True redo-aortic root replacement versus root replacement after any previous surgery

Are early outcomes of reoperative aortic root surgery impacted by previous root procedure and indication for reintervention?

Objective

Reoperative aortic root surgery after a previous root procedure is technically demanding, which can impact outcomes. Herein, we examined the impact of previous root procedure and operative indication on early outcomes.

Methods

From January 2010 to December 2022, 632 patients underwent reoperative aortic root surgery after previous root procedure (true redo root) at our institution. Baseline characteristics, operative details, and in-hospital complications were compared between groups on the basis of type of previous root prosthesis and infective endocarditis indication.

Results

In the whole cohort, the operative mortality was 2.2% and estimated survival was 93%, 80%, and 67% at 1, 5, and 10 years, respectively. Operative mortality was similar between previous homograft, Bentall, Freestyle, valve-sparing root reimplantation, and Ross (2%, 4%, 0%, 4%, and 0%, respectively, P = .4). Reoperations after Bentall and valve-sparing root reimplantation (prosthetic grafts) had greater rates of postoperative complications, such as reoperation for bleeding (15% and 8%, P = .01), delayed chest closure (18% and 8%, P = .02), and pacemaker insertion (13% and 12%, P = .03). Although there was no significant difference in operative mortality among patients with endocarditis versus those with other indications (3% vs 1%, P = .08), the postoperative course showed greater rates of reoperation for bleeding (19% vs 5%, P < .01) and prolonged ventilation (38% vs 18%, P < .01).

Conclusions

At experienced centers, aortic root reoperation (true redo root) can be performed with low operative mortality. Explant of prosthetic graft material and endocarditis are associated with more complicated postoperative course, without significantly increased operative mortality.

A multicenter analysis of aortic root replacement: Non-native chest increases risk of postoperative mortality

OBJECTIVE

Re-do root replacement poses a significant technical challenge, increasing the potential risk of morbidity and mortality. This multi-institution study compared the outcomes of aortic root replacement stratified by chest surgery and aortic root history.

METHODS

A retrospective review by the Western Aortic Collaborative was performed of 3 different aortic centers for patients who underwent nonemergency root replacement from 2017 to 2023 with exclusion of patients who underwent more than hemiarch replacement or presented with acute or hyperacute aortic dissection. Patients were stratified into 3 cohorts: native chest, prior sternotomy with no previous root replacement, and true re-do root replacement. Univariate and multivariable logistic regression was performed for the primary end point of in-hospital or 30-day mortality and secondary end points.

RESULTS

A total of 568 patients underwent elective or urgent root replacement, with 338 (59.5%) in the native chest cohort, 165 (29.1%) in the no previous root replacement cohort, and 65 (11.4%) in the true re-do root replacement cohort. The no previous root replacement and true re-do root replacement cohorts were more likely to undergo nonvalve-sparing root replacement (P < .001) and concomitant coronary artery bypass grafting (P = .002) and less likely to undergo hemiarch repair (P < .001). Multivariable analysis showed additional risk associated with prior sternotomy, rather than having a previous root performed.

CONCLUSIONS

Patients undergoing root replacement in a non-native chest have a significant risk of morbidity and mortality. However, prior root and true re-do root replacement do not appear to add additional risk, with primary risk contributed by operating in a prior surgical field.

Reoperative Aortic Root Replacement in Patients with Prior Aortic Valve, Root Replacement, or Arch Replacement Surgery: A Single-Center Experience

This case series evaluated the characteristics and outcomes of reoperative root replacement in patients with prior aortic valve replacement (AVR), aortic root replacement (ARR), or ascending or hemiarch replacement (AoR) from our single institution from 2014 to 2023. A total of 55 (prior surgery: 38 AVR, 5 ARR, and 12 AoR) patients were identified and indication for reoperation included valvular stenosis, endocarditis, aneurysm, and dissection. Perioperative mortality was 10.9% (6 patients) (inpatient complications: 2 stroke, 4 bleeding event, 2 renal failure, and 21 prolonged vent).

In-hospital outcomes predictors and trends of redo sternotomy aortic root replacements: insights from a UK registry analysis

Background

Redo sternotomy aortic root surgery is technically demanding, and the evidence on outcomes is mostly from retrospective, small sample, single-centre studies. We report the trend, early clinical results and outcome predictors of redo aortic root replacement over 20 years in the United Kingdom.

Methods

We retrospectively analysed collected data from the UK National Adult Cardiac Surgery Audit (NACSA) on all redo sternotomy aortic root replacements performed between 30th January 1998 and 19th March 2019. We analysed trends in the volume of operations, characteristics of hospital survivors vs. non-survivors, and predictors of in-hospital outcomes.

Results

During the study period, 1,107 redo sternotomy aortic root replacements were performed (median age 59, 26% of patients were females). Eighty-four per cent of cases (N = 931) underwent a composite root replacement, 11% (N = 119) had homograft root replacement and valve-sparing root replacement was performed in 5.1% (N = 57) of cases. There was a steady increase in the volume of redo sternotomy root replacements beyond 2006, from an annual volume of 22 procedures in 2006 to 106 procedures in 2017. Hospital mortality was 17% (n = 192), postoperative stroke or TIA occurred in 5.2% (n = 58), and postoperative dialysis was required in 11% (n = 109) of patients. Return to the theatre for bleeding/tamponade was required in 9% (n = 102) and median in-hospital stay was 9 days. Age >59 (OR: 2.99, CI: 1.92-4.65, P < 0.001), recent myocardial infarction (OR: 6.42, CI: 2.24-18.41, P = 0.001) were associated with increased in-hospital mortality. Emergency surgery (OR: 3.95, 2.27-6.86, P < 0.001), surgery for endocarditis (OR: 2.05, CI: 1.26-3.33, P = 0.001), salvage coronary artery bypass grafting (OR: 2.20, CI: 1.37-3.54, P < 0.001), arch surgery (OR: 2.47, CI: 1.30-3.61, P = 0.018) and aortic cross-clamp longer than 169 min (OR: 2.17, CI: 1.00-1.01, P = 0.003) were associated with increased risk of mortality. We found no effect of the centre or surgeon volume on mortality (P > 0.05).

Conclusions

Redo sternotomy aortic root replacement still carries significant morbidity and mortality and is sporadically performed across surgeons and centres in the UK.