Brown James A, Serna-Gallegos Derek, Zhu Jianhui, Warraich Nav, Yousef Sarah, Aranda-Michel Edgar, Bianco Valentino, Sultan Ibrahim
Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
J Card Surg. 2022 Dec;37(12):4748-4754. doi: 10.1111/jocs.17121. Epub 2022 Nov 9.
To determine the impact of reoperative versus first-time sternotomy for emergent open repair of acute Type A aortic dissection (ATAAD).
This was an observational study of consecutive aortic surgeries from 2007 to 2021. Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed to assess the impact of reoperative versus first-time sternotomy upon survival after ATAAD repair.
A total of 601 patients with ATAAD were identified, of which 72 (12%) underwent reoperative sternotomy. The reoperative group had a higher prevalence of baseline comorbidities, including hypertension, diabetes, peripheral vascular disease, atrial fibrillation, and coronary artery disease. Central cannulation of the aorta was achieved at a similar rate across each group (81.9% vs. 81.5%, p = .923), and cardiopulmonary bypass (CPB) time was similar across each group (204 ± 84.8 vs. 203 ± 72.4 min, p = .923). Postoperative outcomes were similar across both groups, including in-hospital mortality, stroke, pulmonary complications, renal failure, and reexploration for excessive bleeding. Five-year survival was 74.5% (70.5, 78.3) for the first-time group and was 71.6% (60.0, 81.9) for the reoperative group. After multivariable Cox regression, reoperative sternotomy was not significantly associated with an increased hazard of death compared to first-time sternotomy (hazards ratio: 0.90, 95% confidence interval: 0.56, 1.43, p = .642).
These findings suggest that re-sternotomy can be safely performed with similar outcomes as first-time sternotomy. Central initiation of CPB after sternal reentry limits CPB time and may therefore represent a protective strategy that enhances outcomes for patients presenting with ATAAD and prior cardiac surgery.
确定再次开胸手术与初次开胸手术对急性A型主动脉夹层（ATAAD）急诊开放修复的影响。
这是一项对2007年至2021年连续进行的主动脉手术的观察性研究。采用Kaplan-Meier生存估计和多变量Cox回归分析来评估再次开胸手术与初次开胸手术对ATAAD修复术后生存的影响。
共识别出601例ATAAD患者，其中72例（12%）接受了再次开胸手术。再次手术组基线合并症的患病率较高，包括高血压、糖尿病、外周血管疾病、心房颤动和冠状动脉疾病。每组主动脉中心插管成功率相似（81.9%对81.5%，p = 0.923），每组体外循环（CPB）时间相似（204±84.8对203±72.4分钟，p = 0.923）。两组术后结果相似，包括住院死亡率、中风、肺部并发症、肾衰竭和因出血过多再次手术探查。初次手术组5年生存率为74.5%（70.5，78.3），再次手术组为71.6%（60.0，81.9）。多变量Cox回归分析后，与初次开胸手术相比，再次开胸手术与死亡风险增加无显著相关性（风险比：0.90，95%置信区间：0.56，1.43，p = 0.642）。
这些发现表明再次开胸手术可以安全进行，其结果与初次开胸手术相似。胸骨重新切开后进行CPB中心插管可限制CPB时间，因此可能代表一种保护策略，可改善ATAAD患者及既往心脏手术患者的预后。
