Redo cardiac and great vessel surgery: necessity of meticulous preparation and contingency planning

Recent advances in surgical techniques and perioperative management have significantly improved the outcomes of cardiac and/or thoracic aortic surgery compared with earlier decades. However, redo procedures remain particularly challenging, with surgical results still inferior to those of primary operations. The complexity arises from altered anatomy, dense adhesions, and increased risks of injury to vital structures. Careful surgical planning is therefore indispensable, and four strategic steps are especially critical. First, meticulous preoperative assessment with contrast-enhanced computed tomography is required to delineate the spatial relationship between the heart, great vessels, and sternum. Second, the optimal approach to intrapericardial access must be determined, including whether cardiopulmonary bypass should be instituted prior to median sternotomy. Third, safe and deliberate dissection of adhesions surrounding the heart and great vessels is essential to avoid catastrophic complications. Finally, effective organ protection strategies, particularly for the brain and myocardium, are paramount to ensure favorable outcomes. This review highlights common pitfalls encountered in redo cardiac and/or thoracic aortic surgery and discusses practical strategies to overcome them, aiming to provide surgeons with a structured framework for improving safety and results in these high-risk procedures.