamaguchi 755-8505, Japan; e-mail: [email protected].

Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc

(Ann Thorac Surg 2014;97:1569–75) Ó 2014 by The Society of Thoracic Surgeons

Patients and Methods Preoperative and postoperative data were collected retrospectively for 146 patients who underwent TAR between September 2003 and September 2011. Major postoperative morbidities occurred in 29 patients (19.9%), and their shortterm and long-term outcomes were compared with 117 other patients without major morbidities. In-hospital death and the occurrence of major morbidities, assessed as neurologic deficits including spinal damage, renal failure newly requiring dialysis, prolonged ventilation for more than 24 hours, deep surgical site infection, or reoperation for any reason, were monitored as short-term end points, 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.01.014

ADULT CARDIAC

Mortality and Morbidity After Total Aortic Arch Replacement

1570 ADULT CARDIAC

TANAKA ET AL MORTALITY AND MORBIDITY AFTER TAR

and the overall survival rate was monitored as a long-term end point. The institutional review board approved this retrospective study and waived the need for individual patient consent.

Surgical Technique Operations were performed through a median sternotomy, with the exception of 10 patients who underwent left thoracotomies, with patients under general anesthesia and with intravenous administration of narcotics and muscle relaxants. To perform an arterial return of the cardiopulmonary bypass (CPB) and antegrade selective cerebral perfusion (ASCP), the bilateral axillary artery was exposed using the infraclavicular approach in median sternotomy patients. After the median sternotomy, transverse arteriotomy was performed, and the bilateral axillary artery was cannulated directly using a 14F to 18F wire-reinforced, straight, flexible cannula. The cannula was attached to an inflow line from another pump to its side branch. This arterial inflow established the subsequent cerebral perfusion through the 3 arch vessels. Bicaval venous drainage with ventricular venting was routinely performed. To guarantee thorough cooling and prevent temperature increases during circulatory arrest, CPB was continued for 30 minutes after the initiation of cooling until a rectal temperature of 25 C was reached. After the induction of hypothermic circulatory arrest (rectal temperature of less than 25 C), ASCP was initiated through the bilateral axillary artery by clamping all 3 arch vessels. The proximal aortic arch was opened, and a balloon-tipped cannula was inserted from inside the aorta into the left common carotid artery. The flow of the ASCP was maintained at 8 to 12 mL/kg/min to maintain a mean perfusion pressure greater than 50 mm Hg. Antegrade cold blood cardioplegia was administered to achieve and maintain cardiac arrest. Regardless of the aortic pathology, open distal anastomosis was first performed during hypothermic lower body circulatory arrest (LBCA). A modified elephant trunk procedure and stepwise distal anastomosis were performed for an easy and secure anastomosis in all cases through a median sternotomy. A folded elephant trunk graft was inserted into the distal aorta and anastomosed to the aorta with circumferential pledgeted mattress sutures after a running suture to avoid the need for additional sutures on the distal anastomosis after reconstruction. After the distal anastomosis, the elephant trunk graft was unfolded to pull up the proximal end of the graft, and a 4branched Dacron (DuPont, Wilmington, DE) arch graft was connected. Lower body circulation was resumed from a branch of the arch graft. The patient was warmed but maintained at less than 28 C until the reconstruction of the arch vessels was completed. The 3 arch vessels were reconstructed individually, and the proximal anastomosis and coronary reperfusion were then performed.

Follow-Up The patients were followed up by their referring cardiologist or periodically contacted by a surgeon. For this

Ann Thorac Surg 2014;97:1569–75

study, the follow-up was closed in September 2012, and the follow-up rate was 100%. The mean duration of the follow-up period was 50.6  27.8 months.

Statistical Analysis Statistical analysis was performed using StatView 5.0 software (SAS Institute Inc, Cary, NC). Continuous data are expressed as the mean  standard deviation. Independent risk factors for hospital death and major postoperative morbidities were examined by multivariate logistic regression analysis using risk factors with p values of less than 0.1 by prior univariate analysis. Patient survival was summarized by the Kaplan-Meier method and compared using the log-rank test. We also estimated the standardized mortality ratio after hospital discharge by using the Japanese life tables for the year of the surgical procedure. The standardized mortality ratio provides the observed numbers of deaths relative to the number that would be expected based on Japanese population death rates for comparable ages, sexes, and follow-up times. The statistical significance of the standardized mortality ratio was tested with a Poisson model. Cox proportional hazard analysis was used to determine the risk factors for late death. Variables were determined to be significant at p of less than 0.05.

Results Patient profiles are reported in Table 1. Previous myocardial infarction and ruptured aorta were more frequent in patients with major postoperative morbidity than in patients experiencing no major postoperative morbidity. Among the operative variables (Table 2), there was a higher incidence of concurrent coronary artery bypass grafting in the cohort with major postoperative morbidity. The distribution of the extent of the operation and perfusion data did not differ significantly between the two groups. The hospital mortality was 4.8% (7 of 146), and 1 patient died before being diagnosed with a major morbidity. Four patients with acute type A aortic dissection (AAD) died of organ dysfunction resulting in 3 patients from preoperative malperfusion. Three patients died after thoracotomy: 2 died of perioperative cerebral infarction and the other of aortic graft infection. Several major morbidities occurred postoperatively in 29 patients (19.9%; Table 3). No postoperative spinal cord injury developed, and no patients required long-term renal replacement therapy. The univariate and multivariate analyses (Table 4) confirmed that risk factors for hospital death were operations through a left thoracotomy (p ¼ 0.01), high preoperative serum creatinine values (p ¼ 0.02), and intraoperative blood loss (p ¼ 0.04). Multivariate analyses identified ruptured aorta (p ¼ 0.02) and previous myocardial infarction (p ¼ 0.04) as independent risk factors for any one of the major postoperative morbidities (Table 5). The duration of perfusion data were not associated with hospital death or major postoperative morbidities.

TANAKA ET AL MORTALITY AND MORBIDITY AFTER TAR

1571 ADULT CARDIAC

Ann Thorac Surg 2014;97:1569–75

Table 1. Patient Profiles (N ¼ 146) Major Morbidity a

Variables

Patients Age, y Male Body mass index (>26 kg/m2) Previous or current smoker Diabetes mellitus Creatinine value (2.0 mg/dL) Previous cerebrovascular disease Chronic lung disease Marfan syndrome Previous myocardial infarction History of endovascular aortic repair Left main coronary artery disease Reoperation Urgent operation Emergent operation Aortic pathology Acute dissection Chronic dissection Rupture JapanSCORE, % 30-day operative mortality 30-day mortality or major morbidity Logistic EuroSCORE, % EuroSCORE II, % a

Total

Without

With

146 (100) 66.6  12 90 (61.6) 16 (10.9) 82 (56.2) 11 (7.5) 6 (4.1) 26 (17.8) 17 (11.6) 6 (4.1) 14 (9.6) 3 (2.1) 3 (2.1) 8 (5.5) 7 (4.8) 56 (38.4)

117 (80.1) 66.1  12 70 (59.8) 11 (9.4) 67 (57.3) 9 (7.7) 4 (3.4) 18 (15.4) 13 (11.1) 6 (5.1) 7 (5.9) 3 (2.6) 3 (2.6) 5 (4.3) 5 (4.3) 43 (36.8)

29 (19.9) 68.9  11 20 (68.9) 5 (17.2) 15 (51.7) 2 (6.9) 2 (6.9) 8 (27.6) 4 (13.8) 0 7 (24.1) 0 0 3 (10.3) 2 (6.9) 13 (44.8)

0.27 0.40 0.31 0.53 0.99 0.34 0.17 0.75 0.60 0.0087 0.99 0.99 0.20 0.63 0.52

55 (37.7) 14 (9.6) 8 (5.5)

44 (37.6) 12 (10.2) 4 (3.4)

11 (37.9) 2 (6.9) 4 (13.8)

0.99 0.73 0.048

   

14.2  12.5 41.1  18.9 31.5  15.5 9.8  14.7

0.0007 24 h)

7 (4.8%) 1 2 1 2 1 29 (19.9) 4 (2.7) 7 (4.8) 6 (4.1) 3 (2.1) 17 (11.6)

LOS ¼ low output syndrome.

postoperative morbidity, with a standardized mortality ratio of 1.09 (p ¼ 0.41) and 1.83 (p ¼ 0.12), respectively (Figs 1C, 1D). Nine patients required operations on the distal aorta after the initial procedure (planned in 6 and unplanned in 3); these operations included thoracoabdominal aneurysm repair in 5 patients, descending thoracic aortic repair in 3, and thoracic endovascular aortic repair for a descending atherosclerotic aneurysm in 1. The average interval between the first repair and the second aortic operation was 25.8  21.9 months. Freedom from reoperation on the distal aorta was 90.6% at 5 years. Cox proportional hazard analysis (Table 6) demonstrated that only age (p ¼ 0.03) and a new requirement for hemodialysis (p ¼ 0.03) were independent predictors of long-term death in hospital survivors.

Comment

During the follow-up period, 21 patients died (15 without morbidity and 6 with morbidities), including 1 reoperative death due to distal thoracoabdominal aortic repair. The other 20 deaths were not caused by aortic events: 8 died of pneumonia, 6 of cerebrovascular disease, 2 of malignancy, 2 of weakness, 1 of acute pancreatitis, and 1 of suicide. The postoperative survival of all patients at 5 years was 76.7%  5% (Fig 1A). Patients with and without major morbidity had 5-year survival rates of 83.0%  5% and 51.1%  11%, respectively (p ¼ 0.002; Fig 1B). Among the 139 hospital survivors, the 5-year survival rates were 83.8%  4.7% and 54.2%  14.9% in patients without and with major morbidity, respectively (p ¼ 0.12; Figs 1C, 1D). There was no significant increase in observed vs expected deaths after hospital discharge among patients, regardless of whether they experienced

Contemporary studies from leading institutions have reported that the early mortality rate in aortic arch operations with ASCP ranges from 3.4% to 8.2% [1, 5, 6]. Our early outcomes after TAR compared favorably with those of previous reports. In the present study, a multivariate analysis demonstrated that the risk factors for hospital death include thoracotomy for aortic repair, preoperative serum creatinine values, and intraoperative blood loss. With the exception of surgical approaches, these findings are comparable to previous reports of cohorts undergoing aortic operations through a median sternotomy [2, 5]. Three of 10 patients who underwent left thoracotomy died during hospitalization; these patients were aged older than 70 years. Corvera and colleagues [7] showed excellent results, with no deaths after arch operations

Table 4. Univariate and Multivariate Logistic Regression Model for Hospital Mortality Variables Age, y Male Diabetes mellitus Chronic lung disease Ejection fraction Previous myocardial infarction Preoperative hemoglobin, g/dL Preoperative creatinine, mg/dL Emergency Rupture Concurrent CABG Left thoracotomy Blood loss, mL Operation time, min CPB time, min ASCP time, min LBCA time, min

Univariate OR (95% CI) 1.00 3.93 2.15 2.95 0.92 1.58 0.96 3.06 3.49 7.31 4.07 14.14 1.00 1.01 1.01 0.99 0.99

(0.94–1.06) (0.46–33.54) (0.26–19.65) (0.53–16.49) (0.85–0.99) (0.18–14.13) (0.63–1.46) (1.42–6.59) (0.65–18.63) (1.20–44.60) (0.71–23.26) (2.64–75.81) (1.00–1.00) (1.00–1.01) (0.99–1.02) (0.97–1.02) (0.96–1.01)

p Value 0.94 0.21 0.33 0.22 0.04 0.68 0.84 0.004 0.14 0.03 0.11 0.002 0.01 0.03 0.17 0.49 0.36

ASCP ¼ antegrade selective cerebral perfusion; CABG ¼ coronary artery bypass grafting; bypass; LBCA ¼ lower body circulatory arrest; OR ¼ odds ratio.

Multivariate OR (95% CI)

p Value

0.97 (0.87–1.09)

0.60

3.88 (1.23–12.23)

0.02

9.47 (0.72–125.04)

0.09

51.92 (2.20–1226.39) 1.00 (1.00–1.01) 1.00 (0.99–1.01)

0.01 0.04 0.18

CI ¼ confidence interval;

CPB ¼ cardiopulmonary

TANAKA ET AL MORTALITY AND MORBIDITY AFTER TAR

1573

Table 5. Univariate and Multivariate Logistic Regression Model for Major Postoperative Morbidity Variables Age, y Male Diabetes mellitus Chronic lung disease Ejection fraction Previous myocardial infarction Preoperative hemoglobin, g/dL Preoperative creatinine, mg/dL Emergency Rupture Concurrent CABG Left thoracotomy Blood loss, mL Operation time, min CPB time, min ASCP time, min LBCA time, min

Univariate OR (95% CI) 1.02 1.49 0.88 0.49 0.95 4.86 0.92 1.63 1.54 5.98 4.01 2.96 1.00 1.02 1.00 0.99 0.99

(0.98–1.06) (0.63–3.56) (0.18–4.36) (0.11–2.27) (0.91–0.99) (1.55–15.27) (0.73–1.16) (0.86–3.07) (0.68–3.48) (1.49–23.99) (1.26–12.92) (0.78–11.28) (1.00–1.01) (0.99–1.01) (0.99–1.01) (0.98–1.01) (0.99–1.01)

p Value 0.27 0.37 0.88 0.36 0.04 0.01 0.49 0.13 0.30 0.01 0.02 0.11 0.08 0.18 0.35 0.40 0.70

Multivariate OR (95% CI)

p Value

1.01 (0.95–1.08) 5.13 (1.06–24.83)

0.74 0.04

7.13 (1.38–36.91) 3.53 (0.99–12.66)

0.02 0.05

1.00 (1.00–1.01)

0.08

ASCP ¼ antegrade selective cerebral perfusion; CABG ¼ coronary artery bypass grafting; CI ¼ confidence interval; bypass; EF ¼ ejection fraction; LBCA ¼ lower body circulatory arrest; OR ¼ odds ratio.

through left thoracotomy, in a selected cohort. Our patient selection criteria for thoracotomy should be refined; therefore, we currently adopt a two-stage open reconstruction or thoracic endovascular aortic repair completion after an elephant trunk procedure instead of TAR and descending thoracic aortic replacement through left thoracotomy, especially for the patients aged older than 70 years. Ruptured aorta and previous myocardial infarction were independent risk factors for major postoperative morbidities. Preoperative circulatory instability due to aortic rupture or postoperative low-output condition may adversely affect the patient’s postoperative clinical course. The left ventricular ejection fraction did not have an independent prognostic value; however, not only low-output condition but also severe systemic atherosclerosis in patients with previous myocardial infarction would have negative effects on the postoperative course. Using the STS database, Williams and colleagues [2] reported that in addition to several other predictors, emergent status was significantly associated with major morbidity and operative death and suggested increasing the screening of at-risk populations as well as lowering aortic diameter thresholds for elective intervention to improve outcomes by reducing the fraction of nonelective operations. In our study, 5 of 7 hospital deaths occurred after an emergent operation. The hospital mortality among patients undergoing emergent TAR is likely to be greater (8.1% vs 2.3%, p ¼ 0.24); however, the factor of emergent status did not reach statistical significance for hospital death or major morbidity. Our study cohort included 55 patients (37.7%) with AAD. Our standard policy is to perform TAR for AAD patients with the following aortic conditions: tear in the

CPB ¼ cardiopulmonary

arch (n ¼ 23), tear in the descending aorta (n ¼ 5), complex arch dissection (n ¼ 17), and distal end of dissection in the distal arch (n ¼ 10). In this series, hospital mortality related to total arch replacement for AAD was 7.3%, which is acceptable. Attempts to increase the temperature during ASCP have been made to prevent adverse physiologic changes induced by deep hypothermia and prolonged CPB [6, 8]. The CPB, ASCP, and LBCA times were longer in our series than those in previous reports, whereas our operative results were satisfactory. Corvera and colleagues [7] reported excellent results after extensive thoracic aortic operations necessitating 5 hours of CPB. We believe that prolongation of CPB due to problems with aortic anastomosis and perfusion may be associated with high postoperative mortality and morbidity. Prolonged CPB without procedural or perfusion problems might be of little consequence in itself. The duration of CPB and ASCP in our operations depended mainly on the LBCA time. In our practice, several reasons for the long LBCA duration might include circumferential pledgeted mattress sutures in addition to a running suture for the deep distal aortic anastomosis, graft-to-graft anastomosis, and the adventitial inversion technique for acute dissection repair. We believe that the most important principle for thoracic aortic operations is to avoid surgical bleeding after repair. The Hannover group [9] reported the dangers of prolonged LBCA and revealed that more than 60 minutes of LBCA under ASCP with 2 vessels at a nasopharyngeal temperature between 25 C and 28 C was associated with a mortality rate of 27% and a paraplegia rate of 18%. However, hospital mortality in the present study was 4.8%, and no spinal cord injuries occurred. This discrepancy may be explained by certain differences in

ADULT CARDIAC

Ann Thorac Surg 2014;97:1569–75

1574 ADULT CARDIAC

TANAKA ET AL MORTALITY AND MORBIDITY AFTER TAR

Ann Thorac Surg 2014;97:1569–75

Fig 1. Survival estimated by the Kaplan-Meier method in patients undergoing total aortic arch replacement: (A) Survival of the entire cohort (N ¼ 146); (B) survival of patients with major postoperative morbidity (solid line) and without major postoperative morbidity (dotted line); (C) predicted (dotted-dashed line) and estimated (solid line) survival of hospital survivors without major postoperative morbidity (n ¼ 116); and (D) predicted (dotted-dashed line) and estimated (solid line) survival of hospital survivors with major postoperative morbidity (n ¼ 23).

our study: ASCP was conducted with 3 vessels using bilateral axillary cannulation, and the temperature was maintained below 25 C. Etz and colleagues [10] showed that irreversible spinal cord damage often occurs after 90 minutes, and the damage rate approached 100% at 120 minutes after LBCA with perfusion of 3 arch vessels at 28 C in a pig model. Therefore, these authors hesitated to endorse moderately hypothermic ASCP for routine clinical use in complex aortic arch operations [10]. Our study demonstrated that the mortality rate after TAR was almost equivalent to that of the general population, especially in patients who had not experienced major postoperative morbidities. Etz and associates [11] demonstrated significantly increased mortality (late mortality that was 1.6 to 1.8 times that of a normal population) in patients with arch aneurysm repairs. It is unclear whether the difference in late death between the results of Etz and colleagues [11] and our current results is attributable to clinical profiles, surgical strategies, or incidence of postoperative morbidity.

The only independent risk factor for long-term death was renal failure requiring dialysis in our hospital survivors. Three hospital survivors of 7 patients who needed dialysis recovered preoperative creatinine levels at discharge. However, Hobson and colleagues [12] reported that even for patients with complete renal recovery at discharge after cardiothoracic operations, the 10-year mortality rate was significantly higher compared with that of patients with no acute kidney injury, and the risk of death was independent of other postoperative complications. Postoperative renal injury may result in ongoing progressive renal damage beyond the acute episode. This study has several limitations. This was a retrospective study from a single hospital, and the number of patients was too small to fully confirm the statistical significance of the results. Patients in our series may present relatively lower risk profiles (10.9% with a body mass index exceeding 26 kg/m2, 7.5% with diabetes mellitus, and 11.6% with chronic lung disease) than those of a North American cohort [2]. Each type of major morbidity

TANAKA ET AL MORTALITY AND MORBIDITY AFTER TAR

1575

Table 6. Cox Proportional Hazards Model for Death after Hospital Discharge Variables Age, y Male Diabetes mellitus Chronic lung disease Ejection fraction Previous myocardial infarction Preoperative hemoglobin, g/dL Preoperative creatinine, mg/dL Emergency Rupture Concurrent CABG Left thoracotomy Blood loss, mL Operation time, min CPB time, min ASCP time, min LBCA time, min Deep sternum infection Dialysis requirement Prolonged ventilation Reoperation Stroke

Univariate HR (95% CI)

p Value

Multivariate HR (95% CI)

p Value

1.07 (1.02–1.13) 0.64 (0.45–0.91) 1.06 (0.14–7.94) 0.42 (0.06–3.17) 1.00 (0.96–1.06) 0.95 (0.22–4.13) 0.73 (0.57–0.93) 1.45 (0.76–2.78) 1.47 (0.62–3.46) 2.60 (0.76–8.90) 0.48 (0.06–3.65) 1.19 (0.16–8.95) 1.00 (1.00–1.00) 1.00 (0.99–1.00) 0.99 (0.99–1.00) 0.99 (0.99–1.01) 0.99 (0.98–1.00) 2.21 (0.51–9.51) 5.46 (1.25–23.9) 1.77 (0.52–6.03) Not applicable Not applicable

0.01 0.01 0.95 0.40 0.76 0.94 0.01 0.26 0.38 0.13 0.48 0.87 0.19 0.73 0.37 0.76 0.15 0.29 0.02 0.36 . .

1.06 (1.01–1.13) 0.57 (0.22–1.50)

0.03 0.25

0.85 (0.66–1.11)

0.23

5.59 (1.17–26.73)

0.03

ASCP ¼ antegrade selective cerebral perfusion; CABG ¼ coronary artery bypass grafting; CI ¼ confidence interval; bypass; EF ¼ ejection fraction; HR ¼ hazard ratio; LBCA ¼ lower body circulatory arrest.

has a very different prognostic value for short-term and long-term outcomes; thus, our logistic model for the assessment of major morbidities has limitations. Further studies (eg, propensity analysis) will be needed to elucidate the prognostic value of postoperative morbidities for short-term and long-term outcomes. In conclusion, our approach for TAR demonstrated a low hospital mortality rate and a 19.9% rate of major postoperative morbidities. In hospital survivors, especially those without major morbidities, long-term outcomes were almost equivalent to those of the normal population. Postoperative renal failure requiring dialysis had a strong effect on long-term mortality, even among hospital survivors.

References 1. Kr€ ahenb€ uhl ES, Immer FF, Stalder M, et al. Technical advances improved outcome in patients undergoing surgery of the ascending aorta and/or aortic arch: ten years experience. Eur J Cardiothorac Surg 2008;34:595–9. 2. Williams JB, Peterson ED, Zhao Y, et al. Contemporary results for proximal aortic replacement in North America. J Am Coll Cardiol 2012;60:1156–62. 3. Motomura N, Miyata H, Tsukihara H, Takamoto S. Risk model of thoracic aortic surgery in 4707 cases from a nationwide single-race population through a web-based data entry system: the first report of 30-day and 30-day operative outcome risk models for thoracic aortic surgery. Circulation 2008;118:S153–9.

CPB ¼ cardiopulmonary

4. Okita Y, Ando M, Minatoya K, Kitamura S, Takamoto S, Nakajima N. Predictive factors for mortality and cerebral complications in arteriosclerotic aneurysm of the aortic arch. Ann Thorac Surg 1999;67:72–8. 5. Okada K, Omura A, Kano H, et al. Recent advancements of total aortic arch replacement. J Thorac Cardiovasc Surg 2012;144:139–45. 6. Numata S, Tsutsumi Y, Monta O, et al. Aortic arch repair with antegrade selective cerebral perfusion using mild to moderate hypothermia of more than 28 C. Ann Thorac Surg 2012;94:90–6. 7. Corvera JS, Fehrenbacher JW. Total arch and descending thoracic aortic replacement by left thoracotomy. Ann Thorac Surg 2012;93:1510–6. 8. Zierer A, Detho F, Dzemali O, Aybek T, Moritz A, Bakhtiary F. Antegrade cerebral perfusion with mild hypothermia for aortic arch replacement: single-center experience in 245 consecutive patients. Ann Thorac Surg 2011;91: 1868–74. 9. Kamiya H, Hagl C, Kropivnitskaya I, et al. The safety of moderate hypothermic lower body circulatory arrest with selective cerebral perfusion: a propensity score analysis. J Thorac Cardiovasc Surg 2007;133:501–9. 10. Etz CD, Luehr M, Kari FA, et al. Selective cerebral perfusion at 28 C—is the spinal cord safe? Eur J Cardiothorac Surg 2009;36:946–55. 11. Etz CD, Plestis KA, Homann TM, et al. Reoperative aortic root and transverse arch procedures: a comparison with contemporaneous primary operations. J Thorac Cardiovasc Surg 2008;136:860–7. 12. Hobson CE, Yavas S, Segal MS, et al. Acute kidney injury is associated with increased long-term mortality after cardiothoracic surgery. Circulation 2009;119: 2444–53.

ADULT CARDIAC

Ann Thorac Surg 2014;97:1569–75

Mortality and morbidity after total aortic arch replacement.

Total aortic arch replacement is associated with considerable mortality and morbidity. Although operative death is the most extreme adverse clinical e...
302KB Sizes 0 Downloads 3 Views