Third-time coronary artery bypass grafting: midterm results

Do Patients Profit from Third Time CABG?

Introduction

It has been shown that in experienced hands repeated CABG is doable procedure. However the quality of life after third time CABG has not been evaluated so far.

Patients and Methods

The peri-operative data of 25 (22 male, mean age of 65.5 ± 8.0 years) consecutive patients in a single centre undergoing third time-CABG from 4/96 to 11/06 were studied. Quality of life (QoL) was assessed by Short Form (SF)-36 Questionnaire.

Results

30 day mortality was 12% (3/25). Seven died during follow-up. In 15 survivors median follow-up was 94 months (2–122 months). 1-, 5-, and 10-year survival were 77.8%, 65.0%, and 53.1%, respectively. Present NYHA status was significantly improved in comparison to preoperative values (2.4 ± 0.8 vs. 3.2 ± 0.56, p = 0.012). QoL was comparable with an age matched general population with heart insufficiency.

Conclusion

Third time CABG can be performed with acceptable peri-operative mortality. Significant improvement of NYHA status and acceptable quality of life results justifies our surgical approach in this challenging patient cohort.

Third-time coronary artery bypass grafting

BACKGROUND

In this study we analyze the short- and long-term results, and the clinical, functional, and subjective status of patients after a second coronary reoperation (RE-RE-CABG).

METHODS

The perioperative data of 33 consecutive patients undergoing RE-RE-CABG (1987 to 1998) were studied. Follow-up information was obtained from our follow-up databank. A cross-sectional follow-up was conducted, with additional functional evaluation by the Duke Activity Status Index (DASI), and patients' evaluations of their life situation were registered.

RESULTS

Perioperative mortality was 2 of 33 patients (6%). During the follow-up (mean 51.6 months) 5 patients died. The 26 survivors showed a significant decrease in New York Heart Association class from 3.6+/-0.4 preoperatively versus 2.2+/-0.6 postoperatively. The mean Duke Activity Status Index score was 29.30+/-16.34 (range 7.22 to 48.9). In all, 18 of 26 patients (70%) were declared to have benefitted from the RE-RECABG.

CONCLUSIONS

The significant improve in New York Heart Association class and good postoperative functional capacity, justified the RE-RE-CABG. However, patients must be informed about the limitations of this procedure.

Reoperation for recurrent coronary artery disease: results of 200 consecutive cases

BACKGROUND

It is well known that reoperation for recurrent coronary artery disease is more difficult than primary coronary artery bypass grafting. However, it is possible to reduce the morbidity and mortality of reoperation to the same level as the initial procedure with careful surgical technique.

METHODS

A retrospective study of the first 200 patients who underwent redo coronary bypass grafting was undertaken.

RESULTS

In the first 200 cases of redo coronary bypass grafting at St George Hospital, Sydney (August 1986-January 1995), there were five in-hospital deaths (2.5%). There was one case of sternal infection (0.5%), which required surgical debridement, three cases of stroke (1.5%), one case of postoperative bleeding (0.5%), which required a return to theatre and six cases (3%) required mechanical ventilation for more than 24 h. The need for major postoperative support (such as intra-aortic balloon pumping/adrenaline infusion) was significantly affected by the degree of urgency and the degree of pre-operative ventricular impairment.

CONCLUSIONS

The mortality rate of redo coronary artery bypass grafting in this series is similar to that of primary surgery described in other reports.

Third coronary artery bypass operations: risks and costs

BACKGROUND

Third coronary artery bypass operations are technically difficult and are associated with increased risk.

METHODS

We reviewed the cases of 469 patients who had undergone a third isolated coronary artery bypass operation and used univariate and multivariate testing to examine the effect of preoperative and operative variables on outcome and costs.

RESULTS

The in-hospital mortality was 7.0% (33 patients). Advanced age and severe symptoms were found to increase risk (both p < 0.05): the mortality was 14% (n = 74) in patients 70 years old or older who had severe symptoms. However, the overall mortality for 1993 through 1995 was 4.3% (5/117) and only one death (1.3%) occurred among the 79 patients who were less than 70 years old. The late survival rate was 94%, 84%, and 66% at 1, 5, and 10 postoperative years, respectively, and predictors of decreased late survival were advanced age, abnormal left ventricular function, and diabetes (all p < 0.05). Again, age of 70 years or more was a predictor of a poor outcome. Only 52% of patients in that subgroup (including both early and late mortality) were alive 5 years after operation. Analysis of direct hospital costs showed that the mean costs of third coronary artery bypass operations were 21% higher than the mean costs of primary operations but that the elevation in the mean costs for third operations was related to very high costs in 4 patients. Sex was found to influence the cost of both primary and third operations (increased cost for women).

CONCLUSIONS

Unfavorable outcomes after third coronary artery bypass operations have been associated with preoperatively definable variables, particularly age of 70 years or more. The in-hospital mortality in patients younger than 70 was low, and long-term survival in this group has been favorable. The increased hospital costs associated with third operations are related to high costs in only a few patients and have been unpredictable.

Third-time coronary artery bypass operations: surgical strategy and results

BACKGROUND

Increasingly, patients are returning for a second, third, and even fourth coronary artery bypass graft (CABG) procedure.

METHODS

This report reviews the in-hospital and long-term outcomes for 102 patients undergoing a third or fourth CABG at Emory University from December 1977 to April 1994.

RESULTS

The mean interval from the first to second CABG was 5.2 +/- 3.5 years and from the second to the third CABG 6.8 +/- 4.1 years. The mean age was 6 +/- 9 years, 91% were male, 33% had hypertension, 16% diabetes, 86% class III or IV angina (Canadian Cardiovascular Society), 4.4% congestive failure (New York Heart Association), and 73% three-vessel disease. The in hospital mortality rate was 9.8%, with a perioperative myocardial infarction rate of 8.8% and a stroke rate of 1.9%.

CONCLUSIONS

These perioperative mortality and myocardial infarction rates are several times higher than those reported for initial revascularizations or first-time redo CABG operations. However, the 5- and 10-year survival rates of 79% and 59%, respectively, and a myocardial infarction-free survival of 62% at 5 years, the benefits of a third-time CABG procedure are apparent for this high-risk group of patients.