Coronary reoperation with and without cardiopulmonary bypass

Abstract

Redo coronary artery bypass grafting (CABG) is still associated with increased morbidity and mortality compared to primary operation. Myocardial protection is one of the key issues in redo on pump CABG and is still a matter of debate. Off pump redo CABG seems to be an attractive alternative as native coronary blood flow remains and cross clamping of the aorta is avoided. The aim of this retrospective study was to compare the outcome of redo CABG with and without CPB. From 1/1998 to 5/2004 redo CABG was performed in 195 patients (pts): 162 male (83.1%) and 33 female (16.9%) pts, age 66 +/- 9 years. In 160 pts, CPB with isolated antegrade myocardial protection was used for redo CABG. Off pump redo CABG was performed in 35 pts (30 male (85.7%) and 5 female (14.3%), age 67 +/- 8 years). Perioperative overall mortality rate was 3.6% (n = 7) and comparable in both groups (on pump 3.8% versus off pump 2.9%; p = 0.90), as well as perioperative myocardial infarction, intraaortic balloon pump implantation rate and secondary morbidity. Complete revascularization was achieved in 139 pts (86.9%) after on pump CABG and in 17 pts (48.6%) of the off pump group (p < 0.01). The average number of grafts was significantly higher in the on pump group (2.8 +/- 0.78 versus 1.6 +/- 0.6; p = 0.04).Furthermore, 20 pts (12.5%) in the on pump group died during follow-up (50 +/- 16 months). Five pts (25.0%) died due to cardiac reasons. In the off pump group 3 pts (8.6%) died during follow-up (44 +/- 13 months), noncardiac related. Overall survival was 83.8% in the on pump group and 88.6% in the off pump group (p = 0.92). On pump redo CABG and off pump redo CABG can be safely performed with low mortality and morbidity. Off pump redo CABG might be limited due to incomplete revascularization.

Does off-pump coronary revascularization confer superior organ protection in re-operative coronary artery surgery? A meta-analysis of observational studies

“…The incidence of acute respiratory failure or acute respiratory distress syndrome (ARDS) was 3.03% in the OPCAB group and 4.81% in the ONCAB group, as reported by six studies [11,13,14,16,19,20]. This reduction with OPCAB was statistically significant using the random effects model (OR 0.36; 95% CI 0.24-0.54) (Figure 6), without significant heterogeneity between the studies.…”

“…There were several variations in myocardial arrest and cardioplegia strategy within the ONCAB group. Of the 12 studies, five used cold blood cardioplegia [12,14-16,21], one used cold crystalloid [10], 2 used a combination of cold blood and cold crystalloid [11,20] and one study used a combination of cold blood, warm blood and hypothermic ventricular fibrillation [19]. The majority of studies (5/9) administered a combination of antegrade and retrograde cardioplegia [11,14,16,17,21].…”

“…The majority of studies (5/9) administered a combination of antegrade and retrograde cardioplegia [11,14,16,17,21]. Two studies used only an antegrade approach [19,20] and the remainder did not specify their technique.…”

“…Five studies [11,14,19-21] reported a significantly reduced incidence of low cardiac output states with OPCAB (0.48% vs. 4.35% ONCAB; OR 0.14; 95% CI 0.04-0.56). Five studies [11,13,14,19,20] reported a significantly reduced incidence of respiratory failure/ARDS with OPCAB (1.67% vs. 3.86% ONCAB; OR 0.33; 95% CI 0.18-0.59). Four studies [14,17,20,21] reported a significantly reduced incidence of atrial fibrillation with OPCAB (7.85% vs. 22.6% ONCAB; OR 0.33; 95% CI 0.16-0.70).…”

“…Five studies [11,13,14,19,20] reported a significantly reduced incidence of respiratory failure/ARDS with OPCAB (1.67% vs. 3.86% ONCAB; OR 0.33; 95% CI 0.18-0.59). Four studies [14,17,20,21] reported a significantly reduced incidence of atrial fibrillation with OPCAB (7.85% vs. 22.6% ONCAB; OR 0.33; 95% CI 0.16-0.70).…”