目的:先前心血管手术后的全主动脉弓置换(TAR)在技术上具有挑战性,并且随着主要足弓修复结果的改善而变得越来越频繁。主要。我们分析了与首次TAR相比的再次手术结果。
方法:查询机构主动脉数据库以确定1997年至2022年期间接受TAR的连续患者。426例患者接受了TAR,其中150例(35%)曾接受过心血管手术(reopTAR),276例(65%)接受了首次心血管手术。
结果:手术TAR组年龄较小(61±13vs.71±11,p<0.001),有更多的合并症,如缺血性心脏病(12%vs.4.3%,p=0.006),既往中风(36%vs.14.5%,p<0.001),和肾功能损害(24%vs.12.7%,p=0.004)。ReopTAR的心脏缺血时间更长(119.3±45.5vs.98±31.9分钟,p<0.001),手术死亡率较高(3.3%vs.0.4%,p=0.040),并导致重大不良事件风险增加4倍(95CI1.41-11.49,p=0.009).手术TAR队列的10年生存率也较低[76%vs.82.2%;HR1.79(1.12-2.86),p=0.015],更需要后期再干预,主要在下游主动脉[HR1.29(1.03-1.62),p=0.024]。
结论:再次手术全足弓置换是一项具有技术挑战性的手术,并且与手术死亡率和不良事件增加相关。通过精心的手术计划并将注意力集中在最终器官保护上,可以获得令人满意的结果。在接受重新手术TAR的患者中,晚期再干预的比例明显更高,未来的研究将集中于识别可能从更积极的索引程序中受益的风险人群。
OBJECTIVE: Total aortic arch replacement (TAR) after previous cardiovascular surgery is technically challenging and is becoming more frequent as outcomes for primary arch repair have improved. primary. We analyzed outcomes of reoperative compared with first-time TAR.
METHODS: The institutional aortic database was queried to identify consecutive patients undergoing TAR between 1997 and 2022. In total, 426 patients underwent TAR, of whom 150 (35%) had previous cardiovascular surgery (reop TAR) and 276 (65%) underwent their first cardiovascular operation.
RESULTS: The reop TAR group was younger (61 ± 13 vs 71 ± 11, P < .001) with more comorbidities such as ischemic heart disease (12% vs 4.3%, P = .006), previous stroke (36% vs 14.5%, P < .001), and renal impairment (24% vs 12.7%, P = .004). Reop TAR had longer cardiac ischemic times (119.3 ± 45.5 minutes vs 98 ± 31.9 minutes, P < .001), a greater operative mortality (3.3% vs 0.4%, P = .040), and incurred a 4-fold increased risk of major adverse event (95% confidence interval [CI], 1.41-11.49, P = .009). Ten-year survival was also lower in the reop TAR cohort (76% vs 82.2%; hazard ratio, 1.79; 95% CI, 1.12-2.86, P = .015) and there was greater need for late reinterventions, mainly on the downstream aorta (hazard ratio, 1.29; 95% CI, 1.03-1.62, P = .024).
CONCLUSIONS: Reop TAR is a technically challenging operation and is associated with increased operative mortality and adverse events. Gratifying results can be obtained with meticulous surgical planning and focused attention on end-organ protection. Late reinterventions occur in a significantly greater percentage of patients undergoing reop TAR, and future studies should focus attention on identifying those at-risk groups who may benefit from a more aggressive index procedure.