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(Chest. 1999;115:1593-1597.)
© 1999 American College of Chest Physicians

Long-term Follow-up After Coronary Artery Bypass Grafting Reoperation*

Itzhak Shapira , MD, FCCP; Aharon Isakov , MD; Israel Heller , MD; Marcel Topilsky , MD, FCCP and Amos Pines , MD

* From the Post-Cardiac Surgery Follow-up Clinic (Drs. Shapira, Isakov, and Heller), Internal Medicine H (Dr. Topilsky), and Internal Medicine T (Dr. Pines), the Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.


   Abstract
TOP
 Abstract
Introduction
 Patients and Methods
 Results
 Discussion
 References
 
Background: Coronary artery bypass grafting (CABG) reoperation is being performed with increasing frequency.

Objective: To determine the clinical outcome and the long-term results of a second CABG.

Setting: An 1100-bed urban university-affiliated hospital.

Design: Retrieval of data on selected parameters from medical records before surgery and prospective follow-up afterwards.

Patients and methods: We studied the outcomes of 498 consecutive patients who underwent CABG reoperation in our institution from January 1978 to December 1989 and who were followed postoperatively. Their perioperative mortality, morbidity, and long-term follow-up results were re-evaluated. The end points of the study were December 1997, 15 years of follow-up, or the patient's death.

Results: The perioperative mortality rate was 3%. The cumulative survival rates were 90.1%, 74%, and 63.4% at the 5-year, 10-year, and 15-year follow-ups, respectively. The cardiac event-free survival rates were 91.5%, 83.4%, and 67.8% at the 5-year, 10-year, and 15-year follow-ups, respectively. The risk factors adversely affecting long-term survival were advanced age, hypertension, and a low left ventricular ejection fraction (LVEF).

Conclusions: The long-term results of cumulative survival and cardiac event-free survival in patients who underwent CABG reoperation are good. Although this reoperation is safe overall, advanced age, hypertension, and a decreased LVEF significantly increase the surgical risk.

Key Words: cardiac-event free • coronary artery bypass grafting • long-term follow-up • reoperation • survival


   Introduction
TOP
 Abstract
 Introduction
Patients and Methods
 Results
 Discussion
 References
 
Despite advances in invasive cardiology and preventative pharmacologic therapies, an increasing number of patients require the coronary artery bypass grafting (CABG) reoperation.1 The recurrence of ischemia can be due either to progressive atherosclerotic disease of native vessels and grafts2 or to incomplete revascularization at the initial surgery. As many as 10 to 20% of patients who have had CABG will need a reoperation, usually within 10 years of the first one.2

Although the surgical results of the CABG reoperation, and the short-term and medium-term survival rates for patients who have undergone this reoperation have been well documented,3 4 5 6 7 8 9 10 11 12 13 14 15 data on the long-term follow-up are incomplete.2 16 17 18 19 20 In this paper, we defined the risk factors associated with CABG reoperation, and we prospectively assessed the long-term prognosis.


   Patients and Methods
TOP
 Abstract
 Introduction
 Patients and Methods
Results
 Discussion
 References
 
This study evaluated the surgical results and the long-term follow-up of 498 patients who underwent the CABG reoperation between January 1978 and December 1989. Patients who had this reoperation within 3 weeks of the initial CABG and/or had a combined cardiac procedure were excluded. The clinical characteristics of the patients are shown in Table 1 . Most of them were reoperated on >= 6 years after the primary procedure (Table 2 ). The main indications for CABG reoperation, as obtained from the diagnostic catheterization reports, are listed in Table 3 . The average number of anastomoses per patient was 3.5 (range, 2 to 5). Seventy-eight of the patients (20%) had percutaneous transluminal coronary angioplasty (PTCA) before the CABG reoperation. Seventy-six patients (15%) had urgent surgery; an intra-aortic balloon pump had been used preoperatively in 12 of them. CABG reoperation was elective in 422 patients. Several technical surgical features should be mentioned: the myocardium was protected by using anterograde crystalloid cold cardioplegia; the arterial grafts that were used were pediculated mammary arteries; open or nondiseased grafts were usually not replaced, and open grafts were not usually ligated after replacement; the proximal anastomoses were constructed following removal of the aortic clamp with the help of a side-biting aortic clamp; and the left ventricle was usually vented.


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  		Table 1. Preoperative Characteristics of Patients Undergoing CABG Reoperation*

 

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  		Table 2. Time Interval Between the First and the Second CABG Procedure

 

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  		Table 3. Indications for Reoperative CABG

 
After the initial postoperative examination in the Cardiothoracic Surgery Department, the patients were referred to the Post-Cardiac Surgery Follow-up Clinic, and they underwent clinical evaluations four times per year during the first 2 postoperative years, twice yearly during the following 2 years, and annually thereafter. Patients who experienced cardiac events or had cardiac complaints returned immediately to the clinic for reevaluation and appropriate treatment. The periodic assessment of the study population included the documentation of cardiac symptoms and the recording of cardiac events (ie, occurrence of myocardial infarction [MI], CABG reoperation, or coronary angioplasty). Drug regimens and surgical procedures were decided on by the clinic's physicians in collaboration with the patient's general practitioner. Categorization of the cause of death was based on information retrieved from the medical charts or death certificates. "Cardiac death" was defined as any mortality resulting from cardiac arrhythmias, congestive heart failure, or MI. The end points of the study were December 1997, 15 years of follow-up, or the patient's death. During the study period, 68 of the 498 patients (13.6%) who underwent a CABG reoperation failed to attend all of the scheduled visits to the clinic, and the data on their medical status were obtained by phone interview. Nineteen patients (3.8%) failed to attend any of the follow-up visits, and none of these patients was reported dead by the Israeli Population Registry.

Statistical Analysis
Univariate analysis was employed to determine predictors of operative mortality. The variables included the following: age >= 70 years; gender; preoperative angiographically determined left ventricular ejection fraction (LVEF) [> 55%, 31 to 54%, or < 30%]; resting arterial hypertension (> 150/90 mm Hg); renal insufficiency (serum creatinine > 2.1 mg/dL); diabetes mellitus; hyperlipidemia (total cholesterol > 240 mg/dL or low-density lipoprotein cholesterol > 140 mg/dL); and the time interval from the first CABG to the second CABG (< 1 year, 1 to 5 years, 6 to 10 years, or > 10 years). Actuarial analysis (using the Kaplan-Meier test) was employed to assess mortality and cardiac events.


   Results
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
Discussion
 References
 
The immediate surgical mortality rate (ie, within 30 days of hospitalization) was 3% (15 patients). In patients whose second surgery was carried out <= 1 year after the first one, the perioperative mortality was significantly higher than it was for the others (3/30 vs 12/468; p < 0.05). Other independent risk factors that correlated with perioperative mortality (p < 0.05) were LVEF < 30% (3 fatalities in 27 cases), diabetes mellitus (7 fatalities in 129 cases), and age > 70 years (9 fatalities in 169 cases). In the 238 patients who had CABG reoperation because of graft failure, patients with grafts that we found to be both patent and stenotic bore a greater risk of having to undergo reoperation than patients with occluded grafts did. Graft failure occurred in 24 patients. Eleven of these patients died, 9 had an MI, and 4 had a neurologic event in the perioperative period. Sixteen of these patients had grafts that were patent but stenotic; however, the difference in mortality and perioperative morbidity between these patients and those with occluded grafts was not significant. The complications of surgery are listed in Table 4 .


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  		Table 4. Early Postoperative Complications

 
Long-term follow-up data are displayed in Figure 1 . Of the 159 patients who died during the follow-up period, 114 of the deaths (71.7%) were due to cardiac causes. The cumulative survival rates were 90.1%, 74%, and 63.4% at the 5-year, 10-year, and 15-year follow-ups, respectively. The risk factors adversely affecting long-term survival were age, hypertension, and decreased LVEF. The cardiac event-free (ie, no third intervention such as CABG or PTCA and/or MI) survival rates were 91.5%, 83.4%, and 67.8% at the 5-year, 10-year, and 15-year follow-ups, respectively (Fig 2 ). Table 5 displays the number of events that occurred during each year of the follow-up. Most of the patients (88%) reported subjective improvement of symptoms (ie, anginal pains and/or dyspnea symptoms) during the first year after the CABG reoperation.



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  		Figure 1. Cumulative survival (ie, total mortality, cardiac mortality, and noncardiac mortality).

 


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  		Figure 2. Cumulative cardiac event-free survival.

 

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  		Table 5. No. of Events Occurring During the Follow-up Period (498 Patients)

 

   Discussion
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
References
 
This study assessed the long-term results of CABG reoperation procedures performed in a large urban hospital during a period of 11 years. Today, decades after the introduction of CABG as a routine procedure in many medical centers, 1 in every 5 to 7 patients who have undergone one CABG may need a reoperation. Despite surgical advances in coronary vascular surgery, including the routine use of arterial grafts, incomplete revascularization and technical or graft failure remain the causes of late failure of surgery. The development of PTCA and stent implantation techniques enable more patients with diffuse diseases to be candidates for these procedures, and this increases the absolute number of patients who experience either a partial or a complete treatment failure.

CABG reoperation is a challenge for heart surgeons because of the altered anatomy, adhesions, and scar tissue of the patients. Patients are also likely to be more apprehensive than they were the first time. Moreover, cardiologists face the difficult task of selecting patients who can benefit from a CABG reoperation vis-a-vis the risk factors for cardiac mortality, which can prevent long-term and cardiac event-free survival.

The objectives of our study were to determine the clinical outcome and the long-term prognosis of CABG reoperation in our center. Previous studies had addressed the issues of perioperative morbidity and mortality, cumulative survival, and cumulative cardiac event-free survival by studying series of 106 to 1,500 patients who underwent CABG reoperations.4 7 9 10 15 16 17 19 21 22 23 24 The mortality rates in these series varied from 2.8 to 9.2%, a perioperative MI was recorded in 0.8 to 8.9% of the patients, and the stroke incidence ranged from 0.9 to 3.5%. Similar figures were obtained in our series of 498 patients. The 5-year survival rates in other studies reached 81 to 93%, and the 10-year survival rates reached 65 to 75%. Our results for cumulative survival rates were 90.1%, 74%, and 63.4% at the 5-year, 10-year, and 15-year follow-ups, respectively. Our results for cardiac mortality alone were 91.4%, 80.3%, and 72.9% at the 5-year, 10-year, and 15-year follow-ups, respectively. In other studies, the cardiac event-free survival rates ranged from 28 to 86% at 5 years and then ranged from 30 to 48% at 10 years. In our patients, the cardiac event-free survival rates were 91.5%, 83.4%, and 67.8% at the 5-year, 10-year, and 15-year follow-ups, respectively.

We found that age, hypertension, and low LVEF adversely affected the long-term survival of patients who have undergone CABG reoperation. This was expected because it has already been recognized that these factors decrease the chances of long-term survival for patients with a variety of types of acquired heart disease who undergo either medical or surgical treatment.2 Christenson et al5 found that early CABG reoperation (ie, <= 1 year from primary bypass and usually due to graft failure) was associated with an increased operative risk. The patient's age at the time of the reoperation was a potent factor affecting perioperative mortality17 19 and long-term survival.2 17 While Foster et al25 reported a 3% incidence of CABG reoperations in 9,364 patients, the cumulative percentage of these reoperations reached 11.4% at 10 years and an astounding 17.3% at 12 years. Christenson et al23 evaluated whether patients with very low LVEF (ie, <= 25%) should be accepted for CABG reoperation and concluded that such patients, as well as patients with two- to three-vessel coronary artery diseases, should not categorically be refused the CABG reoperation. Noppeney et al8 and Lytle et al19 did not find any predominant risk factor that influences long-term survival. LVEF, as determined by preoperative angiography, proved to be a strong determinant of long-term survival in other studies.2 17 19 26 Awad et al3 evaluated the outcome of cardiac reoperation in patients aged > 70 years and found that CABG reoperation carried an acceptable operative morbidity and mortality with good functional improvement at medium-term follow-up. Kron et al27 evaluated the results of CABG reoperation in cases of chronic ischemic cardiomyopathy and found that surgery in these patients is associated with substantially higher rates of early mortality and morbidity. PTCA carries lower procedural morbidity and mortality risks, although it is associated with less complete revascularization and a greater need for subsequent revascularization. Stephan et al24 addressed the issue of the relative risks and benefits of PTCA and CABG reoperation in 632 patients. In their nonrandomized series of patients requiring revascularization, an initial strategy of either PTCA or CABG reoperation resulted in an equivalent overall survival, cardiac event-free survival, and relief of angina. Although arterial grafts are now used almost exclusively in our institution, they were rarely used during the period covered by this study.

Improved outcomes of patients undergoing CABG reoperations depend on surgeons recognizing high risk conditions, acquiring more experience in the technical aspects of the surgery, bettering their selection of patients, and improving perioperative and postoperative care. Our study shows that the perioperative mortality and complication rates for CABG reoperation are relatively low. Long-term results regarding cumulative survival and cardiac event-free survival are also good. Although CABG reoperation is safe overall, advanced age, hypertension, and decreased LVEF function significantly increase the surgical risk.


   Acknowledgements
 
ACKNOWLEDGMENT: The authors wish to thank Yael Villa, PhD, for statistical evaluation of the data, Ms. Esther Eshkol for manuscript preparation, and Ms. Esther Lior for secretarial assistance in running the Post-Cardiac Surgery Follow-up Clinic.


   Footnotes
 
Correspondence to: Itzhak Shapira, MD, FCCP, Deputy Director General, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel; e-mail: shapiraiz@tasmc.health.gov.il

Abbreviations: CABG = coronary artery bypass grafting; LVEF = left ventricular ejection fraction; MI = myocardial infarction; PTCA = percutaneous transluminal coronary angioplasty

Received for publication May 19, 1998. Accepted for publication January 4, 1999.


   References
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 References
 

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