Related Experiment Videos
Reoperative CABG using left thoracotomy: a tailored strategy
J G Byrne1, L Aklog, D H Adams
1Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, Massachusetts 02115, USA. jgbyrne@bics.bwh.harvard.edu
Insights
Reoperative coronary artery bypass grafting (CABG) via left thoracotomy is complex. A tailored strategy using multiple techniques, including off-pump CABG, offers a viable approach for challenging cases.
Area of Science:
- Cardiovascular Surgery
- Thoracic Surgery
Background:
- Reoperative coronary artery bypass grafting (CABG) through a left thoracotomy presents significant surgical challenges.
- A dominant surgical approach for this procedure has not been established.
Purpose of the Study:
- To present a tailored strategy for reoperative CABG via left thoracotomy.
- To integrate newer technologies into surgical decision-making for these complex patients.
Main Methods:
- A consecutive series of 50 patients undergoing reoperative CABG via left thoracotomy between 1991 and 1999.
- Surgical approaches included conventional cardiopulmonary bypass (n=33), Heartport endoaortic balloon occlusion (n=4), and off-pump beating heart techniques (n=13).
- Patient demographics and graft patency rates were recorded.
Main Results:
- The off-pump CABG technique was increasingly utilized in later cases.
- Operative mortality was 6% (3 of 50 patients), with deaths occurring in the conventional and endoaortic occlusion groups.
- The mean length of hospital stay for survivors was 7.8 days.
Conclusions:
- Reoperative CABG via left thoracotomy remains a challenging procedure.
- A combination of surgical techniques, including off-pump CABG, conventional cardiopulmonary bypass, circulatory arrest, and endoaortic balloon occlusion, should be available.
- A tailored approach based on patient indications is crucial for successful outcomes.
Background:
Reoperative coronary artery bypass grafting (CABG) through a left thoracotomy is a challenging operation with no one dominant approach. We developed a tailored strategy for this difficult group of patients, integrating the currently available newer technologies for each patient indication.
Methods:
Between October 1991 and October 1999, 50 consecutive patients underwent reoperative CABG through a left thoracotomy. Age was 65 +/- 9 years, 40 (80%) were men, and preoperative ejection fraction was 40 +/- 13. In 36 patients (72%) the left internal mammary artery had been placed to the left anterior descending coronary artery during the primary CABG and in 25 of 36 patients (70%) this left internal mammary artery-left anterior descending coronary artery graft was patent. The mean duration from previous CABG was 8.0 +/- 4.8 years. Three approaches were used: (1) conventional cardiopulmonary bypass using fibrillatory or circulatory arrest (n = 33, 66%); (2) Heartport endoaortic balloon occlusion (n = 4, 8%); and (3) off-pump beating heart techniques (n = 13, 26%).
Results:
The off-pump CABG technique was used in the majority of recent patients and 1 (7.7%) had to be converted to cardiopulmonary bypass due to hemodynamic instability. When cardiopulmonary bypass was used its duration was 122 +/- 59 minutes and mean temperature on bypass was 24 degrees +/- 6 degrees C. In the 4 patients in whom the Heartport system was used, the median endoaortic occlusion duration was 49 minutes. Patients received an average of 1.4 grafts/patient. In 60 of 70 patients (89%) distal anastomoses were performed to an anterolateral coronary target. There were 3 of 50 (6%) operative deaths, 2 in the conventional group and 1 in the endoaortic balloon occlusion group. The mean length of stay in the 47 survivors was 7.8 +/- 3.9 days (median, 7 days).
Conclusions:
Reoperative CABG by left thoracotomy remains a challenging operation. Several techniques, including off-pump CABG, conventional cardiopulmonary bypass, circulatory arrest, and endoaortic balloon occlusion, should be in the surgeon's armamentarium to allow a tailored approach for each operation based on patient indications.