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Reinterventions for recurrent ischemic heart disease following a successful first re-do myocardial revascularization:
T K Kaul1, B L Fields, L S Riggins
1Department of Cardiac Surgery, Baptist Medical Center, Birmingham, AL, USA.
Insights
Reintervention after first re-do CABG surgery is needed in 16.81% of patients. Second re-do CABG is more effective than graft angioplasty for long-term outcomes in coronary artery bypass grafting patients.
Area of Science:
- Cardiovascular Surgery
- Interventional Cardiology
Background:
- A significant proportion of patients undergoing first re-do coronary artery bypass grafting (CABG) require subsequent reintervention.
- Understanding predictors for reintervention and outcomes of different reintervention strategies is crucial for patient management.
Purpose of the Study:
- To examine predictors for reintervention after a successful first re-do CABG.
- To evaluate the success and limitations of reintervention procedures, including graft angioplasty and second re-do CABG.
Main Methods:
- Retrospective analysis of 1796 patients who underwent first re-do CABG between March 1988 and March 1995.
- Comparison of graft angioplasty versus second re-do CABG based on patient characteristics and lesion severity.
- Analysis of predictors for reintervention and graft angioplasty failure.
- Evaluation of cardiac event rates and survival following reintervention.
Main Results:
- 16.81% of patients required reintervention after first re-do CABG.
- Graft angioplasty was preferred in older patients (≥70 years) and those with low LVEF (<30%).
- Second re-do CABG was preferred for multivessel disease, proximal occlusive disease, and longer graft disease duration.
- Lack of arterial revascularization and incomplete previous revascularization were independent predictors of reintervention.
- Cardiac event rates were higher and survival was lower following graft angioplasty compared to second re-do CABG at 8 years.
- Second re-do CABG demonstrated more effectiveness and durability.
Conclusions:
- Second re-do CABG offers more effective and durable long-term results compared to graft angioplasty after initial re-do CABG.
- Graft angioplasty can serve as a palliative option, potentially delaying high-risk surgery in selected patients.
- Predictors for reintervention and failure of specific procedures should guide treatment decisions in complex coronary artery disease management.
Abstract:
Predictors for a reintervention following a successful first re-do surgical revascularization (CABG) were examined. Success and limitations of the reintervention procedures were evaluated. Between 3/88 and 3/95, 16.81% (302/1796) patients who had undergone a first re-do CABG surgery in the authors' center, required a reintervention. Graft angioplasty was performed in 158 (52.32%) patients and a second re-do CABG in 47.68% (n = 144). Graft angioplasty was preferred over surgery in patients aged 70 years or older (43% versus 24.3%, P<0.001) and in patients with unstable angina (55.6% versus 33.3%, NS) or a Left Ventricular Ejection Fraction (LVEF) <30% (34.8% versus 20%, P<0.05). Re-do CABG was preferred over graft angioplasty for multivessel revascularization (3+/-0.3 versus 1+/-0.6, P<0.001), proximal occlusive disease (P<0.001) and for graft disease of a longer duration (7.18+/-1.7 years versus 3+/-0.6 years, P<0.01). The independent predictors of a reintervention were (i) lack of arterial revascularization and (ii) inability to achieve a complete revascularization in a previous operation. The predictors of a failed graft angioplasty were diameter stenosis >70%, long occlusive lesions (multivariate), angulation, calcification and asymmetrical lesions (univariate). Failed graft angioplasty required a re-do CABG (n = 48: early 21, late 27), repeat graft angioplasty (n = 34: early 8, late 26) or transplant (n = 1). Recurrent symptoms following a second re-do CABG required a graft angioplasty (n = 6: early 2, late 4), a subsequent re-do CABG (n = 32) or a transplant (n = 4). Cumulative incidence of cardiac events at 1 month, and 1 and 8 years were: 20, 40.45 and 66.44% following graft angioplasty and 5.5, 10 and 56.55% following a second re-do CABG, respectively (P<0.05). Actuarial survival at 1 month and 6 years following graft angioplasty were 97.15 and 77.22%, and 94.7 and 83.26% after a second re-do CABG, respectively (NS). Re-do CABG was more effective and durable. Graft angioplasty provided a good palliation in suitable cases and also postponed the need for a high-risk surgical intervention for more favorable conditions.