title: Multicentre analysis of current strategies and outcomes in open aortic arch surgery: heterogeneity is still an issue.
abstract: OBJECTIVE
  The study was conducted to evaluate, on the basis of a multicentre analysis, current results of elective open aortic arch surgery performed during the last decade.
  
  
  METHODS
  Data of 1232 consecutive patients who underwent aortic arch repair with reimplantation of at least one supra-aortic artery between 2004 and 2013 were collected from 11 European cardiovascular centres, and retrospective statistical examination was performed using uni- and multi-variable analyses to identify predictors for 30-day mortality. Acute aortic dissections and arch surgeries not involving the supra-aortic arteries were not included.
  
  
  RESULTS
  Arch repair involving all 3 arch arteries (total), 2 arch arteries (subtotal) or 1 arch artery (partial) was performed in 956 (77.6%), 155 (12.6%) and 121 (9.8%) patients, respectively. The patients' characteristics as well as the surgical techniques, including the method of cannulation, perfusion and protection, varied considerably between the clinics participating in the study. The in-hospital and 30-day mortality rates were 11.4 and 8.8% for the entire cohort, respectively, ranging between 1.7 and 19.0% in the surgical centres. Multivariable logistic regression analysis identified surgical centre, patient's age, number of previous surgeries with sternotomy and concomitant surgeries as independent risk factors of 30-day mortality. The follow-up of the study group was 96.5% complete with an overall follow-up duration of 3.3 ± 2.9 years, resulting in 4020 patient-years. After hospital discharge, 176 (14.3%) patients died, yielding an overall mortality rate of 25.6%. The actuarial survival after 5 and 8 years was 72.0 ± 1.5% and 64.0 ± 2.0, respectively.
  
  
  CONCLUSIONS
  The surgical risk in elective aortic arch surgery has remained high during the last decade despite the advance in surgical techniques. However, the patients' characteristics, numbers of surgeries, the techniques and the results varied considerably among the centres. The incompleteness of data gathered retrospectively was not effective enough to determine advantages of particular cannulation, perfusion, protection or surgical techniques; and therefore, we strongly recommend further prospective multicentre studies, preferably registries, in which all relevant data have to be clearly defined and collected.
authors.affiliation: Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany p.urbanski@kardiochirurg.de.
authors.forename: Paul P
authors.initials: PP
authors.lastname: Urbanski
authors.affiliation: Department of Cardiac Surgery, Ludwig-Maximilians University Munich, Munich, Germany.
authors.forename: Maximilian
authors.initials: M
authors.lastname: Luehr
authors.affiliation: Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Di Bartolomeo
authors.affiliation: Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany.
authors.forename: Anno
authors.initials: A
authors.lastname: Diegeler
authors.affiliation: Cardiovascular Department, European Hospital, Rome, Italy.
authors.forename: Ruggero
authors.initials: R
authors.lastname: De Paulis
authors.affiliation: Cardiovascular Department, Cliniche Humanitas Gavazzeni, Bergamo, Italy.
authors.forename: Giampiero
authors.initials: G
authors.lastname: Esposito
authors.affiliation: Department of Cardiovascular Medicine, University of Birmingham, Birmingham, UK.
authors.forename: Robert S
authors.initials: RS
authors.lastname: Bonser
authors.affiliation: Department of Cardiac Surgery, Leipzig Heart Centre, University of Leipzig, Leipzig, Germany.
authors.forename: Christian D
authors.initials: CD
authors.lastname: Etz
authors.affiliation: Clinic for Cardiac Surgery, University Hospital Heidelberg, Germany.
authors.forename: Klaus
authors.initials: K
authors.lastname: Kallenbach
authors.affiliation: Heart Center Freiburg University, Freiburg, Germany.
authors.forename: Bartosz
authors.initials: B
authors.lastname: Rylski
authors.affiliation: Clinic for Heart, Thoracic and Vascular Surgery, Medical University of Hannover, Germany.
authors.forename: Malakh Lal
authors.initials: ML
authors.lastname: Shrestha
authors.affiliation: Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, University of Duisburg-Essen, Essen, Germany.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Tsagakis
authors.affiliation: Cardiovascular Clinic Bad Neustadt, Bad Neustadt, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Zacher
authors.affiliation: Division of Thoracic and Cardiovascular Surgery, Johann-Wolfgang-Goethe University, Frankfurt/Main, Germany.
authors.forename: Andreas
authors.initials: A
authors.lastname: Zierer
mesh_terms: D000784:Aortic Dissection / Q000601:surgery*; D001013:Aorta, Thoracic / Q000601:surgery*; D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000379:methods / Q000592:standards*; D017558:Elective Surgical Procedures / Q000379:methods / Q000592:standards; D005060:Europe / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome
keywords: Aortic arch; Aortic surgery; Cerebral protection