The influence of reoperation on aortic arch reconstructive surgery: Evidence from a multicenter, national registry.

Abstract

To analyze the in-hospital outcomes of patients undergoing reoperative aortic arch repair and identify risk factors for mortality and morbidity using data from a multicenter, national registry. We collected data on patients undergoing aortic arch repair (hemiarch or total arch replacement with or without elephant trunk/frozen elephant trunk) under circulatory arrest between 2002 and 2021, including those with acute aortic dissection. Patients with a history of previous open-heart surgery were defined as the redo cases (aortic-redo group and other-redo group). The primary outcomes were operative mortality and a modified Society of Thoracic Surgeons composite end point for mortality and major morbidity (MMOM). The MMOM composite end point was defined as operative mortality, stroke, dialysis-dependent renal failure, deep sternal wound infection, reoperation, and prolonged ventilation >40 hours. Blood transfusion rates were also analyzed. Overall, 374 (15%) of 2481 patients were in the redo cohort. The overall operative mortality of aortic arch reoperations was 12%. Although redo patients had a significantly higher comorbidity burden, no significant difference was identified for the operative mortality among primary, aortic-redo, and other-redo groups (9.3% vs 11% vs 14%; P = .132), and for the MMOM incidence (30% vs 34% vs 39%; P = .075). Additionally, transfusion requirements and intensive care unit/hospital stays were higher in both redo groups (P < .001). To further analyze the redo group, all patients were divided into 4 groups: Primary hemiarch group (n = 1800), primary total-arch group (n = 307), redo hemiarch group (n = 266), and redo total-arch group (n = 108). Operative mortality was significantly higher in the redo hemiarch group (P = .014). In contrast, there was no significant difference in mortality or MMOM between primary and redo total-arch groups (P > .05). Multivariable analyses identified older age, acute aortic dissection, and prolonged cardiopulmonary bypass time (log-transformed) as independent predictors of both operative mortality and MMOM in reoperative arch repair. This study of a national registry demonstrated that selected aortic arch reoperations can be performed with acceptable safety. Older age, acute aortic dissection, and prolonged cardiopulmonary bypass time are associated with worse operative outcomes. Further studies are needed to optimize surgical techniques and perioperative care, in addition to selecting patients who would benefit most from reoperative open arch surgery.