Reoperative CABG using left thoracotomy: a tailored strategy

Abstract

Background. Reoperative coronary artery bypass grafting (CABG) through a left thoracotomy is a challenging operation with no one dominant approach. We developed a tailored strategy for this difficult group of patients, integrating the currently available newer technologies for each patient indication. Methods. Between October 1991 and October 1999, 50 consecutive patients underwent reoperative CABG through a left thoracotomy. Age was 65 ± 9 years, 40 (80%) were men, and preoperative ejection fraction was 40 ± 13. In 36 patients (72%) the left internal mammary artery had been placed to the left anterior descending coronary artery during the primary CABG and in 25 of 36 patients (70%) this left internal mammary artery–left anterior descending coronary artery graft was patent. The mean duration from previous CABG was 8.0 ± 4.8 years. Three approaches were used: (1) conventional cardiopulmonary bypass using fibrillatory or circulatory arrest (n = 33, 66%); (2) Heartport endoaortic balloon occlusion (n = 4, 8%); and (3) off-pump beating heart techniques (n = 13, 26%). Results. The off-pump CABG technique was used in the majority of recent patients and 1 (7.7%) had to be converted to cardiopulmonary bypass due to hemodynamic instability. When cardiopulmonary bypass was used its duration was 122 ± 59 minutes and mean temperature on bypass was 24° ± 6°C. In the 4 patients in whom the Heartport system was used, the median endo-aortic occlusion duration was 49 minutes. Patients received an average of 1.4 grafts/patient. In 60 of 70 patients (89%) distal anastomoses were performed to an anterolateral coronary target. There were 3 of 50 (6%) operative deaths, 2 in the conventional group and 1 in the endo-aortic balloon occlusion group. The mean length of stay in the 47 survivors was 7.8 ± 3.9 days (median, 7 days). Conclusions. Reoperative CABG by left thoracotomy remains a challenging operation. Several techniques, including off-pump CABG, conventional cardiopulmonary bypass, circulatory arrest, and endoaortic balloon occlusion, should be in the surgeon’s armamentarium to allow a tailored approach for each operation based on patient indications.