Third-time coronary bypass operation. Analysis of selection mechanisms, results and long-term follow-up

Twenty-six patients underwent a third coronary artery revascularization between 1984 and 1993 at Hôpital de la Tour, Geneva, Switzerland. These patients represent 5.4% of coronary artery bypass graft (CABG) reoperations and 0.8% of the total CABG operations (3129) during the same time period. There were 23 men (85%), the mean age was 57.2 years (range 33-71), 18 patients (69%) had 3-vessel disease and the mean left ventricular ejection fraction (LVEF) was 59% (range 32-83%). The reason for the third operation was graft failure in 62% of the cases. Twenty-five patients (96%) were in Canadian Cardiovascular Society (CCS) class 3 or 4 preoperatively. Direct myocardial revascularization was performed in all patients with a mean of 3.2 grafts per patient (range 1-6). Thromboendarterectomy was performed in six patients (23%) and patch was used in four (15%). The internal mammary artery (IMA) was utilized in 85% of the patients. In-hospital mortality was 11.5% (3 patients). Non-fatal perioperative myocardial infarction and re-exploration for bleeding did not occur in this group of patients. Respiratory failure necessitating prolonged ventilatory support occurred in five patients (19.2%). Long-term follow-up was carried out for all 23 hospital survivors. The mean follow-up time was 52 months. The 5-year actuarial survival rate was 84.5% for the entire group and 95.7% for hospital survivors. The preoperative CCS functional class had significantly improved at the end of the follow-up, P < 0.001. Our data suggests that a third-time coronary revascularization can be justified, with gratifying operative success and good long-term clinical results.