Re-Interventions on the Proximal Thoracic Aorta: In-Hospital and Long-Term Outcomes

Aim: To assess the outcomes of surgical treatment of thoracic aortic disease in patients following elective cardiac surgery.

Methods: Medical records of 44 patients following elective surgery on the proximal thoracic aorta who underwent re-interventions in the period from January 2011 to September 2022 at the Federal Center of Cardiovascular Surgery (Chelyabinsk) were retrospectively reviewed. The mean age of patients at the time of the re-intervention was 55.3±12.8 (24–76) years. Indications for re-intervention were as follows: aortic aneurysm (n=17 (38.6%)), dysfunction of aortic valve (AV) prosthesis (n=10 (22.7%)), native aortic valve disease (n=8 (18.2%)), false aortic aneurysm (n=4 (9.1%)), type A aortic dissection (n=2 (4.6%)), and prosthetic valve endocarditis (n= 3 (6.8%)).

Results: One patient died (2.3%) due to multiple organ dysfunction syndrome. The mean aortic crossclamp time was 151.4±42.1 (69–245) min and the mean cardiopulmonary bypass (CPB) time was 240.9±63.5 (141–390) min. Thirteen patients (29.5%) underwent hypothermic circulatory arrest with antegrade cerebral perfusion in aortic arch surgery. The mean hypothermic circulatory arrest time was 24.8±10.2 (12–40) min. Resternotomy for excessive bleeding was performed in 3 patients (6.8%). Eight patients (18.2%) required prolonged mechanical ventilation (over 24 hours). The length of stay in the intensive care unit was 8.3±14.6 (3–100) days and 23.1±15.9 (10–111) in the general ward. Successfully discharged patients were regularly followed up. The mean follow-up period was 42.2±26.6 (from 1 to 130) months. Four patients died in the follow-up period. The long-term survival was 85.2%.

Conclusion: These patients are considered as a group of increased surgical risk. Optimal surgical management with a precise planning (access for the re-intervention, cannulation, cerebral and myocardial protection, etc.) allows achieving favorable in-hospital outcomes. This group of patients require regular follow-up.

1. Di Eusanio M, Berretta P, Bissoni L, Petridis FD, Di Marco L, Di Bartolomeo R. Re-operations on the proximal thoracic aorta: results and predictors of shortand long-term mortality in a series of 174 patients. Eur J Cardiothorac Surg. 2011 Nov;40(5):1072-6. doi: 10.1016/j.ejcts.2011.02.039.

2. Bianco V, Kilic A, Gleason TG, Aranda-Michel E, Habertheuer A, Wang Y, Navid F, Kacin A, Sultan I. Reoperative Cardiac Surgery Is a Risk Factor for LongTerm Mortality. Ann Thorac Surg. 2020 Oct;110(4):1235- 1242. doi: 10.1016/j.athoracsur.2020.02.028.

3. Shrestha M, Khaladj N, Baraki H, Al Ahmad A, Koigeldiyev N, Pichlmaier M, et al. Aortic root reoperation: a technical challenge. The Journal of Heart Valve Disease. 2010.19.177-81.

4. Di Bartolomeo R, Berretta P, Petridis FD, Folesani G, Cefarelli M, Di Marco L, Di Eusanio M. Reoperative surgery on the thoracic aorta. J Thorac Cardiovasc Surg. 2013 Mar;145(3 Suppl):S78-84. doi: 10.1016/j.jtcvs.2012.11.055.

5. Malvindi PG, van Putte BP, Heijmen RH, Schepens MA, Morshuis WJ. Reoperations on the aortic root: experience in 46 patients. Ann Thorac Surg. 2010 Jan;89(1):81-6. doi: 10.1016/j.athoracsur.2009.09.014.

6. Di Bartolomeo R, Pacini D, Savini C, Pilato E, MartinSuarez S, Di Marco L, Di Eusanio M. Complex thoracic aortic disease: single-stage procedure with the frozen elephant trunk technique. J Thorac Cardiovasc Surg. 2010 Dec;140(6 Suppl):S81-5; discussion S86-91. doi: 10.1016/j.jtcvs.2010.07.039.

7. Williams JB, Peterson ED, Zhao Y, O’Brien SM, Andersen ND, Miller DC, Chen EP, Hughes GC. Contemporary results for proximal aortic replacement in North America. J Am Coll Cardiol. 2012 Sep 25;60(13):1156-62. doi: 10.1016/j.jacc.2012.06.023.

8. Cabrol C, Pavie A, Gandjbakhch I, Villemot JP, Guiraudon G, Laughlin L, Etievent P, Cham B. Complete replacement of the ascending aorta with reimplantation of the coronary arteries: new surgical approach. J Thorac Cardiovasc Surg. 1981 Feb;81(2):309-15.

9. Svensson LG. Approach for insertion of aortic composite valve grafts. Ann Thorac Surg. 1992 Aug;54(2):376-8. doi: 10.1016/0003-4975(92)91409-3.

10. Uchida T, Hamasaki A, Kuroda Y, Yamashita A, Sadahiro M. Simple Redo Proximal Thoracic Aortic Surgery with Peripheral Cardiopulmonary Bypass and Minimal Dissection. Ann Thorac Cardiovasc Surg. 2020 Feb 20;26(1):55-59. doi: 10.5761/atcs.nm.19-00187.

11. Gelsomino S, Frassani R, Da Col P, Morocutti G, Masullo G, Spedicato L, Livi U. A long-term experience with the Cabrol root replacement technique for the management of ascending aortic aneurysms and dissections. Ann Thorac Surg. 2003 Jan;75(1):126-31. doi: 10.1016/s0003-4975(02)04284-4.

12. Dayan V, Arocena MJ, Fernandez A, Silva E, Zerpa DP. Previous Cardiac Surgery: a Predictor of Mortality in Aortic Valve Replacement? Braz J Cardiovasc Surg. 2019 Mar-Apr;34(2):173-178. doi: 10.21470/1678-9741-2018-0251.

13. Kirmani BH, Brazier A, Sriskandarajah S, Azzam R, Keenan DJ. A meta-analysis of computerized tomography scan for reducing complications following repeat sternotomy for cardiac surgery. Interact Cardiovasc Thorac Surg. 2016 Apr;22(4):472-9. doi: 10.1093/icvts/ivv367.

14. Quintana E, Bajona P, Schaff HV, Dearani JA, Daly RC, Greason KL, Pochettino A. Open aortic arch reconstruction after previous cardiac surgery: outcomes of 168 consecutive operations. J Thorac Cardiovasc Surg. 2014 Dec;148(6):2944-50. doi: 10.1016/j.jtcvs.2014.05.087.

15. Raanani E, David TE, Dellgren G, Armstrong S, Ivanov J, Feindel CM. Redo aortic root replacement: experience with 31 patients. Ann Thorac Surg. 2001 May;71(5):1460-3. doi: 10.1016/s0003-4975(01)02410-9.

16. Park CB, Suri RM, Burkhart HM, Greason KL, Dearani JA, Schaff HV, Sundt TM 3rd. What is the optimal myocardial preservation strategy at re-operation for aortic valve replacement in the presence of a patent internal thoracic artery? Eur J Cardiothorac Surg. 2011 Jun;39(6):861-5. doi: 10.1016/j.ejcts.2010.11.007.

17. Frederick JR, Yang E, Trubelja A, Desai ND, Szeto WY, Pochettino A, Bavaria JE, Woo YJ. Ascending aortic cannulation in acute type a dissection repair. Ann Thorac Surg. 2013 May;95(5):1808-11. doi: 10.1016/j.athoracsur.2012.10.086.

18. Fernandez-Zamora MD, Gordillo-Brenes A, BanderasBravo E, Arboleda-Sánchez JA, Hinojosa-Pérez R, AguilarAlonso E, Herruzo-Aviles Á, Curiel-Balsera E, SánchezRodríguez Á, Rivera-Fernández R; ARIAM Andalucía Group. Prolonged Mechanical Ventilation as a Predictor of Mortality After Cardiac Surgery. Respir Care. 2018 May;63(5):550-557. doi: 10.4187/respcare.04915.

19. Esaki J, Leshnower BG, Binongo JN, Lasanajak Y, McPherson L, Thourani VH, Chen EP. Reoperative aortic root replacement: Outcome in a contemporary series. J Thorac Cardiovasc Surg. 2017 Sep;154(3):800-808.e3. doi: 10.1016/j.jtcvs.2017.04.084.