Improved clinical outcomes after operation of the proximal aorta: A 10-year experience

Background. This study evaluated the impact of recent advances (particularl y noninvasive diagnosis, retrograde cerebral perfusion, heparin-bonded circ uits, and use of collagen-impregnated grafts and antifibrinolytic agents) o n clinical outcomes of patients undergoing proximal aortic operations. Methods. One hundred eight consecutive patients undergoing 111 proximal aor tic operations over 10 years were studied. The cohort was divided into two groups: early, 1987 to 1993 and late, 1994 to 1997. Results. Baseline patients profiles, indications for operation (aneurysm, 6 6 patients; dissection, 45 patients), priority of the operation, and surgic al procedures were comparable for both groups. Mortality and morbidity for the entire cohort were 13.5% (15 of 111) and 66% (73 of 111), respectively. Compared with the early group, the late group was characterized by signifi cantly higher use of noninvasive diagnostic modalities (69% versus 10%), ex clusive use of heparin-bonded circuits and collagen-impregnated grafts (100 % versus 0% for both), use of antifibrinolytic agents (79% versus 8%), and the introduction of retrograde cerebral perfusion (43% versus 0%) (p < 0.00 001 for all). These changes in practice were associated with a substantial decrease in operative mortality (26% [13 of 49] versus 3% [2 of 62], p = 0. 001), overall morbidity (77% [38 of 49] versus 56% [35 of 62], p = 0.02), b lood transfusions (55.6 +/- 48 donor units versus 29.3 +/- 35 donor units, p = 0.003), and a shorter hospital stay (21.6 +/- 31 days versus 12.1 +/- 1 5 days, p 0.07). Average long-term follow-up for 99% (107 of 108) of patien ts was 29.6 +/- 30 months (1 to 120 months). Ten-year actuarial survival wa s 57.3% +/- 8% with 93% being in New York Heart Association functional clas s I or II. Conclusions. Recent advances, particularly noninvasive diagnosis and improv ed operative management, have led to a substantial reduction in mortality a nd morbidity after proximal aortic operation. Improved short- and long-term outcomes were achieved both in acute dissection and aneurysm procedures, a lthough patients remain at risk for long-term distal aortic complications. (Ann Thorac Surg 1999;67:1030-7) (C) 1999 by The Society of Thoracic Surgeo ns.