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Reoperative coronary artery bypass procedures: risk factors for early mortality and late survival
J T Christenson1, M Schmuziger, F Simonet
1The Cardiovascular Surgery Unit, Hôpital de la Tour, Meyrin-Geneva, Switzerland.
Insights
Redo coronary artery bypass grafting (CABG) is effective but carries higher operative risks. Identifying risk factors like unstable angina and poor heart function improves outcomes for these reoperations.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Reoperative Cardiac Procedures
Background:
- Coronary artery disease reoperations are increasing.
- REDO-CABG patients present with more comorbidities and severe disease than primary-CABG patients.
- Preoperative left ventricular ejection fraction is significantly lower in REDO-CABG patients.
Purpose of the Study:
- To identify risk factors for REDO-CABG.
- To evaluate the outcomes and long-term results of REDO-CABG.
- To compare REDO-CABG with primary-CABG.
Main Methods:
- Retrospective analysis of 594 REDO-CABG patients and 3157 primary-CABG patients (1984-1994).
- Comparison of preoperative characteristics, operative details, and postoperative outcomes.
- Identification of independent risk factors for mortality using multivariate analysis.
Main Results:
- REDO-CABG had higher operative mortality (9.6% vs 2.8%) and morbidity.
- Short reoperative interval (<1 year) was associated with significantly higher mortality (21% vs 8.9%).
- Independent risk factors for mortality included urgent operation, severe angina, low LVEF, and renal insufficiency.
Conclusions:
- Reoperative CABG is effective with encouraging long-term survival rates (5-year: 89%).
- Increased operative mortality and morbidity are associated with REDO-CABG.
- Unstable angina, poor LVEF, renal insufficiency, diabetes, and short reoperative interval are key risk factors for mortality.
Objectives:
The number of coronary artery disease reoperations is increasing. The aim of this paper is to identify risk factors and evaluate the results of REDO coronary artery bypass grafting (CABG).
Material:
Between January 1984 and October 1994, 594 patients underwent REDO-CABG and 3157 underwent primary-CABG. The mean age was 62 years with 84% men. Hypertension, hyperlipidemia, insulin dependent diabetes, smoking and renal insufficiency were all more frequent in the REDO-group. A significantly higher number of patients undergoing REDO-CABG were in the Canadian Cardiovascular Society (CCS) angina class 3 and 4, had instable angina, had left main stem stenosis of greater than 70% and 3-vessel disease compared to those undergoing primary-CABG. The mean preoperative left ventricular function (LVEF) was 49.8 (REDO) vs. 58.2%, with a P value of less than 0.001.
Results:
The overall postoperative mortality rate for REDO-operations was 9.6 (57/594) vs. 2.8% for primary-CABG. Patients with a reoperative interval of more than 1 year had an 8.9% mortality rate, compared to those reoperated less than 1 year after the initial CABG, where the mortality was 21% with a P value of less than 0.05. Postoperative low cardiac output syndrome, intraaortic balloon pump support, prolonged ventilatory support (> 24 h), hemorrhage and gastrointestinal complications were prominent features of the REDO-group (all P < 0.01). Urgent operation, CCS class 3 and 4, LVEF of less than 40%, generalized arteriosclerotic disease and advanced age (> 80 years) were independent risk factors for postoperative death in both groups. Preoperative renal insufficiency, diabetes and short interval from primary-CABG were added risk factors in the REDO-group. The 5-years survival rate after REDO-CABG was 89%, while the cardiac event-free survival rate was 79% and at 7 years 84 and 62%, respectively.
Conclusions:
Reoperative CABG is effective, but has an increased operative mortality and morbidity. The long-term results are encouraging. Unstable angina, poor preoperative left ventricular function, renal insufficiency, insulin dependant diabetes and an interval shorter than 1 year of the initial operation were independent riskfactors for mortality.