Journal of cardiac surgery · 2022
Long-term outcomes of total arch replacement versus proximal aortic replacement in acute type A aortic dissection: Meta-analysis of Kaplan-Meier-derived individual patient data.
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Sá Michel Pompeu, Jacquemyn Xander, Tasoudis Panagiotis T, Van den Eynde Jef, Erten Ozgun, Sicouri Serge, Dokollari Alexander, Torregrossa Gianluca, Kurz Stephan, Heuts Samuel, Nienaber Christoph A, Coselli Joseph S, Ramlawi Basel
Аннотация
OBJECTIVES: To evaluate the long-term outcomes of a conservative approach (with proximal aortic replacement with or without hemiarch replacement) versus an aggressive approach (with total aortic arch replacement) in the treatment of acute type A aortic dissection (ATAAD).
METHODS: We performed a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing the aforementioned approaches to treat patients with ATAAD.
RESULTS: Eighteen studies met our eligibility criteria, comprising 5243 patients with follow-up (Conservative: 3676 patients; Aggressive: 1567 patients). We observed a statistically significant difference in overall survival favoring the aggressive approach (hazard ratios [HR] 0.86, 95% confidence interval [CI] 0.76-0.98, p = .022), but no statistically significant difference in the risk of reoperation (HR 0.89, 95% CI 0.66-1.2, p = .439) in the overall follow-up. Landmark analyses revealed that, in the first 3 months after the procedure, mortality rates were comparable between conservative and aggressive approaches (HR 1.04, 95% CI 0.88-1.24, p = .627), but the results beyond 3 months showed improved survival in patients undergoing the aggressive surgical procedure (HR 0.71, 95% CI 0.59-0.85, p < .001). The landmark analyses also revealed that, in the first 7 years after the procedure, reoperation rates were comparable between the approaches (HR 1.03, 95% CI 0.76-1.40, p = .848), but the results beyond 7 years showed a lower risk of reoperation in patients undergoing the aggressive surgical procedure (HR 0.10, 95% CI 0.01-0.75, p = .025).
CONCLUSION: The aggressive approach seems to confer better long-term survival and lower risk of the need for reoperation in the follow-up of patients treated for ATAAD.
METHODS: We performed a pooled analysis of Kaplan-Meier-derived individual patient data from studies with follow-up comparing the aforementioned approaches to treat patients with ATAAD.
RESULTS: Eighteen studies met our eligibility criteria, comprising 5243 patients with follow-up (Conservative: 3676 patients; Aggressive: 1567 patients). We observed a statistically significant difference in overall survival favoring the aggressive approach (hazard ratios [HR] 0.86, 95% confidence interval [CI] 0.76-0.98, p = .022), but no statistically significant difference in the risk of reoperation (HR 0.89, 95% CI 0.66-1.2, p = .439) in the overall follow-up. Landmark analyses revealed that, in the first 3 months after the procedure, mortality rates were comparable between conservative and aggressive approaches (HR 1.04, 95% CI 0.88-1.24, p = .627), but the results beyond 3 months showed improved survival in patients undergoing the aggressive surgical procedure (HR 0.71, 95% CI 0.59-0.85, p < .001). The landmark analyses also revealed that, in the first 7 years after the procedure, reoperation rates were comparable between the approaches (HR 1.03, 95% CI 0.76-1.40, p = .848), but the results beyond 7 years showed a lower risk of reoperation in patients undergoing the aggressive surgical procedure (HR 0.10, 95% CI 0.01-0.75, p = .025).
CONCLUSION: The aggressive approach seems to confer better long-term survival and lower risk of the need for reoperation in the follow-up of patients treated for ATAAD.