Increased Risk of Major Adverse Cardiovascular Events in Elective Aortic Arch Replacement Patients undergoing Concomitant Coronary Artery Bypass Grafting
Presented During:
Thursday, April 25, 2024: 5:38PM - 7:00PM
Sheraton Times Square
Posted Room Name:
Central Park
Abstract No:
P0170
Submission Type:
Abstract Submission
Authors:
Adam Carroll (1), Michael Kirsch (1), Nicolas Chanes (1), Joseph Cleveland (1), Jessica Rove (1), Muhammad Aftab (1), T. Brett Reece (1)
Institutions:
(1) University of Colorado Anschutz, Denver, CO
Submitting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Co-Author(s):
Michael Kirsch
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University of Colorado Anschutz
University of Colorado Anschutz
Nicolas Chanes
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University of Colorado Anschutz
University of Colorado Anschutz
*Joseph Cleveland
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University of Colorado Anschutz
University of Colorado Anschutz
Jessica Rove
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University of Colorado Anschutz
University of Colorado Anschutz
*Muhammad Aftab
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University of Colorado Anschutz
University of Colorado Anschutz
*T. Brett Reece
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University of Colorado Anschutz
University of Colorado Anschutz
Presenting Author:
Adam Carroll
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University of Colorado Anschutz
University of Colorado Anschutz
Abstract:
Objective
Due to the improvement in morbidity and mortality after aortic arch replacement, as well as an aging population, concomitant need for coronary revascularization has increased in aortic patients. This subgroup of patients has the potential to have more baseline comorbidities, and it remains unclear whether the potential of revascularization outweighs any risks of MACE in the perioperative period. We sought to clarify the characteristics and risk of morbidity, mortality and MACE in elective aortic arch patients undergoing adjunctive coronary artery bypass grafting.
Methods
We reviewed our single institution prospectively maintained database for patients who underwent elective aortic arch replacement from April 2009 to May 2023. In total, 564 patients were included in our analysis. Patients were stratified into two cohorts based on whether planned concomitant CABG was performed. Between groups comparisons were performed for pre-operative, operative and post-operative variables, as dictated by distribution of data, and nature of variable. The primary endpoint assessed was perioperative MACE defined as MI, stroke or mortality with subsequent multiple logistic regression analysis performed based on significant pre-operative and operative risk factors.
Results
41 patients underwent aortic arch replacement with adjunctive CABG, and 523 patients without a CABG. Patients who had a CABG were significantly older (p<0.001), more likely to be male (p=0.003), have a higher BMI (p=0.049) and have more comorbidities including HLD (p<0.001), HTN (p<0.001), DM2 (p<0.001), atrial fibrillation (p=0.009) and pulmonary disease (p=0.050). Most patients in both cohorts underwent hemiarch replacement, however, CABG patients were significantly more likely to undergo a hemiarch (p=0.015), and less likely undergo total arch replacement (p=0.050). Despite undergoing less extensive arch replacement, CABG patients had longer cardiopulmonary bypass times (p=0.001) and aortic cross-clamp times (p=0.005), but not circulatory arrest times. CABG patients were also more likely to undergo adjunctive atrial fibrillation procedures (p=0.008) and required more intraoperative platelet transfusion (p=0.008). CABG patients had higher rates of post-operative infection (p=0.02), prolonged ventilation (>48 hours, p=0.031), mechanical circulatory support (p=0.050), and post-operative arrhythmias (p<.001). CABG patients were more likely to have post-operative MACE (p=0.022). Multiple logistic regression demonstrated excellent fit (AUC=0.786, p<0.001), however, neither performance of any CABG (p=0.071) or number of vessels revascularized were independently significant.
Conclusion
Despite undergoing less extensive arch intervention, aortic surgery patients who require concomitant CABG face an increased risk of morbidity and perioperative MACE. Our results suggest this is not due to the performance of the CABG itself or the number of bypassed vessels, but rather due to the conglomeration of increased risk factors in patients requiring CABG. Adjunctive CABG should be performed when clinically indicated, although caution should be taken given the more comorbid population requiring coronary intervention.
Due to the improvement in morbidity and mortality after aortic arch replacement, as well as an aging population, concomitant need for coronary revascularization has increased in aortic patients. This subgroup of patients has the potential to have more baseline comorbidities, and it remains unclear whether the potential of revascularization outweighs any risks of MACE in the perioperative period. We sought to clarify the characteristics and risk of morbidity, mortality and MACE in elective aortic arch patients undergoing adjunctive coronary artery bypass grafting.
Methods
We reviewed our single institution prospectively maintained database for patients who underwent elective aortic arch replacement from April 2009 to May 2023. In total, 564 patients were included in our analysis. Patients were stratified into two cohorts based on whether planned concomitant CABG was performed. Between groups comparisons were performed for pre-operative, operative and post-operative variables, as dictated by distribution of data, and nature of variable. The primary endpoint assessed was perioperative MACE defined as MI, stroke or mortality with subsequent multiple logistic regression analysis performed based on significant pre-operative and operative risk factors.
Results
41 patients underwent aortic arch replacement with adjunctive CABG, and 523 patients without a CABG. Patients who had a CABG were significantly older (p<0.001), more likely to be male (p=0.003), have a higher BMI (p=0.049) and have more comorbidities including HLD (p<0.001), HTN (p<0.001), DM2 (p<0.001), atrial fibrillation (p=0.009) and pulmonary disease (p=0.050). Most patients in both cohorts underwent hemiarch replacement, however, CABG patients were significantly more likely to undergo a hemiarch (p=0.015), and less likely undergo total arch replacement (p=0.050). Despite undergoing less extensive arch replacement, CABG patients had longer cardiopulmonary bypass times (p=0.001) and aortic cross-clamp times (p=0.005), but not circulatory arrest times. CABG patients were also more likely to undergo adjunctive atrial fibrillation procedures (p=0.008) and required more intraoperative platelet transfusion (p=0.008). CABG patients had higher rates of post-operative infection (p=0.02), prolonged ventilation (>48 hours, p=0.031), mechanical circulatory support (p=0.050), and post-operative arrhythmias (p<.001). CABG patients were more likely to have post-operative MACE (p=0.022). Multiple logistic regression demonstrated excellent fit (AUC=0.786, p<0.001), however, neither performance of any CABG (p=0.071) or number of vessels revascularized were independently significant.
Conclusion
Despite undergoing less extensive arch intervention, aortic surgery patients who require concomitant CABG face an increased risk of morbidity and perioperative MACE. Our results suggest this is not due to the performance of the CABG itself or the number of bypassed vessels, but rather due to the conglomeration of increased risk factors in patients requiring CABG. Adjunctive CABG should be performed when clinically indicated, although caution should be taken given the more comorbid population requiring coronary intervention.
Aortic Symposium:
Aortic Arch
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