Redo Coronary Bypass via Thoracotomy Approach
david G. harris1, Andre Saaiman2, Gabriel J. Rossouw1.
1Tygerberg Hospital, University of Stellenbosch, Cape Town, Cape town, South Africa, 2Kuils River Private Hospital, Cape Town, Cape town, South Africa.
OBJECTIVE: Repeat coronary artery bypass has increased risks including injury to a patent left internal mammary to left anterior descendens (LIMA-LAD) graft. Thoracotomy is advocated specifically in patients with intact LIMA-LAD grafts needing lateral wall grafting.
METHODS: From 2000 to 2012, 88 patients underwent surgery. Mean age was 63.2 (41-82), and age at previous operation was 52.0 years (29-69). Six (6.8%) had their third operation. Comorbidities were diabetes (48.8%), renal impairment (12.5%), calcified aorta (17.1%), carotid disease (9.0%), peripheral vascular disease (27.3%). Eleven (12.5%) had a pre-operative intra aortic balloon pump. Predicted mortality (logistic EuroSCORE) was 12.1%.
RESULTS: Sixty six patients (75%) had intact LIMA-LAD grafts. Fifteen patients (17%) had stents placed during the same admission, as a hybrid procedure. Forty patients (45.4%) had 1 distal graft, 46 patients (52.3%) had 2 grafts, and 2 patients (2.3%) had three distal grafts performed. The LIMA was used in 9 patients, where it had not been used before. There were 139 distal grafts (including 9 sequential grafts). A total of 82 venous, and 45 radial artery grafts were used Proximal graft site was proximal descending aorta 30.7%, distal aorta in 54.7%, and subclavian in 14.6%. In 11 patients (12.5%) the distal branches of the right coronary (posterior descendens or right posterolateral) were grafted.
Mean blood loss/ 24 hours was 436 mls (125-1100), mean ventilation time was 6.8hours (0-12), icu stay 3.7 days (2-8), and hospital stay 6.3 days (3-20). There were no major complications. There was one death. There were two late deaths. Fourteen patients underwent repeat cardiac catheterisation
CONCLUSIONS: The left thoracotomy redo is safe, especially in patients with intact LIMA-LAD grafts. The in hospital death rate (1.1%) compares well with the EuroSCORE predicted mortality (12.1%). The technique has been refined over the latter half of the study, using a smaller less invasive incision. As a result, patients previously thought unsuitable or less worthwhile for surgery are now being referred. Most cardiologists are not aware of this procedure, so we now consider it essential to mark the site of the proximal graft on the descending aorta with a formal coronary marker.
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