Redo CABG Research Articles

Multiarterial Grafting in Redo CABG: Type of Arterial Conduit and Patient Sex Determine Benefit

To evaluate whether multiarterial grafting provides incremental benefit above single arterial grafting in isolated redo CABG. From 1/1980 to 7/2020, 6559 adults underwent 6693 isolated CABG reoperations. Patients undergoing multiarterial grafting were propensity-score matched with those undergoing single arterial grafting, with or without additional vein grafts, yielding 2005 well-matched pairs. Endpoints were in-hospital postoperative complications, hospital mortality, and long-term mortality. Median follow-up was 10 years with 25% followed >17 years. Multivariable multiphase hazard modeling and nonparametric random survival forests for survival were used to identify patients for whom multiarterial grafting was most beneficial. Among propensity-matched patients, postoperative complications for multiarterial versus single arterial grafting were any reoperation, 50 (2.5%) versus 65 (3.2%); renal failure, 73 (3.6%) versus 55 (2.7%); stroke, 44 (2.2%) versus 38 (1.9%); and deep sternal infection, 36 (1.8%) versus 25 (1.2%). Hospital mortality was 1.7% (n=35) versus 2.8% (n=56) (P=.03). Comparing multiarterial to single arterial grafting, survival at 1 and 3 years was 95% versus 94% and 92% versus 88%, and at 5, 15, and 20 years, survival was 87%, 49%, and 31% versus 82%, 42%, and 25%. Better survival after multiarterial grafting was confined to males with 2 patent internal thoracic artery grafts (P<.0001). Redo CABG with multiarterial grafting can be performed with lower in-hospital mortality and similar major morbidity to single arterial grafting. It is associated with better long-term survival, particularly in males when 2 internal thoracic artery grafts are used.

Early cardiac contractility outcome of reoperative coronary artery bypass grafting using right gastroepiploic artery.

Reoperative coronary artery bypass grafting (redo CABG) still carries higher mortality and increased morbidity compared with primary CABG. In this study, we retrospectively reviewed our operative outcome of redo CABG to evaluate the impact of the left anterolateral thoracotomy approach using the right gastroepiploic artery (RGEA). Between 1994 and 2020, 11 patients (mean age 60.3 ± 13.1 years; nine men, two women) underwent isolated redo CABG using the RGEA via the left anterolateral thoracotomy. The mean duration from the initial CABG was 128.3 ± 88.4 months. Redo CABG was performed because of graft occlusion in six patients (54.5%), graft stenosis in one patient (9.1%), and progressive disease of previously ungrafted vessels in four patients (36.4%). The total number of bypasses using RGEA (including Y-composite vein grafts) was 16 (four left anterior descending branches, two diagonal branches, five circumflex branches, five right coronary arteries). No residual graft injury, major comorbidity, or in-hospital death was observed. Changes in echocardiographic values before and after redo CABG were 210.9 ± 48.2 ml and 175.0 ± 41.4 ml in left ventricular end-diastolic volume, 130.2 ± 49.2 ml and 94.4 ± 33.0 ml in left ventricular end-systolic volume, and 45.6 ± 11.0% and 52.2 ± 10.7% in left ventricular ejection fraction, respectively. These parameters significantly improved after redo CABG. Redo CABG with RGEA grafting via the left anterolateral thoracotomy approach is a safe and effective surgical procedure especially in improving cardiac contractility in patients who required revascularization.

Analysis of direct results of reoperative coronary artery bypass surgery

Aim. To compare the immediate results of treatment of patients after redo coronary artery bypass grafting (reCABG) off pump and with cardiopulmonary bypass.Methods. The retrospective study included 138 patients who underwent isolated reCABG for recurrence of angina pectoris in the period of 2013 to 2019 at the Almazov Research Centre. The operation was performed with cardiopulmonary bypass using isothermal blood cardioplegia in 74 cases (group A). Sixty-four operations were performed without cardiopulmonary bypass (group B). The primary endpoint was a major adverse cardiovascular event (e.g. myocardial infarction, acute cerebrovascular accident, cardiovascular death) during hospitalisation. Secondary endpoints were cardiovascular failure, respiratory failure, renal failure, and wound healing complications during hospitalisation.Results. Redo CABG with cardiopulmonary bypass compared with CABG off pump was more often complicated by cardiovascular failure (39.2% versus 20.3%, p = 0.043), respiratory failure (7.8% versus 2.7%, p = 0.047), and postpericardiotomy syndrome (13.5% versus 0%, p = 0.047). The revascularisation index was higher in the group of reCABG off pump (2.9) compared to the group of reCABG with cardiopulmonary bypass (2.4). In the early postoperative period there was a decrease in the duration of inpatient treatment and stay in the intensive care unit, the duration of surgery, as well as a lower incidence of postoperative complications in group B.Conclusion. Redo CABG showed satisfactory results in the early postoperative period. Performing reCABG off pump was advantageous and was associated with a decrease in the incidence of postoperative complications. Received 23 June 2020. Revised 9 September 2020. Accepted 10 September 2020. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributions Conception and design: I.K. Ismail-zade, V.K. GrebennikData collection and analysis: I.K. Ismail-zade, D.G. Zavarzina, N.R. AbutalimovaDrafting the article: I.K. Ismail-zade, I.Yu. Ivanov, G.I. IshmukhametovCritical revision of the article: V.K. Grebennik, M.l. GordeevFinal approval of the version to be published: M.L. Gordeev, V.K. Grebennik, I.K. Ismail-zade, G.I. Ishmukhametov, I.Yu. Ivanov, N.R. Abutalimova, D.G. Zavarzina

Off-pump versus on-pump redo coronary artery bypass grafting: a systematic review and meta-analysis.

Redo coronary artery bypass grafting (redo CABG) is associated with increased mortality and morbidity. The aim of this study was to systematically evaluate the evidence comparing the outcomes of off-pump with on-pump redo CABG. Studies were systematically searched and identified using PubMed, EMBASE, the Cochrane Library, and the International Clinical Trials Registry Platform (ICTRP) by two researchers independently. The primary outcome was 30-day mortality, and the secondary outcomes were in-hospital mortality, post-operative complications, completeness of revascularization, blood transfusion rate, duration of mechanical ventilation, intensive care unit and hospital stays. The 21 studies including 4,889 patients were enrolled in our meta-analysis. Compared with on-pump, the off-pump technique was associated with significantly reduced 30-day mortality (odds ratio [OR] = 0.43, 95% confidence interval [CI] = 0.26-0.72, p = 0.001). Moreover, a notably decreased in-hospital mortality (OR = 0.55, 95% CI = 0.39-0.76, p = 0.0004) and incidence of post-operative new-onset atrial fibrillation, myocardial infarction, acute kidney injury, low cardiac output state, blood transfusion rate (OR = 0.46, 95% CI = 0.35-0.60, p < 0.00001; OR = 0.54, 95% CI = 0.38-0.78, p = 0.0007; OR = 0.51, 95% CI = 0.37-0.70, p < 0.0001; OR = 0.31, 95% CI = 0.20-0.47, p < 0.00001; OR = 0.29, 95% CI = 0.14-0.61, p = 0.001) and significantly shortened duration of mechanical ventilation, intensive care unit and hospital stays (mean difference [MD] = -8.21 h, 95% CI = -11.74 to -4.68, p < 0.00001; MD = -0.77 d, 95% CI = -0.81 to -0.73, p < 0.00001; MD = -2.24 d, 95% CI = -3.17 to -1.32, p < 0.00001) could be observed when comparing the outcomes of off-pump with on-pump redo CABG. There was nonsignificant difference between off-pump and on-pump redo CABG in completeness of revascularization. In patients undergoing redo CABG surgery, the off-pump technique was associated with decreased mortality, less post-operative complications when compared to on-pump.

Trends of repeat revascularization choice in patients with prior coronary artery bypass surgery.

To examine rates and predictors repeat revascularization strategies (percutaneous coronary intervention [PCI] and coronary artery bypass grafting [CABG]) in patients with prior CABG. Using the National Inpatient Sample, patients with a history of CABG hospitalized for revascularization by PCI or CABG from January 2004 to September 2015 were included. Regression analyses were performed to examine predictors of receipt of either revascularization strategy as well as in-hospital outcomes. The rate of redo CABG doubled between 2004 (5.3%) and 2015 (10.3%). Patients who underwent redo CABG were more comorbid and experienced significantly worse major adverse cardiovascular and cerebrovascular events (odds ratio [OR]: 5.36 95% CI 5.11-5.61), mortality (OR 2.84 95% CI 2.60,-3.11), bleeding (OR 5.97 95% CI 5.44-6.55) and stroke (OR 2.15 95% CI 1.92-2.41), but there was no difference in cardiac complications between groups. Thoracic complications were high in patients undergoing redo CABG (8%), especially in females. Factors favoring receipt of redo CABG compared to PCI included male sex, age < 80 years, and absence of diabetes and renal failure. Reoperation in patients with prior CABG has doubled in the United States over a 12-year period. Patients undergoing redo CABG are more complex and associated with worse clinical outcomes than those receiving PCI.

SAT-115 PROLONGED ICU STAY IN POST CABG CKD PATIENTS AND POST-OPERATIVE QUALITY OF LIFE (QOL) AT 6 MONTHS

Intensive Care Unit(ICU) is associated with costly and limited resources in third world countries. Prolonged ICU stay not only increases hospital cost but it also prevents hospital equipment to be used by other patients who need them. Conflicting results have been found regarding risk factors that prolong ICU stay after cardiac surgery in Chronic Kidney Disease(CKD) patients. The aim of this study was to identify factors that impact the duration of ICU stay in post CABG CKD patients and to assess how CKD and prolonged ICU stay affect their QOL 6 months after Cardiac Surgery. Knowing these factors can help timely management and resource planning. We analysed medical records of 191 post CABG patients at our Cardiac Surgery ICU. CABG patients, above 18 years with and without CKD were included. However, those with redo CABG and valve surgery were excluded. Patients were categorized as normal ICU stay (less than 48 hours) and prolonged ICU stay (more than 48 hours). The effect of different patient variables and peri operative risk factors on prolonged ICU stay were analysed using Pearson Chi square test. QOL was assessed at 6 months follow up using SF36 QOL questionnaire: categorised as poor, good and excellent. Mean age of the patients was 57.83 years (± 9.862 SD). 32(16.8%) were females and 159(83.2%) were males.145 patients (75.9%) were hypertensive and 110(57.6%) were diabetic and all had dyslipidemias(Table 1). 72/191 (37.6%) patients had CKD 3-5 : 66- CKD 3, 4-CKD 4, 2-CKD 5). 56/191 patients (29.3%) had prolonged ICU stay. Patients who had Diabetes Mellitus and Chronic kidney disease(stage 3-5) had prolonged ICU stay(p value of 0.003 and 0.027 respectively). Patients who had a recent Myocardial Infarction (MI) (less than 90 days prior to CABG), diastolic dysfunction, and LV EF (Left Ventricular Ejection Fraction)less than 35% also had prolonged ICU stay (p value of 0.072, 0.06 and 0.003). Within the ICU, patients with post CABG arrhythmias(Atrial fibrillation, Supraventricular tachycardia, Ventricular tachycardia) and Cardiogenic shock had prolonged ICU stay(p value of 0.001 and 0.029). Patients with AKI and those who had dialysis post CABG had prolonged ICU stay (p value 0.02 and 0.02 respectively), as shown in Table 2. Out of 72 CKD patients,24 patients had prolonged ICU stay. Among CKD cohort, prolonged ICU stay was observed in diabetics (p : 0.05), patients who needed dialysis (p:0.04), patients with post op arrhythmias (p :0.001) and in those with LV EF <35% (p:0.002) (Table 3). Further analysis revealed a strong correlation of on pump surgeries with prolonged ICU stay (p value :0.04) and 50% of the CKD patients on pump had prolonged ICU stay. Out of 191 patients, 129 were available for follow up of QOL at 6 months. Only one patient in Stage 3 CKD had poor QOL. 34 patients in CKD 3 and 4 had good QOL. 14 patients with CKD 3 and 4 had excellent QOL (Table 4). There was no mortality at 6 months follow up. Significant correlation of the following risk factors was found with prolonged ICU stay: Diabetes mellitus, CKD, AKI, Dialysis, MI less than 90 days pre CABG, Post op arrhythmias, Shock, Diastolic dysfunction and LV EF<35%. However in CKD cohort, prolonged ICU stay was seen with AKI, dialysis, diabetics, post op arrhythmias and LV EF<35%.

Diagnostic accuracy of 256 slices computed tomography coronary angiography in post coronary artery bypass graft Egyptian patients

Objective: Evaluate the diagnostic accuracy of 256 slices computed tomography (CT) coronary angiography (CA) (multidetector CT [MDCT]) in the assessment of native coronary arteries and grafts in post-coronary artery bypass graft (CABG) surgery Egyptian patients. Patients and Methods: It included 70 patients with a history of isolated CABG with recurrent chest pain. We excluded patients with a history of redo CABG or other open-heart surgeries, renal impairment, severe claustrophobia, chronic liver disease, dye allergy, tachycardia with contraindication to beta blockers (BB), pregnancy. All patients were subjected MDCT and CA. Both examinations were done within 3 months. Results: In our study, 161 grafts evaluated (63 left internal mammary artery [LIMA] in situ grafts, 5 right internal mammary artery (RIMA) and 2 radial grafts, and 91 venous grafts). CA failed to detect 3 LIMA and 7 venous grafts. All were seen only by MDCT. For grafts CT compared to CA has sensitivity (91.5%, 84.8%), specificity (98%, 100%), accuracy (95.65%, 96.9%), positive predictive value (PPV) (96.43%, 100%), and negative predictive value (NPV) (95.24%, 96.2%) in the assessment of significant stenosis and total occlusion of grafts, respectively. For grafted vessels CT has sensitivity (94%, 100%), specificity (98%, 100%), accuracy (96.94%, 100%), PPV (95.92%, 100%), and NPV (97%, 100%) in the assessment of significant stenosis and total occlusion of grafted vessel, respectively. For native vessels CT has sensitivity (100%, 97.7%), specificity (84.2%, 98.4%), accuracy (97.14%, 98.1%), PPV (96.6%, 97.7%), and NPV (100%, 98.37%) in the assessment of significant stenosis and total occlusion of native vessels, respectively. Conclusion: Our study demonstrated a high diagnostic accuracy of MDCT for the assessment of bypass grafts and grafted or native coronary arteries compared with CA. Detection of grafts or native vessels occlusion was better than detection of substantial stenosis. MDCT is a good negative test for native vessels as it has a high sensitivity since it tends to overestimate stenosis degree, so patients with negative MDCT angiographic results mostly have patent vessels.

Evaluations of factors affecting the outcome of redo coronary bypass surgery and long term results: A retrospective observational study

Aim: Advanced atherosclerosis of coronary arteries, existence of patent arterial grafts, redo sternotomy, shortage of available vascular conduits, difficulty of exploration of the coronary vessels are the factors that render the coronary reoperations challenging and they may be responsible of higher mortality and morbidity rates of reoperations. The aim of this study is to evaluate the factors that affect the progression of atherosclerotic coronary artery disease in the post-operative period of coronary artery bypass surgery which results in a redo operation. Methods: A number of 115 patients who underwent coronary bypass re-operations between January 1997 and August 2007 were included. Patients were divided into two groups as follows: Group 1 was the risk factor positive group, Group 2 was the risk factor negative group. The time interval between the initial operative procedure and the redo operation was calculated and the effect of risk factors upon this time interval and the mortality rates were evaluated. Results: The time interval between the first operative procedure and the reoperation was 77.31 months in Group 1 and 93.88 months in Group 2. Smoking had a more negative effect on the reoperation rate compared to the other risk factors (p=0.025). Mortality rate was higher in the risk factor positive group (p=0.027). Preoperative EF had a significant effect on the mortality rates (p=0.018). Conclusion: The presence of any risk factor for CAD increases the chance of having a reoperation. Off-pump surgery technique should be chosen in appropriate cases to lower the mortality risk of redo CABG operations and choosing the combined cardioplegia administration in on-pump redo coronary bypass operations would lower the mortality rate as well.

TCTAP C-060 Saphenous Vein Y-graft Intervention Using Double Kissing Crush Technique in a Patient After a Redo CABG

### Patient Initials or Identifier Number MU ### Relevant Clinical History and Physical Exam A 67-year-old gentleman with diabetes and hypertension, presented in the ER with chest pain. He underwent CABG in 1993 with LIMA to LAD, and vein grafts to OMl, RCA, and diagonal arteries. He developed

Pitfall of redo CABG after CABG

Pitfall of redo CABG after CABG

Clinical Impact of Custodiol Cardioplegic Solution on Patients Undergoing Complex Cardiac Surgery With Mild to Moderate Impairment of Left Ventricular Systolic Function

Background: The Bretschneider HTK solution is used widely for multiorgan preservation for transplantation, as well as a cardioplegic agent that allows single dose administration which is an attractive option for lengthy complex cardiac surgery. It was proved that it is simple to use, safe and practical. Moreover, it is considered to confer sufficient myocardial protection for more than 2 h of cardiac arrest. We undertook this descriptive study to analyze the performance of HTK solution in patients undergoing complex cardiac surgery with mild to moderate impairment of left ventricular systolic function. Patients and methods: A total of 50 patients underwent different complex cardiac surgery at national heart institute from January 2015 to November 2016 using single dose Custodiol cardioplegia as the primary and sole cardioplegic agent, their data was prospectively collected and their hospital outcome was analyzed as regards to ten study endpoints namely Prolonged ventilation, return to theatre for bleeding, renal failure, stroke, 30 days mortality, postoperative MI, need for inotropes, time on inotropes, ICU stay and hospital stay. Pre- and postoperative echocardiography was done to compare and evaluate the change of LV function using the parameters of End Systolic Dimension, End Diastolic Dimension, Fraction Shortening and Ejection Fraction of the left ventricle. Results: Half of the patients were males. Their age ranged between 16 – 65 years with a mean (standard deviation) of 47.46(11.10). preoperative ejection fraction ranged from 30 % to 49% with a mean (standard deviation) of 41.8 (6.32), the majority of them (64%) had NYHA class of 3 and half of them had CCS of 3. all patients were done electively. The most common procedure done was redo DVR 24% (12 patients) followed by Bentall operation 22%(11 patients). This is followed by CABG + MVR 7 patients (14%), then an equal number of 6 patients (12%) who underwent redo MVR post-infective endocarditis and CABG+ MVrep. The repair of tricuspid valve was done for 14 patients (28%) either with MVR or DVR. 4 patients (8%) had CABG +AVR for their combined lesions and another equal number of two patients (4%) underwent redo CABG and AVR + conduit (valve separate tube graft operation). prolonged ventilation occurred in 20% of the cases. An equal percentage of 6% of the patients had to return to the operative room and had postoperative MI. Renal failure occurred in 4% of the patients and as far as 30-day mortality is concerned, a similar 4% of patients died within this period. EF and FS were very similar when compared together (41.8 ± 6.32 %, 20.8 ± 2.35 % preoperatively compared to 41.92 ± 7.49%, 20.85 ± 3.25% postoperatively). P value was insignificant (0.937 and 0.929) respectively. Conclusion: A single dose of an HTK cardioplegic solution provides good myocardial protection in complex cardiac surgery with mild to moderate impairment of LV function and has a good immediate postoperative outcome.

Outcome of Percoutaneous Coronary Intervention in Patients With Prior Coronary Artery Bypass Surgery

in such patients. Patients and Methods: In this study, 111 symptomatic patients with pervious history of single coronary artery bypass graft (without concomitant vale surgery) underwent PCI by a single operator between March 2008 and March 2012. Then, they were followed during the following year after PCI and the incidence of death redo CABG, persistent cardiac symptom and rate of hospitalization were recorded Results: The successful rate of PCI in this study was estimated to be 94.5% (104 of 111). In hospital MACE was 9.6% (three deaths and one myocardial infarction). 67% (73) of patients were male and 33% (33) were female. 79.6% (86) of PCI procedures were done on native coronary arteries and 20.4% (22) on SVG grafts. During one year follow up, we had 7 death in patients with PCI on native vessels (group A) and 1 death in the patients whose PCI was performed on SVG grafts (group B), (P ≥ 0.999). In group A, 27.9% (24) patients were remained symptomatic; while in group B, 18.4% (4) patients were still symptomatic (P = 0.353). Hospitalization because of cardiac syndrome was recorded for 10.5% (9) patients in group A and 9.1% (2) patients of group B (P > 0.955). None of the patients of group B went under redo-CABG during the follow up but 2.3% (2) patients of group A did (P > 0.289). No case of stent restenosis or target vessel revascularization was recorded in either group. The overall rate of death was 7.6% (8 0f 104), persistent cardiac symptoms 27% (28 0f 104), hospitalization for cardiac symptoms 10.5% (11 f 14) and redo CABG 2% (2 of 104). Conclusions: This study shows that PCI in symptomatic post CABG patients follows by high successful and low complication rate and positive impression on their cardiac symptoms and could reduce the need for redo CABG. It seems that there is no difference that PCI is performing on SVG or native vessel, the intervention itself improves the patients’ quality of life.

Reoperative Coronary Artery Bypass Surgery: The Role of On-Pump and Off-Pump Techniques on Factors Affecting Hospital Mortality and Morbidity

Short term results of on-pump and off-pump techniques in patients undergoing reoperative coronary artery bypass grafting (redo CABG) were investigated in this study. A total of 14.430 patients have undergone isolated coronary artery bypass grafting in our clinic from 1998 to 2010. Of these patients, 105 patients who have undergone redo CABG, 53 (50.5%) were operated with cardiopulmonary bypass (on-pump) and 52 (49.5%) without cardiopulmonary bypass (off-pump). Early results for which on or off-pump techniques were independent risk factors were determined with logistic regression analysis. Overall mortality in patients undergoing redo CABG was 12.3% with a 11.5% mortality in the off-pump group and 13.2% mortality in the on-pump group and the difference was not statistically significant (p >0.05). Blood product transfusion requirement (p <0.05, OR: 3.620, 95% CI: 1.295-10.119), new onset atrial fibrillation rhythm (AFR) (p <0.05, OR: 13.357, 95% CI: 1.656-107.721), prolonged ventilation (p <0.05, OR: 9.066, 95% CI: 1.091-75.323) and duration of hospitalization (p <0.01, OR: 5.252, 95% CI: 1.784-15.459) were significantly higher in the on-pump group. The number of patients with postoperative low cardiac output was significantly higher in the off-pump group (p <0.05, OR: 5.337, 95% CI: 1.094-26.043). The ratio of complete bypass was significantly higher in the on-pump group compared to the off-pump group (p <0.05, OR: 2.913, 95% CI: 1.204-7.046). Despite the lower morbidity and mortality in the off-pump group, the rate of target vessel bypass grafting was lower. Off-pump technique may be considered as a safer option for cardiopulmonary bypass in the high risk population.

The Validity of Euro Score in Patients who underwent off pump coronary artery bypass graft

European score system has been used to predict the morbidity and mortality rate of the patients who underwent open heart surgery. This is an attempt to evaluate the validity of Euro SCORE in off-pump coronary artery bypass surgery at Afshar Heart Center. 367 consecutive patients who underwent primary or redo off-pump CABG in Afshar Heart Center during October 2010 to March 2011 were collected. The Euro SCORE forms were filled and incidence of post-operative morbidity and mortality were determined. The Patients were categorized into 4 groups of low-risk (logistic score: 0-1.99), medium-risk (logistic score: 2-10.99), high-risk (logistic score: 11-19.99) and severe risk (logistic score: 20-62.80). The mean patient age was 61.19±10.90 years including 66.8% male and 33.2% female. Overall average mortality rate was 4.4%. Hospital stay was 6.1±3.6 days. IABP was used in 3.8%. Major complications were renal failure, bleeding, arrhythmia, pulmonary emboli, CVA, respiratory failure and MI. Arrhythmia was the most common complication that was the cause of mortality. The mortality rates were 0%, 1.7%, 13.2%, and 38.9% in low, medium, high and severe-risk groups, respectively. Euro SCORE is valid in OPCAB to modify the risk stratification of the patients who underwent OPCAB.

左前側方開胸アプローチ，左内胸動脈－橈骨動脈 I-composite graftを用いたredo CABGの1例

症例は72歳の男性．56歳時，経皮的冠動脈形成術を施行された際，左前下行枝が解離により閉塞したため緊急冠動脈バイパス術(Ao-SVG-#7，Ao-SVG-#9-#14，Ao-SVG-#4PD)を施行された．定期評価でAo-SVG-#7，Ao-SVG-#4PDのグラフト閉塞とAo-SVG-#9-#14グラフトの中枢側に狭窄を認め，再冠動脈バイパス術を施行した．手術は左第5肋間前側方開胸アプローチ，PCPS補助下でLITA-RA I-composite graftを#14に側々吻合し，引き続き#4PDに端側吻合した．Redo CABGにおいては，適切な到達経路，使用グラフトの選択，バイパスグラフトデザインを選択することが重要であり，左開胸アプローチ，composite graftを用いたグラフトデザインは有効な術式の一つと考えられた．

Clinical application of redo coronary artery bypass grafting

To determine the clinical characteristics and outcomes of redo CABG. The outcomes of 42 consecutive patients who underwent redo CABG from January 2002 to December 2010 was analyzed. There were 29 males and 13 females, aging from 46 to 78 years old with a mean of (61.2 ± 2.1) years. Off-pump CABG was applied for 31 patients and on-pump CABG for 11 patients. There were 1 patient underwent concomitant aortic valve replacement and 1 patient underwent aortic root and right aortic arch replacement respectively. Three patients died of right ventricle rupture, heart failure and multiple system organ failure respectively and the perioperative mortality rate was 4.8%. The post-operatively mechanical ventilation time varied from 9 to 27 h with a mean of (17 ± 7) h. There was no residual angina and perioperative myocardial infarction in the remaining patients who were all discharged uneventfully. Intraoperative 6 patients had accepted intraaortic balloon counterpulsation. During the follow-up from 6 months to 4.5 years for 38 patients, which showed no evidence of recurrent angina and postoperative coronary CT angiography in 12 patients showed the patency of grafts is good. Satisfactory outcome of redo coronary artery bypass grafting can be achieved if proper indication were choose and reasonable management were performed.

Outcomes following PCI in patients with previous CABG

Limited data is available to guide operators as to the optimal revascularisation strategy in patients with previous CABG representing with angina. Retrospective analysis of 161 patients with prior CABG undergoing PCI in two centres between September 2005 and April 2008. 161 patients (132 male, 68 ± 8 years) underwent PCI at 126 ± 65 months after index CABG. Clinical presentation of recurrent ischaemia was stable in 59.7% and as an acute coronary syndrome in 40.3% of patients. Mean follow-up after PCI was 13.5 ± 4.8 months. About 62.7% of patients underwent native vessel PCI, 32.9% had a graft only PCI, and 4.4% having a combination of both. Drug eluting stents were used in 84.9% of cases. There was one cardiac death and one case of redo CABG during follow-up. Mean CCS angina class decreased from 2.87 to 0.67 (P < 0.0001) in the follow-up group. About 13.6 % of all patients had a MACE at follow up. This was higher in the graft PCI group (21.6% vs. 8.9%, P = 0.048). About 12.4% of the total cohort underwent repeat PCI although 30% of these required PCI for a de-novo lesion. TVR rate was significantly higher in patients undergoing graft PCI than native vessel PCI (15% vs. 4.9%, P = 0.031). Graft PCI was an independent predictor (HR 3.73, 1.27-10.87 [95%CI], P = 0.016) of MACE in these patients. PCI significantly improved angina in these patients with low overall rates of TVR. However TVR rate was significantly higher in patients undergoing graft PCI than those undergoing native vessel PCI.

Treatment Option Approaches to the Management of Chronic Total Occlusions

You have a consultation from a 67-year-old patient with severe effort angina. Full-dose prescription could not relieve his symptoms. He had bypass surgery (coronary artery bypass graft [CABG]) more than 10years ago. Saphenous vein graft (SVG) to a big right coronary artery (RCA) was recently occluded. SVG to a small circumflex artery was occluded before. Left internal mammary artery graft to left anterior descending artery was nicely patented. His native RCA has been occluded since before he received CABG. How can we treat these patients? Among the treatment options between redo CABG and percutaneous coronary intervention (PCI) for the chronic total occlusion of his native RCA, I propose choosing the latter option.

Myocardial revascularization using on-pump beating heart among patients with left ventricular dysfunction

ObjectivesOn-pump beating heart technique for myocardial revascularization has been used successfully among both low and high risk patients. Its application among low ejection fraction patients is limited. The aim of our study is to evaluate this technique among patients with low ejection fraction and to compare results with off-pump bypass technique.MethodsThis retrospective study includes 137 patients with ejection fraction below 0.35 who underwent isolated coronary artery bypass surgery. 39 patients underwent myocardial revascularization using on-pump beating heart (ONCAB/BH), while 98 patients had off-pump beating heart (OPCAB). Different preoperative, operative and postoperative variables were evaluated among both groups.ResultsPatients profiles and risk factors were similar among both groups, except for the number of patients undergoing redo CABG which was significantly higher among ONCAB/BH (13% vs 3%; p = 0.025). Ejection fraction (EF) varied from 10-34%. The mean EF for patients who underwent ONCAB/BH was 28 ± 6 in comparison to 26 ± 5 for OPCAB patients (P = 0.093). Predicted risk for surgery according to EuroSCORE was similar among both groups (P = 0.443). The number of grafts performed per patient was significantly more among patients who underwent ONCAB/BH (2.2 ± 0.7 Vs 1.7 ± 0.7; P = 0.002). Completeness of revascularization was significantly greater in the ONCAB/BH patients (72% Vs 46%, P = 0.015). The incidence of hospital mortality and combined major morbidity was more among ONCAB/BH in comparison to OPCAB, but the difference was not significant. However, the incidence of blood loss, ventricular arrythmias, inotropic support, ICU, hospital stay and blood transfusion were significantly greater among patients who underwent ONCAB/BH.ConclusionsOn-pump beating heart technique can be used in myocardial revascularization among patients with left ventricular dysfunction. The technique was found to be associated with better myocardial revascularization when compared with OPCAB technique. However, the incidence of morbidity and mortality was more than OPCAB.

Outcomes of Redo CABG From the ASCTS Database

Outcomes of Redo CABG From the ASCTS Database