Long-Term Outcomes and Risk Factors of Mortality After Reoperation on the Aortic Root: A Single-Center 20-Year Experience

Objective: Over the last ten years, aortic surgery has transitioned from a high-risk procedure to a well-established operation, offering favorable outcomes and survival when performed by experienced hands. Advances in surgical techniques and evolving technologies allow treatment of older and more complex patients with reoperations. However, outcome data are limited. This study aims to identify risk factors for adverse outcomes after reoperation on the aortic root. Methods: This retrospective study included patients who received aortic root reoperation from 1999 to 2023 in a high-volume center, with a history of previous surgery on the thoracic aorta or aortic valve. Patients under the age of 18 or those with transcatheter aortic valve implantation as an index procedure were excluded. Results: A total of 192 patients were analyzed. Mean age was 57 +/- 13 years, and 77.6% were men. The main procedure was Bentall (88.5%). An elective operation was performed in 54.7% of the patients. The mean time between the index operation and reoperation was 8.61 (3.01-16.05) years. Mortality at 30 days was 13%. Survival rates at one, five, and ten years were 84%, 81%, and 71%, respectively. Female gender, non-elective surgery, concomitant procedures, and combined procedures on the aortic root and arch were associated with worse survival. In the Cox regression, age (HR = 3.98, p < 0.01), EuroSCORE II (HR = 1.46, p < 0.01), concomitant procedures at reoperation (HR = 2.53, p = 0.01), prolonged cardiopulmonary bypass time (HR = 1.01, p < 0.01), bleeding complications (HR = 6.11, p < 0.01), and need for temporary mechanical circulatory support (HR = 4.86, p = 0.01) were significantly associated with a higher mortality. Analysis of the receiver operating characteristic curve revealed that age > 60 years at reoperation is a strong predictor for poor outcomes (AUC = 0.712, p < 0.01). Conclusions: Mortality following aortic root reoperation is primarily driven by baseline patient risk and perioperative complications. Reduced survival was observed in patients over 60 years of age, females, those having non-elective surgery, combined root and arch operations, and procedures with additional concomitant operations. Bleeding events, the use of temporary mechanical circulatory support, and concomitant interventions at reoperation emerged as independent predictors of mortality.