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Published on: March 27, 2018
Reoperative coronary bypass surgery using normothermic cardiopulmonary bypass: comparison with first-time procedures
R A Ott1, R Steedman, J Eugene
1Memorial Health Care Systems, Anaheim, California, USA.
Insights
Redo coronary artery bypass grafting (CABG) carries higher risks than first-time CABG, potentially due to inadequate myocardial preservation. Current methods may not sufficiently protect patients undergoing repeat procedures.
Area of Science:
- Cardiovascular Surgery
- Cardiac Anesthesia
- Thoracic Surgery
Background:
- Redo coronary artery bypass grafting (CABG) presents increased patient risk compared to first-time CABG.
- Higher incidence of postoperative low-output syndrome suggests inadequate myocardial preservation in redo CABG.
- The optimal myocardial preservation strategy for redo CABG remains an area of investigation.
Purpose of the Study:
- To compare the efficacy of normothermic cardiopulmonary bypass with cold blood cardioplegia in first-time versus redo CABG.
- To determine if a single myocardial preservation approach is adequate for both first-time and redo CABG procedures.
- To identify clinical features distinguishing first-time from redo CABG patients.
Main Methods:
- Retrospective review of 517 consecutive CABG patients.
- Comparison of 454 first-time CABG procedures with 44 redo CABG procedures.
- Analysis of clinical features, operative mortality, and length of stay.
Main Results:
- Redo CABG patients had higher rates of previous percutaneous transluminal coronary angioplasty (71% vs 19%) and preoperative intra-aortic balloon pump use (71% vs 38%).
- Parsonnet risk scores were significantly higher in the redo CABG group (19.2 vs 11.7).
- While operative mortality was not statistically significant (6.4% vs 3.4%), redo CABG patients had a longer length of stay (8.7 vs 6.0 days).
Conclusions:
- Redo CABG is a distinct procedure from first-time CABG, necessitating enhanced myocardial preservation strategies.
- Normothermic cardiopulmonary bypass with cold blood cardioplegia may not provide adequate myocardial protection for redo CABG patients.
- Further research into improved myocardial preservation techniques for redo CABG is warranted.
Abstract:
Redo coronary artery bypass grafting (CABG) is characterized by increased patient risk compared with first-time CABG. The reason for higher risk is not completely understood but it is logically related to inadequate myocardial preservation evidenced by the higher incidence of postoperative low-output syndrome. We compared normothermic cardiopulmonary bypass with cold blood maintenance cardioplegia in both first-time and redo CABGs to determine whether this single approach is appropriate for both instances. Five hundred seventeen consecutive CABG patients were retrospectively reviewed. Four hundred fifty-four first-time CABG procedures were compared with 44 redo procedures. All aspects of the operation were identical including myocardial preservation. Retrospective univariant analysis of both groups followed. Three clinical features distinguished first-time versus redo CABG. These were previous percutaneous transluminal coronary angioplasty (first-time 19% vs redo 71%; P < 0.001), preoperative intra-aortic balloon pump (first-time 38% vs redo 71%; P < 0.001), and Parsonnet risk score (first-time 11.7+/-8.2 vs redo 19.2+/-8.8; P < 0.001). Operative mortality for redo CABG was higher than in first-time procedures (3.4% vs 6.4%; P = not significant), although small sample size limited statistical significance. The length of stay was statistically longer in redo patients (8.7+/-10.8 vs 6.0+/-5.1 days; P < 0.01) and is related to a higher Parsonnet score, increased postoperative pneumonia, and failed percutaneous transluminal coronary angioplasty before redo CABG. We conclude that redo CABG is a different operation from first-time procedures and requires enhanced myocardial preservation. Normothermic cardiopulmonary bypass with cold blood maintenance cardioplegia does not appear to achieve this goal.
