Modern practice and outcomes of reoperative cardiac surgery

To evaluate recent practice and outcomes of reoperative cardiac surgery via re-sternotomy. Use of early versus late institution of cardiopulmonary bypass (CPB) before sternal re-entry was of particular interest. From January 2008 to July 2017, 7640 patients underwent reoperative cardiac surgery at Cleveland Clinic. The study group consisted of 6627 who had a re-sternotomy and preoperative computed tomography scans; 755 and 5872 were in the early and late institution of CPB groups, respectively. Patients were stratified into high (n = 563) or low (n = 6064) anatomic risk of re-entry on the basis of computed tomography criteria. Weighted propensity-balanced operative mortality and morbidity were compared with surgeon as a random effect. Reoperative procedures most commonly incorporated aortic valve replacement (n = 3611) and coronary artery bypass grafting (n = 2029), but also aortic root (n = 1061) and arch procedures (n = 527). Unadjusted operative mortality was 3.5% (235/6627), and major sternal re-entry and mediastinal dissection injuries were uncommon (2.8%). In the propensity-weighted analysis, similar mortality (3.1% vs 4.5%; P = .6) and major morbidity, including stroke (1.8% vs 3.2%) and dialysis (0 vs 2.6%), were noted in the high anatomic risk cohort between early and late CPB groups. Similar trends were observed in the low anatomic risk cohort (mortality 3.5% vs 2.1%; P = .2). Reoperative cardiac surgery is associated with low operative morbidity and mortality at an experienced center. Early and late CPB strategies have comparable outcomes in the context of an image-guided, team-based strategy. Patients who underwent reoperative sternotomy were grouped into peripheral cardiopulmonary bypass (CPB) before redo sternotomy (early) and those placed on CPB after redo sternotomy (late). Further categories were based on high or low anatomic risk as revealed by computed tomography imaging. Patients with hemodynamic instability who quickly required unplanned early cardiopulmonary bypass were excluded from comparative effectiveness comparisons. The bottom portion of the illustration shows computed tomography features favoring use of each approach—early versus late institution of CPB. Overall operative mortality for reoperative cardiac surgery is low at an experienced center with comparable outcomes across early or late CPB strategies. Optimal outcomes with reoperative cardiac surgery require continuous team-based practice and preparedness, use of advanced i