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Size-Dependent Association Between Ascending Aortic Diameter and Cardiac-Related Deaths for Patients with Ascending Aortic Aneurysm
Nicolai P. Ostberg, M.S., Mohammad A. Zafar, M.B.B.S, John A. Elefteriades, M.D..
The Aortic Institute at Yale-New Haven Hospital, New Haven, CT, USA.

OBJECTIVE: Determine if there is a size-dependent relationship between aortic diameter and non-aortic causes of mortality amongst patients with ascending aortic aneurysm.
METHODS: Any patient with an ascending aortic aneurysm undergoing evaluation for surgical repair between 2013-2020 at a single tertiary referral center was included. Cause of death was established via death certificate. A cause-specific cox proportional hazards model was fitted for each cause of death with time-dependent ascending diameter encoded as a fourth-degree restricted cubic spline. Two models were produced, one only using ascending aortic diameter (Model 1) and another adjusted for patient comorbidities (Model 2).
RESULTS: A total of 2,487 patients were included in this study. The median ascending aortic diameter was 4.70 cm (IQR, 4.20, 5.20). A total of 636 patients died over the course of follow-up in this cohort. The most common cause of death was cardiac related (119/636, 18.7%) while confirmed ascending-aorta related causes of death were reported for only 43 deaths (6.8%). Cox regression revealed that increasing aortic diameter increased the risk of all-cause death and ascending aorta related deaths as expected (Figure 1A,B). Unexpectedly, increased ascending diameter was also associated with increased risk of cardiac related death (Figure 1C). This association was not observed for other causes of death in the cohort (Figure 1D-F).
CONCLUSIONS: A size-dependent association was observed between ascending aortic diameter and cardiac related deaths. Potential explanations include hemodynamic changes impacting cardiac and coronary blood flow due to ascending aneurysms or misclassification of type A dissection deaths as myocardial infarction.


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