Off-Pump Surgery and Alternatives to Standard Operation in Redo Coronary Surgery

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Abstract

Background

Reoperative coronary artery bypass grafting (CABG) has been associated with higher mortality and morbidity than first-time CABG. Off-pump surgery has been introduced in an effort to reduce morbidity associated with traditional on-pump CABG. However, these techniques present unique challenges in the reoperative setting. A review of our experience was undertaken to determine safety, efficacy, and technical challenges in beating heart reoperative CABG.

Methods

From January 1999 through April 2003 reoperative CABG procedures performed by a single surgeon were treated on an “intention to treat” basis without cardiopulmonary bypass. A standardized operative technique employing suction stabilization and exposure devices were used for sternotomy procedures with stabilization devices employed for limited access single-vessel revascularization.

Results

Eighty-six of eighty-seven (99%) consecutive patients undergoing reoperative CABG had the procedure initiated off-pump. There were 24 of 62 females/males (28%/72%) with a mean age of 64.3 (34 to 92). Eighty-one of eighty-six (94.2%) procedures were successfully completed off-pump. Five (5.8%) conversions were due to hemodynamic instability, inability to dissect dense adhesions (2), inability to locate an intramyocardial LAD (1). The procedures were performed via a median sternotomy in 67 patients (78%) and by limited anterior or lateral thoracotomy in 19 patients (22%). The operative mortality was 2 of 86, predicted risk 6.7%. There was no mortality in the converted patients. Postoperative length of stay was 5.5 days. There were no strokes or perioperative myocardial infarctions. Complications included reoperation for bleeding in 2.2%. Sixty-one of sixty-six (92.4%) patients were able to be extubated in the operating room. The rate of transfusion was 23 in 86 patients (26.5%), and atrial fibrillation was 5 in 86 patients (5.8%).

Conclusion

Off-pump CABG can technically be performed safely in most patients presenting for reoperative CABG. Outcomes appear to be improved compared with published outcomes of reoperative on-pump CABG surgery.

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