Elective Concomitant Ascending Aortic Replacement Increases Operative Risk in Coronary Artery Bypass Grafting

M. Salna¹, C. Wang², R. Logan³, I. Anzai⁴, P. Kurlansky², H. Takayama^5
1Columbia University Medical Center, Philadelphia, Pennsylvania ²Division of Cardiothoracic Surgery, Columbia University Irving Medical Center, New York, New York ³Columbia HeartSource, Columbia University, New York, New York ⁴Columbia University Medical Center, New York, New York ⁵Columbia University, New York, New York

Purpose: The 2022 ACC/AHA Aortic Disease guideline recommends concomitant ascending aortic replacement at the same size criteria for all cardiac operations. We sought to determine the added risk of performing an elective prophylactic ascending aortic replacement during coronary artery bypass grafting (CABG) using the STS database.

Methods: The STS database was queried for all elective adult CABG’s in North America from 2014-2022 with either triple vessel disease or left main disease >50%. A subgroup of these patients who underwent concomitant elective planned ascending aortic replacement was identified. Inverse probability of treatment weighting (IPTW) was used to balance confounders between the CABG and CABG/aortic groups before comparing them based on STS reportable outcomes such as death, stroke, prolonged ventilation, and renal failure. Weighted incidences of these outcomes were estimated and compared between the groups. Relative risks were calculated to determine the added risks of adding an ascending aortic replacement to CABG.

Results: A total of 374,087 CABG patients were identified including 835 (0.2%) concomitant elective ascending aortic replacement patients. Before IPTW, aortic patients were more likely to be male, non-diabetic, and over the age of 70. After IPTW, mortality between the Aortic and CABG groups did not differ significantly (2.3% vs. 1.5%, p =0.05) but there was a significantly higher incidence of combined morbidity and mortality in the Aortic group (16.5% vs. 8.3%, p< 0.001). Specifically, there were significantly higher rates of stroke (3.7% vs. 1.1%, p< 0.01) and prolonged ventilation (10.2% vs. 4.4%, p< 0.001), and renal failure (2.3% vs. 1.4%, p=0.018). There were no significant differences in the rates of deep sternal wound infection, or reoperation. The relative risk of death for adding an ascending aortic replacement to CABG was 1.56 (95% CI: 1.0-2.4), stroke: 3.43 (95% CI: 2.42-4.82), prolonged ventilation: 1.70 (95% CI: 1.09 – 2.62), and the relative risk of combined morbidity and mortality was 1.98 (95% CI: 1.70 – 2.30) (Table).

Conclusion: Elective ascending aortic replacement is not common in primary coronary artery bypass grafting but is associated with significantly higher risk of poor outcomes – namely stroke and prolonged ventilation. These findings may help inform guidelines regarding the relative risk of concomitant ascending aortic replacement in elective CABG patients.

Identify the source of the funding for this research project: Rudin Foundation