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

Background. This study evaluated the impact of recent advances (particularly noninvasive diagnosis, retrograde cerebral perfusion, heparin-bonded circuits, and use of collagen-impregnated grafts and antifibrinolytic agents) on clinical outcomes of patients undergoing proximal aortic operations. Methods. One hundred eight consecutive patients undergoing 111 proximal aortic 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, 66 patients; dissection, 45 patients), priority of the operation, and surgical 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 significantly higher use of noninvasive diagnostic modalities (69% versus 10%), exclusive 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< 0.00001 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), blood 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 ± 15 days, p = 0.07). Average long-term follow-up for 99% (107 of 108) of patients was 29.6 ± 30 months (1 to 120 months). Ten-year actuarial survival was 57.3% ± 8% with 93% being in New York Heart Association functional class I or II. Conclusions. Recent advances, particularly noninvasive diagnosis and improved operative management, have led to a substantial reduction in mortality and morbidity after proximal aortic operation. Improved short- and long-term outcomes were achieved both in acute dissection and aneurysm procedures, although patients remain at risk for long-term distal aortic complications