Stephen Fremes, MD, FRCSC, and Christopher Tarola, MD, FRCSC
Central Message
Purposeful preoperative planning and use of the multidisciplinary heart team may help reduce the surgical risks associated with reoperative cardiac surgery to levels comparable with primary surgery.
See Article page 1755.
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 colleagues
1
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.2
, 3
, 4
As surgeons continue to face an increasing number of redo operations in often older patients, whether due to increased life expectancy or changes to surgical recommendations and patient preferences (ie, increasing use of bioprosthetic valves among younger patients5
), it is critical for surgeons to have a thorough understanding of reoperative risks and outcomes.In this issue of the Journal, Kindzelski and colleagues
6
describe their outcomes in reoperative cardiac surgery with prior sternotomy among 6627 patients, excluding those undergoing heart transplant or endovascular stenting of the thoracic aorta. The investigation's focus is outcomes based, with particular attention drawn to the utility of cardiopulmonary bypass (CPB) initiation before (early) or after (late) redo sternotomy, generally on the basis of operative risk screening. The cohort was stratified into 755 versus 5872 patients who received early versus late CPB, respectively, and each group subclassified to high versus low risk reentry based on the following criteria: sternal adherence of bypass grafts crossing midline, ascending aorta adherence to the sternum, and pseudoaneurysm in close proximity to the sternum. In both the high- and low-risk surgical groups, there was no difference in propensity-weighted operative mortality and long-term survival among patients who received an early or late CPB strategy.6
Foremost, the authors should be commended for their excellent outcomes, having achieved 3.5% all-comer mortality. However, this result should be interpreted in the context of this institution's experience, having completed more than 7500 redo operations in less than 10 years, or approximately 750 redo operations annually, with more than 18% re-redo operations. The conclusion that reoperation does not confer increased procedural risk is likely generalizable to large-volume, highly experienced centers. This group has improved on the 4.5% mortality reported in their 2008 cohort,
7
which demonstrates the effectiveness of continuous quality improvement and evidences a potential pathway forward toward reducing surgical risk with reoperation that may be generalizable to a greater number of surgical centers.The authors highlight the importance of implementing preoperative screening protocols to evaluate perioperative risk and use of the heart team model. All patients received preoperative contrast-enhanced computed tomography when possible (if not, then noncontrast) to evaluate the risk of sternal reentry and operative approach, and complex cases were reviewed by a multidisciplinary heart team. This ensures that the current range of surgical options can be explored. The heart team should maintain regularly scheduled conferences to screen complex cases for operative risk, and it is important that decisions are based not only on literature-based evidence but also on patient choices and institutional experience.
Recent cohort studies from several jurisdictions have suggested that valve-in-valve is a lower risk strategy than redo aortic valve replacement for failing bioprostheses, at least for moderate-risk patients.
8
, 9
, - Hirji S.A.
- Percy E.D.
- Zogg C.K.
- Malarczyk A.
- Harloff M.T.
- Yazdchi F.
- et al.
Comparison of in-hospital outcomes and readmissions for valve-in-valve transcatheter aortic valve replacement vs reoperative surgical aortic valve replacement: a contemporary assessment of real-world outcomes.
Eur Heart J. 2020; 41: 2747-2755
10
Kindzelski and colleagues6
instead maintain that prior sternotomy in and of itself should not be an automatic indication to defer to a more minimally invasive surgical approach. Rather, multidisciplinary heart teams should comprehensively risk stratify patients to optimize outcomes, and decisions should consider local expertise.Although the choice of instituting early versus late CPB likely can be left to the operating surgeon on a case-by-case, risk-stratified basis, Kindzelski and colleagues
6
highlight the importance of preoperative planning and preparedness while encouraging the cardiac surgical community that redo surgery can consistently result in a positive outcomes and may trend toward outcomes similar to primary surgery.References
- Reoperative cardiac surgery is a risk factor for long-term mortality.Ann Thorac Surg. 2020; 110: 1235-1242
- Predicting in-hospital mortality after redo cardiac operations: development of a preoperative scorecard.Ann Thorac Surg. 2012; 94: 778-784
- Contemporary results show repeat coronary artery bypass grafting remains a risk factor for operative mortality.Ann Thorac Surg. 2009; 87: 1386-1391
- Surgical factors and complications affecting hospital outcome in redo mitral surgery: insights from a multicentre experience.Eur J Cardiothorac Surg. 2016; 49: 127-133
- National trends in utilization and in-hospital outcomes of mechanical versus bioprosthetic aortic valve replacements.J Thorac Cardiovasc Surg. 2015; 149: 1262-1269
- Modern practice and outcomes of reoperative cardiac surgery.J Thorac Cardiovasc Surg. 2022; 164: 1755-1766.e16
- Adverse events during reoperative cardiac surgery: frequency, characterization, and rescue.J Thorac Cardiovasc Surg. 2008; 135: 316-323
- Transcatheter ViV versus redo surgical AVR for the management of failed biological prosthesis: early and late outcomes in a propensity-matched cohort.JACC Cardiovasc Interv. 2020; 13: 765-774
- Comparison of in-hospital outcomes and readmissions for valve-in-valve transcatheter aortic valve replacement vs reoperative surgical aortic valve replacement: a contemporary assessment of real-world outcomes.Eur Heart J. 2020; 41: 2747-2755
- Transcatheter valve-in-valve aortic valve replacement as an alternative to surgical re-replacement.J Am Coll Cardiol. 2020; 76: 489-499
Article info
Publication history
Published online: January 28, 2021
Accepted:
January 20,
2021
Received in revised form:
January 18,
2021
Received:
January 18,
2021
Footnotes
Disclosures: 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.
Identification
Copyright
© 2021 Published by Elsevier Inc. on behalf of The American Association for Thoracic Surgery
ScienceDirect
Access this article on ScienceDirectLinked Article
- Modern practice and outcomes of reoperative cardiac surgeryThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 6
00167-7&id=fx1.jpg){kind=link}