title: Surgical factors and complications affecting hospital outcome in redo mitral surgery: insights from a multicentre experience.
abstract: OBJECTIVE
  Several single-centre experiences have reported significant operative mortality and morbidity after mitral valve surgery in redo scenarios (ReMVS). Several preoperative risk factors outlining 'high-risk' categories have been reported, but scanty data on the impact of different operative techniques for these major challenging procedures have been analysed to date. The aim of the study is to investigate those intraoperative factors and postoperative events affecting early survival after redo mitral procedures.
  
  
  METHODS
  Operative mortality and major morbidity events from a large multicentre registry enrolling 832 consecutive redo mitral procedures were analysed. Intraoperative technical issues and postoperative complications impacting operative mortality were identified.
  
  
  RESULTS
  ReMVS was associated with significant operative mortality (12.5%), acute myocardial infarction (AMI; 5.9%), stroke (4.9%), acute respiratory insufficiency (14.8%), pneumonia (7.0%), acute renal insufficiency (16.1%) and failure (12.6%), reintervention for bleeding (7.6%), massive transfusion (28.0%), need for permanent pacemaker (10.1%). Injury of a previous patent left internal mammary artery (LIMA) graft [odds ratio (OR) 4.2, 95% confidence interval (CI): 1.6-11.5; P = 0.005], major cardiovascular iatrogenic lesions at re-entry (OR 19.2, 95% CI: 9.2-39.9; P < 0.001), extracellular crystalloid cardioplegia (OR 7.3, 95% CI: 1.4-37.8; P = 0.018), and incremental cardiopulmonary bypass time (OR 1.1, 95% CI: 1.0-1.2; P = 0.001) independently predicted operative mortality, whereas combined antegrade + retrograde cardioplegia (OR 0.2, 95% CI: 0.09-0.4; P = 0.001) was the only protective factor against mortality. Among complications, AMI (OR 4.1, 95% CI: 1.8-9.6; P = 0.001), need for intra-aortic balloon pumping (IABP; OR 3.1, 95% CI: 1.5-6.1; P = 0.001), prolonged intubation >48 h (OR 5.3, 95% CI: 2.9-9.4; P = 0.001) and massive (>6 units) transfusions (OR 4.4, 95% CI: 2.4-8.0; P = 0.001) also predicted operative mortality.
  
  
  CONCLUSIONS
  ReMVS still carries the risk of significant early mortality and major morbidity. Major lesion to cardiovascular structures is the most dreadful iatrogenic complication, and injury of a previous LIMA graft identifies patients at higher risk of operative mortality. Prolonged cross-clamp times, extracellular crystalloid cardioplegia and massive transfusions have profound impact on early outcome, as well as the development of perioperative AMI, eventually requiring IABP and prolonged intubation. The combination of antegrade and retrograde cardioplegia seems to offer a better myocardial protection in these high-risk patients.
authors.affiliation: Division of Cardiac Surgery, University of Verona, Verona, Italy francesco.onorati@ospedaleuniverona.it.
authors.forename: Francesco
authors.initials: F
authors.lastname: Onorati
authors.affiliation: Department of Cardiac Surgery, University Hospital of Besancon, Besancon, France.
authors.forename: Andrea
authors.initials: A
authors.lastname: Perrotti
authors.affiliation: Division of Cardiac Surgery Univesitat Klinikum Eppendorf, Hamburg, Germany.
authors.forename: Daniel
authors.initials: D
authors.lastname: Reichart
authors.affiliation: Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Wing, Glenfield Hospital, Leicester, UK.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Mariscalco
authors.affiliation: Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Caserta, Italy.
authors.forename: Ester
authors.initials: E
authors.lastname: Della Ratta
authors.affiliation: Cardiovascular Center, Klinikum Nürnberg-Paracelsus Medical University, Nuremberg, Germany.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Santarpino
authors.affiliation: Department of Cardiac Surgery, University of Genoa, Genoa, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Salsano
authors.affiliation: Division of Cardiac Surgery, University of Catania, Catania, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Rubino
authors.affiliation: University of Oulu, Oulu, Finland.
authors.forename: Fausto
authors.initials: F
authors.lastname: Biancari
authors.affiliation: Division of Cardiac Surgery, Cattinara Hospital, Trieste, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Gatti
authors.affiliation: Department of Cardiac Surgery, University of Insubria, Varese, Italy.
authors.forename: Cesare
authors.initials: C
authors.lastname: Beghi
authors.affiliation: Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, Caserta, Italy.
authors.forename: Marisa
authors.initials: M
authors.lastname: De Feo
authors.affiliation: Division of Cardiac Surgery, University of Catania, Catania, Italy.
authors.forename: Carmelo
authors.initials: C
authors.lastname: Mignosa
authors.affiliation: Division of Cardiac Surgery, Cattinara Hospital, Trieste, Italy.
authors.forename: Aniello
authors.initials: A
authors.lastname: Pappalardo
authors.affiliation: Cardiovascular Center, Klinikum Nürnberg-Paracelsus Medical University, Nuremberg, Germany.
authors.forename: Theodor
authors.initials: T
authors.lastname: Fischlein
authors.affiliation: Department of Cardiac Surgery, University Hospital of Besancon, Besancon, France.
authors.forename: Sidney
authors.initials: S
authors.lastname: Chocron
authors.affiliation: Division of Cardiac Surgery Univesitat Klinikum Eppendorf, Hamburg, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Detter
authors.affiliation: Department of Cardiac Surgery, University of Genoa, Genoa, Italy.
authors.forename: Francesco
authors.initials: F
authors.lastname: Santini
authors.affiliation: Division of Cardiac Surgery, University of Verona, Verona, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Faggian
mesh_terms: D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D006349:Heart Valve Diseases / Q000401:mortality / Q000601:surgery*; D006760:Hospitalization; D006801:Humans; D008943:Mitral Valve / Q000601:surgery*; D011183:Postoperative Complications / Q000401:mortality*; D012086:Reoperation / Q000009:adverse effects / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
keywords: Mitral repair; Mitral surgery; Mitral valve; Outcomes; Redo; Valve disease