Redo minimally invasive direct coronary artery bypass grafting
Stephan Jacobs1, David Holzhey, Thomas Walther
1Department of Cardiac Surgery, Heartcenter, University of Leipzig, Germany. stjacobs@aol.com
Insights
Minimally invasive direct coronary artery bypass grafting offers a viable alternative for redo procedures. This approach demonstrated acceptable survival and event-free rates in selected patients, reducing risks associated with conventional reoperations.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
Background:
- Redo coronary artery bypass grafting (CABG) carries significant risks including mortality and morbidity.
- These risks stem from manipulating patent grafts, mediastinitis, and pericardial adhesions.
- Minimally invasive direct coronary artery bypass grafting (MIDCAB) presents a potential alternative for specific patient groups.
Purpose of the Study:
- To evaluate the safety and efficacy of MIDCAB as a reoperation for coronary artery bypass grafting.
- To assess outcomes including mortality, morbidity, and long-term survival in patients undergoing MIDCAB for redo CABG.
Main Methods:
- A retrospective analysis of 46 patients who underwent MIDCAB between January 1997 and October 2003.
- Patients had prior cardiac surgery via median sternotomy, without left internal thoracic artery use, and presented with significant left anterior descending artery stenosis.
- The procedure involved using the left internal thoracic artery to bypass the left anterior descending artery on a beating heart.
Main Results:
- The in-hospital mortality rate was 4.6% (2 deaths).
- Mean hospital stay was 9.4 days, with no stroke or myocardial infarction.
- Actuarial 4-year survival was 74.8%, and 4-year event-free survival was 81%.
Conclusions:
- Minimally invasive direct coronary artery bypass grafting is a feasible alternative for redo CABG in carefully selected patients.
- This technique may reduce the risks associated with conventional redo CABG procedures.
Background:
Conventional redo coronary artery bypass grafting is associated with an increased risk of mortality and morbidity as a result of manipulation of patent grafts, mediastinitis, and the presence of pericardial adhesions. Minimally invasive direct coronary artery bypass grafting may be an alternative approach in selected patients.
Methods:
From January 1997 to October 2003, 46 patients (mean age, 66 +/- 7.4 years) underwent minimally invasive direct coronary artery bypass grafting using the left internal thoracic artery to the left anterior descending artery on the beating heart as a reoperation. Patients after previous cardiac operation by means of median sternotomy without use of the left internal thoracic artery presenting with a significant left anterior descending artery stenosis ("culprit lesion") were included. Predicted mortality was 13.6% (range, 2.4% to 72.8%) as calculated by the logistic Euroscore; ejection fraction was 0.531 (range, 0.14 to 0.81). Surgical results were analyzed for mortality, morbidity, duration of the procedure, hospital stay, and event-free survival.
Results:
Mean operating time was 103 +/- 34 minutes. There were two in-hospital deaths (4.6%), one for malignant ventricular arrhythmia (Euroscore, 60.9%) and the second as a result of severe gastrointestinal bleeding (Euroscore, 29.2%). One patient (2.3%) was successfully reoperated on because of perianastomotic hematoma using the same approach after 6 days. Patients were discharged after 9.4 +/- 2.6 days. There were no other serious adverse events, no stroke, and no myocardial infarction. During follow-up (37 +/- 21 months, complete in 92.1%), 1 patient experienced angina and 6 patients died. The actuarial 4-year survival is 74.8% (95% confidence interval, 51% to 92%), and the actuarial 4-year event-free survival including freedom from angina, major adverse cardiac events, and reintervention is 81% (95% confidence interval, 54% to 97%).
Conclusions:
Minimally invasive direct coronary artery bypass grafting can be considered as an alternative approach for redo coronary artery bypass grafting in selected patients.
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