title: Incidence and outcome of re-entry injury in redo cardiac surgery: benefits of preoperative planning.
abstract: OBJECTIVE
  Repeat sternotomy for redo cardiac surgery may be associated with catastrophic injuries to mediastinal structures. The purpose of this study was to determine the frequency of these injuries, associated outcome and if a preoperative computerized tomography (CT) scan reduces the risk of re-entry injury.
  
  
  METHODS
  Five hundred and forty-four patients who underwent redo cardiac surgery between 2001 and 2011 were identified by review of our unit's prospectively maintained cardiac surgery database. Demographic details, surgical strategy, re-entry injuries, hospital stay, in-hospital mortality and long-term survival were analysed.
  
  
  RESULTS
  The mean age was 61 years; 326 were male, 218 were female. Four hundred and eighty six patients underwent first time redo surgery, while 58 patients had multiple previous operations. The median logistic EuroSCORE was 11, in-hospital mortality rate was 9.5% and observed to expected mortality rate was 0.8. Re-entry complications occurred in 15 cases (2.7%). These included injuries to the aorta (n = 2), right atrium (n = 1), innominate vein (n = 2), internal mammary artery (n = 2), pulmonary artery (n = 2), lung parenchyma (n = 1), saphenous vein graft (n = 2), right ventricle (n = 2) and ventricular fibrillation (n = 1). The mortality rate in patients with re-entry injury was 26% (n = 4) compared with 9% (n = 48) in those without re-entry complications. Preoperative planning by CT scan was performed in 162 cases and adherence of vital structures to the sternum was found in 60 cases; the right ventricle, innominate vein and bypass grafts in 41, 11 and 8, respectively. The incidence rate of re-entry injury was 0.6% in these patients vs 3.6% in those who did not have a preoperative CT scan (P = 0.046). Peripheral arterial cannulation was carried out in 35 patients (6.4%) to establish cardiopulmonary bypass (CPB) prior to sternotomy, and there were no mediastinal injuries observed in these cases. Multivariate logistic regression analysis revealed re-entry injury as one of the independent predictors of in-hospital mortality (P = 0.039).
  
  
  CONCLUSIONS
  The incidence of re-entry injury during repeat sternotomy is low; however, it is associated with a significant increase in the risk of in-hospital mortality. Preoperative planning using CT scan reduces the risk by identifying adherent structures, and, in selected patients, establishing CPB prior to sternotomy is a safe strategy in redo cardiac surgery.
authors.affiliation: Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, UK umar79@hotmail.com.
authors.forename: Umar
authors.initials: U
authors.lastname: Imran Hamid
authors.affiliation: Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, UK.
authors.forename: Ruairi
authors.initials: R
authors.lastname: Digney
authors.affiliation: Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, UK.
authors.forename: Lorraine
authors.initials: L
authors.lastname: Soo
authors.affiliation: Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, UK.
authors.forename: Samantha
authors.initials: S
authors.lastname: Leung
authors.affiliation: Department of Cardiothoracic Surgery, Royal Victoria Hospital, Belfast, UK.
authors.forename: Alastair N J
authors.initials: AN
authors.lastname: Graham
mesh_terms: D000328:Adult; D006348:Cardiac Surgical Procedures / Q000379:methods*; D005260:Female; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000401:mortality / Q000517:prevention & control*; D011300:Preoperative Care / Q000379:methods*; D012086:Reoperation / Q000009:adverse effects; D012189:Retrospective Studies; D056346:Sternotomy / Q000009:adverse effects*; D014057:Tomography, X-Ray Computed; D006113:United Kingdom / Q000453:epidemiology
keywords: Computed tomography scan; Re-entry injury; Redo cardiac surgery