Reoperation for myocardial revascularization

Abstract

At The Cleveland Clinic Foundation, reoperations for myocardial revascularization make up 2.7% of all cardiac oPerations. Major indications for reoperation include: (a) graft failure, (b) progressive atherosclerosis in grafted or ungrafted vessels, (c) previous incomplete revascularization, and (d) combinations of the other 3. Almost one-half of the candidates satisfy more than 1 of the first 3 indications. Although few in number, late graft closure due to atherosclerosis is seen with increasing frequency. Systemic hypothermia coupled with intermittent cold cardioplegia shortens operating time, enhances myocardial protection, and markedly reduces the occurrence of low cardiac output postoperatively. Recent methods of blood conservation and their potential effect on morbidity are discussed.In the first 219 patients operated on through mid-1975, the operative mortality rate was 3.7%, and in subsequent years it was 2%. Although complete relief of angina is achieved less frequently after reoperation, in a follow-up period of 2.5 years, 87% of the 202 surviving patients improved at least one functional class. Relief of angina is virtually the same for each indication category. Those with progressive atherosclerosis had essentially the same clinical result as those operated on for graft failure. A successful result depends on selection of patients with adequate vessel caliber and runoff. Internal mammary artery (IMA) grafting is the procedure of choice for a failed anterior descending vein graft. Although complete revascularization is ideal, many of those who still have perfusion deficits because of diffuse disease can be improved clinically.Neither medical nor surgical treatment "cures" coronary atherosclerosis. Depending on the inter-

Management and Prevention of Cardiovascular Hemorrhage Associated With Mediastinitis

“…Control of the myocardial hemorrhage was initially undertaken by compression in 6 patients (patient 1 [ Table 1] died during an attempt to oversew the right ventricle in the recovery room). In the five patients who survived, extracorporeal circulation was instituted via cannulation of the femoral vessels (the two patients died before placement on cardiopulmonary bypass), and ventricular defects were closed with pledgeted sutures.…”