Repeat surgery for coronary artery bypass grafting: the role of the left thoracotomy approach
David G Harris1, Andre R Coetzee, Johan T Augustyn
1Department of Cardiac Surgery and Cardiology, Kuils River Private Hospital, Cape Town, South Africa. drdharris@yahoo.co.uk
Insights
Repeat coronary artery bypass surgery using a left thoracotomy approach with off-pump techniques is safe and effective, especially for patients with intact left internal mammary artery (LIMA) grafts. This minimally invasive method reduces risks and improves outcomes in complex cardiac revascularization procedures.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
- Coronary Artery Bypass Grafting
Background:
- Repeat coronary artery bypass surgery (CABG) carries higher risks than primary operations, including potential graft injury and low cardiac output.
- The left thoracotomy approach is advantageous for patients with intact left internal mammary artery (LIMA) grafts to the left anterior descending coronary artery (LAD) requiring lateral wall revascularization.
Purpose of the Study:
- To evaluate the safety and efficacy of a left thoracotomy approach combined with off-pump coronary artery bypass grafting (OPCAB) in patients undergoing repeat CABG.
- To assess the outcomes in patients with intact LIMA-to-LAD grafts needing lateral wall grafting.
Main Methods:
- A retrospective analysis of 55 patients undergoing repeat OPCAB via left thoracotomy over 8 years.
- Patient demographics, comorbidities, previous interventions (including stents), and surgical details were recorded.
- Surgical outcomes including graft patency, conversion rates, blood loss, ventilation time, and length of stay were analyzed.
Main Results:
- The majority of patients (78.1%) had intact LIMA-to-LAD grafts.
- No patient required conversion to cardiopulmonary bypass or sternotomy; no postoperative intra-aortic balloon pump was needed.
- The in-hospital mortality rate was 1.8%, significantly lower than the predicted EuroSCORE of 14.2%.
Conclusions:
- The left thoracotomy OPCAB technique is a safe and effective option for repeat CABG, particularly in patients with patent LIMA-to-LAD grafts.
- This approach preserves cardiac and pulmonary function and offers a less invasive alternative to sternotomy.
- Preoperative planning with multislice computed tomography aids in optimizing graft implantation sites for less invasive incisions.
Objective:
Repeat coronary artery bypass surgery has increased risks compared with the first operation, including low cardiac output and injury to patent grafts. The left thoracotomy approach has been advocated specifically in patients with intact grafts of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) needing lateral wall grafting. We have evaluated this technique in conjunction with an off-pump procedure in all patients.
Methods:
There were 55 patients over an 8-year period, and 6 (10.9%) were female. The mean age was 63.2 years (range, 41-82 years), and the age at the time of the previous operation was 51.7 years (range, 31-69 years). Four patients (7.2%) underwent a third operation. Comorbidities were diabetes mellitus (25 patients, 45.5%), renal impairment (8 patients, 14.5%), calcified ascending aorta (9 patients, 16.4%), carotid disease (4 patients, 7.2%), and peripheral vascular disease (11 patients, 20.0%). Fifteen patients (27.2%) had previous coronary stents. Nine patients (16.4%) had a preoperative intra-aortic balloon pump. Predicted mortality (logistic EuroSCORE) was 14.2%.
Results:
Forty-three patients (78.1%) had intact LIMA-to-LAD grafts. Twenty-two patients (40.0%) required a major posterolateral thoracotomy, and 33 patients (60.0%) had a minor thoracotomy. Thirteen patients (23.6%) had stents placed as a hybrid procedure during the same admission. Thirteen patients (23.6%) additionally underwent anterior wall grafting (LAD to the first marginal area). The LIMA was used in 7 patients where it had not been used before. There were 91 distal grafts (including 4 sequentials). We performed 54 venous grafts and 26 radial artery grafts. Twenty-one patients (38.1%) had 1 distal graft, 32 patients (58.1%) had 2 grafts, and 2 patients (3.6%) had 3 distal grafts performed (mean, 1.6 grafts/patient). The proximal graft site was the proximal descending aorta in 20.0% of the patients, the distal aorta in 67.5%, and the subclavian artery in 12.5%. In 10 patients (18.2%), the distal branches of the right coronary (posterior descendens or right posterolateral) were grafted. No patient required conversion to cardiopulmonary bypass or sternotomy. No patient needed an intra-aortic balloon pump postoperatively. The mean blood loss (24 hours) was 380 mL (range, 125-1100 mL), the mean ventilation time was 4.8 hours (range, 0-12 hours), the mean intensive care unit stay was 2.7 days (range, 2-8 days), and the mean hospital stay was 6.3 days (range, 5-20 days). There was 1 postoperative death (1.8% mortality). One late death occurred on follow-up. Four patients underwent cardiac catheterization for chest pain, and the grafts were shown to be open.
Conclusion:
The procedure is safe, especially in patients with intact LIMA-to-LAD grafts needing lateral and inferior wall revascularization. Multislice computed tomography scanning allows better preoperative planning, especially regarding the site of implantation of the proximal graft, allowing a less invasive incision. The off-pump technique preserves cardiac and pulmonary function. The in-hospital death rate (1.8%) compares very well with the EuroSCORE-predicted mortality (14.2%).
