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Modern practice and outcomes of reoperative cardiac surgery

Published:January 22, 2021DOI:https://doi.org/10.1016/j.jtcvs.2021.01.028

      Abstract

      Objectives

      To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest.

      Methods

      From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect.

      Results

      Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2).

      Conclusions

      Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy.

      Graphical abstract

      Key Words

      Abbreviations and Acronyms:

      CABG (coronary artery bypass grafting), CPB (cardiopulmonary bypass), CT (computed tomography)
      Figure thumbnail fx2
      Early cardiopulmonary bypass approach for a hemiarch aortic replacement.
      Reoperative cardiac surgery requires a multidisciplinary approach and meticulous planning to optimize outcomes.
      In cardiac reoperations involving sternal re-entry, strategies involving early and late institution of cardiopulmonary bypass are associated with favorable outcomes in appropriately selected cases. Modern-day pillars of a successful approach include image guidance, meticulous myocardial protection, use of novel adjuncts, and a coordinated team-based approach to minimize risk and optimize rescue.
      See Commentaries on pages 1767 and 1769.
      The changing landscape of cardiovascular care and prolonged patient life expectancy have led to cardiac surgeons performing increasingly complex operations on high-risk patients, including those requiring reoperation. Cardiac reoperations are associated with increased morbidity and mortality.
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      • et al.
      Clinical outcomes of mitral valve reoperations in the United States: an analysis of the Society of Thoracic Surgeons national database.
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      • Legare J.F.
      Predicting in-hospital mortality after redo cardiac operations: development of a preoperative scorecard.
      • Svensson L.G.
      Reoperation of the aortic valve.
      They remain challenging not only because of more complex pathology and patient comorbidities, but also, from a technical standpoint, because of the proximity of cardiovascular structures to the posterior table of the sternum, with risk of inadvertent injury during re-entry and mediastinal dissection necessary for adequate exposure and safe conduct of the operation.
      • Roselli E.E.
      • Pettersson G.B.
      • Blackstone E.H.
      • Brizzio M.E.
      • Houghtaling P.L.
      • Hauck R.
      • et al.
      Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue.
      • Reyes K.G.
      • Pettersson G.B.
      • Mihaljevic T.
      • Roselli E.E.
      A strategy for safe sternal reentry in patients with pseudoaneurysms of the ascending aorta using the PORT-ACCESS EndoCPB system.
      • Mehta A.R.
      • Hammond B.
      • Unai S.
      • Navia J.L.
      • Gillinov M.
      • Pettersson G.B.
      Percutaneous cardioplegic arrest before repeat sternotomy in patients with retrosternal aortic aneurysm.
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      • et al.
      Advising complex patients who require complex heart operations.
      Peripheral cannulation and initiation of cardiopulmonary bypass (CPB) before re-sternotomy have been used to avoid or mitigate catastrophic cardiovascular injury and manipulation.
      • Svensson L.G.
      Reoperation of the aortic valve.
      ,
      • Singh A.K.
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      • Schwartz C.
      Redo sternotomy for cardiac reoperations using peripheral heparin-bonded cardiopulmonary bypass circuits without systemic heparinization: technique and results.
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      Cardiac reoperation by Carpentier bicaval femoral venous cannula: GATA experience.
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      • et al.
      Does the arterial cannulation site for circulatory arrest influence stroke risk?.
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      • Kern J.A.
      • et al.
      A protocol-driven approach to cardiac reoperation reduces mortality and cardiac injury at the time of resternotomy.
      • Svensson L.G.
      Reoperation on the aortic arch.
      However, their routine use is debated because of the need for early heparinization and risks of increased bleeding and excessive CPB time. In addition, a new team-based approach, taking advantage of high-resolution imaging, preparedness for rescue, optimal myocardial protection, and novel percutaneous and endovascular adjuncts characterizes modern approaches to cardiac reoperations.
      • Svensson L.G.
      Reoperation of the aortic valve.
      ,
      • Roselli E.E.
      • Pettersson G.B.
      • Blackstone E.H.
      • Brizzio M.E.
      • Houghtaling P.L.
      • Hauck R.
      • et al.
      Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue.
      ,
      • Pettersson G.B.
      • Martino D.
      • Blackstone E.H.
      • Nowicki E.R.
      • Houghtaling P.L.
      • Sabik III, J.F.
      • et al.
      Advising complex patients who require complex heart operations.
      The objective of this study was to evaluate current practice and outcomes of reoperative cardiac surgery, with particular interest in image-guided stratification of sternal re-entry risk and utility of peripheral cannulation and initiation of CPB before re-sternotomy.

      Methods

      Study Population

      From January 2008 to July 2017, 7640 adults underwent reoperative cardiac surgery via redo median sternotomy at Cleveland Clinic. Patients without previous sternotomy, those who underwent thoracic endovascular stent grafting or heart transplant, and those without available preoperative computed tomography (CT) scans were excluded, leaving a study cohort of 6627 patients (Figure 1).
      Figure thumbnail gr1
      Figure 1Consolidated Standards of Reporting Trials–style diagram of the study. Of 7640 patients who underwent reoperative cardiac surgery, 1013 were excluded as enumerated in the top gray box; these exclusions are not mutually exclusive. The remaining patients are stratified into early and late institution of cardiopulmonary bypass (CPB) groups, which are further classified into high and low anatomic risk cohorts on the basis of computed tomography (CT) features. From the early CPB group, 95 patients are excluded (bottom gray box) from comparative effectiveness analyses because of high physiologic risk (see ) necessitating early institution of CPB. TEVAR, Thoracic endovascular aortic repair.
      Patients were stratified on the basis of timing of CPB. Those placed on peripheral CPB before redo sternotomy were classified as “early CPB” (n = 755; 11%), and those placed on CPB after redo sternotomy, with or without additional mediastinal dissection, were classified as “late CPB” (n = 5872; 89%) (Table E1). The right axillary artery was cannulated in 428 early CPB patients (57%).
      Patients were classified as high risk or low risk for re-entry based on the anatomic features observed on preoperative CT scans. High-risk re-entry (141 patients in the early CPB group [19%], 422 in the late CPB group [7.2%]) required 1 or more of the following criteria to be met: (1) sternal adherence of bypass grafts crossing midline, (2) ascending aorta adherence to the sternum, or (3) pseudoaneurysm of the aorta within close proximity to the sternum.
      A group of 95 patients (Figure 1) were additionally classified as high physiologic risk if the operating surgeon instituted early CPB as an emergency because of hemodynamic instability or collapse before redo sternotomy. Included were patients who crashed upon induction of general anesthesia, developed malignant arrhythmias, and/or demonstrated low cardiac output refractory to intervention. For all analyses of comparative effectiveness of early versus late CPB, these 95 patients were excluded because they are nonexchangeable between CPB strategies, so their outcomes cannot be compared.

      Redo Process and Protocols

      Multiple guiding principles have been identified over the years, based on hundreds of reoperations, to minimize risk and optimize outcomes.
      • Svensson L.G.
      Reoperation of the aortic valve.
      ,
      • Roselli E.E.
      • Pettersson G.B.
      • Blackstone E.H.
      • Brizzio M.E.
      • Houghtaling P.L.
      • Hauck R.
      • et al.
      Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue.
      ,
      • Pettersson G.B.
      • Martino D.
      • Blackstone E.H.
      • Nowicki E.R.
      • Houghtaling P.L.
      • Sabik III, J.F.
      • et al.
      Advising complex patients who require complex heart operations.
      The main pillars of a successful strategy include a multidisciplinary team approach with close collaboration among cardiovascular imaging, cardiology, cardiac surgery, cardiovascular anesthesia critical care, perfusion, transfusion medicine, nursing, and other care participants. Image guidance and multidisciplinary expertise are particularly important in high-risk anatomic situations. CT scans are routinely obtained before reoperative cardiac surgery. If aortic disease is suspected and no significant kidney disease noted, CT imaging is done with contrast; otherwise, a noncontrast CT scan is obtained. Information on relevant anatomy provides insight into high-risk features portending use of preemptive wires or an axillary or groin cutdown, and allows assessment of whether reoperative sternotomy is appropriate for a trainee to perform. Certain high-risk cases might warrant adjuncts, including endovascular aortic balloon occlusion or percutaneous cardioplegic arrest, before repeat sternotomy.
      • Reyes K.G.
      • Pettersson G.B.
      • Mihaljevic T.
      • Roselli E.E.
      A strategy for safe sternal reentry in patients with pseudoaneurysms of the ascending aorta using the PORT-ACCESS EndoCPB system.
      ,
      • Mehta A.R.
      • Hammond B.
      • Unai S.
      • Navia J.L.
      • Gillinov M.
      • Pettersson G.B.
      Percutaneous cardioplegic arrest before repeat sternotomy in patients with retrosternal aortic aneurysm.
      Early CPB for hemiarch aortic replacement with associated axillary arterial and femoral venous cannulation is illustrated in Figure 2.
      Figure thumbnail gr2
      Figure 2Early cardiopulmonary bypass approach for a hemiarch aortic replacement with associated axillary arterial cannulation via a side graft and femoral venous cannulation. A patent left internal thoracic artery graft can be seen anastomosed to the left anterior descending coronary artery from a previous coronary bypass operation. Placement of a percutaneous coronary sinus catheter with access from the right internal jugular vein and confirmation of catheter positioning was performed using transesophageal echocardiography. Left illustration shows ascending aortic tear with antegrade perfusion catheters located in the brachiocephalic and left carotid arteries. Right illustration shows hemiarch replacement with a completed distal aortic anastomosis.
      A continuous quality improvement process is in place to report monthly aggregate and per-surgeon outcomes of all categories of operations, including reoperations. In addition, complex procedures, including reoperations, are discussed at a weekly conference with the aim of ensuring appropriate patient selection and operative strategy and determining the need for additional attending-level participation. These tough case conferences were held ad hoc for the duration of the study and in the last 5 years have been formalized and held weekly. Best practices are also shared during monthly educational conferences, such as the Morbidity and Mortality conference.
      Collaborative communication among team members in the operating room is integral to successful conduct of cardiac reoperations. Regular structured briefings and debriefings are conducted for all members, emphasizing roles, responsibilities, and rescue plans.
      In general, exposing the right axillary artery or femoral vessels in placing percutaneous femoral arterial and venous wires is done selectively based on patient- and surgeon-related factors. However, the senior author (L.G.S.) routinely used an early CPB strategy with right axillary artery for inflow and percutaneous right femoral vein for outflow (Video 1). In addition, his patients received 10 U of platelets and 4 of fresh frozen plasma after heparin reversal, particularly in arch and frozen elephant trunk cases.
      • Svensson L.G.
      • Blackstone E.H.
      • Apperson-Hansen C.
      • Ruggieri P.M.
      • Ainkaran P.
      • Naugle R.I.
      • et al.
      Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial.
      Earlier in the experience, certain aortic surgeons kept patients intubated until the morning of postoperative day 2 for better control of hemodynamics, avoiding blood pressure variations, and allowing for diuresis to optimize the lungs before extubation. This has largely changed over time, with a more liberal timeline for early extubation.

      Data

      Data on preoperative, operative, and postoperative variables were retrieved from the Cleveland Clinic Cardiovascular Information Registry, which is maintained by nurse-abstractors for national quality reporting (Appendix E1). The institutional review board of Cleveland Clinic approved the study (18-346) on March 23, 2018, with patient consent waived.

      End Points

      Study end points were operative mortality and major morbidity, including stroke, myocardial infarction, prolonged ventilation, renal failure requiring dialysis, and deep sternal wound infection, as defined for the Society of Thoracic Surgeons Adult Cardiac Surgery Database.
      • Shahian D.M.
      • Jacobs J.P.
      • Badhwar V.
      • Kurlansky P.A.
      • Furnary A.P.
      • Cleveland Jr., J.C.
      • et al.
      The Society of Thoracic Surgeons 2018 adult cardiac surgery risk models: part 1—background, design considerations, and model development.
      Variables related to bleeding were measured, including reoperation for bleeding along with intraoperative and postoperative transfusions. Other outcomes included intraoperative cardiovascular injury, site of injury, operative times, and postoperative length of stay.

      Data Analysis

      Statistical analyses were performed using SAS software version 9.4 (SAS Institute, Cary, NC). Categorical data are summarized by frequencies and percentages, with the χ2 test used for comparisons. Continuous variables are summarized by mean ± SD, or 15th, 50th (median), and 85th percentiles when data were skewed; comparisons were made using the Wilcoxon rank sum (nonparametric) test.
      Three models were developed for the early versus late CPB groups in: (1) the high anatomic risk cohort, (2) the low anatomic risk cohort, and (3) the subset of the low anatomic risk cohort in whom early axillary–femoral cannulation was performed. Because characteristics of patients and their operations differed between those managed by early versus late CPB, weighted propensity-score matching was used to compare outcomes.
      • Li L.
      • Greene T.
      A weighting analogue to pair matching in propensity score analysis.
      We first constructed parsimonious logistic regression models to identify variables associated with patients receiving early CPB. Variable selection among variables listed in Appendix E1 used bootstrap aggregation with automated analysis of 1000 resampled data sets and a P-value criterion for retention of variables of ≤.05.
      • Rajeswaran J.
      • Blackstone E.H.
      Identifying risk factors: challenges of separating signal from noise.
      This was followed by tabulating frequency of occurrence of single variables and closely related clusters of variables (aggregation). The final parsimonious models retained variables occurring in 50% or more of these models (Table E2, Table E3, Table E4).
      Thereafter, these models were augmented with variables from each organized group of variables listed in Appendix E1 in an attempt to account for unrecorded selection factors (saturated model). By solving the resulting model equation, propensity scores, representing the probability of having an early CPB approach, were estimated for each operation and used for propensity weighting.
      • Li L.
      • Greene T.
      A weighting analogue to pair matching in propensity score analysis.
      The sum of weights for each treatment is the effective sample size.
      Comparisons of groups before and after matching were assessed using standardized differences (Figure E1). Outcomes between propensity-weighted groups were compared using generalized mixed models (SAS PROC GLIMMIX) to incorporate surgeon as a random effect while adjusting for propensity weights. Survival estimates were obtained using the Kaplan-Meier method with matching weights, and groups were compared using the log-rank test.

      Results

      Patient Characteristics and Imaging Findings

      Use of early CPB decreased somewhat across the study period (Figure E2). Early CPB patients were younger and more likely to be male than late CPB patients (Table E1). Compared with the late CPB group, prevalence of aortic valve disease and aortic dissection was higher in the early CPB group, and mitral valve and coronary artery disease were lower. Prevalence of right ventricular wall adherence to the sternum was similar between groups, but the early CPB group had a higher prevalence of bypass grafts and aortic aneurysms/pseudoaneurysms adherent to the sternum. Original and propensity-weighted risk profiles of the prespecified cohorts of high anatomic risk, low anatomic risk, and early axillary–femoral cannulation are outlined in Table E5, Table E6, Table E7, respectively. A simplified decision algorithm for reoperative strategy selection is shown in Figure 3.
      Figure thumbnail gr3
      Figure 3Simplified decision support algorithm for operative strategy selection for resternotomy in patients without a physiologic indication for early institution of cardiopulmonary bypass (CPB). Arrows indicate degree of strength of consideration for each strategy. CT, Computed tomography; OR, operating room; CABG, coronary artery bypass grafting.

      Intraoperative Comparisons

      Reoperative procedures (up to 7th-time sternotomy) most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (CABG; n = 2029), but also included aortic root surgery (n = 1061) and aortic arch surgery (n = 527). Twenty-one patients (0.32%) had a supplemental thoracotomy performed for adhesiolysis. One endovascular aortic balloon or percutaneous retrograde cardioplegia was used in 19 and 18 cases, respectively. Table E1 shows intraoperative variables in the early and late CPB groups. The early CPB group was more likely to undergo aortic valve replacement or aortic surgery, including circulatory arrest, arch operations, and elephant trunk procedures, whereas the late CPB group was more likely to undergo CABG and mitral and tricuspid valve procedures.

      Unadjusted Outcomes, Intraoperative Events, and Process Measures

      Operative mortality for the entire cohort was 3.5% (235 of 6627 patients) and was 4.1% in the early and 3.5% in the late CPB groups. Major intraoperative cardiovascular (re-entry) injuries occurred in 188 patients (2.8%). Right axillary artery cannulation with a side graft sewn on was favored by most surgeons operating on the aortic arch, given the benefit of antegrade brain perfusion. However, there were also non-arch cases that used the axillary artery. These decisions were based on individual surgeon preference. Femoral–arterial cannulation was used in only 171 patients (2.6%). There were 28 reoperations for access site complications, 9 axillary and 19 femoral. Non–risk-adjusted survival curves are shown in Figure E3.

      High Anatomic Risk Cohort

      A total of 563 patients met the criteria for high anatomic risk, 141 in the early and 422 in the late CPB groups. Within the late CPB group, 143 patients (34%) had preemptive groin exposure, 20 (4.7%) had wires placed into the femoral artery/vein, and 204 had axillary artery exposure (48%). Unadjusted operative mortality was 2.8% (n = 4) and 3.8% (n = 16) in the early and late CPB groups, respectively. Propensity-weighted outcomes for the early and late CPB groups in the high anatomic risk cohort were similar, except for more intraoperative transfusions in the early CPB group but fewer postoperative platelet units transfused (Table 1). CPB times were similar in the early and late CPB groups, but early CPB was associated with shorter myocardial ischemic and total operative times. Long-term survival was similar in propensity-weighted early and late CPB groups in the high-risk cohort (P = .8; Figure 4, A).
      Table 1Outcomes, events, and process measures for early and late CPB groups after matching: high anatomic risk cohort
      VariablePropensity-weighted
      Early CPB (n = 111)Late CPB (n = 110)P value
      n
      Patients with data available.
      No. (%) or 50th [15th, 85th] percentilesn
      Patients with data available.
      No. (%) or 50th [15th, 85th] percentiles
      Intraoperative
       Major re-entry injury11011 (10)1108.7 (7.9).6
       Blood products given, U
      Any110101 (92)11087 (79).009
      Red blood cells
      In cases with units (>0) given.
      834.0 [2.0, 8.0]704.0 [2.0, 10].07
      Platelets
      In cases with units (>0) given.
      942.0 [1.0, 3.0]742.0 [1.0, 4.0].11
      Fresh frozen plasma
      In cases with units (>0) given.
      914.0 [2.0, 6.0]664.0 [2.0, 9.0].14
      Cryoprecipitate
      In cases with units (>0) given.
      473.0 [2.0, 5.0]373.0 [2.0, 6.0].9
       Total CPB time, min111155 [88, 246]110151 [96, 262].02
       Myocardial ischemic time, min10590 [45, 151]107104 [58, 179].8
       Operative time, min111411 [314, 514]110446 [310, 610].9
       IABP1115.1 (4.6)1104.7 (4.3).9
       ECMO1114.4 (4.0)1103.9 (3.5).9
       Chest left open at completion11113 (12)11013 (12).7
      Postoperative blood products, U
       Any11185 (77)11079 (72).4
       Red blood cells
      In cases with units (>0) given.
      762.0 [1.0, 6.0]733.0 [1.0, 7.0].2
       Platelets
      In cases with units (>0) given.
      421.0 [1.0, 3.0]323.0 [1.0, 6.0].01
       Fresh frozen plasma
      In cases with units (>0) given.
      371.0 [1.0, 6.0]342.0 [1.0, 8.0].6
       Cryoprecipitate
      In cases with units (>0) given.
      221.0 [1.0, 2.0]291.0 [1.0, 3.0].13
      Morbidity and mortality
       Operative mortality1113.4 (3.1)1105.0 (4.5).6
       Dialysis1050 (0)1042.7 (2.6).9
       Permanent stroke1112.0 (1.8)1103.5 (3.2).5
       Atrial fibrillation8525 (30)8620 (23).3
       Prolonged ventilation (>24 h)11042 (38)11032 (29).11
       Reoperation for bleeding or tamponade1112.9 (2.6)1104.5 (4.1).5
       Deep sternal wound infection1081.4 (1.3)1090.75 (0.68).6
      Length of stay
       Intensive care unit, h11169 [42, 239]11064 [25, 185].7
       Postoperative, d1119.0 [6.0, 21]1108.0 [6.0, 20].4
       Discharged to home10780 (75)10576 (73).7
      CPB, Cardiopulmonary bypass; IABP, intra-aortic balloon pump; ECMO, extracorporeal membrane oxygenation.
      Patients with data available.
      In cases with units (>0) given.
      Figure thumbnail gr4
      Figure 4Propensity-weighted survival curves for (A) high-risk and (B) low-risk patients. Red curves indicate patients receiving early cardiopulmonary bypass (CPB) and blue curves patients receiving late CPB. Each symbol represents a death and vertical bars 68% confidence limits, equivalent to ±1 standard error.

      Low Anatomic Risk Cohort

      A total of 5969 patients met criteria for low anatomic risk, with 519 and 5450 in the early versus late CPB groups, respectively. Within the late CPB group, 823 patients (15%) had preemptive groin exposure, 75 (1.4%) had wires placed into the femoral artery/vein, and 1103 had axillary artery exposure (20%). Among propensity-weighted groups, operative mortality was similar in the early (3.5%) and late (2.1%) CPB groups (P = .2; Table 2). However, there were fewer major re-entry and dissection injuries, shorter myocardial ischemic times, and less postoperative atrial fibrillation in the early CPB group, but more blood products transfused intraoperatively and postoperatively compared with the late CPB group. Long-term survival was similar in the propensity-weighted early and late CPB groups in the low-risk cohort (P = .2; Figure 4, B).
      Table 2Outcomes, events, and process measures for early and late CPB groups after matching: low anatomic risk cohort
      VariablePropensity-weighted
      Early CPB (n = 480)Late CPB (n = 480)P value
      n
      Patients with data available.
      No. (%) or 50th [15th, 85th] percentilesn
      Patients with data available.
      No. (%) or 50th [15th, 85th] percentiles
      Intraoperative
       Major re-entry injury4804.0 (0.83)48014 (2.8).03
       Blood products given, U
      Any480418 (87)479302 (63).002
      Red blood cells
      In cases with units (>0) given.
      2383.0 [1.0, 5.0]2003.0 [1.0, 6.0].7
      Platelets
      In cases with units (>0) given.
      3912.0 [1.0, 3.0]2562.0 [1.0, 3.0].6
      Fresh frozen plasma
      In cases with units (>0) given.
      3384.0 [2.0, 5.0]1874.0 [2.0, 6.0].8
      Cryoprecipitate
      In cases with units (>0) given.
      1012.0 [2.0, 4.0]1002.0 [2.0, 4.0].04
       Total CPB time, min48099 [69, 144]478119 [76, 196].4
       Myocardial ischemic time, min47557 [37, 88]47585 [51, 140].04
       Operative time, min480329 [255, 421]480363 [263, 513].4
       IABP48014 (3.0)4807.8 (1.6).16
       ECMO4807.0 (1.5)4802.7 (0.56).18
       Chest left open at completion48011 (2.3)48011 (2.4).9
      Postoperative blood product, U
       Any479320 (67)478264 (55).13
       Red blood cells
      In cases with units (>0) given.
      2782.0 [1.0, 6.0]2302.0 [1.0, 5.0].9
       Platelets
      In cases with units (>0) given.
      1811.0 [1.0, 3.0]1121.0 [1.0, 3.0].7
       Fresh frozen plasma
      In cases with units (>0) given.
      1271.0 [1.0, 4.0]1001.0 [1.0, 4.0].7
       Cryoprecipitate
      In cases with units (>0) given.
      901.0 [1.0, 2.0]651.0 [1.0, 2.0].8
      Morbidity and mortality
       Operative mortality48017 (3.5)48010 (2.1).2
       Dialysis4527.7 (1.7)4413.9 (0.88).3
       Permanent stroke4806.0 (1.3)48010 (2.1).3
       Atrial fibrillation393101 (26)393126 (32).05
       Prolonged ventilation (>24 h)479121 (25)48091 (19).3
       Reoperation for bleeding or tamponade48014 (2.9)48015 (3.1).9
       Deep sternal wound infection4720 (0)4731.6 (0.34).9
      Length of stay
       Intensive care unit, h48066 [27, 147]47747 [23, 139].06
       Postoperative, d4808.0 [6.0, 13]4808.0 [5.0, 14].9
       Discharged to home464377 (81)469390 (83).4
      CPB, Cardiopulmonary bypass; IABP, intra-aortic balloon pump; ECMO, extracorporeal membrane oxygenation.
      Patients with data available.
      In cases with units (>0) given.

      Early Pump Subgroup: Axillary–Femoral Cannulation Strategy

      Axillary arterial with femoral venous cannulation was used in 428 patients in the early CPB cohort. Findings of previous comparisons involving the entire early versus late CPB groups (Tables 2 and 3) were largely consistent with propensity-weighted outcomes in this study (Table 3).
      Table 3Outcomes, events, and process measures for early and late CPB groups after matching: low anatomic risk cohort using early axillary–femoral cannulation
      VariablePropensity-weighted
      Early CPB (n = 406)Late CPB (n = 406)P value
      n
      Patients with data available.
      No. (%) or 50th [15th, 85th] percentilesn
      Patients with data available.
      No. (%) or 50th [15th, 85th] percentiles
      Intraoperative
       Major re-entry injury4064.0 (0.98)40612 (2.8).06
       Blood products given, U
      Any406349 (86)405257 (63).005
      Red blood cells
      In cases with units (>0) given.
      2083.0 [1.0, 5.0]1703.0 [1.0, 7.0].5
      Platelets
      In cases with units (>0) given.
      3262.0 [1.0, 3.0]2172.0 [1.0, 3.0].6
      Fresh frozen plasma
      In cases with units (>0) given.
      2784.0 [2.0, 5.0]1594.0 [2.0, 6.0].7
      Cryoprecipitate
      In cases with units (>0) given.
      892.0 [1.0, 4.0]842.0 [2.0, 4.0].2
       Total CPB time, min406100 [69, 147]404118 [76, 196].5
       Myocardial ischemic time, min40257 [37, 88]40284 [51, 139].03
       Operative time, min406330 [250, 420]406361 [262, 512].4
       IABP40615 (3.6)4066.7 (1.6).09
       ECMO4067.0 (1.7)4062.4 (0.60).15
       Chest left open at completion40610 (2.5)4069.4 (2.3).9
      Postoperative blood product, U
       Any405272 (67)404225 (56).12
       Red blood cells
      In cases with units (>0) given.
      2332.0 [1.0, 6.0]1962.0 [1.0, 5.0]>.9
       Platelets
      In cases with units (>0) given.
      1562.0 [1.0, 3.0]961.0 [1.0, 3.0].8
       Fresh frozen plasma
      In cases with units (>0) given.
      1091.0 [1.0, 4.0]871.0 [1.0, 4.0].8
       Cryoprecipitate
      In cases with units (>0) given.
      721.0 [1.0, 2.0]541.0 [1.0, 2.0].7
      Morbidity and mortality
       Operative mortality40614 (3.4)4068.9 (2.2).3
       Dialysis3785.0 (1.3)3703.3 (0.90).6
       Permanent stroke4066.3 (1.5)4068.6 (2.1).5
       Atrial fibrillation33088 (27)331106 (32).14
       Prolonged ventilation (>24 h)405109 (27)40679 (19).3
       Reoperation for bleeding or tamponade40612 (3.1)40613 (3.2).9
       Deep sternal wound infection4020 (0)4001.5 (0.38).9
      Length of stay
       Intensive care unit, h40667 [27, 163]40447 [23, 140].09
       Postoperative, d4068.0 [5.0, 13]4068.0 [5.0, 14].7
       Discharged to home392317 (81)396329 (83).4
      CPB, Cardiopulmonary bypass; IABP, intra-aortic balloon pump; ECMO, extracorporeal membrane oxygenation.
      Patients with data available.
      In cases with units (>0) given.

      Discussion

      Principal Findings

      Reoperative cardiac surgery performed at a high-volume center with established quality and rescue protocols can be accomplished with considerable safety, with few major sternal re-entry and mediastinal dissection injuries regardless of the timing of institution of CPB. Operative mortality was 3.5%, with low prevalence of stroke, renal failure, and deep sternal wound infection despite patients' comorbidities and the high case complexity, including circulatory arrest in 25% of early CPB cases and 8% of late CPB cases.
      Critical elements for success entailed image-based guidance, vigilant myocardial protection strategies, and use of adjuvant percutaneous technology when faced with a hostile sternal re-entry, all in the context of a multidisciplinary approach and institutional experience (Figure 5).
      Figure thumbnail gr5
      Figure 5Patients who underwent reoperative sternotomy were grouped into peripheral cardiopulmonary bypass (CPB) before redo sternotomy (early) and those placed on CPB after redo sternotomy (late). Further categories were based on high or low anatomic risk as revealed by computed tomography imaging. Patients with hemodynamic instability who quickly required unplanned early cardiopulmonary bypass were excluded from comparative effectiveness comparisons. The bottom portion of the illustration shows computed tomography features favoring use of each approach—early versus late institution of CPB. Overall operative mortality for reoperative cardiac surgery is low at an experienced center, with comparable outcomes across early or late CPB strategies. Optimal outcomes with reoperative cardiac surgery require continuous team-based practice and preparedness, use of advanced imaging, implementation of technological adjuncts, and a multidisciplinary effort.

      Preoperative Imaging

      As previously reported by our group, preoperative CT imaging and careful study of coronary angiography for bypass graft location and mobility are critical for anatomic risk stratification and intraoperative planning.
      • Svensson L.G.
      Reoperation of the aortic valve.
      ,
      • Roselli E.E.
      • Pettersson G.B.
      • Blackstone E.H.
      • Brizzio M.E.
      • Houghtaling P.L.
      • Hauck R.
      • et al.
      Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue.
      ,
      • Svensson L.G.
      • Blackstone E.H.
      • Rajeswaran J.
      • Sabik III, J.F.
      • Lytle B.W.
      • Gonzalez-Stawinski G.
      • et al.
      Does the arterial cannulation site for circulatory arrest influence stroke risk?.
      • LaPar D.J.
      • Ailawadi G.
      • Harris D.A.
      • Hajzus V.A.
      • Lau C.L.
      • Kern J.A.
      • et al.
      A protocol-driven approach to cardiac reoperation reduces mortality and cardiac injury at the time of resternotomy.
      • Svensson L.G.
      Reoperation on the aortic arch.
      ,
      • Kamdar A.R.
      • Meadows T.A.
      • Roselli E.E.
      • Gorodeski E.Z.
      • Curtin R.J.
      • Sabik J.F.
      • et al.
      Multidetector computed tomographic angiography in planning of reoperative cardiothoracic surgery.
      Such imaging information, coupled with intimate knowledge and understanding of disease pathology, physiologic risk, and strategic delivery of myocardial protection, are key elements of safe and successful conduct of cardiac reoperations. Occurrence of re-entry injuries in this more recent experience was lower than in our 2008 study.
      • Roselli E.E.
      • Pettersson G.B.
      • Blackstone E.H.
      • Brizzio M.E.
      • Houghtaling P.L.
      • Hauck R.
      • et al.
      Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue.

      Choice of Early Versus Late CPB Strategy

      Peripheral cannulation, including axillary, and early CPB facilitate expeditious re-entry and dissection by decompressing cardiovascular structures and affording a safety margin through better control of bleeding or hemodynamics in case of accidental cardiovascular injury. Dr Floyd Loop, former chief of our Thoracic and Cardiovascular Surgery department, advocated this approach for redo CABG dissection of the left ventricle. Some surgeons prefer an early CPB approach regardless of anatomic (cardiovascular structural injury) or physiologic (hemodynamic) risk.
      • Svensson L.G.
      Reoperation of the aortic valve.
      ,
      • Singh A.K.
      • Stearns G.
      • Maslow A.
      • Feng W.C.
      • Schwartz C.
      Redo sternotomy for cardiac reoperations using peripheral heparin-bonded cardiopulmonary bypass circuits without systemic heparinization: technique and results.
      ,
      • Kuralay E.
      • Bolcal C.
      • Cingoz F.
      • Gunay C.
      • Yildirim V.
      • Kilic S.
      • et al.
      Cardiac reoperation by Carpentier bicaval femoral venous cannula: GATA experience.
      ,
      • Svensson L.G.
      Reoperation on the aortic arch.
      Institution of early CPB with active cooling and circulatory arrest is particularly important when aortic injury is highly anticipated based on preoperative imaging studies (eg, pseudoaneurysm adherent to the chest wall).
      However, avoiding early heparinization and performing more dissection off-pump to achieve needed exposure may be advantageous, particularly in multicomponent cases requiring extensive and time-consuming dissection, as long as the patient is hemodynamically stable and tolerating cardiac manipulation. In addition, late CPB in low anatomic risk situations affords an opportunity for trainees to be supervised through a sternal re-entry and mediastinal dissection.
      In our cohort, most early CPB cases entailed an aortic valve replacement, root procedure, aortic arch or elephant trunk procedure, or ascending aortic replacement component. Previously, in a randomized trial of total arch replacements—39% reoperations—risk of stroke and death was 0.8% for both, and our study confirms this low risk with early CPB, including right axillary cannulation for antegrade brain protection.
      • Svensson L.G.
      • Blackstone E.H.
      • Rajeswaran J.
      • Sabik III, J.F.
      • Lytle B.W.
      • Gonzalez-Stawinski G.
      • et al.
      Does the arterial cannulation site for circulatory arrest influence stroke risk?.
      ,
      • Svensson L.G.
      Reoperation on the aortic arch.
      ,
      • Svensson L.G.
      • Blackstone E.H.
      • Apperson-Hansen C.
      • Ruggieri P.M.
      • Ainkaran P.
      • Naugle R.I.
      • et al.
      Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial.
      Individual surgeons had different thresholds regarding early CPB to mitigate anatomic risk during re-entry.
      Although delaying CPB might be expected to reduce CPB time, similar times were observed in the early and late groups in the high anatomic risk cohort. In contrast, late CPB was associated with longer bypass times in the low anatomic risk cohort, a finding that might be explained by factors related to operating surgeon and case mix.
      Several studies have linked perioperative red blood cell transfusion with worse outcomes in cardiac surgical patients.
      • Koch C.
      • Li L.
      • Figueroa P.
      • Mihaljevic T.
      • Svensson L.
      • Blackstone E.H.
      Transfusion and pulmonary morbidity after cardiac surgery.
      ,
      • LaPar D.J.
      • Hawkins R.B.
      • McMurry T.L.
      • Isbell J.M.
      • Rich J.B.
      • Speir A.M.
      • et al.
      Preoperative anemia versus blood transfusion: which is the culprit for worse outcomes in cardiac surgery?.
      Although a higher percentage of patients received intraoperative blood transfusions in the early CPB group, more units of platelets and cryoprecipitate were transfused in the late CPB group in the high-risk cohort. The early CPB strategy was associated with a systematic preference to aggressively correct coagulopathy in the operating room, with routine administration of platelets and fresh frozen plasma. In recent years, thromboelastography has increasingly guided intraoperative transfusion therapy, particularly in the late CPB group. In cases of diffuse coagulopathy, an open-chest strategy might be necessary, particularly in high-risk anatomic situations.
      • Bakaeen F.G.
      • Haddad O.
      • Ibrahim M.
      • Pasadyn S.R.
      • Germano E.
      • Mok S.
      • et al.
      Advances in managing the noninfected open chest after cardiac surgery: negative-pressure wound therapy.
      A recent study showed that re-entry injury was an independent predictor of in-hospital deaths, with 26% mortality.
      • Imran Hamid U.
      • Digney R.
      • Soo L.
      • Leung S.
      • Graham A.N.
      Incidence and outcome of re-entry injury in redo cardiac surgery: benefits of preoperative planning.
      Therefore, an early CPB approach to sternal re-entry with peripheral cannulation has been advocated.
      • Singh A.K.
      • Stearns G.
      • Maslow A.
      • Feng W.C.
      • Schwartz C.
      Redo sternotomy for cardiac reoperations using peripheral heparin-bonded cardiopulmonary bypass circuits without systemic heparinization: technique and results.
      ,
      • Kuralay E.
      • Bolcal C.
      • Cingoz F.
      • Gunay C.
      • Yildirim V.
      • Kilic S.
      • et al.
      Cardiac reoperation by Carpentier bicaval femoral venous cannula: GATA experience.
      Our group previously reported that intraoperative adverse events, including re-entry injuries, were associated with worse outcomes, including mortality, morbidity, and higher hospital costs, but there was no association between outcomes and injured structure or timing of when the injury occurred.
      • Roselli E.E.
      • Pettersson G.B.
      • Blackstone E.H.
      • Brizzio M.E.
      • Houghtaling P.L.
      • Hauck R.
      • et al.
      Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue.
      Despite case complexity and the large proportion of patients with >2 reoperations, major re-entry and dissection-associated injuries were infrequent and less than half of what was previously published by our group.
      • Roselli E.E.
      • Pettersson G.B.
      • Blackstone E.H.
      • Brizzio M.E.
      • Houghtaling P.L.
      • Hauck R.
      • et al.
      Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue.
      Since that earlier series, we have mandated preoperative CT scans and more consistently adopted common reoperative strategies and surgical practices to prevent adverse events. In low-risk situations, early CPB was associated with decreased major re-entry injuries compared with late CPB, but this association was not maintained in the high-risk cohort. Likely, preventive strategies were more rigorously used in the perceived highest-risk cases, with transition to cannulation and CPB if needed.

      Surgeon and Institutional Experience

      Reported mortality for reoperative cardiac surgery ranges from 2.5% to more than 10% and depends on multiple factors, including patient- and procedure-related variables.
      • Roselli E.E.
      • Pettersson G.B.
      • Blackstone E.H.
      • Brizzio M.E.
      • Houghtaling P.L.
      • Hauck R.
      • et al.
      Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue.
      ,
      • Bianco V.
      • Kilic A.
      • Gleason T.G.
      • Aranda-Michel E.
      • Habertheuer A.
      • Wang Y.
      • et al.
      Reoperative cardiac surgery is a risk factor for long-term mortality.
      • Kalra A.
      • Raza S.
      • Hussain M.
      • Shorbaji K.
      • Delozier S.
      • Deo S.V.
      • et al.
      Aortic valve replacement in bioprosthetic failure: insights from the Society of Thoracic Surgeons national database.
      • Naji P.
      • Griffin B.P.
      • Sabik J.F.
      • Kusunose K.
      • Asfahan F.
      • Popovic Z.B.
      • et al.
      Characteristics and outcomes of patients with severe bioprosthetic aortic valve stenosis undergoing redo surgical aortic valve replacement.
      • Leontyev S.
      • Borger M.A.
      • Davierwala P.
      • Walther T.
      • Lehmann S.
      • Kempfert J.
      • et al.
      Redo aortic valve surgery: early and late outcomes.
      • Ruggieri V.G.
      • Lenglet N.R.
      • Anselmi A.
      • Fletcher E.
      • Harmouche M.
      • Ingels A.
      • et al.
      Logistic EuroSCORE I risk analysis in aortic valve reoperations after bioprosthetic replacement.
      Another important factor is surgical experience.
      • Moon M.R.
      • Henn M.C.
      • Maniar H.S.
      • Pasque M.K.
      • Melby S.J.
      • Kachroo P.
      • et al.
      Impact of surgical experience on operative mortality after reoperative cardiac surgery.
      At a high-volume center such as ours, risk-adjusted outcomes of reoperation approach those of primary operation for aortic valve replacement and CABG.
      • Naji P.
      • Griffin B.P.
      • Sabik J.F.
      • Kusunose K.
      • Asfahan F.
      • Popovic Z.B.
      • et al.
      Characteristics and outcomes of patients with severe bioprosthetic aortic valve stenosis undergoing redo surgical aortic valve replacement.
      ,
      • Sabik III, J.F.
      • Blackstone E.H.
      • Houghtaling P.L.
      • Walts P.A.
      • Lytle B.W.
      Is reoperation still a risk factor in coronary artery bypass surgery?.
      This observation in itself is strong evidence that reoperative sternotomy is safe and adds minimally to operative risk. Thus, redo operations per se do not add to procedural risk and should not be regarded as automatic markers to inappropriately triage otherwise low-risk patients to a transcatheter valve-in-valve procedure, percutaneous coronary intervention, or endovascular aortic repair, or to prohibit treatment. At our institution, new and junior staff surgeons are often assisted by senior surgeons, particularly for high-risk reoperations. This strategy aims at improving preparedness for rescue and assists in accelerating junior surgeon readiness for taking on complex cases.

      Re-Sternotomy Versus Other Approaches

      Although our preferred approach for reoperation is repeat sternotomy, others have shown encouraging results with alternative strategies.
      • Casselman F.P.
      • La Meir M.
      • Jeanmart H.
      • Mazzarro E.
      • Coddens J.
      • Van Praet F.
      • et al.
      Endoscopic mitral and tricuspid valve surgery after previous cardiac surgery.
      Avoiding a high-risk sternotomy might be advantageous, but adequate access and effectiveness of de-airing might be issues in a thoracotomy approach. In our experience, a right thoracotomy approach to redo mitral valve surgery was associated with higher prevalence of stroke compared with redo sternotomy.
      • Svensson L.G.
      • Gillinov A.M.
      • Blackstone E.H.
      • Houghtaling P.L.
      • Kim K.H.
      • Pettersson G.B.
      • et al.
      Does right thoracotomy increase the risk of mitral valve reoperation?.
      The current results suggest that even in high-risk anatomic situations, careful and meticulous preoperative planning for strategic reoperative sternotomy using an early or late CPB approach yields excellent outcomes.

      Myocardial Protection

      Myocardial protection is paramount during reoperative cardiac surgery.
      • Roselli E.E.
      • Pettersson G.B.
      • Blackstone E.H.
      • Brizzio M.E.
      • Houghtaling P.L.
      • Hauck R.
      • et al.
      Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue.
      ,
      • Pettersson G.B.
      • Martino D.
      • Blackstone E.H.
      • Nowicki E.R.
      • Houghtaling P.L.
      • Sabik III, J.F.
      • et al.
      Advising complex patients who require complex heart operations.
      ,
      • Park C.B.
      • Suri R.M.
      • Burkhart H.M.
      • Greason K.L.
      • Dearani J.A.
      • Schaff H.V.
      • et al.
      What is the optimal myocardial preservation strategy at re-operation for aortic valve replacement in the presence of a patent internal thoracic artery?.
      This is particularly challenging when a patent left internal thoracic artery graft is present.
      • Park C.B.
      • Suri R.M.
      • Burkhart H.M.
      • Greason K.L.
      • Dearani J.A.
      • Schaff H.V.
      • et al.
      What is the optimal myocardial preservation strategy at re-operation for aortic valve replacement in the presence of a patent internal thoracic artery?.
      With the early CPB approach, more systemic cooling without occluding the patent graft and less retrograde cardioplegia were used than in the late approach, but both were effective. Intra-aortic balloon pump insertion and use of extracorporeal membrane oxygenation were low and similar between the early and late CPB groups, suggesting adequate myocardial protection despite the complexity of cases and regardless of timing of CPB initiation.

      Novel Strategies and Endovascular Adjuncts

      In reoperative cases involving a hostile environment for sternal re-entry, adjuncts such as an endoaortic balloon or percutaneous cardioplegia may be considered, but these strategies might require a hybrid operating room.
      • Reyes K.G.
      • Pettersson G.B.
      • Mihaljevic T.
      • Roselli E.E.
      A strategy for safe sternal reentry in patients with pseudoaneurysms of the ascending aorta using the PORT-ACCESS EndoCPB system.
      ,
      • Mehta A.R.
      • Hammond B.
      • Unai S.
      • Navia J.L.
      • Gillinov M.
      • Pettersson G.B.
      Percutaneous cardioplegic arrest before repeat sternotomy in patients with retrosternal aortic aneurysm.
      These approaches are used before completed sternal re-entry to avoid or minimize circulatory arrest time. Within our cohort of cases, these adjuncts were used more frequently in more recent cases.

      Strengths and Limitations

      Primary limitations are those inherent to a single-center observational study. However, the size of this study, with more than 6000 patients, plus use of propensity weighting allow for reliable comparisons between groups. Data acquisition relating to intraoperative injury is linked to surgeon-specific operative reports and thus might be underestimated. Small dissection or sternal opening–related injuries that were trivial and fixed primarily were likely under-reported. Nonetheless, the most severe injuries requiring alterations to the planned approach or emergency cannulation were captured.

      Conclusions

      Cardiac reoperations are associated with low cardiovascular major injury risk and excellent outcomes at a high-volume center with experienced teams. Patient-related anatomic and physiologic considerations are important in selecting a particular surgical approach, and surgeon experience and preference are important when there is no obvious a priori advantage for a given approach, such as brain protection for complex arch operations during circulatory arrest. Deliberate planning and practice, advanced imaging, technological adjuncts, and a systemwide multidisciplinary effort are modern-day pillars of a successful approach to cardiac reoperations.

      Conflict of Interest Statement

      The authors reported no conflicts of interest.
      The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
      The authors thank Brian Kohlbacher and Joe Pangrace for graphic design expertise and Tess Parry for editorial assistance.

      Supplementary Data

      Appendix E1. Variables Considered in Analyses

      Demographics

      Age (years),
      Variables used in the propensity model.
      sex,
      Variables used in the propensity model.
      race (white,
      Variables used in the propensity model.
      black, other), weight (kg), height (cm), body mass index (kg/m2)
      Variables used in the propensity model.

      Symptoms

      New York Heart Association functional class (I-IV)
      Variables used in the propensity model.

      Ventricular Function

      Left ventricular ejection fraction (%)
      Variables used in the propensity model.

      Cardiac Comorbidity

      Atrial fibrillation,
      Variables used in the propensity model.
      endocarditis, number of previous cardiac operations

      Noncardiac Comorbidity

      Peripheral arterial disease,
      Variables used in the propensity model.
      hypertension,
      Variables used in the propensity model.
      diabetes,
      Variables used in the propensity model.
      chronic obstructive pulmonary disease,
      Variables used in the propensity model.
      history of smoking,
      Variables used in the propensity model.
      previous stroke,
      Variables used in the propensity model.
      preoperative dialysis, creatinine (mg/dL),
      Variables used in the propensity model.
      blood urea nitrogen (mg/dL),
      Variables used in the propensity model.
      bilirubin (mg/dL),
      Variables used in the propensity model.
      hematocrit (%)
      Variables used in the propensity model.

      Valve Pathology

      Aortic valve regurgitation,
      Variables used in the propensity model.
      aortic valve stenosis,
      Variables used in the propensity model.
      mitral valve regurgitation,
      Variables used in the propensity model.
      mitral valve stenosis,
      Variables used in the propensity model.
      tricuspid valve regurgitation,
      Variables used in the propensity model.
      tricuspid valve stenosis

      Coronary Artery Disease

      System disease greater than 50% stenosis (left anterior descending coronary artery,
      Variables used in the propensity model.
      left circumflex coronary artery,
      Variables used in the propensity model.
      left main trunk,
      Variables used in the propensity model.
      right coronary artery), number of systems with greater than 50% stenosis
      Variables used in the propensity model.

      Previous Cardiac Operations

      Number of previous sternotomies,
      Variables used in the propensity model.
      previous mediastinal radiation, patent internal thoracic artery or graft crossing midline,
      Variables used in the propensity model.
      time from last surgery (years),
      Variables used in the propensity model.
      place of last surgery (Cleveland Clinic or outside),
      Variables used in the propensity model.
      coronary artery bypass grafting,
      Variables used in the propensity model.
      left internal thoracic artery graft, aortic valve repair,
      Variables used in the propensity model.
      valve-sparing root replacement, aortic valve replacement, mitral valve repair, mitral valve replacement, tricuspid valve repair, tricuspid valve replacement, aortic root replacement,
      Variables used in the propensity model.
      aortic arch aneurysm repair, elephant trunk, aortic dissection repair, hemiarch replacement

      Imaging

      Adherence of right ventricle to sternum,
      Variables used in the propensity model.
      adherence of bypass graft(s) crossing midline to sternum, adherence of ascending aorta to sternum, aortic pseudoaneurysm within close proximity to sternum,
      Variables used in the propensity model.
      proximity (<1 cm) of right ventricle to sternum, proximity (<1 cm) of bypass graft crossing midline to sternum, proximity (<1 cm) of ascending aorta to sternum,
      Variables used in the propensity model.
      adherence of brachiocephalic vein to sternum, proximity (<1 cm) of brachiocephalic vein to sternum
      Variables used in the propensity model.

      Experience

      Date of operation (years since 1/1/2008)
      Variables used in the propensity model.

      Index Reoperation

      Coronary artery bypass grafting,
      Variables used in the propensity model.
      aortic valve procedure (repair, replacement),
      Variables used in the propensity model.
      valve-sparing root replacement, mitral valve procedure (repair, replacement),
      Variables used in the propensity model.
      tricuspid valve procedure (repair, replacement),
      Variables used in the propensity model.
      aortic root replacement,
      Variables used in the propensity model.
      ascending aorta repair,
      Variables used in the propensity model.
      aortic arch aneurysm repair, elephant trunk, hemiarch replacement
      Figure thumbnail fx4
      Figure E1Quality of propensity-weighted matching of patients undergoing reoperation with use of early versus late institution of cardiopulmonary bypass (CPB). Each pair of graphs depicts on left a mirrored histogram of the distribution of propensity scores for early and late CPB groups, and on right a graph of standardized mean differences of selected variables before (mauve triangles) and after (green squares) matching. Top row: Patients with high-risk anatomic feature on computed tomography (CT) imaging. Middle row: Patients with low anatomic risk according to CT imaging. Bottom row: Patients with low anatomic risk according to CT imaging who had early axillary–femoral cannulation. Asc., Ascending; LVEF, left ventricular ejection fraction; PAD, peripheral arterial disease; BMI, body mass index; MR, mitral regurgitation; NYHA, New York Heart Association; TR, tricuspid regurgitation.
      Figure thumbnail fx5
      Figure E2Use of early institution of cardiopulmonary bypass (CPB) for reoperations across calendar years. Red circles are raw yearly percentages, and red line is a loess smoother.
      Figure thumbnail fx6
      Figure E3Unadjusted survival. A, Early CPB (red circles) versus late CPB (blue circles). B, Low-risk (green circles) versus high-risk (yellow circles) groups. C, All 4 groups: high-risk early CPB (red circles) and late CPB (blue circles) groups, and low-risk early CPB (red triangles) and late CPB (blue squares) groups. CPB, Cardiopulmonary bypass.
      Table E1Patient demographics and preoperative, imaging, and intraoperative details stratified according to early versus late CPB
      VariableEarly CPB (n = 755)Late CPB (n = 5872)Std. Diff.
      n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]
      Demographics
       Age, y75562 ± 15587264 ± 14−15
       Female755173 (23)58721980 (34)−24
       Black race74927 (3.6)5809293 (5.0)−7.1
       Body mass index, kg/m275128 ± 5.5584229 ± 6.0−10
      Noncardiac comorbidities
       Hypertension747557 (75)58264396 (75)−2.1
       COPD755199 (26)58681663 (28)−4.4
       History of smoking748396 (53)58273323 (57)−8.2
       Previous stroke746106 (14)5811881 (15)−2.7
       Peripheral arterial disease755131 (17)5870992 (17)1.2
       Renal dialysis7126 (0.84)5629166 (2.9)−15
       Creatinine, mg/dL7550.98 [0.77, 1.3]58481.1 [0.80, 1.5]−23
       Hematocrit, %75238 ± 5.7580637 ± 6.126
      Cardiac comorbidities
       Previous CABG755250 (33)58722793 (48)−30
       LVEF, %59656 ± 9.9489353 ± 1225
       Coronary artery disease
      Any system or left main trunk disease >50% stenosis.
      740147 (20)57331698 (30)−23
       Aortic valve disease
      Severe regurgitation755137 (18)5872722 (12)16
      Stenosis744347 (47)58042226 (38)17
       Mitral valve disease
      Severe regurgitation75543 (5.7)58721002 (17)−36
      Stenosis74257 (7.7)58091245 (21)−40
       Tricuspid valve disease
      Severe regurgitation75532 (4.2)5872670 (11)−27
      Stenosis7423 (0.40)578734 (0.59)−2.6
       Previous mediastinal radiation75112 (1.6)5839114 (2.0)−2.7
       Previous cardiac surgery
      Previous sternotomies75558681.7
      1620 (82)4864 (83)
      2112 (15)782 (13)
      315 (2.0)169 (2.9)
      46 (0.79)40 (0.68)
      ≥52 (0.26)13 (0.22)
      Previous ITA graft755205 (27)58712194 (37)−22
      Previous aortic valve procedure
      Repair75598 (13)5870281 (4.8)29
      Replacement755357 (47)58722169 (37)21
      Previous mitral valve procedure
      Repair75445 (6.0)5872816 (14)−27
      Replacement75551 (6.8)5867773 (13)−22
      Previous tricuspid valve procedure
      Repair75413 (1.7)5872272 (4.6)−17
      Replacement7553 (0.40)587271 (1.2)−9.1
      Previous valve-sparing root replacement73620 (2.7)571951 (0.89)14
      Previous aortic root replacement754125 (17)5862586 (10.0)19
      Previous aortic arch aneurysm repair75426 (3.4)587143 (0.73)19
      Previous elephant trunk7548 (1.1)587015 (0.26)0.10
      Previous aortic dissection repair75588 (12)5871205 (3.5)31
      Imaging and risk
       Adherence of
      Right ventricle to sternum755199 (26)58631566 (27)−0.80
      Bypass graft(s) crossing midline to sternum75521 (2.8)586998 (1.7)7.5
      Ascending aorta to sternum75573 (9.7)5869150 (2.6)30
       Aortic pseudoaneurysm within close proximity to sternum75566 (8.7)5855197 (3.4)23
       Low anatomic risk755614 (81)58725450 (93)−35
       High anatomic risk755141 (19)5872422 (7.2)35
      Reoperative index procedure
       CABG75588 (12)58721941 (33)−53
       Aortic valve
      Repair75533 (4.4)5871108 (1.8)15
      Replacement755512 (68)58713099 (53)31
       Mitral valve
      Repair75543 (5.7)5871929 (16)−33
      Replacement75563 (8.3)58711509 (26)−47
       Tricuspid valve
      Repair75541 (5.4)58711265 (22)−49
      Replacement7557 (0.93)5871130 (2.2)−10
       Root replacement751124 (17)5858937 (16)1.4
       Ascending aortic aneurysm repair/replacement753335 (44)5868678 (12)79
       Arch aneurysm repair/replacement753143 (19)5867251 (4.3)47
       Elephant trunk75490 (12)5864173 (3.0)35
       Retrograde cardioplegia753341 (45)58715217 (89)−105
      Support
       CPB time, min755110 [75, 175]5853127 [80, 199]−28
       Myocardial ischemic time, min73463 [39, 103]566295 [57, 151]−77
       Circulatory arrest755185 (25)5868470 (8.0)46
       Circulatory arrest time, min18526 [11, 44]46726 [12, 85]−16
       Operative time, min755351 [263, 468]5872377 [276, 513]−26
      CPB, Cardiopulmonary bypass; Std. Diff., standardized difference; SD, standard deviation; COPD, chronic obstructive pulmonary disease; CABG, coronary artery bypass grafting; LVEF, left ventricular ejection fraction; ITA, internal thoracic artery.
      Patients with data available.
      Any system or left main trunk disease >50% stenosis.
      Table E2Patient factors associated with early versus late CPB: high anatomic risk cohort
      FactorCoefficient ± SEOdds ratio (95% CI)P valueReliability, %
      Percent of times variable or cluster of variables appeared in 1000 bootstrap models.
      Higher likelihood of early CPB use
       Previous surgery outside Cleveland Clinic0.52 ± 0.271.7 (1.0-2.8).0556
       Previous aortic root surgery0.48 ± 0.251.6 (0.98-2.7).0561
       CT: proximity (<1 cm) of ascending aorta to chest wall/sternum1.006 ± 0.232.7 (1.7-4.3)<.000198
       Ascending aortic aneurysm repair0.47 ± 0.221.6 (1.02-2.5).0460
       Earlier date of operation
      Years since January 1, 2008.
      −0.089 ± 0.040.91 (0.85-0.99).0356
      Higher likelihood of later CPB use
       Female−0.72 ± 0.250.49 (0.30-0.79).00452
       Coronary artery bypass grafting−0.54 ± 0.260.58 (0.35-0.98).0451
      C-statistic = 0.77; full semisaturated propensity model C-statistic = 0.82. SE, Standard error; CI, confidence interval; CPB, cardiopulmonary bypass; CT, computed tomography.
      Percent of times variable or cluster of variables appeared in 1000 bootstrap models.
      Years since January 1, 2008.
      Table E3Patient factors associated with early versus late CPB: low anatomic risk cohort
      FactorCoefficient ± SEOdds ratio (95% CI)P valueReliability (%)
      Percent of times variable or cluster of variables appeared in 1000 bootstrap models.
      Higher likelihood of early CPB use
       Previous surgery outside Cleveland Clinic0.35 ± 0.111.4 (1.14-1.8).00270
       Previous aortic valve repair0.55 ± 0.161.7 (1.3-2.4).000771
       Elective surgery (not urgent or emergency)0.42 ± 0.121.5 (1.2-1.9).000563
       Aortic valve surgery0.45 ± 0.121.6 (1.2-2.0).000363
       Ascending aortic aneurysm repair1.4 ± 0.113.9 (3.2-4.9)<.0001100
       Earlier date of operation
      Years since January 1, 2008.
      −0.109 ± 0.0200.90 (0.86-0.93)<.000175
      Higher likelihood of later CPB use
       Lower hematocrit0.030 ± 0.00971.03 (1.01-1.05).00268
       Higher NYHA functional class−0.17 ± 0.0710.84 (0.73-0.97).01484
       Mitral valve surgery−1.3 ± 0.160.28 (0.20-0.38)<.0001100
       Tricuspid valve surgery−1.6 ± 0.280.20 (0.12-0.35)<.000174
       Coronary artery bypass grafting−1.7 ± 0.170.19 (0.13-0.26)<.0001100
      C-statistic = 0.85; full semisaturated propensity model C-statistic = 0.88. SE, Standard error; CI, confidence interval; CPB, cardiopulmonary bypass; NYHA, New York Heart Association.
      Percent of times variable or cluster of variables appeared in 1000 bootstrap models.
      Years since January 1, 2008.
      Table E4Patient factors associated with early versus late CPB: low anatomic risk cohort using early axillary–femoral cannulation
      FactorCoefficient ± SEOdds ratio (95% CI)P valueReliability (%)
      Percent of times variable or cluster of variables appeared in 1000 bootstrap models.
      Higher likelihood of early CPB use
       Previous surgery outside Cleveland Clinic0.32 ± 0.121.4 (1.09-1.7).00861
       Previous aortic valve repair0.63 ± 0.171.9 (1.3-2.6).000378
       Elective surgery (not urgent or emergency)0.57 ± 0.121.8 (1.4-2.3)<.000175
       Aortic valve surgery0.41 ± 0.131.5 (1.2-2.0).00261
       Ascending aortic aneurysm repair1.3 ± 0.123.7 (2.9-4.7)<.0001100
       Earlier date of operation
      Years since January 1, 2008.
      −0.13 ± 0.0210.87 (0.84-0.91)<.000180
      Higher likelihood of later CPB use
       Higher NYHA functional class−0.21 ± 0.0770.81 (0.70-0.94).00685
       Mitral valve surgery−1.3 ± 0.170.28 (0.20-0.39)<.0001100
       Tricuspid valve surgery−1.5 ± 0.280.23 (0.13-0.40)<.000173
       Coronary artery bypass grafting−1.6 ± 0.180.19 (0.13-0.27)<.0001100
      C-statistic = 0.85; full semisaturated propensity model C-statistic = 0.87. SE, Standard error; CI, confidence interval; CPB, cardiopulmonary bypass; NYHA, New York Heart Association.
      Percent of times variable or cluster of variables appeared in 1000 bootstrap models.
      Years since January 1, 2008.
      Table E5Patient demographics and preoperative, imaging, and intraoperative details before and after matching: high anatomic risk cohort
      VariablesAll dataPropensity-weighted
      Early CPB (n = 141)Late CPB (n = 422)Std. Diff.Early CPB (n = 111)Late CPB (n = 110)Std. Diff.
      n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]
      Demographics
       Age, y14160 ± 1642261 ± 15−1111160 ± 1411061 ± 7.6−3.3
       Female14130 (21)422138 (33)−2611127 (25)11028 (25)−0.045
       Black race1407 (5.0)41427 (6.5)−6.51105.8 (5.3)1086.8 (6.3)−4.4
       Body mass index, kg/m214027 ± 5.541628 ± 5.3−9.511027 ± 5.110827 ± 2.50.53
      Noncardiac comorbidities
       Hypertension138100 (72)420309 (74)−2.510878 (72)10979 (72)−0.70
       COPD14137 (26)421107 (25)1.911126 (23)11027 (24)−2.4
       History of smoking13775 (55)416230 (55)−1.210757 (54)11059 (54)−0.39
       Previous stroke13828 (20)41869 (17)9.810820 (18)10920 (19)−0.73
       Peripheral arterial disease14131 (22)42174 (18)1111125 (23)11026 (23)−1.12
       Renal dialysis1330 (0)4077 (1.7)−191050 (0)1040.33 (0.31)−7.9
       Creatinine, mg/dL1410.99 [0.78, 1.3]4181.0 [0.79, 1.5]−181111.0 [0.77, 1.4]1101.0 [0.80, 1.4]−4.4
       Hematocrit, %14137 ± 5.741236 ± 6.28.511137 ± 5.210837 ± 3.2−4.4
      Cardiac comorbidities
       Previous CABG14142 (30)422203 (48)−3811137 (34)11039 (35)−2.7
       LVEF, %11455 ± 1136152 ± 13199254 ± 108754 ± 5.70.57
       Coronary artery disease
      Any system or left main trunk disease >50% stenosis.
      13522 (16)410113 (28)−2710619 (18)10821 (19)−3.2
       Aortic valve disease
      Severe regurgitation14117 (12)42262 (15)−7.711114 (13)11019 (17)−11
      Stenosis13854 (39)417147 (35)8.010840 (37)10841 (38)−1.0
       Mitral valve disease
      Severe regurgitation1419 (6.4)42251 (12)−201118.5 (7.7)1107.5 (6.8)3.4
      Stenosis1378 (5.8)41843 (10)−161076.7 (6.3)1096.6 (6.1)0.88
       Tricuspid valve disease
      Severe regurgitation1414 (2.8)42236 (8.5)−251113.2 (2.9)1104.9 (4.5)−8.2
      Stenosis1380 (0)4161 (0.24)−6.91080 (0)1090.01 (0.01)−1.4
       Previous mediastinal radiation1402 (1.4)41910 (2.4)−7.01102.0 (1.8)1102.6 (2.4)−3.7
       Previous cardiac surgery
      Previous sternotomies1414227.41111103.2
      198 (70)308 (73)77 (69)78 (70)
      231 (22)78 (18)26 (23)24 (22)
      36 (4.3)29 (6.9)4.1 (3.7)6.4 (5.8)
      44 (2.8)5 (1.2)3.1 (2.8)1.0 (0.91)
      ≥52 (1.4)2 (0.47)1.2 (1.1)1.1 (1.00)
      Previous ITA graft14135 (25)422157 (37)−2711131 (28)11030 (27)2.5
      Previous aortic valve procedure
      Repair14116 (11)42234 (8.1)1111113 (11)11010 (9.0)7.4
      Replacement14179 (56)422201 (48)1711160 (54)11059 (54)0.37
      Previous mitral valve procedure
      Repair1416 (4.3)42232 (7.6)−141115.0 (4.5)1106.2 (5.6)−4.9
      Replacement1415 (3.5)42239 (9.2)−231114.6 (4.1)1106.1 (5.5)−6.7
      Previous tricuspid valve procedure
      Repair1401 (0.71)4229 (2.1)−121101.0 (0.91)1102.5 (2.2)−10
      Replacement1410 (0)4222 (0.47)−9.81110 (0)1100.31 (0.28)−7.4
      Previous valve-sparing root replacement1394 (2.9)4089 (2.2)4.31093.3 (3.1)1081.7 (1.6)9.7
      Previous aortic root replacement14142 (30)42072 (17)3011130 (27)10928 (25)3.7
      Previous aortic arch aneurysm repair14110 (7.1)42210 (2.4)221116.7 (6.0)1104.7 (4.3)8.1
      Previous elephant trunk1414 (2.8)4215 (1.2)121113.0 (2.7)1102.7 (2.4)2.1
      Previous aortic dissection repair14129 (21)42242 (10.0)3011122 (20)11020 (18)3.2
      Imaging and risk
       Adherence of
      Right ventricle to sternum14139 (28)420146 (35)−1511133 (30)11034 (31)−2.3
      Bypass graft(s) crossing midline to sternum14121 (15)42198 (23)−2111119 (18)11016 (14)8.7
      Ascending aorta to sternum14173 (52)422150 (36)3311155 (50)11051 (47)6.2
      Aortic pseudoaneurysm within close proximity to sternum14166 (47)422197 (47)0.2511152 (47)11053 (48)−1.9
      Reoperative index procedure
       CABG14127 (19)422131 (31)−2811122 (20)11024 (22)−3.4
       Aortic valve
      Repair1415 (3.5)4229 (2.1)8.51114.3 (3.8)1102.8 (2.5)7.6
      Replacement14189 (63)422247 (59)9.411169 (62)11070 (63)−1.9
       Mitral valve
      Repair14110 (7.1)42250 (12)−161119.3 (8.4)1105.0 (4.5)16
      Replacement1417 (5.0)42267 (16)−361116.5 (5.8)1109.2 (8.3)−9.6
       Tricuspid valve
      Repair1417 (5.0)42259 (14)−311116.7 (6.0)1106.9 (6.2)−0.78
      Replacement1411 (0.71)4225 (1.2)−4.91111.0 (0.90)1100.54 (0.49)5.0
       Root replacement14141 (29)420136 (32)−7.211135 (32)11035 (32)0.75
       Ascending aortic aneurysm repair/replacement14176 (54)422125 (30)5111155 (50)11056 (51)−2.1
       Arch aneurysm repair/replacement14133 (23)42249 (12)3111124 (22)11021 (19)7.1
       Elephant trunk14117 (12)42230 (7.1)1711112 (11)11015 (14)−7.6
       Retrograde cardioplegia
      Variables not used in propensity matching.
      14186 (61)422367 (87)−6211168 (62)11095 (86)−56
      Support
      Variables not used in propensity matching.
       CPB time, min141153 [90, 246]420148 [93, 243]1.4111155 [88, 246]110151 [96, 262]−7.7
       Myocardial ischemic time, min14188 [42, 147]422104 [58, 173]−3811189 [41, 148]110102 [55, 175]−46
       Circulatory arrest14162 (44)42289 (21)5011146 (42)11041 (37)8.9
       Circulatory arrest time, min6225 [12, 45]8929 [13, 88]−304624 [11, 45]4139 [11, 101]−48
       Operative time, min141407 [310, 512]422437 [310, 580]−21111411 [314, 514]110446 [310, 610]−38
      CPB, Cardiopulmonary bypass; Std. Diff., standardized difference; SD, standard deviation; COPD, chronic obstructive pulmonary disease; CABG, coronary artery bypass grafting; LVEF, left ventricular ejection fraction; ITA, internal thoracic artery.
      Patients with data available.
      Any system or left main trunk disease >50% stenosis.
      Variables not used in propensity matching.
      Table E6Patient demographics and preoperative, imaging, and intraoperative details before and after matching: low anatomic risk cohort
      VariablesAll dataPropensity-weighted
      Early CPB (n = 519)Late CPB (n = 5450)Std. Diff.Early CPB (n = 480)Late CPB (n = 480)Std. Diff.
      n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]
      Demographics
       Age, y51962 ± 15545064 ± 14−1548062 ± 1548062 ± 4.3−1.6
       Female519109 (21)54501842 (34)−29480103 (21)480103 (21)0.05
       Black race51414 (2.7)5395266 (4.9)−1147514 (2.9)47519 (4.1)−6.2
       Body mass index, kg/m251628 ± 5.5542629 ± 6.0−5.447729 ± 5.347629 ± 1.6−0.38
      Noncardiac comorbidities
       Hypertension514389 (76)54064087 (76)0.19476358 (75)469350 (75)1.7
       COPD519128 (25)54471556 (29)−8.8480116 (24)479116 (24)−0.33
       History of smoking519270 (52)54113093 (57)−10480249 (52)476254 (53)−3.2
       Previous stroke51365 (13)5393812 (15)−6.947661 (13)47659 (12)1.05
       Peripheral arterial disease51985 (16)5449918 (17)−1.348079 (16)47977 (16)0.67
       Renal dialysis4912 (0.41)5222159 (3.0)−204542.0 (0.44)4454.1 (0.92)−5.8
       Creatinine, mg/dL5190.98 [0.78, 1.3]54301.1 [0.80, 1.5]−254800.99 [0.78, 1.3]4781.0 [0.80, 1.3]−8.5
       Hematocrit, %51639 ± 5.4539437 ± 6.14247739 ± 5.347639 ± 1.61.8
      Cardiac comorbidities
       Previous CABG519173 (33)54502590 (48)−29480163 (34)480172 (36)−4.0
       LVEF (%)40756 ± 9.7453253 ± 122837756 ± 9.336756 ± 2.71.5
       Coronary artery disease
      Any system or left main trunk disease >50% stenosis.
      513111 (22)53231585 (30)−19474106 (22)47798 (21)4.0
       Aortic valve disease
      Severe regurgitation519107 (21)5450660 (12)2348097 (20)48099 (21)−1.4
      Stenosis512258 (50)53872079 (39)24475243 (51)473252 (53)−4.0
       Mitral valve disease
      Severe regurgitation51919 (3.7)5450951 (17)−4648019 (4.0)48020 (4.2)−1.4
      Stenosis51131 (6.1)53911202 (22)−4847431 (6.5)47231 (6.7)−0.51
       Tricuspid valve disease
      Severe regurgitation51911 (2.1)5450634 (12)−3848010 (2.2)4809.7 (2.0)1.2
      Stenosis5102 (0.39)537133 (0.61)−3.14742.0 (0.42)4680.57 (0.12)5.8
       Previous mediastinal radiation5164 (0.78)5420104 (1.9)−9.94774.0 (0.84)4776.5 (1.4)−4.9
       Previous cardiac surgery
      Previous sternotomies5195446−7.04804792.2
      1446 (86)4556 (84)410 (85)413 (86)
      265 (13)704 (13)62 (13)51 (11)
      37 (1.3)140 (2.6)7.0 (1.5)11 (2.3)
      41 (0.19)35 (0.64)1.0 (0.21)2.8 (0.59)
      ≥50 (0)11 (0.21)0 (0)0.97 (0.20)
      Previous ITA graft519141 (27)54492037 (37)−22480133 (28)480142 (30)−4.2
      Previous aortic valve procedure
      Repair51973 (14)5448247 (4.5)3348062 (13)48063 (13)−0.46
      Replacement519241 (46)54501968 (36)21480225 (47)480215 (45)4.0
      Previous mitral valve procedure
      Repair51925 (4.8)5450784 (14)−3348024 (5.0)48030 (6.3)−5.4
      Replacement51928 (5.4)5445734 (13)−2848027 (5.7)47924 (5.1)2.8
      Previous tricuspid valve procedure
      Repair5196 (1.2)5450263 (4.8)−224806.0 (1.2)4808.8 (1.8)−4.8
      Replacement5192 (0.39)545069 (1.3)−9.74802.0 (0.42)4801.2 (0.25)2.9
      Previous valve-sparing root replacement50316 (3.2)531142 (0.79)1746615 (3.2)4707.6 (1.6)10
      Previous aortic root replacement51878 (15)5442514 (9.4)1747972 (15)48072 (15)0.01
      Previous aortic arch aneurysm repair51812 (2.3)544933 (0.61)1447911 (2.4)4805.4 (1.1)9.5
      Previous elephant trunk5194 (0.77)544910 (0.18)8.54804.0 (0.83)4792.0 (0.41)5.4
      Previous aortic dissection repair51955 (11)5449163 (3.0)3048049 (10)48055 (11)−3.6
      Imaging and risk
       Adherence of
      Right ventricle to sternum519119 (23)54431420 (26)−7.4480107 (22)478107 (22)−0.43
      Bypass graft(s) crossing midline to sternum5190 (0)54480 (0)0.04800 (0)4790 (0)0.0
      Ascending aorta to sternum5190 (0)54470 (0)0.04800 (0)4800 (0)0.0
      Aortic pseudoaneurysm within close proximity to sternum5190 (0)54330 (0)0.04800 (0)4780 (0)0.0
      Reoperative index procedure
       CABG51944 (8.5)54501810 (33)−6448044 (9.2)48043 (9.1)0.36
       Aortic valve
      Repair51926 (5.0)544999 (1.8)1848022 (4.6)48021 (4.4)1.13
      Replacement519379 (73)54492852 (52)44480355 (74)480336 (70)8.4
       Mitral valve
      Repair51922 (4.2)5449879 (16)−4048022 (4.6)48021 (4.4)0.99
      Replacement51928 (5.4)54491442 (26)−6048028 (5.8)48029 (6.0)−0.75
       Tricuspid valve
      Repair51911 (2.1)54491206 (22)−6448011 (2.3)48013 (2.7)−2.4
      Replacement5193 (0.58)5449125 (2.3)−144803.0 (0.62)4801.6 (0.33)4.3
       Root replacement51775 (15)5438801 (15)−0.6347874 (16)47976 (16)−1.2
       Ascending aortic aneurysm repair/replacement518237 (46)5446553 (10)86479199 (41)480202 (42)−1.5
       Arch aneurysm repair/replacement517100 (19)5445202 (3.7)5047884 (18)48081 (17)1.8
       Elephant trunk51867 (13)5442143 (2.6)3947957 (12)47959 (12)−1.8
       Retrograde cardioplegia
      Variables not used in propensity matching.
      517184 (36)54494850 (89)−132478174 (36)480433 (90)−135
      Support
      Variables not used in propensity matching.
       CPB time, min51999 [70, 143]5433126 [79, 195]−5948099 [69, 144]478119 [76, 196]−74
       Myocardial ischemic time, min51957 [37, 87]543992 [53, 148]−10748057 [37, 87]47984 [50, 140]−150
       Circulatory arrest519105 (20)5446381 (7.0)3948090 (19)479133 (28)−22
       Circulatory arrest time, min10532 [11, 44]37826 [12, 84]−139031 [11, 43]13122 [12, 91]−22
       Operative time, min519327 [255, 420]5450373 [275, 507]−47480329 [255, 421]480363 [263, 513]−58
      CPB, Cardiopulmonary bypass; Std. Diff., standardized difference; SD, standard deviation; COPD, chronic obstructive pulmonary disease; CABG, coronary artery bypass grafting; LVEF, left ventricular ejection fraction; ITA, internal thoracic artery.
      Patients with data available.
      Any system or left main trunk disease >50% stenosis.
      Variables not used in propensity matching.
      Table E7Patient demographics and preoperative, imaging, and intraoperative details using early axillary–femoral cannulation strategy before and after propensity-weighted matching: low anatomic risk cohort
      VariablesAll dataPropensity-weighted
      Early pump (n = 428)Late pump (n = 5450)Std. Diff.Early pump (n = 406)Late pump (n = 406)Std. Diff.
      n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]n
      Patients with data available.
      No. (%) or mean ± SD or median [15th, 85th percentiles]
      Demographics
       Age, y42862 ± 15545064 ± 14−1440662 ± 1540662 ± 4.0−1.1
       Female42894 (22)54501842 (34)−2740690 (22)40689 (22)1.0
       Black race42411 (2.6)5395266 (4.9)−1240211 (2.7)40217 (4.2)−8.0
       Body mass index, kg/m242528 ± 5.2542629 ± 6.0−7.5040328 ± 5.140228 ± 1.4−0.31
      Noncardiac comorbidities
       Hypertension423312 (74)54064087 (76)−4.2402296 (74)396289 (73)1.9
       COPD428106 (25)54471556 (29)−8.640698 (24)40597 (24)0.64
       History of smoking428231 (54)54113093 (57)−6.4406218 (54)403215 (53)0.48
       Previous stroke42356 (13)5393812 (15)−5.240254 (13)40352 (13)1.8
       Peripheral arterial disease42870 (16)5449918 (17)−1.340667 (16)40565 (16)1.15
       Renal dialysis4002 (0.50)5222159 (3.0)−193802.0 (0.53)3743.7 (0.98)−5.3
       Creatinine, mg/dL4280.99 [0.80, 1.3]54301.1 [0.80, 1.5]−224060.99 [0.80, 1.3]4051.0 [0.80, 1.3]−4.9
       Hematocrit, %42539 ± 5.5539437 ± 6.13840339 ± 5.440339 ± 1.51.3
      Cardiac comorbidities
       Previous CABG428144 (34)54502590 (48)−29406138 (34)406146 (36)−4.1
       LVEF, %32356 ± 9.5453253 ± 122730856 ± 9.230356 ± 2.51.2
       Coronary artery disease
      Any system or left main trunk disease >50% stenosis.
      42392 (22)53231585 (30)−1840189 (22)40383 (21)3.9
       Aortic valve disease
      Severe regurgitation42886 (20)5450660 (12)2240680 (20)40680 (20)−0.28
      Stenosis425226 (53)53872079 (39)30403217 (54)400213 (53)1.3
       Mitral valve disease
      Severe regurgitation42815 (3.5)5450951 (17)−4740615 (3.7)40617 (4.2)−2.7
      Stenosis42431 (7.3)53911202 (22)−4340231 (7.7)39931 (7.8)−0.27
       Tricuspid valve disease
      Severe regurgitation4289 (2.1)5450634 (12)−384069.0 (2.2)4069.1 (2.3)−0.24
      Stenosis4242 (0.47)537133 (0.61)−1.94022.0 (0.50)3960.58 (0.15)6.2
       Previous mediastinal radiation4254 (0.94)5420104 (1.9)−8.24034.0 (0.99)4045.4 (1.3)−3.1
       Previous cardiac surgery
      Previous sternotomies4285446−6.34064060.72
      1367 (86)4556 (84)347 (85)348 (86)
      253 (12)704 (13)51 (13)44 (11)
      37 (1.6)140 (2.6)7.0 (1.7)9.6 (2.4)
      41 (0.23)35 (0.64)1.0 (0.25)2.8 (0.68)
      ≥50 (0)11 (0.21)0 (0)0.94 (0.23)
      Previous ITA graft428115 (27)54492037 (37)−23406110 (27)406119 (29)−5.0
      Previous aortic valve procedure
      Repair42861 (14)5448247 (4.5)3440654 (13)40656 (14)−1.1
      Replacement428198 (46)54501968 (36)21406189 (46)406178 (44)5.2
      Previous mitral valve procedure
      Repair42823 (5.4)5450784 (14)−3140623 (5.6)40626 (6.5)−3.9
      Replacement42825 (5.8)5445734 (13)−2640624 (6.0)40622 (5.5)2.4
      Previous tricuspid valve procedure
      Repair4286 (1.4)5450263 (4.8)−204066.0 (1.5)4068.1 (2.0)−3.9
      Replacement4282 (0.47)545069 (1.3)−8.64062.0 (0.49)4061.2 (0.30)3.0
      Previous valve-sparing root replacement41514 (3.4)531142 (0.79)1839513 (3.3)3986.4 (1.6)11
      Previous aortic root replacement42766 (15)5442514 (9.4)1840562 (15)40658 (14)3.0
      Previous aortic arch aneurysm repair42812 (2.8)544933 (0.61)1740612 (2.8)4064.7 (1.2)12
      Previous elephant trunk4284 (0.93)544910 (0.18)104064.0 (0.98)4051.6 (0.40)7.1
      Previous aortic dissection repair42847 (11)5449163 (3.0)3240644 (11)40648 (12)−3.3
      Imaging and risk
       Adherence of
      Right ventricle to sternum42895 (22)54431420 (26)−9.140689 (22)40590 (22)−0.51
      Bypass graft(s) crossing midline to sternum4280 (0)54480 (0)0.04060 (0)4050 (0)0.0
      Ascending aorta to sternum4280 (0)54470 (0)0.04060 (0)4060 (0)0.0
      Aortic pseudoaneurysm within close proximity to sternum4280 (0)54330 (0)0.04060 (0)4040 (0)0.0
      Reoperative index procedure
       CABG42837 (8.6)54501810 (33)−6340637 (9.1)40637 (9.1)0.12
       Aortic valve
      Repair42821 (4.9)544999 (1.8)1740619 (4.6)40617 (4.3)1.7
      Replacement428310 (72)54492852 (52)42406297 (73)406280 (69)9.2
       Mitral valve
      Repair42821 (4.9)5449879 (16)−3740621 (5.2)40618 (4.4)3.5
      Replacement42823 (5.4)54491442 (26)−6040623 (5.7)40626 (6.4)−3.2
       Tricuspid valve
      Repair42811 (2.6)54491206 (22)−6240611 (2.7)40613 (3.1)−2.5
      Replacement4283 (0.70)5449125 (2.3)−134063.0 (0.74)4061.6 (0.40)4.4
       Root replacement42655 (13)5438801 (15)−5.340455 (14)40557 (14)−1.2
       Ascending aortic aneurysm repair/replacement427189 (44)5446553 (10)83405167 (41)406171 (42)−1.7
       Arch aneurysm repair/replacement42687 (20)5445202 (3.7)5340477 (19)40670 (17)4.4
       Elephant trunk42758 (14)5442143 (2.6)4140552 (13)40552 (13)0.20
       Retrograde cardioplegia
      Variables not used in propensity matching.
      426157 (37)54494850 (89)−128404151 (37)406366 (90)−132
      Support
      Variables not used in propensity matching.
       CPB time, min428100 [70, 147]5433126 [79, 195]−55406100 [69, 147]404118 [76, 196]−66
       Myocardial ischemic time, min42857 [36, 88]543992 [53, 148]−10540657 [36, 88]40684 [50, 138]−142
       Circulatory arrest42888 (21)5446381 (7.0)4040678 (19)406115.0 (28)−21
       Circulatory arrest time, min8833 [12, 44]37826 [12, 84]−117832 [12, 44]11322 [12, 92]−15
       Operative time, min428329 [250, 420]5450373 [275, 507]−48406330 [250, 420]406361 [262, 512]−58
      Std. Diff., Standardized difference; SD, standard deviation; COPD, chronic obstructive pulmonary disease; CABG, coronary artery bypass grafting; LVEF, left ventricular ejection fraction; ITA, left internal thoracic artery; CPB, cardiopulmonary bypass.
      Patients with data available.
      Any system or left main trunk disease >50% stenosis.
      Variables not used in propensity matching.

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      Linked Article

      • Commentary: Redo cardiac surgery: Striving for the best but prepared for the worst
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
        • Preview
          The increased morbidity and mortality associated with reoperative cardiac surgery are well documented by single-center experiences. More recently, an adjusted analysis of propensity-matched cohorts by Bianco and colleagues1 demonstrated a significant increase in operative mortality (8.37% vs 6.07%) and associated excess mortality at 30 days (hazard ratio [HR], 1.36), 1 year (HR, 1.3), and 5 years (HR, 1.3) among propensity-matched cohorts. Similar findings exist in the redo coronary bypass, valvular, and aortic surgical populations.
        • Full-Text
        • PDF
      • Commentary: Reoperative cardiac surgery: The importance of surgeon judgment
        The Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
        • Preview
          Reoperative cardiac surgery has been associated with adverse perioperative outcomes.1-3 While reoperative patients typically present with increasingly complex cardiac pathologies as well as an increased burden of clinical comorbidities, redo cardiac surgery also carries inherent risk. In the setting of adhesive disease that develops after previous open-heart surgery, resternotomy increases the potential for injuring the ascending aorta, right ventricle, or previous bypass grafts. Strategies to mitigate these risks have been numerous, including routine computed tomography for preoperative risk-stratification, alternative cannulation strategies for establishing cardiopulmonary bypass (CPB), and minimized dissection of cardiac and mediastinal structures.
        • Full-Text
        • PDF