Total Arch Replacement with Frozen Elephant Trunk in Acute Type A Aortic Dissection Reduces Mortality: An Analysis of a National Cardiac Surgery Database

P0351 

Abstract Submission 

Henry Kwon (1), George Divine (2), Kyle Miletic (1), Loay Kabbani (3)

(1) N/A, United States, (2) Henry Ford Health, Detroit, MI, (3) N/A, Ann Arbor, MI

Henry Kwon    -  Contact Me
N/A

George Divine    -  Contact Me
Henry Ford Health

Kyle Miletic    -  Contact Me
N/A

Loay Kabbani    -  Contact Me
N/A

Henry Kwon    -  Contact Me
N/A

Objective: Frozen Elephant Trunk (FET) along with total aortic arch replacement (TAR) is a viable surgical option for Acute Stanford Type A aortic dissection (TAAD) with distal dissection flap. The addition of FET to TAR has the advantage of providing a distal landing zone for subsequent TEVAR as well as potentially improving aortic remodeling by directing flow down the distal true lumen. However, there are concerns of complications with FET, such as risk of distal malperfusion. We thus sought to compare TAR+FET versus TAR alone.
Methods: The Society of Thoracic Surgeons (STS) database was queried for patients who had surgery for acute TAAD from January 2017 to December 2020 (n=18706). All patients with distal dissection extent beyond zone 2 were included while those with missing data or previous cardiac operations were excluded. This yielded 4066 eligible records. We excluded 1322 patients as they did not undergo arch repair leaving 2744 patients. From this dataset we specifically focused on those who underwent TAR ± FET (n= 237). Demographic, intraoperative, and post-operative data were analyzed using descriptive statistics. To minimize bias associated with baseline characteristics between those who did and did not undergo FET, we utilized multiple regression with prespecified variables to calculate risk adjusted odds ratio adjusted for age, sex, race, high volume center, and preoperative malperfusion.
Results: Of the 237 patients analyzed, 77 underwent TAR and 196 underwent TAR with FET. Baseline characteristics (Table 1) showed statistically significant differences in race and preoperative malperfusion was higher in the TAR+FET group. Intraoperatively there was a difference in arterial cannulation site and an increase in unplanned aortic valve replacement in the TAR+FET group. There was, however, no significant difference in cardiopulmonary bypass time and circulatory arrest time. Those who underwent TAR+FET had significantly lower 30-day mortality (OR=0.455 p=0.02) though more patients in this group presented with malperfusion. Those who underwent TAR+FET had similar length of stay and ICU time to those who had TAR alone. Although not statistically significant, there was a trend towards fewer 30-day readmissions in the TAR+FET cohort. There was no significant difference in complications between the two groups, specifically: renal failure, liver dysfunction, stroke, and spinal cord ischemia. After adjusting for multiple potential confounders, 30-day mortality remained significantly lower in those who underwent TAR+FET with an adjusted Odds Ratio (aOR) of 0.49 (CI= 0.25 to 0.98, p=0.04). Our risk adjusted logistical regression found that presentation with malperfusion (aOR=2.03 [CI:1.04-3.95], p=0.04), and presentation at a lower-volume center (fewer than 30 cases per year) (aOR=2.54 [CI:1.06-6.08], p=0.04) were shown to be significant risks for mortality within our model.
Conclusion: Total Arch Replacement with FET is associated with reduced early mortality compared to TAR alone in those presenting with greater than zone 2 TAAD despite a greater proportion of patients in the TAR+FET group presenting with malperfusion, which in our adjusted analysis increases mortality. With the theoretical benefits of decreased reintervention and promoting aortic remodeling, FET may be ideal for those presenting with TAAD, especially with clinical malperfusion.

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