Redo Cardiac Surgery Research Articles

Hybrid intraoperative pulmonary artery stenting in redo congenital cardiac surgeries

ObjectiveReconstruction of branch pulmonary arteries (PAs) can be challenging in redo congenital heart surgeries. Treatment options like percutaneous stent implantation and surgical patch angioplasty may yield suboptimal results. We present our experience with hybrid intraoperative stenting which may be an effective alternative option.MethodsWe retrospectively analyzed data of all patients with PA stenosis who underwent intraoperative PA branch stenting in our institution between January 2011 and December 2012.ResultsTen patients [6 females, median age 10 (1.4 to 37) years], underwent hybrid stenting of the PA. Primary cardiac diagnoses were pulmonary atresia with ventricular septal defect (VSD) in three patients, pulmonary atresia with intact ventricular septum in two, Tetralogy of Fallot (TOF) in one, Double outlet right ventricle (DORV) with pulmonary stenosis (PS) in one, complex single ventricle in two and VSD with bilateral branch PA stenosis in one patient. Concomitant surgeries were revision/reconstruction of RV-PA conduit in 4, Fontan completion in 4, repair of TOF with conduit placement in 1 and VSD closure in 1 patient. The left PA was stented in 7, the right in 2 and both in 1, with a total of 11 stents. There were no complications related to stent implantation. Two early postoperative deaths were unrelated to stent implantation. At mean follow-up period of 14.8 (12–26) months, stent position and patency were satisfactory in all survivors. None of them needed repeat dilatation or surgical reintervention.ConclusionHybrid stenting of branch PA is a safe and effective option for PA reconstruction in redo cardiac surgeries. With meticulous planning, it can be safely performed without fluoroscopy.

The association between tranexamic acid and convulsive seizures after cardiac surgery: a multivariate analysis in 11 529 patients

Because of a lack of contemporary data regarding seizures after cardiac surgery, we undertook a retrospective analysis of prospectively collected data from 11 529 patients in whom cardiopulmonary bypass was used from January 2004 to December 2010. A convulsive seizure was defined as a transient episode of disturbed brain function characterised by abnormal involuntary motor movements. Multivariate regression analysis was performed to identify independent predictors of postoperative seizures. A total of 100 (0.9%) patients developed postoperative convulsive seizures. Generalised and focal seizures were identified in 68 and 32 patients, respectively. The median (IQR [range]) time after surgery when the seizure occurred was 7 (6-12 [1-216]) h and 8 (6-11 [4-18]) h, respectively. Epileptiform findings on electroencephalography were seen in 19 patients. Independent predictors of postoperative seizures included age, female sex, redo cardiac surgery, calcification of ascending aorta, congestive heart failure, deep hypothermic circulatory arrest, duration of aortic cross-clamp and tranexamic acid. When tested in a multivariate regression analysis, tranexamic acid was a strong independent predictor of seizures (OR 14.3, 95% CI 5.5-36.7; p < 0.001). Patients with convulsive seizures had 2.5 times higher in-hospital mortality rates and twice the length of hospital stay compared with patients without convulsive seizures. Mean (IQR [range]) length of stay in the intensive care unit was 115 (49-228 [32-481]) h in patients with convulsive seizures compared with 26 (22-69 [14-1080]) h in patients without seizures (p < 0.001). Convulsive seizures are a serious postoperative complication after cardiac surgery. As tranexamic acid is the only modifiable factor, its administration, particularly in doses exceeding 80 mg.kg(-1), should be weighed against the risk of postoperative seizures.

Minimally invasive approach for redo mitral valve surgery.

Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining "mitral valve" with the following terms: 'minimally invasive', 'reoperation', and 'alternative approach'. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed "mini" thoracotomy or "port access". The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and efficacy of these procedures has never been compared to open reoperations in a randomized trial, although published case series and comparisons to historical cohorts suggest that they are an effective and feasible alternative. Ongoing follow-up on current series will further define these procedures and provide valuable clinical outcome data.

A Practical Approach to Cardiac Anesthesia, 5th ednF. A.HensleyJr, D. E.Martin &amp; G. P.Gravlee, eds. Philadelphia, PA: Lippincott, Williams and Wilkins, 2013. ISBN 978‐1451137446, 907 pp., Price £60.00

This fifth edition claims to remain true to its original purpose in providing ‘an easily accessible, practical reference designed to help the practitioner prepare for and manage cardiac anaesthetics’. To that end, it is presented in five sections covering Cardiovascular Physiology and Pharmacology; Anaesthetic Management for Cardiac Surgery; Anaesthetic Management of Specific Cardiac Disorders; Circulatory Support; and Thoracic Anaesthesia and Pain Management. Each section is divided into separate chapters and each chapter is structured as a series of headings and subheadings providing an outline and referenced to the specific page where it is discussed. This allows for easy identification of each topic within the chapter. In addition, there is a list of up to 19 (but usually between 6 and 10) key points presented at the beginning of each chapter as a list of the major learning topics to be addressed. Where these topics are discussed in the body of the chapter they are highlighted by the appearance of the relevant learning point number in the margin. The use of the heading and subheading technique has been reasonably well adapted by most authors to provide a short but practical discussion of relevant topics. Illustrations, diagrams and echocardiographic images are used sparingly throughout the text but are of good quality and relevant when employed. Allowing for the lead time to textbook publication, most chapters include up to date information with references dating up to and including 2011. The book certainly provides an introduction and practical approach to the practice of cardiac anaesthesia. The chapter headings have been well chosen to provide a broad spectrum of relevant information. Integrating a large number of authors and topics can be difficult and repetition of topics has been minimised. However, this is at the cost of making some relevant, and reasonably common, issues for those starting out in cardiac anaesthesia difficult to find; for example, the approach to the patient scheduled for redo cardiac surgery, where a practical discussion would prove useful. A discussion on repeat sternotomy can be found in the chapters on myocardial revascularisation, congenital heart disease and also transplantation. It must be noted that only four of the 55 authors are from outside the United States and only two from outside North America, and none of the authors are European. There are a small number of typographical errors, but these are of little significance other than to those who read things meticulously. In terms of the target audience for the book, the information contained is certainly more than that required for the FRCA examination. Although presenting a heavily North American approach it does offer a very good, broad introduction to the specialty of cardiac anaesthesia. With this in mind it would be a reasonable addition to a hospital library, or for the trainee interested in pursuing a career in cardiothoracic anaesthesia.

Minimally Invasive Mitral Valve Surgery Can Be Performed With Optimal Outcomes in the Presence of Left Ventricular Dysfunction

Minimally invasive approaches to mitral valve repair have demonstrated equivalent technical outcomes and more rapid recovery when compared with traditional sternotomy. These techniques have been widely accepted for mitral insufficiency and stenosis. The utilization of minimally invasive techniques in the presence of left ventricular (LV) dysfunction has been controversial. We hypothesized that minimally invasive mitral valve surgery could be safely performed in the presence of compromised myocardial function, thereby minimizing recovery time. All patients undergoing minimally invasive mitral valve surgery at our center from November 1998 through June 2012 were analyzed. During this time 1,103 patients underwent minimally invasive, port access, mitral valve surgery utilizing a video-assisted limited right thoracotomy approach. Patients with LV dysfunction (ejection fraction ≤ 0.40, n = 140) were compared with patients with normal ventricular function (n = 963). Preoperative, intraoperative, and postoperative variables were compared between cohorts. Patients with LV dysfunction were able to undergo mitral valve surgery with minimal mortality (2.1% vs 1.7%, p = 0.7) and morbidity, that was comparable with patients with normal ventricular function. Postoperative recovery was only slightly longer compared with patients with normal LV function as noted by time to extubation (6.0 vs 7.0 hours, p = 0.005) and hospital length of stay (7.0 vs 6.0 days, p < 0.001). A significant percentage of patients with LV dysfunction underwent redo cardiac surgery (40.0%) through minimally invasive approaches. Minimally invasive, port-access, mitral valve surgery can be safely performed with minimal morbidity and mortality in the presence of cardiomyopathy. This approach may be considered in patients with isolated mitral valve pathology and LV dysfunction in an experienced center.

Computed tomographic imaging in planning redo cardiac surgery after coronary bypass grafting - a roadmap to safety.

Patent coronary artery bypass grafts are at risk of injury during redo cardiac surgery. In particular, damage to a patent left internal mammary artery (LIMA) graft during repeat surgery is a well-described and potentially lethal complication [1]. Precise anatomical information is important for planning the surgical approach in reoperative cardiac surgery. The standard preoperative work-up including coronary angiography and chest X-ray may provide unsatisfactory information about the exact anatomical location of grafts [2]. This case report illustrates the value of preoperative computed tomography angiography (CT angiography) in patients undergoing repeat cardiac surgery after prior aortocoronary bypass surgery.

Fate of transcatheter valve-in-valve implantation and redo cardiac surgery for failing bioprosthetic valves in patients with high operative risk

Purpose: Transcatheter valve-in-valve implantation is a feasible treatment for patients with failing cardiac bioprostheses who have increased operative risk. The study aimed to compare the outcome of this therapy with redo cardiac surgery. Methods: The study compared the survival of patients with failing cardiac bioprostheses or mitral valve annuloplasty treated with transcatheter valve-in-valve with high risk patients who underwent redo cardiac surgery in a single institution. Results: Overall 16 patients (age 80±2 years, 25% male) underwent transcatheter valve-in-valve procedure and 16 patients (age 70±1 years, 50% male) redo valve surgery. The valve in valve treated group was comparable with surgery treated group with respect to logistic Euroscore (34.1±14.6% vs. 30.8±20.3% p=0.605), New York Heart Association functional class (≥III: 9 (56%) vs. ≥III 7 (44%), p=1.000) and left ventricular ejection fraction (37% (27-52) vs. 40% (26-57), p=0.724). After a median follow up of 21 (7-44) months, overall 10 (30%) patients died. One-year survival of patients treated with valve-in-valve did not differ from those treated with redo surgery (75% vs. 72%, respectively; log-rank p=0.939). Conclusion: Patients with failing cardiac bioprostheses and high operative risk treated with transcatheter valve-in-valve have similar survival compared to high risk patients undergoing redo cardiac surgery.

To stent or not to stent - a challenging decision in a rare condition

Introduction: In this case we discuss the management of a patient with recurrent acute coronary syndrome due to Takayasu arteritis (TA). Case report description: In 2007, a 13-year-old Caucasian male with angina, electrocardiographic and troponin abnormalities consistent with an acute coronary syndrome, and widespread bruits, was found to have multiple arterial stenoses involving the aorta, renal and carotid arteries. The erythrocyte sedimentation rate was 32mm (0-7), C reactive protein 36 mg/L (0-7) with a mild normocytic anaemia. Coronary angiography showed triple vessel disease and he was diagnosed with TA with coronary artery involvement. Coronary artery bypass graft surgery (free left internal mammary graft to the left anterior descending artery and sequential saphenous vein graft to the intermediate and left posterolateral vessels) was performed. The patient received intensive medical therapy and angioplasty for hypertension due to bilateral renal artery stenosis. His condition continued to progress and angina recurred in 2012 with coronary angiography demonstrating occlusion of the vein graft segment to the posterolateral artery. The patient was managed medically but was diagnosed with a non-ST elevation myocardial infarction in 2013 due to occlusion of the vein graft to the intermediate. He suffered ongoing symptoms of cardiac ischaemia and after discussion with the Cardiosurgical team a decision was made to treat the diseased native right coronary artery by percutaneous coronary artery intervention (PCI) with drug eluting stents. Despite this measure the patient has experienced ongoing angina and further PCI to the ungrafted left coronary artery territories is under consideration. Discussion: TA most commonly presents in 20-30 year-old females of East Asian descent and coronary artery involvement in children is very rare. From a cardiac perspective this case highlights the challenge of managing coronary artery disease in the setting of active large vessel vasculitis. Limited data exist to guide clinicians in this setting. Whether redo cardiac surgery at age 18 would be superior to a percutaneous approach is unclear. Implications to clinical practice: 1. Our case highlights the importance of considering vasculitis in the differential diagnosis of a young patient presenting with chest pain. 2. Rare clinical scenarios can pose a management dilemma for the treating physician due to the paucity of supporting research available to direct the decision making process. Treatment strategies should be decided on a case-by-case basis and consensus opinion from the multidisciplinary team is recommended.

EComment. Efforts to further enhance the safety of sternal re-opening in the paediatric age group

We thank Gandolfo et al. for their effective and easy reproducible technique for managing major vessel injuries during chest re-entry in children [1]. As diagnostic and therapeutic interventions in congenital heart diseases advance progressively, cardiac surgeons have begun to deal with chest re-opening more frequently. Although major venous damages like innominate vein can be managed by a Fogarty catheter, cardiac surgeons are still facing challenging problems, such as damage of cardiac chambers, retrosternal right ventricle to pulmonary artery conduits and ascending aortic aneurysms during the re-sternotomy procedures performed in children. In such cases, we believe that the inflation of Fogarty catheters may even enlarge the defect and make it more uncontrollable in an incomplete sternotomy. In our practice, patients with a sternotomy history are carefully evaluated before the operation. Although the best option in imaging work-up is computed tomography, its routine usage is avoided so as not to increase the exposure of ionizing radiation in the paediatric age group. In most of the patients with redo cardiac surgery, magnetic resonance angiography or lateral projection of cardiac cine-angiography studies demonstrate the potential adhesions of the anatomic structures to the posterior part of the sternum. At the operation, we regularly mark the femoral vessels with Doppler ultrasonography and prepare a cardiopulmonary bypass (CPB) set-up before initiating the incision. The skin incision is performed subsequently, the sternal wires are untwisted and an oscillating saw is used to open the anterior table of the sternum until contact with the sternal wires at the posterior side is felt. The untwisted wires are held with clamps and the sides of the sternum are pulled upwards in which a lateral retraction force is strictly avoided. Afterwards, the posterior table of the sternum is carefully opened starting with xiphoid process towards the jugular fossa with the aid of Mayo scissors. We believe hyperinflation of the lungs, which decompresses the right atrium and ventricle, is a safe and easy measure during this part of the re-entry process [2]. We neither use electrocautery nor blunt digital manipulation for the dissection of the mediastinum. As described by Holst et al. we can clinically group cardiac injuries during sternal re-entry procedures into two categories [3]. A cardiac injury in re-sternotomy is an anticipated (i.e. expected) injury when there is a conduit, an aortic aneurysm, an enlarged right atrium or ventricle which is adherent to the posterior surface of the sternum. In such cases, we prefer to initiate CPB with femoral arterial and venous cannulation before sternal re-entry. This provides us with a safer re-entry process in the mediastinum with decompressed cardiac chambers. The main disadvantage of initiating CPB at the early stage of surgery is the prolonged duration of CPB and uneasiness of controlling the haemostasis in a heparinized patient. CPB may be discontinued after the safe entry to the mediastinum and dissection may be completed off-pump in order to shorten the CPB time. In unanticipated injuries, when a massive bleeding occurs, we discontinue the re-sternotomy and join the two sides of the sternum with two towel clamps. The femoral artery and vein are then promptly cannulated before further dissection at the mediastinum after which CPB is initiated. As a result, besides meticulous surgical technique and judicious usage of CPB, we believe that simple and easily applicable precautions can decrease the incidence of cardiac injuries being encountered during sternal re-opening procedures. These precautions will obviously stipulate a prudent, safe and bloodless operative field for the surgical team. Conflict of interest: none declared.

Severe Aortic Regurgitation, Aortic Valve Preserving Procedures: A Viable Alternative to Prosthetic AVR

Severe Aortic Regurgitation, Aortic Valve Preserving Procedures: A Viable Alternative to Prosthetic AVR

EComment. Is the sternal closure technique using titanium hooks and wires cost-effective?

The publication by Kilian et al. proposes a new technique for sternal closure in patients with secondary or additional stabilization [1]. They successfully performed the new technique using titanium hooks and wires in 15 patients and revealed very satisfactory results. The most striking feature was the possible avoidance of substernal dissection in redo cases with sternal instability, thereby decreasing the risk of graft or myocardial/pulmonary injury. We congratulate the authors for their effort and successful results. We believe that there is one more topic to be emphasized on this subject. It is very well known that substernal dissection in redo cardiac surgery including sternal repair may lead to injury in adjacent structures. In this context, the use of thermoreactive nitinol clips was reported recently by our group [2]. We documented the ease of the technique due to the nature of the material and the parasternal application procedure. Moreover, we also reported the cost-effectiveness of the method. From the early years of cardiac surgery, various reports documenting sternal re-closure techniques have been published. The most frequently employed technique is still the Robicsek weave [3]. It is simple, cheap and objectively effective. The only drawback is the need for substernal re-dissection. In our study, we also compared the costs of sternal re-closure methods avoiding substernal re-dissection. The cost for thermoreactive nitinol clip implantation was $550; $700-1400 for rigid-plate fixation and $8500 for the transverse sternal-plating system. We concluded that thermoreactive nitinol clip implantation was more advantageous. We think that the authors should also have done a cost analysis to provide readers with a possible comparison between the mentioned techniques. Conflict of interest: none declared.

Managing major vessel injuries with a Fogarty catheter during chest re-opening in children

Injury of structures, leading to a major bleeding during chest opening, is a severe and potentially life-threatening complication, especially in redo cardiac surgery, both in adults and children. In three paediatric redo operations performed via midline sternotomy, we managed this complication successfully and uneventfully by using an inflated Fogarty catheter to plug the blood leak from the injured vessel before repairing the lesion under direct vision in a bloodless surgical field. Herein we report in detail the technique used and a comment on our experience.

Complete graft dehiscence 8 months after repair of acute type A aortic dissection

Acute type A aortic dissection is a dreaded differential diagnosis of acute chest pain. Long-term outcome mainly depends on pre-existing comorbidities and post-operative complications. We present a patient with aortic graft dehiscence and subsequent severe aortic regurgitation due to fungal graft infection 8 months after repair of acute type A aortic dissection. Redo aortic surgery had to be delayed for 28 days due to intracerebral haemorrhage caused by septic embolism and clipping of a mycotic left middle cerebral artery aneurysm. Surgery revealed a circumferentially detached graft at the site of the proximal anastomosis thereby forming a massive pseudoaneurysm. The patient underwent successful aortic root replacement using a Freestyle porcine root bioprosthesis (25 mm), followed by re-anastomosis of the coronary arteries and partial replacement of the ascending aorta with a 28 mm Dacron graft. The patient was discharged on day 67 in stable cardiac condition with persistent neurological deficits. This case highlights the challenging management of patients with aortic graft infection and neurological dysfunction after redissection of the ascending aorta who require redo cardiac surgery.

EComment. Retained temporary epicardial pacing wires in cardiac surgery

We read with great interest the best evidence topic by Shaikhrezai and colleagues regarding retained temporary epicardial pacing wires (TEPWs) in cardiac surgery and we agree with their recommendations [1]. TEPWs are used routinely in the postoperative period following cardiac surgery and its use is associated with low morbidity and mortality [1, 2]. Significant predictors for pacing in the postoperative period include diabetes mellitus, preoperative arrhythmias and need for pacing during the operation (coming off cardiopulmonary bypass, etc). If patients with these risk factors were excluded, only 2.6% patients of coronary artery bypass graft (CABG) surgery will require pacing [2]. The incidence of major complications following TEPWs removal is 0.04% [2]. The risk of complications is higher in redo cardiac surgery and anti-coagulated patients [2]. Patients' vital signs should be monitored following the removal of TEPWs to allow early and prompt identification of related potential complications [2]. Retained TEPWs rarely cause problems [1, 2]. Chung and Smith have reported on two cases of delayed presentation of anterior mediastinal foreign body reaction secondary to retained TEPWs [3]. The first case was related to a 59-year-old man who had CABG and six years later, presented with an abscess in the lower third of his sternotomy incision, which was treated with debridement and removal of the underlying sternal wires. Even though the wound had healed well, a mid-sternal swelling combined with right subcostal sinus eventually developed [2]. A computed tomography scan showed a retrosternal, ill-defined area of soft tissue extending into the superior mediastinum containing the retained TEPWs. The patient was treated successfully with opening of the sinus, removal of the TEPWs and remaining sternal wires with healing of the wounds by secondary intention [3]. The second case was quite similar to the first one and was related to a 64-year old woman who had CABG and five years later was presented with abscess in the lower third of the sternotomy scar. The same approach with the first case was used successfully after confirmation with a CT scan of the retrosternal collection associated with retained TEPWs [2]. Lyons et al., in 1986, have reported on four cases with infection and bacteraemia due to retained TEPWs [3]. The authors illustrated that the failure of removal of the TEPWs should be considered as a real surgical complication and not just a trivial event [4]. In conclusion, because it is suggested that off-pump CABG may be associated with reduced requirement of TEPWs, its routine insertion might be considered carefully [2, 5]. In the case of retained TEPWs, the patient has to be aware of any related potential complication, the incident has to be documented in the patient records and its inclusion in the differential diagnosis of any relevant postoperative complication is of paramount importance [1]. Conflict of interest: none declared

Implantation of a HeartMate II Left Ventricular Assist Device via Left Thoracotomy

Left thoracotomy was used as an approach for the implantation of pulsatile ventricular assist devices. Avoiding the standard approach of median sternotomy is attractive in patients undergoing complicated redo cardiac surgery, especially with prior mediastinal radiation. We report a case of the use of left thoracotomy for the implantation of the HeartMate II axial-flow pump.

Saphenous Vein Cannulation in Re-Redo Cardiac Surgery

The widely used peripheral vein site of cannulation (i.e., the femoral vein) cannot always be employed in the setting of re-redo procedures. We propose a safe and simple surgical technique for a femoral vein cannulation using the greater saphenous vein as the inflow tract for the venous drainage in the setting of redo cardiac surgery.

The Surgical Treatment of Concomitant Atrial Arrhythmias During Redo Cardiac Operations

With improving surgical care yielding better outcomes, patients who have undergone a cardiac operation are surviving longer, and surgeons will inevitably face an increasing number of reoperative procedures. There are few data reporting risk and outcome for patients undergoing atrial fibrillation ablation in this clinical setting. From January 1994 through May 2009, we performed surgery for AF in 245 patients (134 female) who have had at least1 prior cardiac operation. Median age was 45 years (range 1 to 75 years) and preoperative atrial fibrillation was paroxysmal in 161 patients (66%). Most common cardiac diagnoses included Ebstein anomaly (n=43), tetralogy of Fallot (n=36), and acquired valvular or ischemic heart disease (n=35). Median prior sternotomies was 1 (range 1 to 6). Ablative lesions most commonly included isolated right-sided maze (n=123; cryothermy in 84, cut and sew in 39), biatrial maze (n=52; cryothermy in 26, cut and sew in 26), and right atrial isthmus ablation (n=41; isolated in 30, concomitant in 11). There were 14 early deaths (5.7%). New permanent pacemaker was required in 39 patients (18%); indication was complete heart block in 9. Rhythm at late follow-up (median: 4.1 years, maximum: 17.2 years) was 89% in the setting of congenital heart disease and 78% in acquired heart disease. Atrial fibrillation is common with a variety of pathologies requiring redo cardiac surgery. Lesion set and energy source are dependent on primary procedure. Concomitant AF ablation during redo cardiac reoperations can be performed with reasonable safety and success.

111 Development of a Novel Scorecard Predicting In-Hospital Mortality Following Redo Cardiac Surgery

Redo cardiac surgery is known to be associated with a high rate of morbidity and mortality. Most of the literature, however, focuses on risk factors for adverse outcome following redo coronary surgery. The objective of this study was to identify independent predictors of in-hospital mortality following redo cardiac surgery of various types and to develop an easy to use predictive scorecard. All patients at a single institution who received cardiac surgery via sternotomy multiple times between 1995 and 2010 were included. Thoracotomy procedures, ventricular assist device implantations, and transplants were excluded from the study population. Clinical characteristics of patients who survived and patients who died after redo surgery were examined univariately. Variables with p-value <0.2 or those considered to be clinically relevant were retained for multivariate analysis. A logistic regression model was developed and variables were retained if the final p-value was <0.05. The final model was then used to create a scorecard. 1521 out of 17645 patients were included in the study. The unadjusted in-hospital mortality for patients undergoing redo surgery was 9.7% compared to 3.4% for those undergoing a first time procedure (p<0.001). The following variables were identified as independent predictors of in-hospital mortality following redo cardiac surgery of various types: a composite urgency variable that included active endocarditis, urgent or emergent redo surgery, myocardial infarction within 21 days of the redo procedure, or preoperative intra aortic balloon pump (OR=3.47); older age (70-79 OR=2.74, >=80 OR=3.32); >2 previous sternotomies (OR=2.69); current procedure other than isolated coronary or valve surgery (OR=2.64); preoperative renal failure (OR=1.89); and peripheral vascular disease (OR=1.55) - all p<0.05. These variables were used to generate a scorecard that stratifies patients undergoing redo cardiac surgery into 6 categories of in-hospital mortality risk ranging from <5% to >40% risk. Redo cardiac surgery is often associated with significantly higher in-hospital mortality than first time procedures. As far as we know, we have created the first preoperative scorecard for predicting in-hospital mortality specific to redo procedures of various types. The scorecard is easy to use and can assist clinicians in identifying the most appropriate candidates for redo surgery.

Predicting In-Hospital Mortality After Redo Cardiac Operations: Development of a Preoperative Scorecard

The present study generated a risk model and an easy-to-use scorecard for the preoperative prediction of in-hospital mortality for patients undergoing redo cardiac operations. All patients who underwent redo cardiac operations in which the initial and subsequent procedures were performed through a median sternotomy were included. A logistic regression model was created to identify independent preoperative predictors of in-hospital mortality. The results were then used to create a scorecard predicting operative risk. A total of 1,521 patients underwent redo procedures between 1995 and 2010 at a single institution. Coronary bypass procedures were the most common previous (58%) or planned operations (54%). The unadjusted in-hospital mortality for all redo cases was higher than for first-time procedures (9.7% vs. 3.4%; p<0.001). Independent predictors of in-hospital mortality were a composite urgency variable (odds ratio [OR], 3.47), older age (70-79 years, OR, 2.74; ≥80 years, OR, 3.32), more than 2 previous sternotomies (OR, 2.69), current procedure other than isolated coronary or valve operation (OR, 2.64), preoperative renal failure (OR, 1.89), and peripheral vascular disease (PVD) (OR, 1.55); all p<0.05. A scorecard was generated using these independent predictors, stratifying patients undergoing redo cardiac operations into 6 risk categories of in-hospital mortality ranging from <5% risk to >40%. Reoperation represents a significant proportion of modern cardiac surgical procedures and is often associated with significantly higher mortality than first-time operations. We created an easy-to-use scorecard to assist clinicians in estimating operative mortality to ensure optimal decision making in the care of patients facing redo cardiac operations.

Midterm outcomes of patients undergoing aortic valve replacement after previous coronary artery bypass grafting

Redo cardiac surgery for aortic valve replacement (AVR) after previous coronary artery bypass grafting (CABG) is technically challenging and carries a high incidence of peri-operative complications. However, experience in the field continues to evolve generating reproducible, and increasingly safer results. We anticipate an increased future role for catheter-based valve procedures and review our operative results to maintain current surgical outcomes for comparison. A retrospective review was conducted from 1996 through 2010 of patients undergoing AVR as a re-operation after previous CABG. Data were obtained through query of the Society of Thoracic Surgeons (STS) database and chart review. Patient outcomes were compared with STS-predicted risk scores. One hundred and thirty-two patients met inclusion criteria (male 83%, female 17%). Average age was 76 (± 7). Thirty-seven patients (28%) required concomitant CABG. Average ejection fraction was 45 (± 14). Comorbid conditions included: diabetes 37% (49/132), hypertension 87% (115/132), NYHA class III/IV 83% (110/132), smoking 51% (67/132), chronic obstructive pulmonary disease 21% (27/132), history of myocardial infarction 61% (80/132), renal failure 16% (21/132) and peripheral arterial disease 38% (50/132).Operative (30-day + hospital) mortality was 6.1% (8/132; 95% CI = 2.9-12.0%), and 30-day mortality was 3.8% (5/132; 95% CI = 1.4-9.1%). One, three and five-year survival rates were 86, 74 and 62%, respectively. Complication rates were as follows: re-operation for bleeding 2.3% (3/132), permanent stroke 0.8% (1/132), prolonged ventilator requirement 18.2% (24/132), deep sternal wound infection 0% (0/132; CI = 0.0-3.5%) and renal failure 9.1% (12/132; none required dialysis). The mean STS-predicted mortality risk score was 7.8% for 111 (applicable) patients for whom actual operative (30-day + hospital) mortality was 3.6%. Low initial operative mortality suggests that surgery is safe and reproducible. However, older age and multiple comorbidities in this patient population may significantly influence late outcomes. The data reported in this study: (i) support open surgical technique as a safe, reliable approach for redo AVR in patients who have undergone previous CABG, and (ii) add to the large body of evidence suggesting that STS scores overestimate risk.