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PubMed1995

[Left thoracotomy approach for coronary reoperation].

We experienced reoperative coronary revascularization through a left thoracotomy in 12 patients between June 1992 and June 1994. All patients underwent grafting to the left coronary system except one, who underwent bypass procedure to the atrioventricular branch of the right coronary artery in addition to grafting to the left anterior descending artery, using the pedicled left internal thoracic artery, the gastroepiploic artery as a free graft, or a reversed saphenous vein graft. In one patient, revascularization was accomplished during temporary occlusion of the coronary artery without cardiopulmonary bypass. On the other hand, in 11 patients, cardiopulmonary bypass was used. Coronary bypass procedure was employed under the ventricular fibrillation with hypothermia in those but one, who underwent revascularization under the beating heart with cardiopulmonary support. All patients were hemodynamically stable in postoperative stage, and artificial ventilation time was not prolonged, with a mean time of 15.7 hours. Postoperative morbidity included reexploration for hemorrhage in one patient, convulsion in one, worsening of hemianopsia in one, ventricular arrhythmia in one, and wound complication in one, however, there were no hospital deaths. All patients underwent repeat coronary angiography, which revealed that all grafts were widely patient except one, which had inadequate flow due to diffuse narrowing. Based on these clinical results, we conclude that a left thoracotomy is a useful approach for reoperative coronary bypass procedures to reduce the surgical risk associated with a sternal reentry in properly selected patients.

Adult↗
PubMed1995

Cultures from genitourinary prostheses at reoperation: questioning the role of Staphylococcus epidermidis in periprosthetic infection.

PURPOSE: We determine the colony counts of organisms present on culture of clinically uninfected genitourinary prostheses at reoperation for reasons other than infection. These results served as control data for comparison with cultures from infected devices to determine the relative incidence of organisms involved. MATERIALS AND METHODS: Cultures were prospectively obtained from 65 penile prostheses and 22 artificial urinary sphincters. Patients were followed for a minimum of 12 months after reoperation or until development of infection (mean 27 months) at which time cultures were again obtained. RESULTS: Low colony counts of Staphylococcus epidermidis were isolated from 40% of uninfected penile prostheses and 36% of artificial urinary sphincters. Only 3 of these devices later became infected (9%) and in all cases a higher colony count of another organism was found at explanation. CONCLUSIONS: While Staph. epidermidis can cause prosthesis infection, low colony counts of the organism may not be associated with clinical infection. Therefore, the high incidence of infection attributed to this organism may be overestimated.

Case-Control Studies↗
PubMedDate not supplied

Improved outcome for seriously ill open heart surgery patients: focus on reoperation and endocarditis.

Although routine cardiac surgical procedures are now performed with low rates of mortality and relatively low rates of morbidity, certain categories of patients continue to present a major challenge. Patients who have reoperations and those with active infective endocarditis represent high-risk categories. The pathophysiologic mechanisms involved in such patients include impaired left ventricular function and low cardiac output, sepsis, endotoxemia, and gut permeability, and impaired hemostasis. Although these mechanisms are distinct, they do interrelate. Low cardiac output and imperfect systemic perfusion during and after cardiopulmonary bypass are known to induce splanchnic ischemia with altered permeability of the gut mucosal barrier to gut contents, including endotoxin. The systemic inflammatory response, triggered by contact activation of factor XII, produces functional disturbance in vital organs, notably the brain and lung. In addition, factor XII activation induces disordered hemostasis, which is related to increased fibrinolysis and a possible disturbance in platelet function. Measures to modify these mechanisms and improve outcome in high-risk patients include pulsatile perfusion during cardiopulmonary bypass and aprotinin therapy to modify the inflammatory response and prevent the disorder in hemostasis. Clinical experience with high-dose aprotinin therapy in patients who have reoperations and active endocarditis has demonstrated a very high level of efficacy in reducing blood loss and blood/blood product transfusion requirements. The potential role of aprotinin in stabilizing the microcirculation and modifying the systemic inflammatory response requires further study and may prove to be a major contribution to improved outcome in high-risk patients.

Aprotinin↗
PubMedDate not supplied

[Acute dissection of the ascending aorta. Can the risk of reoperation be reduced?].

From January 1974 to October 1993, we operated 113 Stanford type A acute dissections of the ascending aorta. There were 19 cases of immediate death but overall mortality was low (17%). During the last 10 years, mortality was reduced to 12%. There were 94 survivors who were followed for 2 months to 19.2 years. Mean follow-up was 6.6 +/- 4.77 years. Total follow-up time was 583 patients/years. There were 21 secondary deaths occurring within 2 months of surgery and the 10th post-operative year. Actuarial survival rate, including operative mortality, was 80 +/- 3.7% at 1 year, 70 +/- 4.6% at 5 years and 53 +/- 6% at 10 years. There were 17 vascular complications during the follow-up including 12 requiring reoperation. There were no vascular complications in 90% of the patients at 3 years, 78% at 6 years and 60% at 10 years. Three cases of aortic insufficiency developed subsequently and required reoperation with prosthetic valve replacement. Operative techniques changed between the first and second decade of this series. During the second decade, cardioplegic protection of the myocardium, open distal anastomosis, systematic exploration of the aortic arch and finally extension of the resection to the isthmus when required were introduced successively. In the absence of sufficient follow-up in the patients operated during the second decade, it is not possible to establish whether these modifications have actually reduced the number of post-operative vascular complications commonly reported.

Acute Disease↗
PubMed1994

A patent internal mammary artery graft decreases the risk of reoperative coronary artery bypass surgery.

In order to evaluate the potential risks of a patent internal mammary artery bypass at reoperative coronary artery bypass grafting, we have reviewed the records of 233 consecutive patients undergoing reoperative coronary artery bypass grafting between 1 January 1991 and 31 December 1993, including 209 patients having an occluded mammary graft or no mammary graft (Group I) and 24 patients having a patent mammary graft (Group II). With regard to preoperative patient characteristics, the only significant differences between the groups were: Group II patients had a higher preoperative left ventricular ejection fraction than did Group I patients (63.7% +/- 8.9% vs. 52.1% +/- 10.1%, p < 0.001); and Group II patients had received fewer grafts per patient than had patients in Group I (2.2 +/- 1.1 vs 3.6 +/- 1.4 grafts per patient, p < 0.001). There were no entry injuries to the grafts or to the heart in either of the groups. No perioperative mortality was encountered in Group II, while 11 patients died in Group I (p < 0.05). Group II had a significantly higher incidence of reexploration for post-operative bleeding, whereas Group I had a significantly higher incidence of low postoperative cardiac output. The incidence of all other perioperative complications did not differ between the groups. The results of this study support the use of mammary grafts even in patients who are likely to need repeat coronary artery bypass grafting and certainly does not disqualify such patients from a 2nd operation.

Coronary Artery Bypass↗
PubMed1993

[Reoperation after failure of unicompartmental knee prosthesis. Therapeutic strategy and results based on 40 cases].

Forty revisions for failure of unicompartmental knee prostheses were assessed. Twenty-eight women and twelve men (mean age: 67 years) were reoperated. Failure of an medial single-compartment prosthesis was involved in 35 cases, of a lateral prosthesis in 5 cases. The initial prostheses had been cemented in 19 cases and uncemented in 21 cases. Preoperative functional conditions were assessed by Hungerford's functional score and a 200-points score. The radiological study before revision showed 35 cases of varus distortion; in 12 of these, the varus distortion exceeded 10 degrees. Rather than studying the causes for failure of the single-compartment prosthesis, it seemed more useful to try to define the adequate reoperation procedure strategy and analyze its results. Our procedure aimed at solving the following difficulties: surgical approach: the same incision as in the initial operation was performed, the primary prosthesis was removed and a two-stage treatment was justified in cases of infection, metallosis involved complete removal of debris, the problem of bone-recutting and, chiefly, the problem of residual bone defect requiring bone-graft. Bone-recutting was performed with the tibial and femoral elements of the primary prosthesis still in place and using the ancillary equipment of the new prosthesis. Bone defects involved the femur as often (14 cases) as the tibia (12 cases); tibial bone defects occurred more frequently with cemented prostheses (9 cases) than with uncemented prostheses (3 cases). Femoral graft being relatively easier to perform one of the two major difficulties in our strategy was the achievement of a tibial graft.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1994

[Reoperative coronary artery bypass grafting in patients with patent internal thoracic artery grafts].

The incidence of reoperative coronary artery bypass grafting (reCABG) is recently increasing. However, there has been no report of reCABG in patients with patent internal thoracic artery (ITA) grafts in Japan. We performed reCABG in three such patients with patent ITA grafts. The first patient was a 49-year-old male who had undergone a 2 CABG (left ITA-LAD, SVG-DX 1), 8 years and 7 months prior to the 2nd operation, he received a re 2 CABG (GEA-RCA, RITA-SVG-DX 1) with a patent prior LITA-LAD graft. The second patient was a 65-year-old female who had undergone CABG in which the LITA had been erroneously anastomosed to the DX 2 in place of the LAD. Three year later, the reCABG (RITA-LAD) was performed with a patent prior LITA-DX 2 graft. The third patient was a 51-year-old male who had undergone 3-CABG (RITA-LAD, LITA-DX, SVG-RCA). The RITA was closed most probably due to technical errors and his angina recurred. Tree year after the first operation, he received a re 3-CABG (GEA-LAD, SVG-RCA, SVG-OM) with a patent prior LITA-DX graft. In each patient, PTCA had been tried twice, twice and once prior to redo operations. Their post-redo courses were uneventful, and they were discharged free from angina. In such cases it is important to manage with care the patent ITA grafts at reoperation. Biplane ITA angiograms are quite helpful to evaluate the course of grafts in relation to the sternum. To cover the ITA graft with a GORE-TEX membrane may also be useful for easy identification of the graft at redo operations.

Aged↗
PubMed1994

[Reoperation and balloon dilatation for stenosed xenograft valved conduits].

Follow-up has been achieved in 41 hospital survivals who received xenograft valved conduits in the pulmonary position. The interval after operation ranged 6 months to 13 years (average 5.2 +/- 3.7 years) (+/- standard deviation). There has been 8 late deaths, 3 of which were sudden. Of the 11 reoperations, 7 underwent graft replacement with no operative death. The actuarial reoperation free survival rate was 73% at 5 years, and 54% at 10 years. There was a significant correlation between the interval after operation (x years) and the pressure gradient across the conduits (y mmHg). (y = 20.7 + 9.7x, r = 0.74, p < 0.001). Balloon dilatation of the conduits was performed in 15 patients. The mean conduit gradient was significantly (p < 0.001) reduced from 85 +/- 29 to 54 +/- 22 mmHg. However, the effect was not satisfactory enough and 4 patients received graft replacement after the balloon dilatation. These results warrant the avoidance of xenograft valved conduits in the pulmonary position, the safety of the graft replacement, and the limitation of the balloon dilatation for the stenosed conduits.

Adolescent↗
PubMed1994

[The second coronary reoperation via the left thoracotomy without cardiopulmonary bypass].

A 75-year-old female who had underwent coronary artery bypass grafting (CABG) reoperation 2 years before was readmitted because of unstable angina. Two arterial grafts and one saphenous vein graft (SVG) were all occluded one and half year after the primary operation. The second operation was approached via the repeated sternotomy. LAD and RCA were revascularized with a Y-shaped SVG which had only one inflow. Coronary angiogram revealed stenosis of LMT and RCA and occlusion of the inflow of the Y-shaped SVG. We performed the 3rd CABG via the left thoracotomy without cardiopulmonary bypass for revascularization of the LAD area. A new SVG was anastomosed from the descending aorta to the old SVG just proximal to the anastomotic site with LAD. Local coronary occlusion time was 7 min without any hemodynamic or electrocardiographic deteriorations. The operation was successfully performed in 3 hr 55 min. The patient recovered well uneventfully. Postoperative angiogram showed that the new SVG was adequately patent and she was discharged without angina. We conclude that CABG without cardiopulmonary bypass via the left thoracotomy is an useful alternative to decrease mortality and morbidity for reoperative myocardial reveascularization.

Aged↗
PubMedDate not supplied

[Complications in reoperations in the popliteal fossa].

For "redo" therapy in the popliteal space an excellent anatomical knowledge is imperative as shown by the results of the dissection of 38 cadaver legs. Dynamic phlebography is the only way to get this information. It is upon this examination that the phlebologist should make his choice either to use sclero-compression therapy or to reoperate the patient. In the case of an reoperation the external access should be chosen even if this implicates an anatomical challenge.

Bandages↗
PubMed1994

[Problems and results of coronary reoperation].

Reoperative coronary bypass surgery has been encountered with increasing frequency over the last few years. It is associated with several major problems: difficulties with myocardial protection secondary to progression of arterial disease and occluded saphenous vein grafts, left ventricular dysfunction, and concomitant medical and vascular disease. We present our experience with 194 consecutive patients operated on between 1980 and 1992. They represent 4.0% of the overall number of isolated coronary revascularizations performed during the same period. There were 178 men and 16 women, mean age 58.6 +/- 7.4 years. The interval between primary coronary bypass grafting operation and redo-operation extended from 4 to 12 years, mean 8.2 years. At reoperation, 91.7% (178/194) of the patients received at least one arterial conduit, whereas revascularization with arterial conduits only was performed in 16 patients. Perioperative mortality amounted to 4.6% and was significantly higher than mortality of primary isolated coronary operations (1.6%) during the same period; the following significant morbidity was encountered: perioperative myocardial infarction (8.2%), postoperative low output requiring intraaortic counterpulsation (8.7%), postoperative bleeding (8.2%) and infectious complications (9.2%). First postoperative follow-up showed a significant improvement of symptomatology with a decrease of 1.5 point in NYHA functional class. Mid term survival is promising with a 5-year survival rate of 88.5%. Improved myocardial preservation and a trend towards complete revascularization should become routine and will probably reduce perioperative mortality and morbidity.

Adult↗
PubMed1994

[Directions for reoperation of patients with Björk-Shiley convexo-concave valve prosthesis, based on long-term experience].

Although a high incidence of strut fracture of the Björk-Shiley convexo-concave (C-C) valve prosthesis has been reported, it is still controversial whether the prosthesis functioning normally should be replaced electively. To clarify our policy for this issue, we reviewed 28 patients who had undergone mitral valve replacement with a C-C valve prosthesis, and evaluated long-term results according to STS guidelines. The incidence of valve-related complications expressed as % patient-year were; structural deterioration 0.30, nonstructural dysfunction 0.30, thromboembolism 1.20. There were no thrombosed valves, anticoagulant-related hemorrhage or prosthetic valve endocarditis. The actuarial free rate after valve replacement with the C-C at 10 years, constructed by the Kaplan-Meier method, were compared with those with St. Jude Medical (SJM) valve prosthesis. (1) Actuarial survival: 77.9 vs 87.3 (NS), (2) Reoperation-free: 91.6 vs 98.0 (p < 0.05), (3) thromboembolism-free: 83.7 vs 83.9 (NS), (4) Event-free (hospital death+reoperation+valve-related complications: 71.2 vs 77.7 (NS). The long-term results with the C-C were compatible to those with a SJM valve prosthesis. However, if a strut fracture occurs, it is very difficult to save the patient's life. The hospital mortality of re-replacement of valve prosthesis during the last 10 years, at our institute, was 2.6%, which is almost equal to the cumulative risk of strut fracture of the C-C valve after 10 years (3.0%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

[Reoperation for late pseudoaneurysm in the ascending aorta following the modified Bentall procedure--a case report].

We performed reoperation for annuloaortic ectasia (AAE) in a patient with Marfan's syndrome. The initial operation was the modified Bentall procedure, in which the root of the ascending aorta and the aortic valve were replaced with a composite graft with a prosthetic mechanical valve, and the coronary arteries were reconstructed by direct anastomosis to the right coronary ostium or with an interposing graft to the left coronary ostium. At 1 year and 6 months after the initial operation, a pseudoaneurysm developed in the ascending aorta following the reconstructed coronary ostium on the right side was detached. At reoperation, the hole in the composite graft was closed, but the right coronary artery could not be reconstructed. Her postoperative course was uneventful. In addition, Piehler's method is effective for reconstruction of the coronary arteries, especially for patients with AAE in the Marfan's syndrome.

Adult↗
PubMed1993

[Emergency reoperations in the reconstructive surgery of abdominal aorta and major arteries of the lower extremities].

The experience with treatment of 564 patients who underwent 642 reoperations on the arterial vessels, including 281 emergency operation, are presented. The causes of the development of pronounced ischemia of the lower extremities and that of the extreme situation are considered. The surgical tactics for the treatment in cases of transplant infection, erosive bleeding from aortal anastomosis etc. have been developed. The original methods for surgical correction in performance of a reoperation have been suggested, the analysis of the results of treatment has been performed.

Anastomosis, Surgical↗
PubMed1993

[Autohemotransfusion in cardiac reoperations].

OBJECTIVE: To evaluate the efficacy of intraoperative autotransfusion with hemodilution (AHT) to reduce postoperative transfusion of blood or blood products (BT) after cardiac surgery reoperation. DESIGN: Retrospective study, follow-up control. SETTING: Italian Institution of Cardiac Surgery (IICC). PATIENTS: 169 patients (51 males, 118 females; mean age 49.5 years) undergoing a reoperation from May 1982 to December 1991. INTERVENTIONS: 143 patients single valve replacement, 16 patients double valve replacement and 10 patients radical correction for tetralogy of Fallot. AHT (mean 620.2 +/- 226.9 ml) was performed in all patients. The shed blood was reinfused at the end of the surgery. PT, PTT, TT, TT Coagulase, FDP, pre- and postoperative platelet count, bleeding and needs for BT were recorded. RESULTS: Preoperatively: PT 71.3 +/- 8.1, PTT (sec.) 36.9 +/- 3.5, TT (sec.) 16.2 +/- 2.3, TTC (sec.) 16.9 +/- 1.7, FDP (ng% ml) 3.8 +/- 2.7, Platelet count (No./mu 11 170 +/- 58. Postoperatively: PT 36.5 +/- 6.5, PTT(sec.) 49.5 +/- 8.7, TT(sec.) 19.1 +/- 1.8, TTC(sec.) 18.9 +/- 2.1, FDP (ng% ml) 13.5 +/- 8.9, Platelet count (No./mu 11) 85 +/- 34. We had one reentry because of bleeding. The mean units of blood or blood products need after surgery were 2.2 +/- 1.02. Bleeding from the drainage was 105.2 +/- 103.8. Two patients died in the postoperative period because of low output syndrome. In a period of one year of F.U. we had only one patient with hepatitis B. CONCLUSIONS: These data suggest that AHT is a safe method, reduces needs for banked blood or blood products, risks of infectious disease transmission and of immunologic reactions and presents hemorheologic benefits because of the diminished blood viscosity.

Blood Transfusion, Autologous↗
PubMed1993

Reoperative coronary artery bypass surgery. Improved preservation of myocardial function with retrograde cardioplegia.

BACKGROUND: Cardiac-related mortality remains high for reoperative coronary artery bypass graft surgery (rCABG) compared with first-time surgery (fCABG). Retrograde cardioplegia (RC) has been suggested but not proven to improve the results for rCABG. METHODS AND RESULTS: We therefore reviewed the records of 240 consecutive patients who had undergone rCABG at our institution since 1988. The interval to reoperation was 9.1 +/- 4.2 years (mean +/- SD), with a range from 0.2 to 18 years. Only 46% of grafts were patent at the time of rCABG. The incision to cardiopulmonary bypass (CPB), incision to cross-clamp (XCL), and XCL per graft time intervals were significantly prolonged compared with 100 consecutive fCABG patients operated on during the same time period. Blood utilization was also significantly increased in rCABG compared with fCABG patients. Overall operative mortality was 5.8% and 0% for rCABG and fCABG patients, respectively (P < .05). High-risk criteria (emergency surgery, angina at rest requiring intravenous nitroglycerin or intra-aortic balloon pump [IABP] support [urgent surgery], recent [<21 days] myocardial infarction, or ejection fraction < 30%) were noted in 136 rCABG patients (57%) and 28 fCABG patients (28%) (P < .001). Profound postoperative myocardial dysfunction (postoperative IABP dependence) occurred in only one of 104 low-risk patients (1%), compared with 14 of 136 high-risk patients (10%) (P < .005). Operative mortality was noted in 13 high-risk patients (9.5%) compared with one low-risk patient (1%) (P < .005). RC was used in 80 patients without complication. Postoperative IABP dependence developed in only 2 of 53 high-risk/RC patients (3.8%) compared with 12 of 83 high-risk/non-RC patients (14.5%) (P < .05). At follow-up, rCABG and fCABG patients enjoyed similar symptomatic improvement. CONCLUSIONS: We conclude that retrograde cardioplegia, possibly by minimizing the increased ischemia associated with rCABG, improves the results of rCABG, specifically in regard to preventing profound myocardial dysfunction in high-risk patients.

Coronary Artery Bypass↗
PubMed1993

Lumbar spinal fusion. A cohort study of complications, reoperations, and resource use in the Medicare population.

Regional variations in lumbar spinal fusion rates suggest a poor consensus on surgical indications. Therefore, complications, costs, and reoperation rates were compared for elderly patients undergoing surgery with or without spinal fusion. Subjects were Medicare recipients who underwent surgery in 1985, with 4 years of subsequent follow-up. There were 27,111 eligible patients, of whom 5.6% had fusions. Mean age was 72 years. Patients undergoing fusion had a complication rate 1.9 times greater than those who had surgery without fusion. The blood transfusion rate was 5.8 times greater, nursing home placement rate 2.2 times greater, and hospital charges 1.5 times higher (all P < 0.0005). Six-week mortality was 2.0 times greater for patients undergoing fusions (P = 0.025). Reoperation rates at 4 years were no lower for patients who had fusion surgery and results were similar in most diagnostic subgroups. Indications for fusion among older patients require better definition, preferably based on outcomes from prospective controlled studies.

Aged↗