Off-pump strategy in high-risk coronary artery bypass reoperations.
ABSTRACT To determine the role of off-pump coronary artery bypass grafting in the treatment of patients with severe recurrent angina after coronary artery bypass grafting who are not suitable for percutaneous coronary intervention and are considered too high risk for conventional on-pump revascularization.
All patients who needed single- or double-vessel revascularization at reoperation with a predicted operative mortality of 10% or higher between March 4, 1994, and December 31, 2002, were studied. Risk stratification was performed using both the Parsonnet risk scoring system and the European System for Cardiac Operative Risk Evaluation. Active follow-up by questionnaire investigated major adverse cardiac events.
This study consisted of 84 patients with a median age of 69 years (interquartile range, 62-75 years); 14 (17%) were female. All patients had class III/IV symptoms. Previous operations included multiple coronary artery bypass grafts (15 patients [18%]) and heart transplantation (1 patient [1%]). Internal thoracic artery graft from a previous operation was patent in 43 patients (51%). Perioperative hemodynamic support with inotropes (35%) and intra-aortic balloon pump (14%) or ventricular assist device (2%) was common. The surgical approach varied for each patient. One operative death (1%) occurred. Estimated survival at 5 and 7 years was 77% and 67%, respectively. Late major adverse cardiac events observed during follow-up were cardiac death (n=66), nonoperative reintervention (n=8), and nonfatal myocardial infarction (n=5).
Off-pump coronary artery bypass grafting can mitigate reoperative risk in patients with an estimated risk of 10% or higher who are undergoing single- or double-vessel revascularization with satisfactory long-term outcome.
- [show abstract] [hide abstract]
ABSTRACT: Cardiac surgery is higher risk in the elderly. It has been suggested that preoperative left ventricular systolic dysfunction (LVSD) and cardiopulmonary bypass (CPB) affect elderly and young patients differently. This study investigates the predictive risk of preoperative LVSD and CPB time for operative mortality in the two groups of patients. We reviewed the data for 2616 consecutive patients aged >/=70 years and 4078 young patients who had coronary artery bypass grafting (CABG) and/or valve surgery between March 1998 and January 2007. Subgroups defined by severity of LVSD (ejection fraction >0.50 [mild], 0.31-0.50 [moderate] and </=0.30 [severe]) were analysed. Logistic regression models were constructed to identify risk factors among elderly and young patients. Elderly patients were higher risk and more often underwent valve operation. Moderate and severe LVSD were present in 22% (n=566) and 6% (n=155) of elderly compared to 18% (n=739) and 5% (n=215) of young patients (p=0.001). Operative mortality for CABG was higher in elderly patients with mild (2.3% vs 0.7%, p<0.0001), moderate (4.7% vs 2.3%, p=0.04) and severe LVSD (13.5% vs 8.8%, p=0.01). Although CPB times for similar procedures were equivalent for the two groups, procedure-specific mortality rates were higher among elderly patients for all operations. Whereas age (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.03-1.15, p=0.002) and CPB time (OR 1.01, 95% CI 1.0-1.02, p<0.0001) were predictors for operative mortality for the elderly, they (age [OR 1.0, 95% CI 0.96-1.05, p=0.87], CPB time [OR 1.0, 95% CI 1.0-1.01, p=0.17]) were not for young patients. Moderate LVSD was a risk factor for young patients (OR 3.01, 95% CI 1.45-6.26, p=0.003) but not for the elderly (OR 1.33, 95% CI 0.77-2.29, p=0.30). Differences in the significance of risk factors between elderly and young patients contribute to the disproportionate operative mortalities. Our data showed that age and CPB duration increased the risk of operative mortality only in the elderly, but the impact of moderate, unlike severe, LVSD was tempered. Further studies are warranted to investigate more biocompatible bypass systems in elderly patients, and if current risk stratification should, perhaps, be revised for elderly patients.European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 12/2008; 35(2):235-40. · 2.40 Impact Factor
- [show abstract] [hide abstract]
ABSTRACT: 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. 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. 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). 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.European Journal of Cardio-Thoracic Surgery 11/2007; 32(4):623-8. · 2.67 Impact Factor
Article: Curriculum Vitae and Bibliography