Is Prior Cardiac Surgery a Risk Factor for Patients in Aortic Surgery: A Systematic Review and Meta-analysis

The rising global incidence of aortic surgical interventions has increased demand for complex reoperations. However, surgical outcomes between primary aortic surgery (PAS) and repeat sternotomy aortic surgery (RAS) remain poorly characterized. This study was designed to evaluate whether prior cardiac surgery constitutes a risk factor for patients undergoing aortic surgery.

A systematic search of PubMed, Embase, and Web of Science was conducted to identify studies comparing surgical outcomes between PAS and RAS. The primary outcome was in-hospital mortality. Secondary outcomes included the incidence of re-exploration for bleeding, renal failure, deep sternal wound infection, neurologic events, cardiopulmonary bypass time, and long-term survival rates at 2-year, 4-year, 8-year, and 10-year follow-ups.

A total of 19 studies involving 31,631 participants were included in this meta-analysis. Patients undergoing PAS demonstrated significantly lower rates of in-hospital mortality (9.3% v 16.0%, odds ratio [OR] 0.55, 95% confidence interval [CI] 0.50-0.60; I² = 0.0%, p < 0.001) compared with the RAS cohort. PAS was also associated with a lower incidence of re-exploration for bleeding (7.2% v 9.4%, OR 0.76, 95% CI 0.68-0.84, p < 0.001), renal failure (13.3% v 15.8%, OR 0.73, 95% CI 0.65-0.81, p < 0.001), and deep sternal wound infection (0.7% v 2.8%, OR 0.47, 95% CI 0.37-0.60, p < 0.001). In anatomical subgroup analyses, patients undergoing primary aortic root surgery demonstrated significantly lower mortality odds compared with repeat sternotomy root procedures (5.0% v 8.4%, OR 0.55, 95% CI 0.50-0.61, p < 0.001); while primary aortic arch surgery demonstrated a mortality benefit compared with repeat sternotomy for arch interventions, this advantage was less pronounced than that observed in root procedures (8.4% v 11.9%, OR 0.60, 95% CI 0.39-0.94, p = 0.026). While short-term survival favored the PAS group (62.6% v 55.2%, 2-year OR 0.74, 95% CI 0.58-0.93, p = 0.01), long-term survival converged between groups (14.8% v 12.7%, 10-year OR 0.82, 95% CI 0.60-1.13, p = 0.23), particularly after propensity score matching.

This study shows that RAS is associated with significantly elevated in-hospital mortality and increased perioperative risks, particularly pronounced in repeat sternotomy root replacement procedures. However, prior cardiac surgery did not diminish the long-term benefits of aortic surgery.