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Updated: Sep 17, 2025
Full-root Aortic Valve Replacement by Stentless Aortic Xenografts in Patients with Small Aortic Roots
Published on: May 21, 2017
Unplanned coronary artery bypass graft in aortic root replacement†
Kavya Rajesh1, Megan Chung1, Dov Levine1
1Division of Cardiothoracic and Vascular Surgery, New York Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA.
Insights
Unplanned coronary artery bypass graft (CABG) during aortic root replacement (ARR) is associated with higher operative mortality and decreased long-term survival. These complex cases require careful consideration of surgical strategy and patient factors.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
- Cardiac Surgery
Background:
- Aortic root replacement (ARR) is a complex procedure, and unexpected difficulties during coronary artery reimplantation can necessitate additional interventions.
- Coronary artery bypass graft (CABG) may be required intraoperatively if coronary artery reimplantation is challenging.
Purpose of the Study:
- To investigate the outcomes of patients undergoing ARR who require an unplanned CABG.
- To identify factors associated with the need for unplanned CABG during ARR.
Main Methods:
- Retrospective analysis of 2416 patients undergoing ARR across two centers from 2004 to 2021.
- Exclusion of planned CABG; concomitant CABG defined as unplanned. Propensity score matching (PSM) used for comparison.
- Landmark analysis at 90 days and multivariable logistic regression to assess mortality and associated factors.
Main Results:
- Unplanned CABG was performed in 8.4% of patients for various reasons, including coronary button issues and dissection.
- The unplanned CABG group showed significantly higher in-hospital mortality, stroke, renal failure, and respiratory failure rates post-PSM.
- Factors associated with unplanned CABG included female sex, chronic kidney disease, reoperation, dissection, endocarditis, and concomitant arch replacement; valve-sparing root replacement was protective.
Conclusions:
- Unplanned CABG during ARR is associated with increased operative mortality and is often required in surgically complex scenarios.
- Patients undergoing ARR with unplanned CABG experience significantly reduced survival probabilities, both early and long-term.
Objectives:
Trouble with coronary artery reimplantation at aortic root replacement (ARR) may require unexpected coronary artery bypass graft (CABG). This study aims to elucidate the outcomes of such unplanned CABG during ARR.
Methods:
This is retrospective study from 2 aortic centres that underwent ARR from 2004 to 2021. Planned CABG for atherosclerotic coronary artery disease were excluded, while other concomitant CABG were defined as 'unplanned'. Propensity score matching (PSM) was performed to compare patients who underwent ARR or ARR + Unplanned CABG alongside landmark analysis at 90 days to study extended operative and long-term mortality. Multivariable logistic regression was used to determine which variables were associated with need for unplanned CABG.
Results:
A total of 2416 patients were divided into 2 groups based on the need of unplanned CABG: ARR (n = 2212) versus ARR + Unplanned CABG (n = 204). Unplanned CABG was required in 204 (8.4%) patients with reasons including 81 for anatomy or friability of coronary button, 33 for involvement of coronary ostia in aortic dissection, 12 for coronary injury during mobilization, and 78 for impaired coronary flow at button anastomosis. After PSM, in-hospital mortality [43 (21.2%) vs 33 (8.2%), P < 0.001), stroke (17 (8.4%) vs 10 (2.5%), P = 0.002], renal failure [37 (18.2%) vs 43 (10.6%), P = 0.01] and respiratory failure [100 (49.3%) vs 110 (27.2%), P < 0.001] were greater in the ARR + Unplanned CABG group compared to the ARR group, respectively. Need for unplanned CABG was associated with following factors: female sex [odds ratio (OR): 1.44 95% confidence interval (CI): (1.02-2.03), P = 0.04], chronic kidney disease [1.77 (1.26-2.48), P < 0.001], reoperation [2.26 (1.62-3.15), P < 0.001], dissection [2.61 (1.69-4.04), P < 0.001], endocarditis [1.39 (1.01-1.91), P = 0.04] and concomitant arch replacement [1.39 (1.01-1.91), P = 0.04], while valve-sparing root replacement (VSRR) was protective [0.41 (0.25-0.68), P < 0.001]. Landmark analysis showed decrease in survival probability up to 90 days in patients with ARR + Unplanned CABG compared to ARR (P < 0.001) with a continued decrease in survival in 90-day survivors (P = 0.002).
Conclusions:
Unplanned CABG occurs in surgically challenging cases and leads to higher operative mortality in ARR. Patients who undergo ARR + Unplanned CABG have decreased survival probability.
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