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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)
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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.
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        • 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