Influence Of Hypertension On Open Aortic Repair Outcomes In Patients With Marfan Syndrome

Patients with Marfan syndrome are generally treated with aggressive blood pressure control in order to reduce aortic dilation and the risk of dissection. Optimal perioperative blood pressure management must balance the deleterious effects of relative hypotension and hypertension. This study aims to examine the effect of blood pressure and hypertensive history in patients undergoing open aortic repair. A retrospective cohort study was conducted using the triNetX database, a global multi-institutional federated network, for all patients diagnosed with Marfan syndrome. Extracted data include demographics, smoking history, diagnoses for comorbidities (hypertension, hyperlipidemia, diabetes, chronic kidney disease, end-stage renal disease, coronary artery disease, chronic obstructive pulmonary disease), and diagnoses of major procedural complications including myocardial infarction, stroke, paraplegia, amputation, pneumonia, acute renal failure, and bowel ischemia). Mean baseline blood pressure and heart rate were calculated by aggregating vital signs gathered prior to the surgical encounter. Statistical analysis was performed using RStudio (RStudio, Boston, Mass). Proportions were compared using the Fisher exact test, means were compared with the Wilcoxon rank sum test, and multivariate analysis was performed with logistic regression. Over the study period, a total of 444,540 encounters were recorded, representing 12,757 unique patients with Marfan syndrome (5445 women and 7237 men). A total of 184 open descending thoracic and abdominal aortic repairs were found. Of these, 66 patients experienced major complications, and 17 expired within 1 year. Although a diagnosis of hypertension was associated with an increased risk of major complications (Table I), average baseline preoperative blood pressure was similar between groups. Multivariate analysis of perioperative factors suggested that a prior diagnosis of hypertension along with tobacco use and chronic kidney disease corresponded with an increased odds ratio for complications (Table II). Hypertension diagnosis was specifically correlated with postoperative renal failure (odds ratio, 3.4; 95% confidence interval, 1.4-9.6; P = .004), and trended towards significant associations with pneumonia (P = .059) and stroke (P = .070). No comorbidities were predictive of mortality at 1 year. However, lower baseline systolic blood pressure was predictive of mortality (P < .001). In patients with Marfan syndrome undergoing open aortic repair, we found that hypertension history was strongly associated with postoperative complications, especially acute renal failure. In addition, lower baseline blood pressure was associated with higher postoperative mortality. This data suggests that overly aggressive blood pressure control in this population may increase the risk of serious complications such as acute kidney injury.Table IPerioperative factor prevalence in patients with marfan syndrome undergoing aortic repair in the triNetX database, comparing patients with vs without 90-day complicationsPerioperative factorMajor complicationP valueNo (n = 118)No. (%)Yes (n = 66)No. (%)Hypertension70 (59)57 (86).0001Hyperlipidemia21 (18)17 (26).24Diabetes II7 (6)4 (6)1.00CKD5 (4)11 (17).006ESRD2 (2)3 (5).35Tobacco use17 (14)19 (29).02CAD13 (11)9 (14).64COPD6 (5%)8 (12%).14Median age, years43.542.47Mean baseline systolic pressure, mm Hg125124.71Mean perioperative systolic pressure, mm Hg121118.63CAD, Coronary artery disease; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; ESRD, end-stage renal disease. Open table in a new tab Table IICovariate-adjusted odds ratios for perioperative factor influences on incidence of complications within 90 days of aortic repair in patients with Marfan syndromePerioperative factorComplications odds ratio (95% CI)P valueHypertension3.83 (1.7-8.5)