Mortality and Morbidity after Total Arch Replacement Using a Branched Arch Graft with Selective Antegrade Cerebral Perfusion

Background. The early outcome after aortic arch surgery has improved. However, some operative survivors have died as a result of postoperative problems soon after discharge. This study determines the factors affecting mortality within 1 year of total arch replacement. Methods. Between July 1993 and November 2001, 103 patients (mean age 65 ± 11 years, 26 women, 35 dissections) underwent total arch replacement through a median sternotomy using a branched arch graft with selective cerebral perfusion. Eighteen operations including 14 acute dissections were performed on an emergency basis. Concomitant procedures were root replacement in 5 patients, mitral valve replacement in 1, coronary artery bypass in 14, and open endovascular stent-graft in 9. The average time (minutes) for bypass, aortic cross-clamp, selective cerebral perfusion, and distal arrest were respectively 273 ± 79, 163 ± 54, 145 ± 36, and 69 ± 22. Results. Mechanical heart support was necessary in 3 patients. Stroke occurred in 9 patients, transient neurologic dysfunction in 7, and paraplegia/paraparesis in 4. The only independent determinant for postoperative stroke was a history of stroke (odds ratio 16.3, 95% confidence interval: 2.8 to 93.8). Thirty-one patients required ventilator support for more than 5 days. Hemodialysis was needed in 5 patients. Sternal infection or mediastinitis occurred in 6 patients. The in-hospital mortality was 12% (12 of 103). The actuarial survival rate at 1 year was 83%, and was 67% at 5 years. For the 1-year mortality independent determinants were emergency surgery (odds ratio 5.3, 95% confidence interval: 1.6 to 17.9) and age 75 years or older (odds ratio 4.0, 95% confidence interval: 1.1 to 13.9). Conclusions. Total arch replacement using a branched arch graft with selective antegrade cerebral perfusion has a favorable 1-year mortality rate except for patients undergoing emergency surgery and for elderly patients.