Treatment of ascending aortic aneurysms by different surgical techniques: Comparison of early and long-term results

Objectives: The proper treatment of aneurysm of the ascending aorta is still under debate. Here we compare the early and late outcome of patients undergoing composite replacement (CR), supracomissural aortic replacement (SCR) and aortic valve sparing operation (AVS) for treatment of aneurysm of the ascending aorta.

Methods and patients: From 1994 until 2010, 287 patients (pts) were operated for ascending aortic aneurysm. 79 pts (28%) underwent SCR, 161 pts (56%) had CR, 47 pts (16%) were operated with AVS using David's technique (D) (34 pts; 12%) and 13 pts (4%) using Yacoub's technique (Y). Average sizes of aneurysms were 5.9±1.4 in SCR, 6.3±1.5 in CR, 5.5±0.8 in D and 7.7±2.2cm in Y and differ significantly between groups (p<0.001). 70% of pts were male, with significant less male patients in Y (p=0.01). Average age with 60±14 years was comparable (p=0.22). Presence of bicuspide aortic valve was comparable (p=0.64), but Marfan's syndrome was more often present in AVS (p=0.005).

Results: Average bypass times were comparable (p=0.22), but aortic cross clamp times differed significantly (p<0.001) with 78±31min in SCR, 102±32min in CR, 114±29min in D and 78±37min in Y. Additional procedures were performed in 42 pts. Stay on ICU was comparable with 4.6±5.5 days (p=0.08). Rethoracotomy for bleeding was required in 20 pts (p=0.34). Overall 30-day-mortality was 6.6% and did not show significant difference between groups (SCR 10.1%, CR 5.9%, D 0% and Y 7.7%; p=0.25). Follow-up was complete for 90.2%, mean follow-up time was 155±125 months. Kaplan-Meyer-Analysis revealed significant reduced survival at 10 years for pts from Y (Logrank p=0.047). 5 pts experienced apoplex with paresis, homogeneous distributed between groups (p=0.079). At last contact, more patients from D presented in NYHA I, while a significantly higher percentage of SCR presented in NYHA III (p<0.0001). Re-operation of the ascending aorta was performed in 5 pts: 3 in Y and each 1 in SCR and CR, revealing a significant difference (p<0.0001). Re-operation on the aortic valve was more often in Y and SCR, and none in D (p=0.003).

Conclusion: Composite replacement and aortic valve sparing according to David result in favorable long-term-results regarding re-operation and clinical performance.