Stacking sternotomies: Does surgical history predict post-transplant risk?

Background Prior sternotomy at the time of heart transplantation (HT) has been linked to decreased post-transplant survival, but whether additional sternotomies confer incremental risk remains uncertain. We compared outcomes among HT recipients with 0, 1, or ≥2 prior sternotomies. Methods HT recipients at a single center from January 2020 to December 2024 were retrospectively reviewed. Patients undergoing multiorgan transplants were excluded. Patients were stratified by 0 prior ( n = 246), 1 prior ( n = 235), and ≥2 prior sternotomies ( n = 71). Multivariate Cox and logistic regression models compared mortality (30 days, 1 year, and 2 years). Secondary end-points included blood product transfusions and vasoplegia. Results On multivariable analysis compared with primary sternotomy, 1 prior sternotomy was associated with lower survival at 30 days (99.6% vs 93.6%, hazard ratios [HR] 14.64, p = 0.019), 1 year (97.6% vs 89.4%, HR 4.47, p = 0.004), and 2 years (94.4% vs 86.6%, HR 2.79, p = 0.007). Similarly, patients with ≥2 prior sternotomies had higher hazards at 30 days (90.1%, HR 20.06, p = 0.016), 1 year (87.3%, HR 4.71, p = 0.008), and 2 years (80.4%, HR 3.71, p = 0.005). In pairwise comparison of 1 vs ≥2 prior sternotomy cohorts, hazards of death were not statistically different at any time point (all p > 0.05). Transfusion requirements and vasoplegia were greater in patients with reoperative sternotomy, while comparisons between the 1 and ≥2 prior sternotomy cohorts were comparable for both measures. Conclusions Reoperative sternotomy is associated with increased blood product utilization, risk of vasoplegia, and post-transplant mortality. However, more than 1 prior sternotomy did not confer a statistically detectable additional risk.