Ann Thorac Surg 2000;70:483-486
© 2000 The Society of Thoracic Surgeons
Original articles: cardiovascular
Third-time coronary artery bypass grafting
Luc Noyez, MDa,
Issa M. Toumaa,
Stefan H. Skotnicki, MDa,
René M.H.J. Brouwer, MD, PhDa
a Department of Thoracic and Cardiac Surgery, University Hospital Nijmegen, Nijmegen, The Netherlands
Address reprint requests to Dr Noyez, Department of Thoracic and Cardiac Surgery–414, University Hospital Nijmegen, PO Box 9101, 6500 HB Nijmegen, The Netherlands
e-mail: l.noyez{at}thchir.azn.nl
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Abstract
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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.
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Introduction
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Despite the increasing number of reoperations for coronary revascularization and studies analyzing the problems concerning this subject, only minimal data are available concerning patients undergoing a third-time coronary artery bypass grafting (RE-RE-CABG). RE-RE-CABGs are not so frequent; but these patients constitute a special group, which may be increasing in the coming years [1]. In this report we describe the short- and long-term results and the clinical, functional, and subjective status of patients after RE-RE-CABG.
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Patients and methods
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With the aid of our database, Coronary Surgery Database-Radboud Hospital (CORRAD), a registry that stores pre-, peri-, and postoperative (in-hospital) data regarding all patients undergoing isolated myocardial revascularization, we identified a consecutive series of 33 patients undergoing a RE-RE-CABG from January 1987 through December 1998. During the same time, 6,083 isolated myocardial revascularizations were carried out; thus these 33 patients represent 0.54% of the total number of myocardial revascularizations performed at our institution.
Table 1 presents the preoperative data of the patient group studied, and also the comparative preoperative data of the patients undergoing a primary CABG (P-CABG) and a first RE-CABG. Hypertension was defined as systolic blood pressure greater than 160 mm Hg or diastolic pressure greater than 100 mm Hg. Hyperlipidemia was defined as total cholesterol level greater than 6.4 mmol/L or triglyceride level greater than 2 mmol/L, and renal dysfunction as a creatinine level greater than 150 µmol/L or preoperative dialysis. Neurologic pathology was registered in patients with a cerebrovascular accident or a transient ischemic attack in their history. A pathological pulmonary pulmonary condition was registered in patients with chronic obstructive pulmonary disease or a history of previous lung disease.
Indications for RE-RE-CABG
The clinical and angiographic indications are summarized in Table 2. The clinical indication in all patients was angina of New York Heart Association (NYHA) class III or greater despite medical therapy with ß-blockers, calcium antagonists, or nitrates, or a combination. Patients with angina at rest were registered as NYHA class IV and patients with ischemia who were not responding to medical therapy, as emergency operation. In 9 patients (27%) there was a documented "poor" left ventricular function (ejection fraction < 35%). The mean NYHA for the total group was 3.6 ± 0.4 (range, 3 to 4). Four patients (12%) were operated on for a single vessel, 2 patients (6%) for two vessels, and 27 patients (83%) for three vessel disease. In 7 patients (21%) an arterial graft (internal mammary artery [IMA]) was already used at one of the previous operations. These IMA grafts were constructed at the first reoperation, and were patent at the moment of the RE-RE-CABG.
Surgical technique
A total of 27 (83%) patients were operated using standard cardiopulmonary bypass, as described in a previous paper [2]. In patients for RE-RE-CABG the groin vessels are routinely exposed before the sternotomy incision. In 4 patients the groin vessels were cannulated because of the probability of adherences between the sternum and a patent graft. Three patients (8.5%) were put on bypass and were operated on an empty beating heart without aortic-cross clamping, and 3 (8.5%) patients were operated on a beating heart without use of the cardiopulmonary bypass.
For the patients operated with cardiopulmonary bypass the mean bypass time was 132.7 ± 69 minutes (range, 30 to 277), and the mean duration of aortic cross-clamping was 52.1 ± 34.0 minutes (range, 9 to 127). Myocardial protection during aortic cross-clamping was performed with cold (4°C) St. Thomas’ Hospital cardioplegia, and since 1995 with cold blood cardioplegia. In 5 patients cardioplegia was delivered antegrade, in the other patients a coronary sinus cannula was used for retrograde perfusion [1]. In two patients intermittent aortic crossclamping was used.
At RE-RE-CABG there was a mean of 1.9 ± 0.8 (range 1 to 3) grafts, and 2.4 ± 1.2 (range 1 to 6) distal anastomoses constructed. Distal and proximal anastomoses were done under one aortic clamp. In 22 of 33 patients (67%) at least one new arterial graft was used, mostly the left IMA, but also the right IMA and the gastoepiploic artery in two patients. Four patients needed intraaortic ballon pump support.
Follow-up
The follow-up of all cardiac patients is registered in our follow-up databank. This databank contains reports of referring cardiologists and family doctors, mostly medical information. For the studied group a cross-sectional follow-up was conducted in May 1999. All information was obtained by telephone contact with the patient or their family and their family doctor. Functional status was evaluated by the NYHA classification. However, because of the limitations of this NYHA classification, an additional functional evaluation by the Duke Activity Status Index (DASI) was performed. The DASI is a 12-item questionnaire that determines a patient’s ability to participate in a spectrum of activity without difficulty and correlates strongly with maximal oxygen consumption during exercise, and this index has been validated in patients with several cardiac disorders [3]. This DASI gives more accurate information about patients’ functional situation than the NYHA classification. All patients and their family doctors were asked to answer the question, "Are you feeling better, worse or is there no improvement since the RE-RE-CABG?"
Statistical analysis
Data are presented as frequency distribution and percentages with 95% confidence intervals. Values of continuous variables are expressed as mean ± SD. Data were analyzed with the Student’s t test and the 
2 test. Survival curve was obtained by the Kaplan-Meier method. Statistical significance was assumed when the p value was less than 0.05.
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Results
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During the 12 years of the study, the number of RE-RE-CABGs increased slowly from 7 of 1811 (0.4%) during the time cohort 1987 to 1990 to over 9 of more than 1881 (0.5%) in the time cohort 1991 to 1994, and 15 of 2,391 (0.6%) in the time cohort 1995 to 1998.
Table 1 presents the preoperative data of the patients. There is a statistical decrease in the number of women for RE-CABG and RE-RE-CABG (25; 11%). The mean age of the RE-RE-CABG group is statistical significant lower than for RE-CABG group and comparable with the p CABG. The percentage of patients with insulin-dependent diabetes, hypertension, a family history of cardiovascular disease increased statistically significantly from the primary group over that of the RE-CABG to that of the group for RE-RE-CABG. The percentage of patients with peripheral vascular disease is significantly the lowest in the RE-RE-CABG group. There is no statistical significant difference between the percentage of neurologic pathology, renal dysfunction, pulmonary pathology, and number of patients with hyperlipidemia among the three groups. The percentage of patients with a preoperative myocardial infarction in their history increased significantly from the primary group to the RE-RE-CABG group.
The perioperative mortality (operative and hospital mortality) was 6% (2/33). Perioperative myocardial infarction (defined as new postoperative Q-waves or T-wave changes accompanied by increased cardiac enzymes) occurred in 4 patients and was the cause death in the 2 patients (6%) who died perioperative. The other postoperative morbidity is presented in Table 3.
The follow-up of the 31 hospital survivors was complete. The mean follow-up time was 51.6 ± 40.0 months (0 to 130 months). The actuarial survival is presented in Figure 1. At 1 month the survival was 96.7%, at 6 months 93.6%, at 24 months 90.4%, and at 46 months 85%. During follow-up 5 patients died; 4 deaths were cardiac-related, and 1 was not cardiac-related. During the follow-up, in 19 patients (61%) an ischemic event defined as return of angina (1 patient), cardiac-related death (4 patients), new arrhythmia (2 patients), or congestive heart failure (12 patients) was identified. In 12 patients (39%) the follow-up was event-free; one of these patients died a non–cardiac-related death.
Family doctors declared that 28 of 31 (90%) of the hospital survivors were better after the RE-RE-CABG than before. For the 26 patients, at the moment of the cross-sectional follow-up, there was a statistical significant improvement in NYHA classification for the total group, preoperative 3.6 ± 0.4 versus 2.2 ± 0.6 postoperative (p < 0.05). Three patients (11.5%) were in NYHA class I, 14 patients (54%) in NYHA class II, and 9 patients (34.5%) in NYHA III. The mean DASI was 29.30 ± 16.34 (range, 7.22 to 48.9). To the question, "Are you feeling better, worse, or is there no improvement since the RE-RE-CABG?" 18/26 patients (69%) answered that they were better since the operation, two patients (7.5%) were feeling worse and six patients (23.5%) answered that there was no improvement. On the same question, but independently, the family doctors answered for 23 patients (88%) that they were better since the RECABG and for three patients (12%) that they were worse, at the moment of the cross-sectional follow-up.
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Comment
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The number of RE-RE-CABGs was limited to 33 patients more than 11 years. The complexity of factors influencing the results, and the fact that this is a retrospective study, and that no standardized pre- and postoperative myocardial viability studies were done are restricting factors in analyzing the problems of these patients.
Over the years we have seen a slight increase of RE-RE-CABGs in our institution from 0.4% to 0.6%. Our general percentage (0.54%) is comparable with other studies concerning RE-RE-CABG [4, 5]. The relatively young age of these patients at the moment of RE-RE-CABG is correlating with other studies [1, 4–9]. Interesting is that this RE-RE-CABG group has a statistically significant younger mean age than the RE-CABG group, indicating that this group of patients received their primary CABG at very young age as already mentioned in our previous report [1]. The percentage of risk factors (diabetes, hypertension, family history of cardiovascular disease) increased significantly to the RE-RE group. On the other hand, the statistically significant low percentage of patients with peripheral vascular disease, an expression of the gravity of the atherosclerosis, and the comparable percentages of patients with neurologic pathology, renal dysfunction, and pulmonary pathology, lets one suppose that only "good candidates" were operated on.
However, patient complaints in combination with proved convertible ischemia are the two essential points of our selection criteria. Age, left ventricular function, and other comorbidity factors are important for risk adjustment but not for indication. Good target vessels makes the decision easier, but even without visualization of target vessels in the jeopardized myocardium we accept the patient for operation if there is a complaint of convertible ischemia. The statistical significant increase of the percentage of patients with a previous myocardial infarction corresponds with the idea that between operations nearly one-third of the patients had a new myocardial infarction [1].
Groin vessels are exposed in all second and third redo operations, in patients with a history of mediastinitis, and tricuspid valve regurgitation is used as a safety measure. In patients with right atrial or ventricular dilation, IMA or other grafts crossing the midline, or adherent to the sternum, arterial, and venous cannulation is performed before resternotomy. Most patients were operated on using retrograde cold blood cardioplegia. This series, however, is too small to evaluate the other operation techniques used.
In this study, perioperative mortality was 6%, which is comparable with other series reporting mortality rates between 7% and 12% [4–9]. Our survival (3-year 85% and 5-year 75%) is comparable with that in other series [8, 9]. It is interesting is to see that dyspnea, a sign of congestive heart failure, was the most noted ischemic event during follow-up.
There was a significant improvement in NYHA class at 3.6 ± 0.4 preoperatively versus 2.2 ± 0.6 postoperatively. The mean DASI (29.3 ± 16.34) corresponds with a maximal oxygen uptake of approximately 22 mL/min/kg, which is just above the normal value [10]. It is, of course, a deficit of our study that no preoperative DASI-scores were known. However, in this study, the DASI score is lower than the DASI score (37.9 ± 9.8 and 38.6 ± 10.42) in our reports concerning myocardial revascularization in patients 45 years old or less and coronary reoperations in patients with a patent internal mammary artery [11, 12]. Despite this lower result in functional status, family doctors declared that 90% of the hospital survivors were better after the RE-RE-CABG than before, which was confirmed by 88% of the patients at the time of the cross-sectional follow-up. This high "success" percentage, provided by the family doctors, is comparable with those in our previous studies [11, 12]. On the other side, the percentage of patients declaring that they were feeling better since the RE-RE-CABG (69%) is considerably less than the 85% [11] and the 82% [12] previously reported. The percentage of patients feeling worse is comparable in the three studies at 10%, 13% and in this study 7.5%. Remarkable is the high percentage of patients answering that there is no improvement since the RE-RE-CABG (23.5%) versus 5% in the other two studies [11, 12]. However, several of these patients paraphrased "no improvement," as it was not as good as after the RE-CABG. The high expectations of these patients of the RE-RE-CABG opposite the final outcome can explain this high percentage.
In conclusion, perioperative mortality and long-term survival of RE-RE-CABG patients is acceptable; however, preoperative patient selection plays an important role here. The good clinical, functional, and subjective status of patients justifies RE-RE-CABG, but it is important that patients be well informed preoperatively about the limitations of these operations and the eventually incomplete recovery to be expected.
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Acknowledgments
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We thank Lisette Peters for her work in the secretarial function of the CORRAD database.
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References
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Noyez L, van Eck F, Skotnicki SH, Brouwer MHJ. Coronary reoperations in patients with a patent internal mammary artery graft [Abstract]. Cardiovascular Surgery 2000; in press.
Accepted for publication February 18, 2000.
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Abstract
Introduction
