Off-pump strategy in high-risk coronary artery bypass reoperations

To determine the role of off-pump coronary artery bypass grafting in the treatment of patients with severe recurrent angina after coronary artery bypass grafting who are not suitable for percutaneous coronary intervention and are considered too high risk for conventional on-pump revascularization.

All patients who needed single- or double-vessel revascularization at reoperation with a predicted operative mortality of 10% or higher between March 4, 1994, and December 31, 2002, were studied. Risk stratification was performed using both the Parsonnet risk scoring system and the European System for Cardiac Operative Risk Evaluation. Active follow-up by questionnaire investigated major adverse cardiac events.

This study consisted of 84 patients with a median age of 69 years (interquartile range, 62-75 years); 14 (17%) were female. All patients had class III/IV symptoms. Previous operations included multiple coronary artery bypass grafts (15 patients [18%]) and heart transplantation (1 patient [1%]). Internal thoracic artery graft from a previous operation was patent in 43 patients (51%). Perioperative hemodynamic support with inotropes (35%) and intra-aortic balloon pump (14%) or ventricular assist device (2%) was common. The surgical approach varied for each patient. One operative death (1%) occurred. Estimated survival at 5 and 7 years was 77% and 67%, respectively. Late major adverse cardiac events observed during follow-up were cardiac death (n=66), nonoperative reintervention (n=8), and nonfatal myocardial infarction (n=5).

Off-pump coronary artery bypass grafting can mitigate reoperative risk in patients with an estimated risk of 10% or higher who are undergoing single- or double-vessel revascularization with satisfactory long-term outcome.