Unplanned coronary artery bypass graft in aortic root replacement

OBJECTIVES: Trouble with coronary artery reimplantation at aortic root replacement (ARR) may require unexpected coronary artery bypass graft (CABG). This study aims to elucidate the outcomes of such unplanned CABG during ARR. METHODS: This is retrospective study from 2 aortic centres that underwent ARR from 2004 to 2021. Planned CABG for atherosclerotic coronary artery disease were excluded, while other concomitant CABG were defined as 'unplanned'. Propensity score matching (PSM) was performed to compare patients who underwent ARR or ARR + Unplanned CABG alongside landmark analysis at 90 days to study extended operative and long-term mortality. Multivariable logistic regression was used to determine which variables were associated with need for unplanned CABG. RESULTS: A total of 2416 patients were divided into 2 groups based on the need of unplanned CABG: ARR (n = 2212) versus ARR + Unplanned CABG (n = 204). Unplanned CABG was required in 204 (8.4%) patients with reasons including 81 for anatomy or friability of coronary button, 33 for involvement of coronary ostia in aortic dissection, 12 for coronary injury during mobilization, and 78 for impaired coronary flow at button anastomosis. After PSM, in-hospital mortality [43 (21.2%) vs 33 (8.2%), P < 0.001), stroke (17 (8.4%) vs 10 (2.5%), P = 0.002], renal failure [37 (18.2%) vs 43 (10.6%), P = 0.01] and respiratory failure [100 (49.3%) vs 110 (27.2%), P < 0.001] were greater in the ARR + Unplanned CABG group compared to the ARR group, respectively. Need for unplanned CABG was associated with following factors: female sex [odds ratio (OR): 1.44 95% confidence interval (CI): (1.02-2.03), P = 0.04], chronic kidney disease [1.77 (1.26-2.48), P < 0.001], reoperation [2.26 (1.62-3.15), P < 0.001], dissection [2.61 (1.69-4.04), P < 0.001], endocarditis [1.39 (1.01-1.91), P = 0.04] and concomitant arch replacement [1.39 (1.01-1.91), P = 0.04], while valve-sparing root replacement (VSRR) was protective [0.41 (0.25-0.68), P < 0.001]. Landmark analysis showed decrease in survival probability up to 90 days in patients with ARR + Unplanned CABG compared to ARR (P < 0.001) with a continued decrease in survival in 90-day survivors (P = 0.002). CONCLUSIONS: Unplanned CABG occurs in surgically challenging cases and leads to higher operative mortality in ARR. Patients who undergo ARR + Unplanned CABG have decreased survival probability.