Myocardial Protection in Reoperative Coronary Artery Bypass Grafting:. Toward Decreasing Morbidity and Mortality

Fazel, Shafie; Borger, Michael A.; Weisel, Richard D.; Cohen, Gideon; Pelletier, Marc; Rao, Vivek; Yau, Terrence M.

doi:10.1111/j.0886-0440.2004.4052_11.x

Cited by 23 publications

(8 citation statements)

References 32 publications

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“…Similarly, PMA is an upcoming CS‐based treatment modality for functional mitral regurgitation, with a recent human feasibility study documenting a 6% incidence of CS‐access‐related adverse events (Joachim et al, 2009). RCP is an established method for myocardial protection during cardiac surgery (Bothe, 2004), especially recommended in certain cases such as redo coronary‐artery‐bypass‐grafting (Fazel et al,2004) or in patients with severe coronary artery disease involving the left main and right coronary arteries (Onorati et al,2003). In fact, failure to use RCP has been shown to be the largest independent predictor of mortality in coronary reoperations (Borger et al,2001).…”

Section: Discussionmentioning

confidence: 99%

The Thebesian valve: Gatekeeper to the coronary sinus

Katti¹,

Patil²

2011

Clinical Anatomy

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Clinical cardiac procedures such as electrophysiology studies, catheter ablation of arrhythmias, retrograde cardioplegia delivery, cardiac resynchronization therapy and, more recently, percutaneous mitral annuloplasty, involve cannulation of the coronary sinus (CS). The presence of a membrane closing the orifice of the CS may cause difficulties during these interventions. Thus, detailed knowledge of the variations and anomalies of the valve of the CS, or the Thebesian valve, now has practical significance. To improve our understanding of this structure, classic anatomical dissection of 50 hearts from dissection room cadavers was performed. A Thebesian valve was present in the overwhelming majority (88%) of cases. Its morphology varied widely, from a few small strands of tissue, to a membrane covering more than half the CS ostium. A significant number (20%) of valves occluded >65% of the ostium, making them "potential complicating factors" in cannulation of the CS. An understanding of these anatomical variations may help in identifying and overcoming potential difficulties during clinical cardiac interventions.

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Section: Discussionmentioning

confidence: 99%

The Thebesian valve: Gatekeeper to the coronary sinus

Katti¹,

Patil²

2011

Clinical Anatomy

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“…Retrograde perfusion of cardioplegia through the coronary sinus in repeat CABG surgery can wash dislodged particles of atheroma out of the epicardial vessels, allows myocardial protection in most heart positions (although sometimes the heart must be manipulated by the surgeon), 38 and can decrease perioperative myocardial infarction and postoperative morbidity. 39 In on-pump repeat CABG surgery, clamping of the aorta is associated with an inherent risk of stroke, and can be difficult because of the location of aortocoronary grafts. Nonsternotomy approaches, such as posterolateral thoracotomy or minimally invasive CABG surgery, can be used in repeat CABG surgery with patent grafts.…”

Section: Challenges Of Repeat Cabg Surgerymentioning

confidence: 99%

Secondary revascularization after CABG surgery

Escaned

2012

Nat Rev Cardiol

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CABG surgery is an effective way to improve symptoms and prognosis in patients with advanced coronary atherosclerotic disease. Despite multiple improvements in surgical technique and patient treatment, graft failure after CABG surgery occurs in a time-dependent fashion, particularly in the second decade after the intervention, in a substantial number of patients because of atherosclerotic progression and saphenous-vein graft (SVG) disease. Until 2010, repeat revascularization by either percutaneous coronary intervention (PCI) or surgical techniques was performed in these high-risk patients in the absence of specific recommendations in clinical practice guidelines, and within a culture of inadequate communication between cardiac surgeons and interventional cardiologists. Indeed, some of the specific technologies developed to reduce procedural risk, such as embolic protection devices for SVG interventions, are largely underused. Additionally, the implementation of secondary prevention, which reduces the need for reintervention in these patients, is still suboptimal. In this Review, graft failure after CABG surgery is examined as a clinical problem from the perspective of holistic patient management. Issues such as the substrate and epidemiology of graft failure, the choice of revascularization modality, the specific problems inherent in repeat CABG surgery and PCI, and the importance of secondary prevention are discussed.

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“…Notably, various technical strategies described to reduce the risk of reoperation have focused on techniques of resternotomy [6,12,13], alternative surgical access including minimally invasive incisions and thoracotomy [8,[14][15][16], myocardial protection [5,17,18] and avoiding cardiopulmonary bypass [19][20][21]. Different combinations of these techniques [7,22] have also been associated with good outcomes.…”

Section: Paradigm Shiftmentioning

confidence: 99%

The impact of symptom severity on cardiac reoperative risk: early referral and reoperation is warranted

Ngaage

Cowen

Griffin

et al. 2007

European Journal of Cardio-Thoracic Surgery

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Background: 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. Method: 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. Result: 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). Conclusion: 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. #

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Myocardial Protection in Reoperative Coronary Artery Bypass Grafting:. Toward Decreasing Morbidity and Mortality

Cited by 23 publications

References 32 publications

The Thebesian valve: Gatekeeper to the coronary sinus

The Thebesian valve: Gatekeeper to the coronary sinus

Secondary revascularization after CABG surgery

The impact of symptom severity on cardiac reoperative risk: early referral and reoperation is warranted

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