Risk factors for prophylactic proximal aortic replacement in the current era

Decision-making in aortic aneurysm involves careful weighing of spontaneous prognosis and operative risk. There is limited recent information regarding operative risk and risk factors using current surgical strategies.

From 1998 to 2010, 1,221 patients (60 ± 15 years, 67 % male) underwent elective proximal aortic replacement (286 ascending aortic replacement, 699 concomitant root and 387 concomitant arch replacement). Additional cardiac procedures were necessary in 48 %. Previous cardiovascular operations had been performed in 9.6 % (aortic valve 6.3 %, ascending aorta 2.9 %, coronary artery bypass grafting 2.2 %).

Early mortality was 4.2 % overall; it was 2.6 % for isolated aortic replacement as primary surgery. In patients younger than 70 years (n = 829), mortality was 2.4 % overall and 1.2 % for isolated and primary surgery; it was 7.9 and 6.4 %, respectively, in patients ≥ 70 years. Mortality was not significantly influenced by root replacement (P = 0.13) or arch replacement (P = 0.27). Multiple logistic regression analysis identified higher age (P < 0.01), chronic aortic dissection (P < 0.01), history of previous cardiovascular surgery (P < 0.01), aortic valve stenosis (P = 0.03), and chronic renal insufficiency (P = 0.03) as independent predictors for increased early mortality. Previous cardiovascular surgery was an independent predictor for increased early mortality in patients younger than 70 (P < 0.01), chronic renal insufficiency was that in patients ≥ 70 years (P < 0.01).

Using contemporary techniques the risk of proximal aortic replacement is low, in particular in younger patients without previous cardiac or aortic surgery. The risk is increased in older patients, in particular with chronic renal insufficiency. This information should be considered in decision-making for prophylactic aortic replacement.