Repeat sternotomy and reoperative cardiac surgery represent some of the most technically demanding and physiologically stressful procedures for both surgeon and anesthesiologist. By the time a patient undergoes a fourth redo cardiac surgery, the cumulative operative risk and the complexity of perioperative management escalate dramatically. Adhesions and scar tissue from prior sternotomies render dissection perilous, increasing the risk of injury to heart chambers, great vessels, grafts, or conduits, and often leading to excessive bleeding, prolonged cardiopulmonary bypass (CPB), and hemodynamic instability during induction and re-entry [1][2]. Preoperative imaging, including CT angiography with three-dimensional reconstructions, becomes essential for the anesthesiologist to anticipate adhesion density and proximity of grafts or conduits to the sternum. In contrast, echocardiography and angiography provide information about ventricular function, valvular lesions, graft patency, and cannulation strategies [1][3]. Patients presenting for fourth redo operations are characteristically older and sicker, frequently with multiple comorbidities such as chronic renal insufficiency, reduced ejection fraction, and anaemia that increase both cardiac and non-cardiac perioperative risks [2][5].

From the anesthetic standpoint, induction and securing the airway must be performed in the context of limited physiologic reserve and a high risk of cardiovascular collapse. Careful fluid management, judicious inotrope support, and readiness for immediate CPB cannulation (often via femoral or axillary access) are key strategies [3][5]. Intraoperative challenges include managing complex CPB initiation in an already adherent mediastinum, protecting the myocardium in the setting of long bypass and cross-clamp times, and controlling massive bleeding or coagulopathy—particularly in re-entry injuries or injury of patent grafts [1][6]. Maintaining hemodynamic stability during one or more anesthetist handovers poses yet another challenge [1]. Incomplete transfer of critical information during care transitions has been associated with higher 30-day and 1-year mortality in cardiac surgery patients, especially in complex redo cases [7]. Advanced invasive and goal-directed monitoring including arterial lines, central venous pressure (CVP), trans-esophageal echocardiography, and devices such as FloTrac, central venous oxygen saturation, or pulse contour systems, can significantly aid titration of fluids and vasopressors in these high-risk patients [8].

Moreover, the incomplete anesthetic plan must anticipate postoperative risks such as prolonged intensive care unit (ICU) stay, acute kidney injury, neurological outcomes including postoperative cognitive dysfunction, and bleeding complications that often accompany prolonged and complex surgeries [5][9]. In fourth redo operations, particularly in the emergency setting perioperative mortality rates soar, with some cohorts reporting mortality of 15% or higher in third to fifth surgeries [6][10]. Despite these grim statistics, careful multidisciplinary planning involving cardiac surgery, perfusion, and anesthesia teams, coupled with meticulous preoperative assessment and intraoperative vigilance, can improve outcomes even in this extreme reoperative setting.

In sum, a fourth redo cardiac surgery presents the cardiac anesthesiologist with a nexus of multiple overlapping challenges viz. dense mediastinal adhesions, high bleeding risk, limited reserve due to comorbidities, need for complex airway and hemodynamic management, long CPB runs, and potential for transition-related errors during anesthetic handover. Recognizing these factors in advance and deploying tailored strategies such as early imaging, peripheral cannulation readiness, advanced monitoring, inotropic support protocols, and structured handover communication are pivotal to navigating the perilous perioperative course and optimizing patient safety and outcomes

A 52-year-old male patient presented to our hospital with progressive shortness of breath for the past 3–4 months, which had gradually worsened to affect his daily activities. His medical history was remarkable for multiple prior cardiac surgeries. In 2002, he had undergone a double valve replacement (mitral and aortic) using bioprosthetic valves due to rheumatic valvular heart disease. Subsequently, owing to prosthetic degeneration, he required a redo double valve replacement in 2010, again with bioprosthetic valves. In 2022, the patient underwent a third cardiac surgery—a repeat redo mitral valve replacement with a mechanical prosthesis due to failure of the previously implanted mitral bioprosthesis.

During the current presentation, routine baseline investigations were performed. Chest radiography revealed cardiomegaly with evidence of pulmonary venous hypertension. A contrast-enhanced computed tomography (CECT) of the chest demonstrated dense mediastinal adhesions and close proximity of cardiac structures to the sternum, which anticipated significant challenges for re-entry. Transthoracic 2D echocardiography showed structural degeneration of the bioprosthetic aortic valve with restricted leaflet mobility, severe aortic regurgitation, and markedly elevated pulmonary artery pressures, confirming severe pulmonary arterial hypertension (PAH). Biventricular systolic function was moderately impaired, consistent with chronic pressure and volume overload.

Given the hemodynamic deterioration and high surgical risk, the patient was planned for a fourth cardiac reoperation. After careful preoperative assessment and multidisciplinary discussion involving the cardiac surgery, anesthesia, and perfusion teams, the patient was taken up for a 4th redo procedure. A modified Bentall operation, involving composite replacement of the aortic valve, aortic root, and ascending aorta with reimplantation of the coronary ostia, was performed. Despite the anticipated difficulties due to multiple prior sternotomies, dense adhesions, and severe PAH, the surgery was accomplished with meticulous intraoperative management, careful myocardial protection, and advanced hemodynamic monitoring.

The patient was weaned off cardiopulmonary bypass with inotropic support and transferred to the intensive care unit for postoperative care. His recovery was uneventful, and he was discharged in stable condition. This case highlights the feasibility of a fourth redo cardiac surgery, even in the setting of complex pathology and high operative risk, when managed with meticulous planning, experienced surgical and anesthesia teams, and optimal perioperative strategies.

Surgical Procedure: Fourth Repeat Sternotomy with Aortic Root Replacement (Bentall Procedure)

Patient Preparation and Anesthesia

The patient was brought to the operating room and positioned supine. Following the induction of general anesthesia, invasive anesthesia monitoring lines were secured, including radial and femoral arterial lines for continuous blood pressure monitoring and a central venous catheter for pressure monitoring and drug delivery. After adequate preparation and sterile draping, the surgical team proceeded with establishing cardiopulmonary bypass.

Cannulation and Establishment of Cardiopulmonary Bypass

Femoral vessels were found to be hostile due to multiple prior cannulations. Therefore, the right external iliac artery and vein were surgically exposed in the iliac fossa. Cardiopulmonary bypass (CPB) was initiated using a 20 Fr Bio-Medicus arterial cannula and a multistage venous cannula. Systemic cooling was commenced, and the patient’s core temperature was initially reduced to 34°C and subsequently cooled to 28°C for myocardial protection.

Sternotomy and Adhesiolysis

A fourth-time median sternotomy was performed with extreme care due to anticipated adhesions. Dense retrosternal and pericardial adhesions over the aorta were meticulously dissected. The right superior pulmonary vein was identified outside the pericardium and prepared for venting.

Myocardial Protection

Myocardial preservation was achieved using antegrade ostial cardioplegia. Venting was carried out via the right superior pulmonary vein, which had been dissected extra pericardially.

Aortic Valve and Root Findings

On performing the aortotomy, visualization was inadequate, and the ascending aorta was therefore transected. Intraoperative assessment revealed a severely degenerated bioprosthetic aortic valve. The posterior annulus appeared fragile, making isolated valve replacement unsuitable. Additionally, severe pannus formation was noted on the undersurface of the Sorin mechanical mitral valve, which was carefully excised.

Bentall Procedure

A composite conduit was prepared by suturing an On-X 21 mm mechanical valve to a 24 mm Dacron graft with a 4-0 Prolene continuous suture. The conduit was implanted at the annular level using 2-0 Ethibond sutures with pledgets for reinforcement. Leak testing with cardioplegia at 100 mmHg confirmed adequate sealing. The left coronary ostium was reimplanted onto the conduit with a continuous CV-5 Prolene suture, and repeat testing again confirmed no leak.

Right Coronary Artery Injury and Reconstruction

During root dissection, the non-dominant right coronary artery (RCA) was inadvertently injured. Cardioplegia delivery into the right coronary artery demonstrated retrograde spurting from the left main ostium, confirming communication. Initial attempts at an end-to-end anastomosis using a saphenous vein graft (SVG) were unsuccessful as the graft tore during pressure testing. A second SVG was then anastomosed in an end-to-side fashion to a suitable segment of the RCA, and its proximal end was anastomosed to the conduit.

Weaning from Cardiopulmonary Bypass

The patient was gradually rewarmed to normothermia. The heart resumed a regular rhythm spontaneously. Modified ultrafiltration (MUF) was performed with a total volume of 500 mL, while slow continuous ultrafiltration (SCUF) was employed throughout CPB, removing 1500 mL in total. The duration of cardiopulmonary bypass was 7 hours, with an aortic cross-clamp time of 266 minutes. The total operative time was approximately 11 hours.

Wound Management and Delayed Closure

Considering the prolonged operative duration, dense adhesions, coagulopathy risk, and massive surgical stress, a decision was made to electively pack the mediastinum and defer definitive sternal closure. The patient was transferred to the intensive care unit with temporary packing in place. On the following day, the patient was returned to the operating theatre, where mediastinal re-exploration and definitive sternal and skin closure were completed.

Postoperative management and outcome:

The patient demonstrated an uneventful postoperative recovery following a high-risk fourth redo sternotomy with aortic root replacement. Despite the complexity of the procedure and the inherent risks associated with multiple reoperations, the postoperative course remained stable, with no evidence of hemodynamic compromise, bleeding, infection, or other major complications. The patient was progressively weaned from inotropes and ventilatory support, tolerated mobilization well, and maintained stable vital parameters throughout the hospital stay. Wound healing was satisfactory, and oral intake was resumed without difficulty. Given the favourable surgical outcome, stable hemodynamic status, and absence of immediate postoperative concerns, the patient was deemed fit for discharge and was successfully discharged on the eighth postoperative day with advice for close follow-up and continuation of guideline-directed medical therapy.

A 2D echocardiography performed at the time of discharge revealed satisfactory findings with LVEF of around 50% and all the valves are functioning well with no evidence of any clots, vegetations, or pericardial pathology.

Structural valve degeneration (SVD) is a recognized long-term complication of valve replacement with bioprosthetic valves, often necessitating redo valve surgery. However, reoperation on the aortic valve carries an inherently higher perioperative risks. To mitigate these risks, surgical strategies may require modification, including the use of minimally invasive approaches or alternative cardiopulmonary bypass techniques. Careful preoperative planning with comprehensive diagnostic evaluation, alongside tailored surgical techniques, plays a pivotal role in identifying potential hazards and overall good surgical outcomes.

Preoperative Planning

Advanced imaging, particularly multidetector CT scans, plays a pivotal role in evaluating the proximity of cardiac and vascular structures to the sternum, assessing the patency of prior grafts, and identifying anatomical variations.

Surgical Approach

• Cautious Sternotomy: Re-entry is high risk due to adhesions and the potential for inadvertent injury to prior grafts, leading to catastrophic bleeding or embolization.
• Alternative Cannulation: Axillary or femoral cannulation may be required to avoid traversing adhesions and to allow rapid initiation of cardiopulmonary bypass (CPB) in case of vascular injury.
• Minimally Invasive/Robotic Techniques: Selected patients may benefit from less invasive access routes, particularly for valve interventions.

Key Challenges for the Anesthesiologist:

• Mediastinal adhesions: Dense adhesions from prior surgeries increase the risk of injury to the heart, great vessels, pulmonary artery, or coronary grafts during re-entry.
• Prolonged surgical dissection and CPB: Adhesions significantly lengthen operating and bypass times.
• High bleeding risk: Dissection through fibrotic planes predisposes to massive haemorrhage.
• Coagulopathy: Blood loss and prolonged CPB contribute to coagulation derangements.
• Complex comorbidities: Older patients often present with advanced heart disease, pulmonary dysfunction, renal insufficiency, and reduced physiological reserves.
• Advanced imaging requirement: 3D CT and angiography are essential for mapping grafts and surgical landmarks.
• Neurological complications: Extended procedures heighten the risk of cerebral ischemia and stroke.
• Difficult cannulation: Peripheral or alternative access may be necessary, particularly in patients with hostile central vessels.
• Multidisciplinary collaboration: Close coordination between surgeon, anesthesiologist, and perfusionist is crucial to optimize perioperative outcomes.

Preoperative Challenges

• Comprehensive evaluation: Review of prior operative notes to identify surgical approaches, complications, and graft/prosthesis locations.
• Comorbidities: Higher prevalence of heart failure, renal impairment, pulmonary dysfunction, and coagulation disorders.
• Imaging and assessment:
  • CT scan: Defines adhesions, proximity of vital structures to sternum, and risk of graft injury.
  • Coronary Angiography: Essential for evaluating bypass graft patency and planning sternotomy entry.
• Vascular access difficulties: Previous interventions may complicate central venous access; peripheral cannulation (e.g., femoro-femoral) may need to be secured before sternotomy to enable emergency CPB.

Intraoperative Challenges

• Resternotomy and adhesions: The most hazardous phase, with risk of catastrophic bleeding or cardiac injury. Adhesions are denser and more vascular if surgery was performed within the preceding six months.
• Vascular injury: Potential damage to patent grafts, cardiac chambers, or great vessels during entry or dissection.
• Prolonged operative and CPB times: Increase risk of systemic inflammation, organ dysfunction, and coagulopathy.
• CPB management:
  • Emergency initiation: Preparedness for rapid CPB institution, sometimes via peripheral cannulation.
  • Cannulation challenges: Calcification, dissections, or distorted anatomy may complicate arterial and venous cannulation.
• Intraoperative monitoring:
  • Transesophageal echocardiography (TEE): Crucial for functional assessment, guiding cannulation, and evaluating repair adequacy, though occasionally limited by esophageal pathology.
• Hemodynamic fragility: Poor cardiac reserve predisposes to instability with minor anesthetic interventions.

Postoperative Challenges

• Bleeding: Common due to extensive dissection and coagulation abnormalities, often requiring aggressive blood product support.
• Sternal wound complications: Repeated sternotomies heighten the risk of infection and mediastinitis.
• Organ dysfunction: Prolonged CPB and operative stress predispose to renal failure, pulmonary dysfunction, and neurological impairment.
• ICU course: Demands vigilant monitoring for bleeding, arrhythmias, infection, and hemodynamic instability.
• Pain management: Multiple sternotomies complicate analgesia, necessitating multimodal strategies for optimal recovery

A fourth-time redo cardiac surgery represents one of the most complex challenges in perioperative medicine. The anesthesiologist plays a central role in managing risks that stem from adhesions, distorted anatomy, frail physiology, and prolonged operative courses. Successful outcomes demand meticulous preoperative planning, advanced imaging, vigilant intraoperative management, and coordinated multidisciplinary care in the postoperative period.

1. Castaing A, Wang S, Vuylsteke A, Mediratta N, Poulin MF, Yap J. Anesthesia for repeat sternotomy in adult cardiac surgery. BJA Educ. 2023; 23(10): 355-62.
2. Sá MPBO, Ferraz PE, Escobar RR, Martins WN, Lustosa PC, Nunes EO, et al. Reoperations in cardiac surgery: experience at a tertiary center. Rev Bras Cir Cardiovasc. 2011;26(3):393-400.
3. Sá MPBO, Ferraz PE, Escobar RR, Martins WN, Lustosa PC, Nunes EO, et al. Predictors of outcome in reoperative cardiac surgery: role of imaging and preoperative planning. Rev Bras Cir Cardiovasc. 2011;26(3):393-400.
4. Ruzza A, Czer LS, Arabia F, Vespignani R, Esmailian F, Cheng W, et al. Redo cardiac surgery: risk factors and outcomes. J Thorac Dis. 2020;12(6):3178-87.
5. Wang S, Yan TD, Tian DH. Risk factors and outcomes in patients undergoing redo cardiac surgery. Eur J Med Res. 2025;30:67.
6. Sá MPBO, Ferraz PE, Escobar RR, Martins WN, Lustosa PC, Nunes EO, et al. Is reoperation still a risk factor in cardiac surgery? Eur J Cardiothorac Surg. 2015;47(5):819-24.
7. Saager L, Turan A, Mascha EJ, Kurz A, Saager R, Sessler DI. Intraoperative transitions of anesthesia care and postoperative mortality. JAMA Netw Open. 2022;5(3):e223456.
8. Ghods AJ, Ziaee M, Sheibani S, Shafiei M, Darvish S. Advanced haemodynamic monitoring in redo valve surgery: FloTrac and CVP experience. Iran Red Crescent Med J. 2023;25(9):e151379.
9. Evered L, Silbert B, Knopman DS, Scott DA, DeKosky ST, Rasmussen LS, et al. Recommendations for the nomenclature of cognitive change associated with anesthesia and surgery. Br J Anaesth. 2018;121(5):1005-12.
10. Ruzza A, Czer LS, Arabia F, Vespignani R, Esmailian F, Cheng W, et al. Challenges and results of redo cardiac surgery. J Thorac Dis. 2020;12(6):3178-87. These studies highlight the complexities and considerations involved in managing patients undergoing repeat cardiac procedures. As surgical techniques and monitoring technologies evolve, it is crucial for healthcare professionals to remain informed about the latest advancements to ensure optimal patient outcomes. ANESTHESIOLOGIST