A safe strategy for redo sternotomy for emergency ascending aorta and hemiarch replacement

Redo sternotomy and complex redo surgery to replace the ascending aorta and the aortic hemiarch in the presence of an aortocutaneous fistula presents a unique technical challenge to prevent exsanguination upon chest re-entry and organ (particularly cerebral) ischemia during circulatory arrest. Meticulous preoperative planning, peripheral cardiopulmonary bypass, moderate hypothermic circulatory arrest before chest re-entry, and apical left ventricular venting were the cornerstones of our successful surgical approach. Adjunctive selective unilateral antegrade cerebral perfusion extended the safe hypothermic circulatory arrest time, reducing neurological morbidity. We present a case of aortic rupture two years after aortic root abscess repair and aortic valve replacement, describing our approach for safe redo surgery while ensuring sufficient cerebral and body perfusion.