Predicting outcome after reoperative procedures on the aortic root and ascending aorta

Reoperations on the ascending aorta after prior aortic procedures are formidable challenges. In order to identify factors predictive of clinical outcome using a uniform surgical approach, results of a 15-year experience were reviewed.

Between 1983 and 1998, 78 reoperations on the ascending aorta were performed in 71 consecutive patients. There were 56 males and 15 females, aged 54+/-13 years (10-73 years), with a mean interval to first reoperation of 60+/-76 months (5-223 months). The original operation was replacement of ascending aorta (23), aortic valve (25), aortic root (7), ascending aorta with valve preservation (9), ascending aorta and aortic valve (7). Surgical approach included femoral vessels dissection and repeat sternotomy, with femoro-femoral bypass limited to cases of traumatic reentry. Reoperation consisted in replacement of the aortic root (48), ascending aorta (15), ascending aorta and aortic valve (6), aortic root with ascending aorta and arch (6), ascending aorta and aortic arch (3). Average aortic crossclamp and cardiopulmonary bypass times were 122+/-86 and 188+/-60 min, respectively.

Early deaths were five (7%), due to low output syndrome (3), hemorrhage (1) and sepsis (1). Mortality for emergent reoperation was significantly higher (38 vs. 3%, P=0.001). A total of 39 early complications were observed in 78 reinterventions (50%), including: traumatic reentry requiring emergent femoro-femoral bypass (4), reexploration for bleeding (4), respiratory failure (12), sepsis (5), transient neurologic dysfunction (4), renal failure (3), myocardial infarction (3), circulatory insufficiency requiring mechanical life support (2), and wound infection (2). Average intensive care unit stay was 4.5+/-9.7 days (0.5-40 days). Survival was 92+/-4%, 78+/-10% and 78+/-10% at 1, 5, and 10 years, respectively. At follow-up (mean 34+/-36 months, 1-170), survivors were in satisfactory clinical conditions (1.6+/-0. 8 mean NYHA class, 1-3) with no evidence of renal, respiratory or neurologic dysfunction. Multivariable analysis showed emergent reoperation (P=0.001), prior aortic valve replacement (P=0.005) and need for arch replacement (P=0.03) to be predictive of higher operative mortality. Longer duration of bypass (P=0.01) and aortic arch replacement (P=0.04) were predictive of higher prevalence of postoperative complications.

Reoperations on the ascending aorta via repeat sternotomy without preventive femoral bypass are associated with low operative risk and high prevalence early complications. Emergent reintervention due to aortic dissection, particularly in patients with prior aortic valve replacement, and need for arch repair are predictive of poorer perioperative outcome. Long-term outlook of hospital survivors is satisfactory.