Reoperative Total Arch Replacement after Previous Cardiovascular Surgery: Outcomes in 426 Consecutive Patients.
Academic Article
Overview
abstract
OBJECTIVE: Total aortic arch replacement (TAR) after previous cardiovascular surgery is technically challenging, and is becoming more frequent as outcomes for primary arch repair have improved. primary. We analyzed outcomes of reoperative compared to first-time TAR. METHODS: The institutional aortic database was queried to identify consecutive patients undergoing TAR between 1997 and 2022. 426 patients underwent TAR of whom150 (35%) had previous cardiovascular surgery (reop TAR) and 276 (65%) underwent their first cardiovascular operation. RESULTS: The reop TAR group was younger (61±13 vs. 71±11, p<0.001) with more comorbidities such as ischemic heart disease (12% vs. 4.3%, p=0.006), prior stroke (36% vs. 14.5%, p<0.001), and renal impairment (24% vs. 12.7%, p=0.004). Reop TAR had longer cardiac ischemic times (119.3±45.5 vs. 98±31.9 minutes, p<0.001), a higher operative mortality (3.3% vs. 0.4%, p=0.040), and incurred a 4-fold increased risk of major adverse event (95%CI 1.41-11.49, p=0.009). Ten-year survival was also lower in the reop TAR cohort [76% vs. 82.2%; HR 1.79 (1.12-2.86), p=0.015] and there was greater need for late reinterventions, mainly on the downstream aorta [HR 1.29 (1.03-1.62), p=0.024]. CONCLUSION: Reoperative total arch replacement is a technically challenging operation, and is associated with increased operative mortality and adverse events. Gratifying results can be obtained with meticulous surgical planning and focused attention on end organ protection. Late reinterventions occur in a significantly greater percentage of patients undergoing reop TAR and future studies will focus attention on identifying those at risk groups who may benefit from a more aggressive index procedure.
