The decision about whether to undergo elective ascending aorta and/or arch replacement is often challenging. For some patients the indication may be obvious, but many patients need to weigh the potential morbidity and even mortality associated with the surgery against the chances that they will experience an acute, life-threatening event. Patients need good information about the risks and the benefits.
The current issue of the Journal of the American College of Cardiology has a report from the Society of Thoracic Surgeons that reports the outcomes of 27,202 patients who underwent elective ascending aorta and/or arch replacement surgery. Such studies of can provide good information about the experience of patients who do choose surgery even as they cannot illuminate the benefits.
The study reported a mortality rate of 3.4%, which the authors describe as excellent. But what we are not told is how the rate varies across centers: Did all the hospitals have roughly similar rates or did mortality vary widely by institution? Ultimately, whether 3.4% mortality is “excellent” may depend on whether you are the surgeon or the patient. We are not given information about whether it is as low as it could be. Finally, this study shows that major morbidity is much more common than mortality: stroke or coma occurred in 3.2% of patients, renal failure in 4.4%, pneumonia in 4.1%, reoperation for bleeding in 5.7%, and prolonged ventilation in 16.2%. The risk seems considerable for an elective procedure.
This study does provide critical information about contemporary practice. I wonder how this information will be incorporated into shared decision-making practices across the Society for Thoracic Surgeons sites. And will the risk estimates be tailored for patients and for the site?