A Multicenter Analysis of Aortic Root Replacement: Non-Native Chest Increases Risk of Post-Operative Mortality

Objective: Re-do root replacement poses a significant technical challenge, increasing potential risk of morbidity and mortality. This multi-institution study compared outcomes in aortic root replacement stratified by chest surgery and aortic root history.

Methods: A retrospective review by the Western Aortic Collaborative was performed for three different aortic centers for patients who underwent non-emergent root replacement from 2017-2023 with exclusion of patients who underwent more than hemiarch replacement or who presented with acute or hyperacute aortic dissection. Patients were stratified into three cohorts: native chest (NC), prior sternotomy with no previous root replacement (NPR) and true re-do root replacement (TRR). Univariate and multivariable logistic regression was performed for the primary endpoint of in-hospital or 30-day mortality and secondary endpoints.

Results: 568 patients underwent elective or urgent root replacement, with 338 (59.5%) in the NC cohort, 165 (29.1%) in the NPR cohort and 65(11.4%) in the TRR cohort.. NPR and TRR patients were more likely to undergo non-valve sparing root replacement(p<0.001), concomitant coronary artery bypass grafting(p =0.002) and less likely to undergo hemiarch repair(p<0.001). Multivariable analysis showed additional risk associated with prior sternotomy, rather than having a previous root performed.

Conclusion: Patients undergoing root replacement in a non-native chest face significant risk of morbidity and mortality. However, prior root and true re-do root replacement does not appear to add additional risk, with primary risk contributed by operating in a prior surgical field.