The impact of symptom severity on cardiac reoperative risk: early referral and reoperation is warranted

Abstract

Background: Operative mortality is comparatively higher for coronary artery bypass grafting (CABG) or valve reoperations. Studies of reoperative risk have focussed on surgical techniques. We sought to determine the risk and predictors of poor outcome in current practice, and the influence of preoperative symptoms. Method: For every redo patient (n = 289), we selected the best-matched pair of patients who underwent a primary operation (n = 578) between 1998 and 2006. Matching variables were age, gender, left ventricular ejection fraction (LVEF) and type of operation. Poor outcome was defined as operative mortality or major morbidity. Result: Median age was 68 (interquartile range 62-73) years and 28% were female for both groups. Severe symptoms and cardiac morbidity dominated the presentation of redo patients. CABG (53%), valve repair/ replacement (34%) and combined CABG and valve (12%) were performed with overall operative mortality of 6.6% (median additive EuroScore 7.0) for redo versus 1.6% (median additive EuroScore 4.0) for primary groups ( p < .0001). Whereas no significant difference was observed between primary (1.6%) and redo CABG (3.9%, p = .19), valve reoperations had higher operative mortality (9.6% vs 1.5%, p < .0001). Major complications occurred more frequently after redo valve compared to primary valve operations (28% vs 14%, p = .001). Reoperation (odds ratio [OR] 1.26, 95% confidence interval [CI] 0.66-2.42, p = .48) was not a predictor of major adverse event after CABG or valve surgery. Determinants of poor outcome after valve reoperations were New York Heart Association class III/IV (OR 6.86, 95% CI 2.29-12.11, p = .03), duration of extracorporeal circulation (OR 1.17, 95% CI 1.02-1.35, p = .03) and mitral valve replacement (OR 4.07, 95% CI 1.83-36.01, p = .04). The predictors of major adverse events after redo CABG were congestive heart failure (OR 1.85, 95% CI 1.04-8.98, p = .006) chronic obstructive pulmonary disease (OR 17.5, 95% CI 1.87-35.21, p = .05) and interval from prior surgery (OR 1.37, 95% CI 1.09-1.92, p = .01). Conclusion: In the current era, redo CABG is nearly as safe as the primary operation. A valve reoperation, on the contrary, is higher risk due, partly, to severe symptoms at presentation. Patients should be referred and operated on early before they develop severe symptoms. #

What are the Predictors that Affect the Excellent Long-term Benefits of Redo Coronary Artery Bypass Grafting?

“…Although the calculated euroSCORE in our patient population was 7.3% (SD = 4.9), we observed a 30-day mortality of 1.9% due to only two peri-operative deaths. Our findings are similar to those reported by Ngaage et al who compared operative mortality and the frequency of adverse events following primary and redo CABG [9]. The operative mortality in this series for 289 coronary re-operations was 3.9% compared to 1.6% following primary CABG.…”

Predictors of in-hospital mortality following redo cardiac surgery: Single center experience

“…Reoperative surgery even for an elderly patient with isolated aortic or mitral valve pathology is associated with excellent long-term survival. However, valve reoperations may have higher risk when patients are not referred and operated on early before they develop severe symptoms [5,11]. Although in-hospital mortality seems higher among the elderly than among younger patients, redo valvular surgery in an elderly cohort can be performed with acceptable morbidity and mortality.…”

“…Even incomplete revascularization is not associated with adverse events during follow-up after CABG [4]. Moreover, redo CABG is nearly as safe as the primary operation [5]. Redo surgery is inevitable in patients with prosthetic heart valves that carry similar morbidity and mortality compared to primary replacement [6].…”

Extension of the right internal thoracic artery with the radial artery in extensive re-do coronary artery bypass grafting

“…There was no intra-operative and no follow up mortality, even though the average STS score was high. Our mortality rate of 0% and complication rates are lower then those reported in the literature for re-do CABG operations [4], however this case series only includes a very limited number of carefully selected patients. In older series the observed mortality has been reported to be much higher ranging from 6.9 to 9.2% [5,6].…”

“…Meta-analyses suggest superiority of the radial artery over the saphenous vein concerning patency [2,3]. RA patency rates range from 83% to 93% at one to seven years after operation [4]. We therefore developed a technique to perform re-do total arterial coronary artery bypass grafting extending the right internal thoracic artery (RITA) with RA in an end to end fashion to gain the needed length.…”