Rescue coronary artery bypass grafting (CABG) after aortic composite graft replacement

Aortic root replacement (ARR) has been recognized as the standard therapy for diseases of the aortic root since its introduction into clinical practice. ARR currently provides excellent long-term benefit with acceptable perioperative risk and excellent long-term morbidity and mortality. During ARR, coronary button misalignment may produce myocardial ischemia, ventricular arrhythmias, and pump failure leading to death if unrecognized. Here we review our experience with coronary insufficiency after ARR.

Between January 1995 and March 2006, 139 consecutive patients underwent ARR at Yale-New Haven Hospital. A retrospective review of their medical records was conducted. The mean age of the patients was 54.5 years. Aortic root aneurysm was the indication for surgery in 123 patients, acute type A dissection in 14, and endocarditis in two.

All patients underwent a modified Bentall operation with a mechanical (87%) or biological (13%) valve prosthesis and coronary artery button reimplantation. The overall 30-day mortality was 4.3% (six patients). Three patients (2.2%) underwent rescue coronary artery bypass grafting (CABG) to the left, right, or both coronary arterial systems for ischemia due to presumed coronary button misalignment. These patients presented with ventricular arrhythmias or hemodynamic compromise. All three showed excellent response to rescue CABG and remain alive and well in late follow-up.

Coronary insufficiency after reconstruction of the aortic root is an uncommon but acutely life-threatening occurrence. This lethal condition may present with difficulty in weaning from cardiopulmonary bypass; echocardiographic signs of major wall motion abnormalities; and electrocardiographic evidence of ischemia, pump failure, and ventricular arrhythmias. Rescue CABG in this situation is life-saving. Immediate rescue CABG should be performed if coronary ischemia is suspected after composite graft replacement of the aortic root.