Reoperative Arch Replacement: Outcomes and Technical Considerations

Reoperative total arch replacement (TAR) following prior cardiovascular surgery presents significant technical challenges and is associated with higher risk profiles. With increasing numbers of patients undergoing reoperation as a result of successful outcomes from primary procedures, we sought to compare the clinical outcomes of reoperative TAR with those of first-time TAR. We reviewed 474 patients who underwent TAR at our institution from 1997 to 2024. Of these, 171 patients (36%) had previously undergone cardiovascular surgery, while the remaining 303 (64%) were undergoing TAR for the first time. Demographic, procedural, and outcome data were collected and analyzed. Comparisons between the reoperative and primary groups were made, and multivariable regression was used to identify covariates associated with major postoperative adverse events (MAEs). Patients in the reoperative group were younger on average (61.5 ± 13.5 vs 70.7 ± 10.9 years, P < 0.001), but presented with a higher burden of comorbidities, including ischemic heart disease (15.8% vs 7.3%, P = 0.006), prior strokes (38.6% vs 15.5%, P < 0.001), and renal impairment (24.6% vs 12.5%, P = 0.001). Operative times were significantly longer for reop TAR, with extended circulatory arrest (48.4 ± 12.8 vs 36 ± 10.8 minutes, P < 0.001), cardiac ischemia (118.2 ± 44.2 vs 99 ± 32.1 minutes, P < 0.001), and cardiopulmonary bypass duration (180.7 ± 38.2 vs 146.7 ± 26.3 minutes, P < 0.001). The reoperative group had higher operative mortality (4.1% vs 0.3%, P = 0.007) and a 2.3-fold increased risk of MAEs (OR 2.27, 95% CI 1.01-5.1, P = 0.046). Reoperative TAR is associated with increased operative risk, longer procedural times, and higher rates of operative complications compared to first-time TAR. Despite these challenges, successful outcomes can be achieved with thorough preoperative planning and attention to key technical details.