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Reoperative coronary artery bypass surgery. Improved preservation of myocardial function with retrograde cardioplegia
T K Rosengart1, K Krieger, S J Lang
1New York Hospital-Cornell Medical Center, NY 10021.
Insights
Retrograde cardioplegia (RC) improves outcomes for reoperative coronary artery bypass graft (rCABG) surgery by reducing myocardial dysfunction, especially in high-risk patients. This technique may minimize ischemia, enhancing results compared to standard methods.
Area of Science:
- Cardiac Surgery
- Cardiovascular Research
- Surgical Outcomes
Background:
- Reoperative coronary artery bypass graft (rCABG) surgery has higher mortality than first-time surgery (fCABG).
- Retrograde cardioplegia (RC) is a potential but unproven method to improve rCABG outcomes.
Purpose of the Study:
- To evaluate the effectiveness of retrograde cardioplegia (RC) in improving outcomes for reoperative coronary artery bypass graft (rCABG) surgery.
- To compare the results of rCABG with and without RC, and against first-time CABG (fCABG).
Main Methods:
- Retrospective review of 240 consecutive rCABG patients and 100 fCABG patients.
- Analysis of operative times, graft patency, blood utilization, mortality, and postoperative myocardial dysfunction.
- Comparison of outcomes between high-risk and low-risk rCABG patients, with and without RC.
Main Results:
- rCABG patients experienced longer bypass times, increased blood use, and higher mortality (5.8%) versus fCABG (0%).
- High-risk criteria were present in 57% of rCABG patients, associated with increased mortality and myocardial dysfunction.
- RC use in 80 patients showed reduced postoperative IABP dependence in high-risk patients (3.8% with RC vs. 14.5% without RC).
Conclusions:
- Retrograde cardioplegia (RC) appears to improve outcomes in reoperative coronary artery bypass graft (rCABG) surgery.
- RC may mitigate the increased ischemia associated with rCABG, particularly preventing myocardial dysfunction in high-risk individuals.
- Both rCABG and fCABG patients achieved similar symptomatic improvement post-surgery.
Background:
Cardiac-related mortality remains high for reoperative coronary artery bypass graft surgery (rCABG) compared with first-time surgery (fCABG). Retrograde cardioplegia (RC) has been suggested but not proven to improve the results for rCABG.
Methods And Results:
We therefore reviewed the records of 240 consecutive patients who had undergone rCABG at our institution since 1988. The interval to reoperation was 9.1 +/- 4.2 years (mean +/- SD), with a range from 0.2 to 18 years. Only 46% of grafts were patent at the time of rCABG. The incision to cardiopulmonary bypass (CPB), incision to cross-clamp (XCL), and XCL per graft time intervals were significantly prolonged compared with 100 consecutive fCABG patients operated on during the same time period. Blood utilization was also significantly increased in rCABG compared with fCABG patients. Overall operative mortality was 5.8% and 0% for rCABG and fCABG patients, respectively (P < .05). High-risk criteria (emergency surgery, angina at rest requiring intravenous nitroglycerin or intra-aortic balloon pump [IABP] support [urgent surgery], recent [<21 days] myocardial infarction, or ejection fraction < 30%) were noted in 136 rCABG patients (57%) and 28 fCABG patients (28%) (P < .001). Profound postoperative myocardial dysfunction (postoperative IABP dependence) occurred in only one of 104 low-risk patients (1%), compared with 14 of 136 high-risk patients (10%) (P < .005). Operative mortality was noted in 13 high-risk patients (9.5%) compared with one low-risk patient (1%) (P < .005). RC was used in 80 patients without complication. Postoperative IABP dependence developed in only 2 of 53 high-risk/RC patients (3.8%) compared with 12 of 83 high-risk/non-RC patients (14.5%) (P < .05). At follow-up, rCABG and fCABG patients enjoyed similar symptomatic improvement.
Conclusions:
We conclude that retrograde cardioplegia, possibly by minimizing the increased ischemia associated with rCABG, improves the results of rCABG, specifically in regard to preventing profound myocardial dysfunction in high-risk patients.