Arminder S. Jassar, MBBS, Nimesh D. Desai, MD, PhD, Dale Kobrin, BA, Alberto Pochettino, MD, Prashanth Vallabhajosyula, MD, Rita K. Milewski, MD, Fenton McCarthy, MD, Jon Maniaci, BS, Wilson Y. Szeto, MD, and Joseph E. Bavaria, MD Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania

Background. Aortic reoperations are technically challenging. This study evaluated outcomes after “true” redo root replacement (previous full root replacement) stratified by cause of prosthesis failure. Methods. Data were compared for 793 patients who underwent a first-time sternotomy (de novo group) and 120 patients who had previously undergone full aortic root replacement (redo group), of which 76 underwent reoperation due to structural valve deterioration (degenerative group), and 44 due to endocarditis (infection group). Results. Overall mortality was 4% (n [ 28) in the de novo group and 5% (n [ 6) in the redo group (p [ 0.43) (degenerative group, 3%, infection group, 9%; p [ 0.19). The infection group had an increased incidence of renal failure, sternal infection, prolonged ventilation, reoperation for bleeding, multisystem failure, and sepsis, and an increased hospital length of stay. The degenerative group and the de

novo group had a similar risk of perioperative death and major complications. The 5-year survival was 86.3% ± 1.3% for the de novo group and 77.3% ± 4.6% for the redo group (p £ 0.01; degenerative, 86.3% ± 5%; infection, 65.3% ± 7.7%; p < 0.01; p [ 0.98 for de novo vs degenerative). Multivariate analysis demonstrated that reoperation for degenerative failure did not increase the risk of perioperative or late death. Conclusions. Redo aortic root replacement can be performed with low perioperative morbidity and death. The presence of infection increases the risk of complications and worsens survival. However, redo root replacement for degenerative failure can be performed with similar short-term complication risk and midterm survival as de novo root replacement. (Ann Thorac Surg 2015;99:1601–9) Ó 2015 by The Society of Thoracic Surgeons

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outcomes for aortic root replacement after a previous aortic root implant and stratify the results based on the cause of failure.

ortic root replacement is frequently performed to treat aortic root pathology, with reported in-hospital mortality rates of less than 5% [1–3]. A variety of prosthetic conduits are available for aortic root replacement, including autograft, homograft, porcine roots, and mechanical composite grafts. Over time, some of these prostheses will fail due to structural deterioration, whereas in other cases, endocarditis or thrombosis may necessitate excision. Aortic root reoperations are technically challenging and have been associated with perioperative mortality rates of up to 18% in some series [4–8]. Several studies have examined outcomes after redo aortic valve operations [9, 10] and aortic reoperations [11, 12] and reported acceptable outcomes. However, there are limited studies examining outcomes of “true “ redo aortic root replacement, defined as full aortic root replacement after a previous full aortic root replacement with a prosthetic graft [13–17]. In this study, we sought to analyze Accepted for publication Dec 8, 2014. Presented at the Fiftieth Annual Meeting of The Society of Thoracic Surgeons, Orlando, FL, Jan 25–29, 2014. Address correspondence to Dr Bavaria, 3400 Spruce St, 6 Silverstein Pavilion, Philadelphia, PA 19104; e-mail: [email protected].

Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier

Patients and Methods The University of Pennsylvania Institutional Review Board approved the study protocol.

Patients Between 2002 and 2013, 1,246 aortic root replacements were performed at the University of Pennsylvania (excluding valve-sparing aortic root replacements and Wheat procedures). The study groups were defined as a (1) de novo group—793 patients undergoing first time sternotomy and a (2) redo group—120 patients who had previously undergone a full aortic root replacement and were undergoing a “true redo” root replacement. The redo group patients were divided into those reoperated on for prosthetic root degeneration (n ¼ 76) and for infection of the prosthetic root (n ¼ 44). Excluded were patients with previous sternotomy for any procedure other than a full aortic root replacement, including coronary artery bypass grafting, valve operations, ascending 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2014.12.038

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Outcomes of Aortic Root Replacement After Previous Aortic Root Replacement: The “True” Redo Root

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JASSAR ET AL REDO ROOT: INFECTION VS DEGENERATION

or aortic arch operations, valve-sparing aortic root operations, or noncardiac thoracic operations (n ¼ 333).

Operative Procedure Complete replacement of the aortic root was performed, with coronary arteries reimplanted as buttons. In patients in the redo group with a high risk of aortic injury on entry (eg, aneurysm/pseudoaneurysm adherent to posterior aspect of sternum), peripheral cannulation was performed before sternotomy. Arterial cannulation in all other patients was established via the ascending aorta, with venous cannulation performed via the right atrium, superior vena cava, and inferior vena cava, as necessary. If arch reconstruction was concomitantly performed, hypothermic circulatory arrest with adjunct antegrade or retrograde cerebral perfusion was used. In patients undergoing redo root replacement, the previous prosthetic root is completely excised, allowing the new prosthesis to be sewn to the native annulus. In infection cases, all infected tissue is aggressively debrided and resected. Extreme caution is used in the dissection of coronary buttons, and modified Cabrol reconstruction with vein interposition is undertaken in cases where the coronary buttons are unsuitable for reimplantation, typically due to infectious involvement. Our general policy in patients in the infection group with neurologic complications is to have a complete neurologic assessment of the patient, including a computed tomography angiogram or conventional cerebral angiography. If mycotic aneurysms are present, these are coiled before the operation. We typically wait 7 to 14 days after a stroke to operate, but intervene earlier in cases of severe hemodynamic instability or ongoing sepsis. In patients who are at a higher risk for hemorrhagic conversion, intraoperative electroencephalography monitoring or early postoperative head computed tomography is used for surveillance.

Follow-Up Of 114 patients in the redo group who were discharged alive from the hospital, follow-up data were available for 107 patients (93.9%), comprising 71 (95.9%) in the degenerative group and 36 (90%) in the infection group (p ¼ 0.23). Mean follow-up was 2.8  2.7 years (degenerative group, 2.5  2.6 years; infection group, 3.3  3.0; p ¼ 0.19). Survival data were supplemented from the online Social Security Death Index and is 100% complete [18].

Statistical Analysis Data were compared using the Student t test for continuous variables and the Fisher exact test for categoric variables. Survival data were analyzed using the KaplanMeier method, and comparisons were made using the log-rank test. Multivariate analysis was performed to identify risk predictors for in-hospital and delayed death using logistic regression and Cox proportional hazards regression models, respectively.

Ann Thorac Surg 2015;99:1601–9

Results Patient Characteristics Preoperative patient characteristics are presented in Table 1.

Incidence of Reoperations Of the 1,246 aortic root replacements performed, 453 patients (36.4%) had undergone a previous sternotomy (Fig 1A). The total number of aortic root replacements performed per year during the study period was nearly constant (mean, 108  10; Fig 1A), whereas the incidence of “true” redo-aortic root replacement increased: 38 (32%) redo aortic root replacements were performed during the first chronologic half of the study period compared with 82 (68%) during the latter half (Fig 1B). Within the redo group, the frequency of degenerative failure increased over the duration of the study. In the first half of the series, 16 operations (42%) were performed for degenerative failure and 22 (58%) for infection, and 60 patients (73%) were operated on for degenerative failure compared with 22 (27%) for infection (p < 0.01) in the latter half of the study. Twenty-eight patients (23%) required multiple redo sternotomy (third time entry in 19, fourth time entry in 6, fifth time entry in 1, and sixth time entry in 2).

Prosthetic Explant and Implant Mean interval to explant was 8.7  5.4 years for the redo group (infection group, 4.7  4.7 years; degenerative group, 11.1  4.3 years; p < 0.01). Details of explanted and implanted prosthetic conduits are presented in Table 2.

Operative Procedures All 120 patients underwent a full aortic root replacement with coronary reimplantation. Details of operative procedures and times are presented in Table 3. The mean cardiopulmonary bypass time and aortic cross-clamp time for the redo group, including each of the degenerative and infection subgroups, was longer than for the de novo group. The circulatory arrest time for concomitant arch procedures in the infection group, which often required excision of infected arch graft, was longer than in the de novo group and in the degenerative group. Of the 11 coronary artery bypass grafting procedures performed in the redo group, 5 were performed to treat coexisting coronary artery disease. The 6 coronary artery bypass procedures performed for technical reasons (1 in the degenerative group and 5 in the infection group) involved the right coronary button, which was injured during dissection in 2 patients and was too damaged by the infectious process or could not be mobilized in 4 patients. In all of these instances, a saphenous vein was interposed in an end-to-end fashion to reimplant the right coronary artery to the neoaorta. Patch repair or augmentation of the pulmonary artery was required in 11 patients, ventricular septal defect repair in 2, and left atrial repair in 1.

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Table 1. Preoperative Characteristics

a

Preoperative Diagnosis

Age, y Male Hypertension Diabetes mellitus Dyslipidemia Cerebrovascular Disease Accident Moderate-severe lung disease Renal failure Need for dialysis Endocarditis Bicuspid aortic valve NYHA heart failure I II III IV Ejection fraction 0.30 0.31–0.50 >0.50 Prior myocardial infarction Arrhythmia Cardiogenic shock Status Elective Urgent Emergency/salvage

De Novo Root (n ¼ 793)

True Redo (n ¼ 120)

p Value De Novo vs Redo

Degenerative Failure (n ¼ 76)

Infection (n ¼ 44)

p Value Degenerative vs Infection

56.7  14.1 598 (76) 505 (64) 82 (10) 350 (44)

50.2  13.3 95 (79) 73 (61) 13 (11) 53 (44)

Outcomes of aortic root replacement after previous aortic root replacement: the "true" redo root.

Aortic reoperations are technically challenging. This study evaluated outcomes after "true" redo root replacement (previous full root replacement) str...
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