title: Open aortic arch reconstruction after previous cardiac surgery: outcomes of 168 consecutive operations.
abstract: OBJECTIVE
  Open arch interventions after previous cardiac surgery are considered high risk. We reviewed our outcomes in patients requiring aortic arch reconstruction after previous cardiovascular surgery.
  
  
  METHODS
  From March 2000 to March 2014, the data from 168 patients with previous sternotomy requiring aortic arch replacement were reviewed. The indications for surgery, perioperative data, and outcomes of reoperation were analyzed.
  
  
  RESULTS
  The mean age was 61 ± 14 years, and 119 were men (70%). The indications for reoperation were aneurysm (57%), valvular disease (13%), impending rupture (12%), aortic dissection (9.0%), and endocarditis (7.7%). The median time from the previous operation to reoperation was 7 years. The mean aortic diameter was 55 mm. Total or partial arch replacement was performed in 38% and 62% of patients, respectively. Fifty-five patients (32.7%) had undergone previous ascending dissection repair and 45 (26.8%) had previous coronary bypass surgery. Deep hypothermic circulatory arrest was used in all. Selective cerebral perfusion was used in 39% and retrograde cerebral perfusion in 14%. The incidence of permanent stroke was 5.4%. Operative mortality (30-day) was 8.3%. Older age (odds ratio, 1.05; 95% confidence interval, 1.00-1.10; P = .04), New York Heart Association class III/IV (odds ratio, 3.15; 95% confidence interval, 1.01-9.86; P = .04), and extracorporeal circulation time (odds ratio, 1.01; 95% confidence interval, 1.00-1.02; P = .001) were predictors of perioperative death. The median follow-up was 3.0 years. Survival was 85%, 78%, and 68% at 1, 3, and 5 years, respectively.
  
  
  CONCLUSIONS
  Reoperations to address the aortic arch have acceptable mortality and morbidity. Open repair under circulatory arrest is the benchmark to which endovascular therapies should be compared.
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn; University of Barcelona, Barcelona, Spain.
authors.forename: Eduard
authors.initials: E
authors.lastname: Quintana
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Pietro
authors.initials: P
authors.lastname: Bajona
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Hartzell V
authors.initials: HV
authors.lastname: Schaff
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Dearani
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Richard C
authors.initials: RC
authors.lastname: Daly
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
authors.forename: Kevin L
authors.initials: KL
authors.lastname: Greason
authors.affiliation: Division of Cardiovascular Surgery, Mayo Clinic College of Medicine, Rochester, Minn. Electronic address: pochettino.alberto@mayo.edu.
authors.forename: Alberto
authors.initials: A
authors.lastname: Pochettino
mesh_terms: D000368:Aged; D001013:Aorta, Thoracic / Q000503:physiopathology / Q000601:surgery*; D001018:Aortic Diseases / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D002560:Cerebrovascular Circulation; D050792:Circulatory Arrest, Deep Hypothermia Induced; D005260:Female; D006349:Heart Valve Diseases / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010477:Perfusion / Q000379:methods; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000401:mortality; D012086:Reoperation; D012307:Risk Factors; D020521:Stroke / Q000209:etiology; D061665:Time-to-Treatment; D016896:Treatment Outcome