title: Open Aortic Arch Reconstruction After Coronary Artery Bypass Surgery: Worth the Effort?
abstract: Open aortic arch surgery after coronary artery bypass grafting (CABG) is considered a high-risk operation. We reviewed our surgical approach and outcomes to establish the risk profile for this patient population. In methods, from 2000-2014, 650 patients underwent aortic arch surgery with circulatory arrest. Of these, 45 (7%) had previous CABG. Complete medical record was available for review including all preoperative coronary angiograms and detailed management of myocardial protection. In results, the mean interval from previous CABG to aortic arch surgery was 6.8 ± 7.1 years. At reoperation, 33 (73%) patients had hemiarch replacement and 12 (27%) had a total arch replacement. The following were the indications for surgery: fusiform aneurysm in 20 (44%), pseudoaneurysm in 6 (13%), endocarditis in 4 (9%), valvular disease in 5 (11%), and acute aortic dissection in 10 (22%). There were 6 perioperative deaths (13%) and 1 stroke (2.2%). Selective antegrade cerebral perfusion was used in 13 patients (28.9%) and retrograde perfusion in 6 (13.3%). Survival was 74%, 65%, and 52% at 1, 3, and 5-year follow-up, respectively. Only predictors of early mortality were age (odds ratio = 1.20, CI: 1.01-1.44; P = 0.04) and nonuse of retrograde cardioplegia for myocardial protection (odds ratio = 6.80, CI: 1.06-43.48; P = 0.04). Intermediate survival of these patients was significantly lower than those of a sex-matched and age-matched population (P < 0.001). In conclusion, aortic arch surgery after previous CABG can be performed with acceptable early and midterm results and low risk of stroke. Perfusion strategies and myocardial protection contribute to successful outcomes.
authors: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota; Cardiovascular Surgery Department, Hospital Clínic de Barcelona, Institut Clínic Cardiovascular, University of Barcelona Medical School, Barcelona, Spain.
authors: Eduard
authors: E
authors: Quintana
authors: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota; Division of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.
authors: Pietro
authors: P
authors: Bajona
authors: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
authors: Hartzell V
authors: HV
authors: Schaff
authors: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
authors: Joseph A
authors: JA
authors: Dearani
authors: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
authors: Richard
authors: R
authors: Daly
authors: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota.
authors: Kevin
authors: K
authors: Greason
authors: Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota. Electronic address: pochettino.alberto@mayo.edu.
authors: Alberto
authors: A
authors: Pochettino
mesh_terms: D000368:Aged; D001013:Aorta, Thoracic / Q000000981:diagnostic imaging / Q000601:surgery*; D001018:Aortic Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality; D001026:Coronary Artery Bypass / Q000009:adverse effects; D016208:Databases, Factual; D057286:Electronic Health Records; D005260:Female; D006324:Heart Arrest, Induced; D006349:Heart Valve Diseases / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D016017:Odds Ratio; D018579:Patient Selection; D011183:Postoperative Complications / Q000209:etiology; D019651:Plastic Surgery Procedures / Q000009:adverse effects / Q000401:mortality; D012086:Reoperation; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013997:Time Factors; D016896:Treatment Outcome
keywords: Aortic arch; Coronary artery surgery; Reoperations; aneurysm; coronary disease