External wrapping of the ascending aorta versus ascending aorta replacement: Systematic review and meta-analysis

In the treatment of a moderately dilated ascending aorta, external wrapping of the ascending aorta may represent an alternative to the gold standard ascending aorta replacement. Concerns regarding the safety and long-term durability of external wrapping of the ascending aorta have limited its widespread adoption.

We conducted a systematic review and meta-analysis comparing external wrapping of the ascending aorta with ascending aorta replacement. The primary outcome was 30-day mortality, defined as 30-day and/or in-hospital mortality, and midterm mortality, as reported by the source studies. Secondary outcomes included intensive care unit and hospital length of stay, cardiopulmonary bypass time, cardiac crossclamp time, reoperation for bleeding, stroke, acute kidney injury, wound infection, concomitant surgeries, and midterm outcomes. Between-group differences were quantified using standardized mean difference. Effect estimates were expressed as odds ratios for binary outcomes, incidence rate ratios for time-dependent mortality, and standardized mean differences for continuous outcomes, each with 95% confidence intervals.

Eight comparative studies comprising 851 patients were identified. A total of 433 patients (50.9%) underwent external wrapping of the ascending aorta, and 418 (49.1%) underwent ascending aorta replacement. The mean follow-up duration was 3.9 years (95% confidence interval, 1.8-8.4 years). No statistically significant differences were observed in 30-day mortality (odds ratio, 0.61; 95% confidence interval, 0.24-1.56), midterm mortality (incidence rate ratio, 0.97; 95% confidence interval, 0.57-1.66), acute kidney injury (odds ratio, 0.66; 95% confidence interval, 0.22-1.96), stroke (odds ratio, 0.67; 95% confidence interval, 0.23-1.93), wound infection (odds ratio, 1.37; 95% confidence interval, 0.41-4.53), concomitant aortic valve replacement (odds ratio, 0.92; 95% confidence interval, 0.42-2.00), coronary artery bypass grafting (odds ratio, 0.86; 95% confidence interval, 0.37-1.99), mitral valve procedures (odds ratio, 0.71; 95% confidence interval, 0.20-2.56), reoperation for bleeding (odds ratio, 0.48; 95% confidence interval, 0.15-1.58), proximal ascending aorta diameter (standardized mean difference, 0.19; 95% confidence interval, -0.21 to 0.59) or midascending aorta diameter at follow-up (standardized mean difference, -0.53; 95% confidence interval, -1.67 to 0.60). External wrapping of the ascending aorta was associated with shorter cardiopulmonary bypass time (unweighted mean absolute difference, 42.4 minutes; standardized mean difference, -2.46; 95% confidence interval, -3.49 to -1.43), crossclamp time (unweighted mean absolute difference, 30.6 minutes; standardized mean difference, -2.12; 95% confidence interval, -3.18 to -1.07), intensive care unit length of stay (unweighted mean absolute difference, 22.6 hours; standardized mean difference, -0.58; 95% confidence interval, -0.81 to -0.36), and hospital length of stay (unweighted mean absolute difference, 2.4 days; standardized mean difference, -0.36; 95% confidence interval, -0.63 to -0.10).

Thirty-day and midterm mortality did not significantly differ between external wrapping of the ascending aorta and ascending aorta replacement. In addition, external wrapping of the ascending aorta was associated with shorter cardiopulmonary bypass and crossclamp times and reduced intensive care unit and hospital length of stay. However, this study did not establish the clinical equivalence of external wrapping of the ascending aorta. Ascending aorta replacement remains the gold standard surgical technique for a moderately dilated ascending aorta. The retrospective design, limited follow-up, heterogeneous patient selection, and inconsistent outcomes reporting of the included studies limit the applicability of these findings to clinical practice.