Reoperative Coronary Artery Bypass Surgery Research Articles

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

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.

Invited Commentary

The old adage “there are a hundred ways to skin a cat” is aptly applicable to this article by Takahashi and colleagues [1Takahashi K. Takeuchi S. Ito K. Chiyoya M. Kondo N. Minakawa M. Reoperative coronary artery bypass surgery: avoiding repeat median sternotomy.Ann Thorac Surg. 2012; 94: 1914-1919Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar]. They have found many approaches, techniques, and conduits to perform revascularization in their patients coming for reoperation. The article highlights the resourcefulness of the authors. They deserve appreciation and applause. Takahashi et al. have demonstrated by comparison that by avoiding resternotomy, they have abolished altogether all mortality and complications in 79 patents. They have also demonstrated the safety and feasibility of using various arterial conduits, inflow sites, and routes to accomplish satisfactory revascularization. Most of their patients required one or two bypass grafts. Perhaps the authors plan to provide graft patency data in the future. Resternotomy is associated with a high risk of problems, such as catastrophic or fatal hemorrhage and injury to patent grafts, because as surgeons we do not generally take the necessary care to make reoperation safe. The large majority of surgeons ignore the risk of not covering the heart or routing coronary grafts across the midline. In my four decades of experience (12,000 operations), I have closed the pericardium (or mediastinal fat, pleura, or thymus) over the heart to avoid these very complications. This was done in all operations including coronary bypass operations. Routing the right internal thoracic artery through the transverse sinus and bringing posterior grafts through the transverse sinus have allowed such complete pericardial cover without compression or other adverse effects. In more than 500 resternotomies, there were none of these complications if at the primary surgery the pericardium was closed and the safety cover for the heart was restored. I believe this article highlights two learning opportunities. 1Take adequate steps at primary surgery (cover the heart and do not route grafts across the midline) to ensure safe resternotomy.2Use alternate routes, conduits, and inflow sites (proximal anastomoses) when redo surgery is inevitable in patients at risk of resternotomy. Reoperative Coronary Artery Bypass Surgery: Avoiding Repeat Median SternotomyThe Annals of Thoracic SurgeryVol. 94Issue 6PreviewMortality and morbidity in reoperative coronary artery surgery are considered to be higher than those for initial surgery. Contributing factors include cardiac injury and damage to patent grafts in repeat median sternotomy. To avoid these complications, reoperative cases were performed off pump to avoid repeat median sternotomy. Full-Text PDF

Late outcomes after radial artery versus saphenous vein grafting during reoperative coronary artery bypass surgery

We investigated whether use of radial artery versus saphenous vein grafts during coronary artery bypass grafting reoperations is associated with a significant long-term survival benefit. We reviewed a series of 347 consecutive coronary artery bypass grafting reoperations (1996-2007; 270 [78%] male patients; age, 65.3 +/- 9.2 years). Internal thoracic artery grafts were used in 248 (71%) patients at the time of the first coronary artery bypass grafting operation and in 154 (44%) patients at reoperation. Patients were grouped based on whether a functional radial artery graft was present after coronary artery bypass grafting reoperation (radial artery cohort, n = 203 [59%]) or not (saphenous vein cohort, n = 144 [41%]). Median time to reoperation was similar for the radial artery (10.3 years) and saphenous vein (10.1 years) cohorts (P = .55). Angiographic data were used to ascertain the number and type of grafts that remained functional from initial coronary artery bypass grafting. Survival data (< or = 12 years) were time segmented based on multiphase hazard modeling at 90 days, and late survival was then analyzed by using proportional hazard Cox regression, with risk adjustment based on a radial artery-use propensity score computed from 48 covariates, including time to reoperation, month of surgical intervention, and total arterial and vein grafts after reoperation. Propensity-matched and propensity quintile comparisons were also done. Follow-up was similar for the radial artery versus saphenous vein cohorts (5.7 +/- 3.4 vs 5.8 +/- 4.0 years, P = .86), and 112 (50 in the radial artery and 62 in the saphenous vein cohorts) deaths were documented. Early mortality (< or = 90 days) did not differ for the radial artery (7.4%) and saphenous vein (12.5%) cohorts (P = .14). Unadjusted late outcomes were superior for the radial artery versus saphenous vein cohorts, with survival of 97.3% versus 92.9%, 84.9% versus 77.2%, and 74.1% versus 60.3% at 1, 5, and 10 years, respectively. Propensity-adjusted radial artery survival was superior, with a hazard ratio of 0.58 (P = .04), and this result was confirmed in a propensity-matched comparison. We conclude that the use of radial artery as opposed to saphenous vein grafting for reoperative coronary artery bypass grafting, either with or without concomitant internal thoracic artery grafts, is associated with a substantial improvement in late survival. This benefit is likely derived from the increased overall number of arterial grafts.

Invited Commentary

The use of three dimensional multi-detector computed tomographic angiography (MDCTA) in assessing patients requiring reoperative cardiothoracic surgery has brought diagnostic information to a new level. The results of reoperative cardiac surgery have been improving despite the increased comorbidities of these patients prior to the introduction of MDCTA. New strategies have evolved such as non-sternotomy approaches, for example, mini-anterior and lateral thoracotomy. Conventional median re-sternotomy has been simplified by creating a mini-tunnel confined to the immediate posterior aspect of the sternum with improved protection of the right ventricle and mediastinal structures. Pharmacologic decompression and peripheral cannulation, either by the axillary or transfemoral routes, and deep hypothermic cardiac arrest minimize trauma to retrosternal coronary artery bypass grafts, the right ventricle, and the aorta, thus minimizing blood loss. Development of new anesthetic, myocardial protection strategies together with improved management of postoperative comorbidities have further contributed to narrowing the mortality gap between primary and reoperations [1Sabik 3rd, J.F. Blackstone E.H. Houghtaling P.L. Waits P.A. Lytle B.W. Is reoperation still a risk factor in coronary artery bypass surgery?.Ann Thorac Surg. 2005; 80: 1719-1727Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar]. Introduction of three-dimensional imaging of important mediastinal structures provides new information that may further improve the level of safety and comfort for the reoperative surgeon. An MDCTA provides detailed information about graft patency and disease with a diagnostic accuracy approaching selective angiography [2Min J. ACCURACY: CT Angiography Accurately Diagnoses Coronary Stenosis.http://www.theheart.orgGoogle Scholar, 3Jones C.M. Athanasiou T. Dunne N. et al.Multi-detector computed tomography in coronary artery bypass graft assessment: a meta-analysis.Ann Thorac Surg. 2007; 83: 341-348Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar]. Recognition and avoiding SV disease minimizes distal atheroembolism. Defining the interrelationship of the bypass grafts and the native vessels assists the surgeon in protecting grafts and locating target arteries. An additional benefit has been the serendipitous findings of unsuspected pulmonary and mediastinal masses. Previously undiagnosed intrathoracic lesions have been found in about 10% of elderly patients undergoing reoperative coronary artery bypass surgery. New iterations of MDCTA with submillimeter definition improve diagnostic accuracy minimizing motion, calcification, and stent artifacts. Incorporation of functional measurements may alter future practice [4Jones C.M. Athanasiou T. Dunne N. et al.Multi-slice computed tomography in coronary artery disease.Eur J Cardiothorac Surg. 2006; 30: 443-450Crossref PubMed Scopus (22) Google Scholar]. Although the striking MDCTA images are of great assistance to the surgeon, complications from additional radiation exposure and introduction of iodine containing dye subject the patients to potential complications of radiation therapy and renal failure. The use of MDCTA is not applicable to patients with an emergent presentation as this may delay surgery. A strategy of routine MDCTA prior to a reoperation therefore requires balancing the risks and benefits. In the situation where urgent re-do surgery is required, it may be sufficient to perform a non-contrast MDCTA, which, while not giving precise information about bypass grafts, does at least demonstrate the position of the aorta and innominate vein in relation to the back of the sternum, which may be sufficient, depending on the procedure that was previously performed. The authors [5Kamdar A.R. Meadows T.A. Gorodeski E.Z. et al.Multi-detector computed tomographic angiography in planning of reoperative cardiothoracic surgery.Ann Thorac Surg. 2008; 85: 1239-1246Abstract Full Text Full Text PDF PubMed Scopus (91) Google Scholar] have demonstrated a low mortality and morbidity after being forewarned of the proximity of bypass grafts and aorta to the posterior aspects of the sternum, thus enabling alternative strategies to be implemented in high-risk patients. Such information is particularly useful in a referral practice where the details of bypass graft anatomy from the primary surgery are not known. Inadequate mobilization of the internal thoracic artery, excessive length, adherence to the sternum, and crossover grafts less than 1 cm behind the sternum make it prone to injury. Coronary artery disease and dilatation of the right ventricle as a result of mitral valve disease represent a high-risk subgroup. The absence of appropriate control data (level C) evidence confirms that no strong recommendations can be made on scientific grounds. The early observational data and benefits to the surgeon suggest that MDCTA will find an important place in the management of most patients presenting for elective reoperative cardiac surgery. Multidetector Computed Tomographic Angiography in Planning of Reoperative Cardiothoracic SurgeryThe Annals of Thoracic SurgeryVol. 85Issue 4PreviewRedo cardiothoracic surgery is associated with increased morbidity and mortality compared with primary operations. Multidetector computed tomographic angiography (MDCTA) delineates the course of previous coronary artery bypass grafts (CABG) and proximity of mediastinal structures to the chest wall. We sought to determine if high-risk preoperative MDCTA findings were associated with greater use of preventive surgical strategies during redo cardiac surgery in patients with prior CABG. Full-Text PDF

Toracotomia esquerda para reoperação de revascularização miocárdica

To describe patient selection criteria, surgical technique and early outcomes in patients undergoing reoperative coronary artery bypass surgery (RECABG) through a left thoracotomy without cardiopulmonary bypass (CPB). Eight patients with patent grafts to the anterior interventricular branch of left coronary artery (four of which had also patent grafts to the right coronary artery) requiring revascularization of the circumflex coronary system had redo-CABG without CPB through a left posterolateral thoracotomy. There was no in-hospital mortality or serious postoperative complications. All patients are angina-free. An off-pump redo-CABG through a left posterolateral thoracotomy may reduce risks attributable to resternotomy in patients who met the selection criteria.

809-1 The changing profile of first reoperative coronary artery bypass surgery: Trends over 17 years in 2,770 patients

809-1 The changing profile of first reoperative coronary artery bypass surgery: Trends over 17 years in 2,770 patients

Elimination of cardiopulmonary bypass: a prime goal in reoperative coronary artery bypass surgery.

The purpose of this study was to evaluate morbidity and mortality in reoperative coronary artery bypass surgery using the New York State database. Patients undergoing reoperative coronary artery bypass between January-1995 and December 1996 were included. Patients were operated using cardiopulmonary bypass (CPB group, n = 184) or without cardiopulmonary bypass (non-CPB group, n = 105) by surgeon preference. Groups were compared for preoperative risk factors, postoperative mortality and major complications. Crude mortality was lower in the non-CPB group, despite a higher expected mortality, resulting in a risk-adjusted mortality of 1.3% versus 2.7% for the CPB group (NS). Of non-CPB patients, 91.4% were without complications, while only 72.1% of CPB patients (P < 0.0001) were complication-free. Major complications were significantly reduced in non-CPB patients compared to CPB patients: stroke 0% versus 3.8% (P < 0.04), cardiovascular complications 4.8% versus 15.8% (P < 0.005), other major complications 1.9% versus 10.4% (P < 0.007). Postoperative IABP support was needed in 1.9% of the non-CPB group patients and in 14.2% of the CPB group (P < 0.0007). The main object of reoperative CABG is to relieve symptoms, since the survival benefit of the procedure has not been demonstrated. Performance of reoperative coronary artery bypass surgery without cardiopulmonary bypass significantly reduces morbidity. We conclude that cardiopulmonary bypass should be avoided whenever possible in reoperative coronary bypass surgery.

Reoperative coronary artery bypass grafting

In recent years reoperative coronary artery bypass surgery has become increasingly more commonplace. This article reviews the current status of this procedure with regard to patient population, risk factors, and long-term follow-up. Important aspects of the specific technical considerations involved in reoperative surgery are also reviewed and evaluated.

Protection of the internal mammary artery pedicle with polytetrafluoroethylene membrane.

With increasing frequency, reoperative coronary artery bypass surgery is being performed in the setting of a patent internal mammary artery (IMA) graft. Injury to the IMA graft at reoperation can result in ischemic myocardial injury and cardiac arrest. This descriptive laboratory study examined use of a polytetrafluoroethylene (PTFE) membrane wrap to protect the IMA pedicle during sternal reentry. Six pigs (25-30 kg) underwent median sternotomy and takedown of left and right IMAs. Grafts were implanted in the epicardium by a modified Vineberg procedure. In each animal, one IMA was wrapped circumferentially with PTFE, while the contralateral bare IMA served as the control. Redo sternotomy was performed 3 months later. Severe adhesions between chest wall, myocardium, and bare IMA grafts were encountered in six of six animals. PTFE-wrapped IMAs were easily identified by appearance and by palpation. There was no adherence between PTFE membranes and surrounding tissue, nor was there evidence of cellular infiltration, disruption, or contraction of the membrane. Most notably, PTFE membranes could not be cut or injured with the electrocautery, since they are electrical nonconductors. This study demonstrates that PTFE membrane: (1) is relatively inert and incites minimal surrounding tissue reaction; and (2) is impenetrable to electrocautery injury. Further studies are necessary to determine the impact of PTFE membrane on IMA graft patency and wound infection. PTFE membrane may prove clinically useful in protecting patent IMA pedicles during reoperative cardiac surgery.

Patients' learning priorities for reoperative coronary artery bypass surgery.

This study describes the perceived learning priorities of patients undergoing reoperative coronary artery bypass surgery (CABS). The study also examines whether reoperative CABS patients' learning priorities are different from those of patients undergoing initial CABS. Data were collected by means of a 40-item questionnaire from 16 reoperative and 20 initial CABS patients during the postintensive care hospital period and again 3 months after discharge. Reoperative patients most frequently rated most items as "very important" to learn about. Few of the 40 items were rated differently by reoperative and initial CABS patients. Inhospital, reoperative patients more frequently rated "knowing who all the doctors and nurses are" as very important. After discharge, reoperative patients more frequently rated "waiting before surgery" and "sharing a room with others" as very important while less frequently rating "coping with stress" as very important. The results suggest that reoperative CABS patients rate learning as very important and that reoperative CABS patients have learning priorities similar to those of initial CABS patients.

Demographic changes in coronary artery bypass surgery and its effect on mortality and morbidity

Over the past 4-5 years, possibly with the advent of percutaneous transluminal coronary angioplasty (PTCA), there has been a changing patient population for coronary artery bypass surgery (CABS) with a gradual increase in the operative mortality. In an attempt to analyze the changing demographics in patients undergoing CABS and its effect on operative mortality, we analyzed data from 5536 consecutive patients undergoing isolated CABS. There was 4151 patients less than 70 years of age and 1385 patients greater than 70 years. Reoperative CABS procedures were performed in 385 patients, and CABS for post infarction unstable angina pectoris was performed in 578 patients. During the same time period, 2910 patients underwent PTCA. The mean age of bypass patients was 68.5 years with 38% being 70 years or older. The left ventricular ejection fraction in patients undergoing CABS averaged 38%. The average number of bypasses performed was 3.1. In comparison, patients presenting for PTCA were younger (average age 55), had normal ejection fractions (average 55%) and were predominantly treated for single or double vessel disease. The hospital mortality for elective CABS in patients less than 70 years of age was 1.8%, for reoperative CABS 3.6%, for post infarction unstable angina pectoris 4%, and for patients greater than 70 years 8%, for a combined operative mortality of 4.8%. These data suggest that because of the increasing number of elderly patients (greater than 70 years of age), and the increasing number of reoperative CABS cases and acute myocardial infarction patients with unstable angina pectoris presenting for CABS, the operative mortality will continue to rise.

S-II-5 冠動脈再手術に関する諸問題

S-II-5 冠動脈再手術に関する諸問題