title: Reoperative sternotomy is associated with increased mortality after heart transplantation.
abstract: BACKGROUND
  Although several studies have examined factors affecting survival after orthotopic heart transplantation (OHT), few have evaluated the impact of reoperative sternotomy. We undertook this study to examine the incidence and impact of repeat sternotomies on OHT outcomes.
  
  
  METHODS
  We conducted a retrospective review of all adult OHT from 2 institutions. Primary stratification was by the number of prior sternotomies. The primary outcome was survival. Secondary outcomes included blood product utilization and commonly encountered postoperative complications. Multivariable Cox proportional hazards regression models examined mortality while linear regression models examined blood utilization.
  
  
  RESULTS
  From January 1995 to October 2011, 631 OHT were performed. Of these, 25 (4.0%) were redo OHT and 182 (28.8%) were bridged to transplant with a ventricular assist device; 356 (56.4%) had undergone at least 1 prior sternotomy. On unadjusted analysis, reoperative sternotomy was associated with decreased 90-day (98.5% vs 90.2%, p<0.001), 1-year (93.1% vs 79.6%, p<0.001), and 5-year (80.4% vs 70.1%, p=0.002) survival. This difference persisted on multivariable analysis at 90 days (hazard ratio [HR] 2.99, p=0.01), 1 year (HR 2.98, p=0.002), and 5 years (HR 1.62, p=0.049). The impact of an increasing number of prior sternotomies was negligible. On multivariable analysis, an increasing number of prior sternotomies was associated with increased intraoperative blood product utilization. Increasing blood utilization was associated with decreased 90-day, 1-year, and 5-year survival.
  
  
  CONCLUSIONS
  Reoperative sternotomy is associated with increased mortality and blood utilization after OHT. Patients with more than 1 prior sternotomy do not experience additional increased mortality. Carefully selected patients with multiple prior sternotomies have decreased but acceptable outcomes.
authors.affiliation: Division of Cardiac Surgery, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: George
authors.forename: Claude A
authors.initials: CA
authors.lastname: Beaty
authors.forename: Gregory A
authors.initials: GA
authors.lastname: Ewald
authors.forename: Stuart D
authors.initials: SD
authors.lastname: Russell
authors.forename: Ashish S
authors.initials: AS
authors.lastname: Shah
authors.forename: John V
authors.initials: JV
authors.lastname: Conte
authors.forename: Glenn J
authors.initials: GJ
authors.lastname: Whitman
authors.forename: Scott C
authors.initials: SC
authors.lastname: Silvestry
mesh_terms: D000293:Adolescent; D000328:Adult; D016063:Blood Loss, Surgical / Q000401:mortality* / Q000706:statistics & numerical data; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000401:mortality / Q000601:surgery*; D016027:Heart Transplantation / Q000401:mortality*; D006801:Humans; D015994:Incidence; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D012086:Reoperation / Q000009:adverse effects* / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D056346:Sternotomy / Q000009:adverse effects* / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D055815:Young Adult