Continuous retrograde cardiac perfusion decreases risk of reoperative coronary artery bypass grafting
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S M Goldman1, F P Sutter, B P Priest
1Lankenau Hospital and Medical Research Center, Wynnewood, Pennsylvania, USA.
Insights
A novel technique for reoperative coronary artery bypass grafting (CABG) significantly reduces risks associated with embolization. This method improves outcomes, making reoperative CABG results comparable to primary CABG.
Area of Science:
- Cardiovascular Surgery
- Cardiac Surgery Outcomes
- Graft Embolization Prevention
Background:
- Reoperative coronary artery bypass grafting (CABG) carries higher risks than primary CABG, largely due to embolization of atheromatous debris from old saphenous vein grafts.
- Patients undergoing reoperative CABG often present with more severe coronary artery disease and reduced cardiac function.
Purpose of the Study:
- To evaluate a novel surgical technique designed to decrease the risks of reoperative CABG.
- To compare the outcomes of reoperative CABG using this technique against primary CABG.
Main Methods:
- A prospective study involving 130 patients undergoing reoperative CABG using minimal dissection, continuous retrograde coronary sinus perfusion (32°C blood), and temporary posterior cardiac interventricular vein occlusion.
- Comparison with a concurrent cohort of 1107 patients undergoing primary CABG.
Main Results:
- Despite longer cross-clamp and perfusion times in the reoperative group, rates of postoperative inotropic support, perioperative myocardial infarction (1.5% vs 2.4%), and mortality (3.1% vs 3.4%) were statistically equivalent between the groups.
- The novel technique demonstrated comparable outcomes for reoperative CABG to those of primary CABG.
Conclusions:
- Continuous retrograde coronary sinus perfusion, posterior cardiac interventricular vein occlusion, and a single cross-clamping technique effectively mitigate the risks of reoperative CABG.
- This approach significantly improves reoperative CABG outcomes, bringing them closer to the success rates of primary CABG.
Abstract:
Embolization of atheromatous debris from old saphenous vein grafts is a major factor that increases the risk of reoperative coronary artery bypass grafting (CABG) when compared with primary CABG. To decrease this risk, a technique consisting of minimal dissection of the heart prior to cross clamping, continuous retrograde coronary sinus perfusion with 32 degrees C blood, and temporary posterior cardiac interventricular vein occlusion, during which time all dissection and anastomoses are performed, was evaluated prospectively in 130 consecutive patients from January 2, 1991, through February 28, 1995. This group was compared with a cohort of 1107 patients undergoing primary CABG performed concurrently. The two groups were similar in age (median sixty-eight years), incidence of hypercholesterolemia, peripheral vascular disease, smoking history, and left main stem stenosis. More patients undergoing reoperative CABG had previous myocardial infarctions (61.5% vs 54.5%), a higher incidence of triple-vessel coronary artery disease (89.2% vs 77.1%, P = 0.002), and a lower ejection fraction (54.0% vs 56.9%). The median interval from primary CABG to reoperative CABG was one hundred twenty-seven months with a range of 2.5 to two hundred seventy-nine months. The cross clamp time (median one hundred three vs sixty-nine minutes, P = 0.000001) and perfusion time (median one hundred thirty-four vs ninety-four minutes, P = 0.000001) were significantly higher in the reoperative CABG group. The requirements for inotropic support postoperatively, perioperative myocardial infarction (1.5% vs 2.4%, P = 0.397), and mortality (3.1% vs 3.4%, P = 0.54) were statistically equivalent in the two groups. These data reveal that continuous retrograde coronary sinus perfusion, posterior cardiac interventricular vein occlusion, and single cross-clamping technique improve outcomes of reoperative CABG to that approaching primary CABG.