Outcomes After Elective Proximal Aortic Replacement: A Matched Comparison of Isolated Versus Multicomponent Operations

Background Guidelines supporting the decision to replace the aorta in patients with chronic asymptomatic proximal aortic disease are limited by lack of data on operative risks and long-term effectiveness in relation to aortic size. Therefore, we assessed and compared outcomes of patients undergoing elective isolated proximal aortic replacement for this disease vs replacement during multicomponent operations. Methods From January 2006 to January 2011, 1,889 patients underwent proximal aortic replacement (isolated, 212; multicomponent, 1,677) for chronic asymptomatic ascending and arch pathology. Mean age was 60 ± 14 years, and maximum proximal aortic diameter was 52 ± 10 mm (isolated) and 49 ± 10 mm (multicomponent; p = 0.0004). Propensity matching using 64 preoperative variables yielded 197 well-matched patient pairs. Results Patients were more likely to undergo isolated replacement if they had prior cardiac operations and a larger middescending aortic diameter ( p < 0.0001). Multicomponent operations were more common among those with connective tissue disorder or porcelain aorta. Among propensity-matched patients, in-hospital mortality was 1 of 197 (0.5%) in the isolated group vs 8 of 197 (4.1%) in the multicomponent group. Occurrence of stroke, renal failure, and prolonged ventilation were similar. Median postoperative stay was 7.9 vs 8.1 days ( p = 0.07). At 30 days, 1 year, and 4 years, survival was 97%, 93%, and 87%, and freedom from reintervention was 98%, 90%, and 89%, respectively, similar between groups. Conclusions Elective ascending aortic replacement is safe and effective. Ascending aneurysms should be treated aggressively even when encountered in patients undergoing a multicomponent operation. An aggressive approach to replacement of the ascending aorta may be warranted given the increased risk of stroke during a subsequent reoperation.