Krishnan Aravind, Dalal Alex R, Pedroza Albert James, Nakamura Ken, Yokoyama Nobu, Tognozzi Emily, Woo Y Joseph, Fischbein Michael, MacArthur John Ward
Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif.
JTCVS Open. 2023 Jan 21;13:1-8. doi: 10.1016/j.xjon.2022.12.014. eCollection 2023 Mar.
Contemporary series of aortic arch replacement at the time of aortic root surgery are limited in number of patients and mostly address hemiarch replacement. We describe outcomes after aortic root and concomitant arch replacement, including total arch replacement.
This single-institution retrospective review studied 1196 consecutive patients from May 2004 to September 2020 who underwent first-time aortic root replacement. Patients undergoing surgery for endocarditis were excluded (n = 68, 5.7%). Patients undergoing concomitant root and arch replacement were propensity matched with patients undergoing isolated root surgery based on indication, clinical and operative characteristics, demographics, medical history including connective tissue disorders, and urgency. Multivariable Cox proportional hazards and logistic regression modeling were used to assess the primary outcome of all-cause mortality and the secondary outcomes of prolonged ventilator use, postoperative blood transfusion, and debilitating stroke, adjusted for patient and operative characteristics.
Among the 1128 patients who underwent aortic root intervention during the study period, 471 (41.8%) underwent concomitant aortic arch replacement. Most underwent hemiarch replacement (n = 411, 87.4%); 59 patients (12.6%) underwent total arch replacement (with elephant trunk: n = 23, 4.9%; without elephant trunk: n = 36, 7.7%). The mean follow-up time was 4.6 years postprocedure. Operative mortality was 2.2%, and total mortality over the entire study period was 9.2%. Propensity matching generated 348 matches (295 concomitant hemiarch, 53 concomitant total arch). Concomitant hemiarch (hazard ratio, 1.00; 95% confidence interval, 0.54-1.86, = .99) and total arch replacement (hazard ratio, 1.60, 95% confidence interval, 0.72-3.57, = .24) were not significantly associated with increased mortality. Rates of stroke were not significantly different among each group: isolated root (n = 11/348, 3.7%), root + hemiarch (n = 17/295, 5.8%), and root + total arch (n = 3/53, 5.7%) replacement ( = .50), nor was the adjusted risk of stroke. Both concomitant arch interventions were associated with prolonged ventilator use and use of postoperative blood transfusions.
Hemiarch and total arch replacement are safe to perform at the time of aortic root intervention, with no significant differences in survival or stroke rates, but increased ventilator and blood product use.
当代关于主动脉根部手术时进行主动脉弓置换的系列研究，患者数量有限，且大多针对半弓置换。我们描述了主动脉根部及同期主动脉弓置换（包括全弓置换）后的结果。
这项单中心回顾性研究纳入了2004年5月至2020年9月期间连续1196例行首次主动脉根部置换术的患者。因感染性心内膜炎接受手术的患者被排除（n = 68，5.7%）。根据适应证、临床和手术特征、人口统计学、包括结缔组织疾病在内的病史以及紧急程度，将同期进行根部和弓部置换的患者与单纯根部手术患者进行倾向匹配。采用多变量Cox比例风险模型和逻辑回归模型评估全因死亡率这一主要结局，以及机械通气时间延长、术后输血和致残性卒中这些次要结局，并根据患者和手术特征进行调整。
在研究期间接受主动脉根部干预的1128例患者中，471例（41.8%）同期进行了主动脉弓置换。大多数患者接受半弓置换（n = 411，87.4%）；59例（12.6%）接受全弓置换（带象鼻支架：n = 23，4.9%；不带象鼻支架：n = 36，7.7%）。术后平均随访时间为4.6年。手术死亡率为2.2%，整个研究期间的总死亡率为9.2%。倾向匹配产生了348对匹配患者（295例同期半弓置换，53例同期全弓置换）。同期半弓置换（风险比，1.00；95%置信区间，0.54 - 1.86，P = 0.99）和全弓置换（风险比，1.60，95%置信区间，0.72 - 3.57，P = 0.24）与死亡率增加无显著相关性。每组的卒中发生率无显著差异：单纯根部置换组（n = 11/348，3.7%）、根部 + 半弓置换组（n = 17/295，5.8%）和根部 + 全弓置换组（n = 3/53，5.7%）（P = 0.50），调整后的卒中风险也无显著差异。两种同期弓部干预均与机械通气时间延长和术后输血相关。
在主动脉根部干预时进行半弓和全弓置换是安全的，生存率和卒中发生率无显著差异，但机械通气和血液制品的使用增加。
