How to avoid problems in redo coronary artery bypass surgery.

The objective of my presentation is to discuss the various intra- and perioperative problems related to redo coronary artery bypass surgery so that we can minimize complications during surgery and improve the final outcomes. When a patient accepts redo cardiac surgery in spite of known higher morbidity and mortality, the patient strongly believes that he will come out of this operation successfully and enjoy several more years of life. Weintraub reported that redo cardiac surgery has higher mortality and morbidity; 5% in elective cases, 11% in urgent cases, and 16.4% in emergency cases. He and associates described that the female gender, a low ejection fraction (EF), and preoperative arrhythmias are significant risk factors. Lemmer and associates described poor postoperative functional results with the majority of patients having emergency repeat coronary artery revascularization developing recurrent ischemic syndrome within a short period of time. I am outlining the problems from our experience of 543 patients in the last five years.

How to avoid problems in redo coronary artery bypass.

BACKGROUND: Redo cardiac surgery still carries higher mortality and increased morbidity as compared with primary coronary revascularizations. Various steps can be taken to decrease the incidences of adverse outcomes. From our experience, we have accumulated safe steps to be taken during the surgical procedure to reach a positive outcome. METHODS: We reviewed our own experience of redo coronary artery bypass surgery (CABG) at two institutions during the last 4 years. Though the surgeons were the same at both institutions, because of institutional variability of patient referrals, operative equipment, anesthesia management, and preoperative care, we kept the data separate. Five surgeons performed CABG with almost similar myocardial preservation techniques; however, the surgical skill varied slightly depending on the seniority and clinical experience. We performed 433 redo coronary artery revascularizations at one institution and 201 in the second institution. Fifteen percent of these patients also had additional procedures, such as valve repair, valve replacement, or aneurysm resection. In this patient group, 160 patients underwent either urgent or emergent CABG. Urgent surgery was defined as patient revascularization during the same admission as cardiac catheterization, and emergency surgery was defined as a patient undergoing surgery on the same day as the catheterization, especially when hemodynamic instability was present. The total mortality was 7%, while the elective redo CABG mortality was 3%. The length of stay ranged from 8.5 to 12.6 days. The morbidity included perioperative stroke in 18 patients and nonfatal perioperative myocardial infarction (MI) in 19 patients. Major factors contributing to the mortality were stroke, perioperative bleeding and exploration, renal failure, respiratory failure, and malnutrition. CONCLUSION: We outlined the precautions and safe surgical approaches to be undertaken during redo CABG for a successful outcome.

Exposure of the mitral valve by transecting the ascending aorta during aortic and mitral valve replacement.

Combined aortic and mitral valve operations are still considered major cardiac surgical procedures. The duration of aortic cross-clamping and cardiopulmonary bypass is longer, which increases morbidity and mortality for these combined, complicated operations. Aortic valve exposure is generally satisfactory, but mitral valve exposure may be difficult and add to the length of the aortic cross-clamping time. We have exposed the mitral valve by transecting the ascending aorta, and retracting both ends apart, to give direct access through the dome of the left atrium in 7 patients. This approach gave good exposure and did not increase the risk of complications. Exposure of the mitral valve through the left atrium using a superior approach, by transecting the ascending aorta, is a good option for patients with multiple cardiac conditions who are undergoing combined aortic and mitral valve operations.

Value of reversed saphenous vein in minimally invasive direct coronary artery bypass graft procedures.

BACKGROUND: Minimally invasive direct coronary artery bypass graft procedures are gaining acceptance for revision as well as primary coronary revascularization. When suitable, the left and right internal mammary arteries are preferred as bypass conduits; in other cases, the greater saphenous vein, used for standard coronary artery bypass graft procedures, may be useful to revascularize coronary artery branches during minimally invasive direct coronary artery bypass graft procedures. METHODS: We used the greater saphenous vein on three occasions during minimally invasive direct coronary artery bypass graft procedures (1) to revascularize the left anterior descending coronary artery by anastomosis to the left axillary artery in the infraclavicular region, (2) as an extension to the left internal mammary artery to reach the left anterior descending coronary artery, and (3) as a bridge from the splenic artery to bypass the distal right coronary artery. RESULTS: Postoperatively, all 3 patients had relief from symptoms of coronary artery insufficiency and none has been readmitted to the hospital with symptoms. Angiography or thallium studies were not performed to confirm graft patency because all patients were elderly and the risks of these procedures were considered to outweigh their potential benefit. CONCLUSIONS: The greater saphenous vein is a potential bypass conduit for use in minimally invasive direct coronary artery bypass graft procedures as well as for coronary artery bypass graft procedures.