Ten-Year Outcomes of Proximal Aortic Surgery for Degenerative Aortic Disease

C. Jensen¹, M. Moya-Mendez², A. Medema², A. Vekstein¹, D. Urick¹, L. Kang³, B. Aykut⁴, A. Williams¹, J. Gaca³, E. Chen³, G. Hughes^3
1Duke University, Durham, North Carolina ²Duke University School of Medicine, Duke University, Durham, North Carolina ³Duke University Medical Center, Durham, North Carolina ⁴Duke, Durham, North Carolina

Purpose: There are little data comparing outcomes of proximal aortic surgery by disease etiology. However, patients with degenerative aortopathy are typically older with more comorbidities than those with aortopathy due to other causes and therefore may face higher surgical risk. This study examines early and late surgical outcomes in this cohort.

Methods: The primary study cohort consisted of patients undergoing proximal aortic surgery for aneurysmal disease due to degenerative aortopathy (hypertension [HTN], atherosclerosis, and non-infectious aortitis) at a single referral center between July 2005 and December 2022. Patients were identified from a prospectively-maintained institutional database. Exclusion criteria included aortopathy due to hereditary aortic disease, including bicuspid aortic valve (BAV), or surgery for acute aortic dissection. Extracted data included preoperative comorbidities, maximum aortic diameter, degree of preoperative aortic insufficiency (AI), and operation performed. Investigated outcomes included 30-day/in-hospital mortality, major morbidity, late overall survival, and late aortic events, defined as a composite of any aortic reintervention and aortic-related death. Patients undergoing proximal aortic surgery for aneurysmal disease due to BAV aortopathy were used as a comparison group.

Results: A total of 1,374 patients (degenerative: 758; BAV: 616) met study inclusion criteria. Patients with degenerative aortopathy were older, less likely to be male, more likely to be Black, and had higher rates of HTN, chronic lung disease, and NYHA Class III-IV congestive heart failure (all p< 0.001, Table). Furthermore, degenerative patients had larger aneurysms (median diameter 5.6 vs. 5.2 cm, p< 0.001) and higher rates of moderate or worse AI (p < 0.001). They were also more likely to undergo non-elective surgery (10.7% vs. 4.4%, p< 0.001) and require aortic root replacement (48.9% vs. 26.6%, p< 0.001), total arch replacement (10.2% vs. 0.9%, p< 0.001), or concomitant CABG (16.9% vs 11.5%, p=0.006), which required significantly longer durations of cardiopulmonary bypass (CPB), aortic cross-clamping (AXC), and hypothermic circulatory arrest (HCA, Table).
All investigated outcomes were worse in patients with degenerative aortopathy, including 30-day mortality (2.6% vs. 0.6%, p=0.01), stroke, renal failure requiring dialysis, and bleeding requiring reoperation (Table). Degenerative patients also had significantly worse overall survival (5 years: 83.8% vs. 93.4%; 10 years: 65.0% vs. 83.3%, log-rank p< 0.0001, Figure) and freedom from late aortic events (5 years: 86.5% vs. 97.6%; 10 years: 79.9% vs. 92.0%, log-rank p< 0.0001).

Conclusion: Degenerative aneurysmal aortopathy is the most common indication for proximal aortic surgery. The current study shows that these patients are older with higher comorbidity burdens, have more extensive aortic involvement more frequently requiring aortic root or total arch replacement, and have inferior early and late outcomes as compared to those with BAV aortopathy. As no prior study has previously examined outcomes by etiology sub-type, these findings may have important implications for future consensus guidelines. Specifically, given the >4-fold higher early mortality with a degenerative etiology, maintaining a 5.5 cm surgical intervention threshold may be more appropriate in this population.

Identify the source of the funding for this research project: American Heart Association (Postdoctoral Grant #903995, to Dr. Jensen)