Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia.
Dell Children's Medical Center, The University of Texas at Austin.
Semin Thorac Cardiovasc Surg. 2022 Summer;34(2):377-382. doi: 10.1053/j.semtcvs.2021.03.035. Epub 2021 May 8.
Re-operative aortic arch operations (REDO) following previous cardiac surgery are challenging procedures associated with significant morbidity and mortality. We investigated post-operative outcomes for patients undergoing REDO and identified risk-factors for mortality in a contemporary series. From 1/2005-6/2018, 365 consecutive patients at an academic center underwent REDO: 257 HEMIARCH and 108 COMPLETE arch (45 stage I elephant trunk, 63 total arch) replacements. Outcomes included mortality and major adverse events. Long-term survival was determined with Kaplan-Meier analysis, and risk-factors for mortality were assessed with Cox proportional hazards regression. Operative mortality for the entire cohort was 6.8%, and rates of stroke, cardiac arrest, and renal failure were 6.0%, 7.4%, and 10.4%. Compared to HEMIARCH, COMPLETE patients had an increased incidence of renal failure requiring dialysis (15.7% vs 8.2%, p = 0.031) and re-exploration for bleeding or delayed chest closure (19.4% vs. 11.7%, p = 0.051). Although operative mortality was similar in both cohorts, long-term follow-up mortality (38.0% vs 26.8%, p = 0.047) was higher among COMPLETE vs. HEMIARCH. Predictors of overall mortality among all-comers undergoing REDO included older age, low body surface area, endocarditis, ejection fraction <30%, emergent status of operation, extended cardiopulmonary bypass duration, intra-aortic balloon pump use, and a more extensive arch operation. Previous aortic surgery was not a risk-factor for mortality. Among all-comers undergoing REDO, survival was 81.4% at 1 year, 66.7% at 5 years, and 56.4% at 10 years of follow-up. While early postoperative outcomes are similar among HEMIARCH and COMPLETE, a more extensive arch-replacement is an independent risk-factor for overall mortality in REDO. Using appropriate clinical indications in the current era, REDO remains a viable option for selected patients.
在先前的心脏手术后进行再次主动脉弓手术（redo）是一项具有挑战性的手术，其与较高的发病率和死亡率相关。我们研究了 redo 患者的术后结果，并在一个现代系列中确定了死亡率的危险因素。从 2005 年 1 月至 2018 年 6 月，一家学术中心的 365 名连续患者接受了 redo：257 例 hemiarch 和 108 例全弓（45 例一期象鼻手术，63 例全弓）置换。结果包括死亡率和主要不良事件。通过 Kaplan-Meier 分析确定长期生存率，并使用 Cox 比例风险回归评估死亡率的危险因素。整个队列的手术死亡率为 6.8%，卒中、心脏骤停和肾衰竭的发生率分别为 6.0%、7.4%和 10.4%。与 hemiarch 相比，全弓患者的肾衰竭需要透析的发生率更高（15.7%比 8.2%，p=0.031），以及因出血或延迟胸部闭合而再次探查的发生率更高（19.4%比 11.7%，p=0.051）。尽管两个队列的手术死亡率相似，但全弓组的长期随访死亡率（38.0%比 26.8%，p=0.047）高于 hemiarch 组。所有接受 redo 的患者的总体死亡率预测因素包括年龄较大、低体表面积、心内膜炎、射血分数<30%、手术紧急状态、体外循环时间延长、主动脉内球囊泵使用以及更广泛的弓部手术。先前的主动脉手术不是死亡率的危险因素。在所有接受 redo 的患者中，1 年时的生存率为 81.4%，5 年时为 66.7%，10 年时为 56.4%。尽管 hemiarch 和全弓的术后早期结果相似，但更广泛的弓部置换是 redo 患者总体死亡率的独立危险因素。在当前时代，使用适当的临床适应证，redo 仍然是选择患者的可行选择。
