Comparison of long-term results after size-reducing aortoplasty vs. composite replacement for patients with aneurysm of the ascending aorta

Objective: Treatment of moderate ascending aortic dilatation (AAD) remains controversial, and simple size reducing aortoplasty (AP)±aortic valve replacement may, although often criticised, represent an alternative to the gold standard of Bentall operation (CR) in selected patients. The purpose of this study was to investigate long-term outcome of a large single center patient cohort comparing CR versus AP.

Methods: We retrospectively evaluated 325 patients (mean age 61±14 years) operated between 1988 and 2008 for AAD, diagnosed with computed tomography, magnetic resonance imaging or echocardiography. Mean operation time, time of hospitalization and intensive care treatment, aortic cross-clamp time (ACCT), extracorporeal circulation (EC) time, and aortic diameter (AD) were evaluated and compared. 30-day mortality rate, long-term survival and need for reoperation were compared between both groups.

Results: 164 (51%) and 161 (49%) patients (pts) underwent AP or CR, respectively. Pts treated with CR had significant larger AD (62.5±14.8 vs. 51.4±7.5mm; p<0.01). Within AP, 146 (89%) pts underwent additional aortic valve replacement. Patients operated with AP were older (62±15 vs. 59±14 years; p=0.012), and both groups included more male (69% AP, 71% CR). There were longer operation time (283±99 vs. 193±49min; p<0.001), ACCT (102±32 vs. 64±23min; p<0.001) and EC (162±71 vs. 100±34min; p<0.001) for CR. Treatment on ICU was significantly longer in CR (4.8±6.2 vs. 2.6±5.0 days; p<0.001). Rethoracotomy for bleeding was required in 6 pts undergoing AP and 11 pts undergoing CR (p=0.16). There was no significant difference in 30-day mortality (5.5 vs. 5.6%; p=0.88). Follow-up was complete for 317 (98%) pts. Mean follow-up time was longer for AP (95±66) compared to CR (72±52 months). Long-term survival at 10 years tend to be higher in CR (Logrank p=0.066), but higher age predicted reduced long-term survival (p<0.001). Six pts after AP and 1 pt after CR needed re-operation (p=0.096). Re-operated patients had significant reduced long-term-survival (Logrank p=0.0153).

Conclusions: CR requires less reoperations and should therefore be considered as technique of choice, but AP may be justified in elder patients.