Impact of planned concomitant coronary artery bypass grafting on risk of major adverse cardiovascular events in elective aortic hemiarch surgery.

Abstract

Background: Hemiarch replacement of the ascending aorta has become routine in many aortic centers. While the addition of coronary bypass does not add a lot of time to the procedure, it carries with more significant comorbidities. We hypothesize that the addition of CABG carries a higher risk of complication than hemiarch alone.

Methods: This is a single-center, retrospective cohort study of 419 patients undergoing elective hemiarch surgery between February 2010 and May 2023. Patients were categorized into concomitant CABG (n = 42) and non-CABG (n = 379) groups. Perioperative variables and outcomes were analyzed. Both univariate and multivariate logistic regressions were used to identify predictors for MACE.

Results: Of 419 patients, 42 (10%) patients received adjunctive CABG. This group was older (68.1 vs. 60.4 years, p < 0.001) with more comorbidities associated with coronary artery disease (CAD), such as hypertension (92.9% vs. 59.2%, p < 0.001), type 2 diabetes (33.3% vs. 8.8%, p < 0.001), and atrial fibrillation (19% vs. 5.8%, p = 0.006). CABG patients had longer cardiopulmonary bypass (158 vs. 131 min, p < 0.001) and aortic cross-clamp (115.5 vs. 95 min, p < 0.001) times and required more intraoperative blood products, FFP (4 vs. 2 units, p = 0.010) and platelets (2 vs. 1 units, p < 0.001). Postoperative complications, including arrhythmia (40.5% vs. 21.8%, p = 0.012), mechanical circulatory support (11.9%, 1.9%, p = 0.004), acute kidney injury (16.7% vs. 0.5%, p < 0.001), infection (11.9% vs. 3.7%, p = 0.032), mortality (9.5% vs. 0.5%, p = 0.001), stroke (9.5% vs. 2.1%, p = 0.024), and the composite outcome- MACE (21.4% vs. 2.9%, p < 0.001) were higher in the CABG group. Multivariate analysis identified the number of bypassed vessels (OR: 2.23, CI 1.33-3.69, p = 0.002), age (OR: 1.07, CI: 1.02-1.13, p = 0.006), and female gender (OR: 3.53, CI: 1.31-9.64, p = 0.012) as significant risk factors for MACE.

Conclusions: Concomitant CABG may increase the risk of MACE compared to other patients undergoing hemiarch. These data argue that the risk may be higher for concomitant CABG but should still undergo revascularization. Future research should focus on preoperative optimization, operative strategies, and sex-specific risk factors to improve elective hemiarch replacement outcomes.