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Ann Thorac Surg 2008;85:1239-1245. doi:10.1016/j.athoracsur.2007.11.075
© 2008 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Multidetector Computed Tomographic Angiography in Planning of Reoperative Cardiothoracic Surgery

Apur R. Kamdar, MDa, Telly A. Meadows, MDa, Eric E. Roselli, MDb, Eiran Z. Gorodeski, MD, MPHa, Ronan J. Curtin, MDa, Joseph F. Sabik, MDb, Paul Schoenhagen, MDa,c, Richard D. White, MDd, Bruce W. Lytle, MDb, Scott D. Flamm, MDa,c, Milind Y. Desai, MDa,c,*

a Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
b Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
c Department of Radiology, Cleveland Clinic, Cleveland, Ohio
d Department of Radiology, University of Florida, Jacksonville, Florida

Accepted for publication November 28, 2007.

* Address correspondence to Dr Desai, Department of Cardiovascular Medicine, Desk F-15, 9500 Euclid Ave, Cleveland, OH 44195 (Email: desaim2{at}ccf.org).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background: Redo cardiothoracic surgery is associated with increased morbidity and mortality compared with primary operations. Multidetector computed tomographic angiography (MDCTA) delineates the course of previous coronary artery bypass grafts (CABG) and proximity of mediastinal structures to the chest wall. We sought to determine if high-risk preoperative MDCTA findings were associated with greater use of preventive surgical strategies during redo cardiac surgery in patients with prior CABG.

Methods: We studied 167 patients (mean age 69 ± 9 years, 79% men) with prior CABG, referred for redo cardiac surgery, who underwent contrast-enhanced MDCTA to assess CABG location and mediastinal relationship to chest wall. Preoperative risk was determined. Prevalence of high-risk MDCTA findings, use of preventive surgical strategies, frequency of severe intraoperative bleeding, and postoperative mortality were recorded.

Results: Mean risk score was high (7.5 ± 3). High-risk MDCTA findings included proximity (<1 cm) of right ventricle/aorta to chest wall (24%) or CABG crossing midline in close proximity (<1 cm anteroposteriorly) to sternum (38%). Preventive surgical strategies included surgery cancelled (4%), nonmidline incision (8%), deep hypothermic circulatory arrest (5%), initiation of peripheral cardiopulmonary bypass (11%) and extrathoracic vascular exposure before incision (53%). These strategies were used at a higher frequency in patients with high-risk MDCTA findings versus those without (88% versus 28%, p < 0.0001). Frequency of severe bleeding, graft injuries, and 1-month mortality were 4.4%, 5%, and 2.5%, respectively.

Conclusions: Routine use of preoperative MDCTA to detect high-risk findings has a strong association with adoption of preventive surgical strategies in high-risk patients undergoing redo cardiac surgery.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 
Reoperative cardiac surgery (RCS) is associated with a significantly higher risk of morbidity and mortality than primary cardiac operations, likely attributable to both increased technical difficulty of RCS, resulting in greater complications, and higher risk profile of RCS patients. Owing to a multitude of factors, including increased longevity resulting from improved overall medical care, the frequency of RCS is increasing [1]. Over the past decade and a half, overall published mortality rates for RCS in patients with previous coronary artery bypass graft surgery (CABG) have ranged from 2.5% to 8.3% [2–8]. Nonetheless, with increasing experience with RCS patients, surgical outcomes have improved, particularly at high-volume centers [1]. Although it is not entirely clear which factors are associated with this improvement in outcomes, comprehensive preoperative planning guiding the use of preventive surgical techniques, and development of preemptive rescue plans likely contribute [9].

Contrast-enhanced multidetector computed tomographic angiography (MDCTA) has emerged as a highly reliable technique for comprehensive assessment of chest, mediastinal, and coronary bypass graft anatomy [10–14]. In addition, MDCTA is also excellent in delineating the relationship of cardiovascular structures to the chest wall [15, 16]. In recent years, as part of comprehensive preoperative planning, we routinely perform cardiothoracic MDCTA on patients undergoing RCS. Based on the continuously improving mortality data in RCS patients over the last 5 years, we sought to determine if the presence of high-risk preoperative MDCTA findings were associated with greater use of preventive surgical strategies in patients with prior CABG undergoing RCS.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 Acknowledgments
 References
 
Study Design and Patient Selection
This was an observational, retrospective, single-center study of 167 patients, with a history of prior CABG, who underwent cardiothoracic MDCTA for preoperative planning, before contemplated RCS between 2003 and 2006. The following patients were excluded: (1) patients without prior history of CABG, (2) planned transmyocardial revascularization procedure, (3) planned left ventricular apical to aortic shunt placement, (4) planned sternal wound repair in patients with mediastinitis, (5) planned pacemaker wire removal, and (6) patients for whom MDCTA was ordered to assess bypass graft patency, not in preparation for RCS. Of the 506 patients in the original database, 339 were excluded. This study was approved by the local Institutional Review Board with waiver of individual consent.

Demographic Data and Calculation of Preoperative Risk
The electronic medical record was reviewed by two investigators (A.R.K. and T.A.M.) to extract baseline demographic variables, and clinical and medication history. History of diabetes mellitus (including use of insulin), hypertension, hyperlipidemia, chronic obstructive pulmonary disease, stroke, and current smoking were determined based upon physician-documented history, documented measurements, and use of medications. Medication use, including aspirin, β-blockers, angiotensin-converting enzyme inhibitors, statins, and diuretics was recorded. Height (cm), weight (kg), and blood pressure (mm Hg) values were recorded from the office visit temporally closest to the MDCTA study. Body mass index was calculated using the following formula: weight in kilograms/(height in meters)2. Routine complete blood count, comprehensive metabolic profile, and lipid values were also recorded from the office visit temporally closest to the MDCTA study (typically within 1 week). Glomerular filtration rate was calculated in each patient using the modification of diet in renal disease formula [17]. Left ventricular ejection fraction and presence/degree of pulmonary hypertension were recorded based upon preoperative echocardiogram. We also recorded emergent status and number of previous operations (first, second, or more RCS). Based upon the extracted variables, a preoperative risk assessment score (Higgins score) was generated for every patient [18]. Social Security numbers were used to query the Social Security Death Index to determine 48-hour, 7-day, and 1-month mortality rates. We chose this as it is more specific (>99%) and potentially less biased than the National Death Index [19–21]. Further, we chose to use all-cause mortality as our endpoint, as it is more objective and unbiased than "cardiac mortality" [22]. Patients’ home zipcodes were used to determine the referral patterns.

MDCTA Data Acquisition and Analysis
Cardiothoracic MDCTA studies were performed with 16-, 40-, and 64-detector scanners (Siemens Sensation, Erlangen, Germany; or Philips Brilliance, Cleveland, Ohio) using the following parameters: gantry rotation 330 to 420 ms, spiral imaging with retrospective electrocardiographic gating and radiation dose modulation, 750 to 850 mAs, 120 kV, 2-mm slice thickness and 90 cc isosmolar contrast. In all cases, detection of peak enhancement in the aortic root was used for timing of the scan. Because we obtained 2-mm slice thickness, the scan parameters generally remained similar despite scanner upgrades. All images were acquired during an inspiratory breath hold of 10 to 20 s, depending upon the particular scanner. Image reconstructions were generated in diastole, typically at 75% of the cardiac cycle. If motion artifacts were present, additional reconstructions were made at different points of the R-R interval. The MDCTA data were extracted out of electronic medical records by two authors (A.R.K., T.A.M.). High-risk findings on preoperative MDCTA were predefined as follows: (a) adherence/proximity (<1 cm) of right ventricle (RV) or adjacent pericardium to the chest wall; (b) bypass graft crossing midline within 1 cm (or adherent to) in anteroposterior direction of the inner edge of the chest wall and sternum; and (c) adherence/proximity (<1 cm) of ascending aorta to the chest wall/sternum.

Analysis of Surgical Operative Data
Surgical operative data were extracted from the electronic medical records by two authors (A.R.K., T.A.M.). On consensus of our cardiothoracic surgeons, use of the following predefined preventive surgical strategies, implemented in these RCS patients, were recorded [23]: (a) use of nonsternotomy approaches (lateral, anterolateral thoracotomy); (b) initiation of peripheral cardiopulmonary bypass (CPB) before incision; (c) peripheral arterial and venous dissection (axillary, femoral vessels) before incision; and (d) use of deep hypothermic circulatory arrest. Cancellation of RCS, the ultimate option in the setting of very high-risk MDCTA findings, was also recorded, based on explicit chart documentation. We also recorded the frequency of injury to vital structures such as bypass grafts, aorta, or the heart, based upon operative reports. Frequency of severe intraoperative bleeding was recorded based upon explicit documentation in operative notes, as dictated by the surgeon of record. Frequency of surgical reexploration for bleeding was also recorded. All the MDCTA and surgical reports were confirmed and adjudicated by a physician (M.Y.D.) experienced in MDCTA and management of postoperative surgical patients, in a blinded fashion.

Statistical Analysis
Baseline demographics, risk factors, and clinical variables are descriptively summarized for the group. Continuous variables are expressed as mean ± SD. Categorical data are presented as % frequency. Differences between groups were compared with the use of Student’s t test and Wilcoxon rank-sum test for continuous variables and the {chi}2 test for categorical variables. Multivariable logistic regression models were used to explore the association between high-risk MDCT finding and use of the preventive surgical strategies. Presence/absence of one or more high-risk MDCT findings or use/nonuse of one or more preventive surgical strategy per patient were considered as either positive or negative findings (binary variables), for {chi}2 and multivariate analyses. The modeling variables were predefined by the investigators. Data assembly and basic statistical comparisons were performed with JMP Software version 6.0.2. Advanced statistical analysis was performed with STATA/SE version 9.2 (Stata Corp, College Station, Texas). A p value less than 0.05 was considered significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 Acknowledgments
 References
 
Demographic Data
The demographic data of patients divided on the basis of high-risk MDCTA findings is shown in Table 1. As expected, there was a high prevalence of comorbidities in this population, and the preoperative risk score was high (Table 1). The vast majority of patients were undergoing their second cardiac operation (first RCS, 78%). Three quarters of the patients, 75%, were referred to our institution from outside a 50-mile radius referral area, 5% were from international centers, and the remainder were from within the immediate referral area or were primary patients of our institution. Almost half of the patients (49%) underwent a combined reoperative CABG and valve repair or replacement surgery. One quarter of the patients had isolated reoperative CABG alone, 24% underwent valve surgery only, and 2% had aortic aneurysm repair surgery.


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  		Table 1 Demographics of Study Population Divided on Basis of High-Risk MDCTA Findings (Total n = 167)
 
High-Risk MDCTA Findings and Preventive Surgical Strategies
One or more high-risk MDCTA findings were observed on 49% of the patients: bypass graft crossing midline and within 1 cm/adherent to the sternum in AP direction (38%; Fig 1) and adherence/proximity less than 1 cm of right ventricle or aorta to the chest wall (24%; Figs 2 and 3). Go Seven patients (4%) had surgery cancelled because of very high-risk MDCTA findings (eg, patent right internal mammary artery with an additional jump graft supplying a left dominant system crossing the sternal midline at an unsafe distance, in a patient with severe valvular heart disease). The data comparing high-risk MDCTA findings versus adoption of preventive surgical strategies are based upon the remaining 160 patients. In a majority of patients (n = 88, 55%), there was adoption of preventive surgical strategies as follows: nonmidline incision (n = 14, 9%), deep hypothermic circulatory arrest (n = 7, 4%), initiation of cardiopulmonary bypass before incision (n = 18, 11%), and peripheral arterial and venous dissection (axillary or femoral) before incision (n = 83, 52%).


Figure 1
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  		Fig 1. (A) Axial views of a contrast-enhanced multidetector computed tomographic angiography (MDCTA) of the chest demonstrating an adherent aortocoronary graft (arrow) to the underside of the sternum. (AA = ascending aorta; DA = descending aorta; LL = left lung; PA = pulmonary artery; RL = right lung; ST = sternum) (B) Sagittal views of a contrast-enhanced MDCTA of the chest demonstrating an adherent aortocoronary graft (arrow) to the underside of the sternum. (LV = left ventricle; RV = right ventricle.)

 

Figure 2
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  		Fig 2. (A) Axial views of a contrast-enhanced multidetector computed tomographic angiography (MDCTA) of the chest demonstrating an adherent right ventricular free wall (arrow) to the underside of the sternum. (DA = descending aorta; LA = left atrium; LV = left ventricle; RA = right atrium; RV = right ventricle.) (B) Sagittal views of a contrast-enhanced MDCTA of the chest demonstrating an adherent right ventricular free wall (arrow) to the underside of the sternum. (DA = descending aorta; LV = left ventricle; RV = right ventricle.)

 

Figure 3
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  		Fig 3. Sagittal views of a contrast-enhanced multidetector computed tomographic angiography (MDCTA) of the chest demonstrating an adherent pseudoaneurysm of ascending aorta (arrow) to the underside of the chest wall. (DA = descending aorta; LV = left ventricle; PSA = pseudoaneurysm of ascending aorta; RV = right ventricle.)

 
Using univariate analysis, a significant association was found between a high-risk preoperative MDCTA finding and adoption of preventive surgical strategies (Table 2). Furthermore, with the use of multivariate logistic regression analysis, only high-risk MDCTA findings demonstrated a significant association with the use of preventive surgical strategies (p < 0.0001). No other clinical or demographic variables showed a significant independent association with the use of preventive surgical strategies, including age, sex, body mass index, renal function, number of reoperative surgery, and preoperative severity score (Table 3).


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  		Table 2 Association Between High-Risk Findings on Cardiothoracic MDCTA and Preventive Surgical Strategies (Total Number of Patients Undergoing Reoperative Cardiac Surgery = 160)
 

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  		Table 3 Association of High-Risk Findings on Cardiothoracic MDCTA With Adoption of Preventive Surgical Strategies: Results of Logistic Regression Analyses (Total Number of Patients Undergoing Reoperative Cardiac Surgery = 160)
 
Outcomes
Injuries to vital structures (injury to left internal mammary artery, aorta, or right ventricle) during the operation were noted in 8 of 160 patients (5%). None of these patients died within 48 hours or at 1 month postoperatively. Severe intraoperative bleeding was noted during surgery in 7 of 160 patients (4.4%), and urgent reexploratory surgery within 72 hours of RCS was required in 10 of 160 patients (6%). There was no difference in the frequency of vital structure injury, severe intraoperative bleeding, or urgent reexploratory surgery in high-risk versus lower-risk MDCTA groups (6% versus 5%, 5% versus 4%, and 8% versus 5%, respectively; all p > 0.05). Of the 8 patients with injury to vital structures, only 2 had documented severe intraoperative bleeding. None of these patients died at 48 hours, and 1 patient died at 1 month postoperatively. Mean perioperative troponin levels were 1.2 ± 1.1 mg/dL. The 48-hour, 7-day, and 1-month postoperative mortality rates were 0.6%, 1.9%, and 2.5%, respectively.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
Acknowledgments
 References
 
The current study demonstrates a significant association between high-risk MDCTA findings and adoption of preventive surgical strategies in patients with history of prior CABG undergoing RCS. This association was independent of other confounding variables including demographics, number of prior surgeries, time since the last CTS procedure, renal function, and the preoperative severity score. This study also demonstrates that 48-hour and 1-month mortality for such patients was low, approaching close to those of primary CTS data published in the literature, despite a high preoperative risk score (on an average, a score >6 is associated with a predicted mortality and morbidity of 7% and 28%, respectively) [18] and inclusion of patients who underwent complicated RCS (valve plus CABG surgery, multivalve surgery, and aortic aneurysm surgery) [1]. The frequency of perioperative complications, including injury to vital structures, associated severe bleeding, myocardial infarction, and reexplorative surgery was also low.

The current study lacks a control group, to compare outcomes with and without MDCTA. Unfortunately, no such control group exists as all RCS patients at our institution from 2002 have undergone MDCTA as part of preoperative evaluation. Comparison with a pre-2002 historical control group is possible, but likely inappropriate, considering the confounding iterative differences in surgical techniques in the two periods. This is particularly significant, considering the data from our institution showing significant improvement in outcomes in patients operated on after 1997 compared with before 1977 [1].

Over the last decade, we have seen the rate of higher preoperative surgical risk steadily increase likely as a result of factors such as aging of the population and the frequency of complicated RCS (eg, multivalve surgery in addition to CABG). Despite this trend, mortality and morbidity for such RCS is steadily decreasing, approaching the level of first-time cardiothoracic surgery, even in the presence of a higher than average preoperative risk score [1]. In fact, for the year 2006, there was 0% mortality for isolated redo CABG operations at our institution (available at: www.clevelandclinic.org/heartcenter/pub/about/surgoutcomes). This rate is significantly better than the reported national RCS average, where RCS, despite a steady reduction, remains relatively risky with persistent high mortality and morbidity rates (>5%) [2–7]. There are many potential reasons for these results, including surgical experience, improved surgical and anesthetic techniques, and use of comprehensive preoperative planning (including routine performance of cardiothoracic MDCTA since 2002). Indeed, as discussed above, RCS outcomes are significantly different in patients operated after 1997, compared with those operated on earlier [1]. Also, it has been described that the vast majority of intraoperative complications are due to suboptimal utilization of preventive surgical techniques [23].

As an aid to preoperative RCS planning, MDCTA has been performed routinely at our institution since approximately 2002. Although the role of preoperative MDCTA in RCS patients has not been prospectively proven, at our institution, the likely reason for routinely performing MDCTA studies in this clinical situation was an evolution in imaging techniques and their perceived utility in planning for such difficult operations. As part of a comprehensive evaluation (including three-dimensional assessment of chest morphology), we evaluate for the presence of the following high-risk findings on preoperative MDCTA: adherence/proximity (<1cm) of right ventricle or aorta to the chest wall, and bypass graft crossing midline within 1 cm in anterioposterior direction of (or adherence to) the sternum. These descriptors are directed at preventing catastrophic hemorrhaging during resternotomy, secondary to injury of underlying patent bypass grafts, right ventricle, and aorta, which had historically been reported to occur in 2% to 6% cases during sternal reentry, with documented mortality of 37% [24]. Indeed, it has been shown that approximately 60% of complications during RCS occur at time of sternotomy and dissection [9]. Similarly, the incidence of internal mammary (left or right) graft injury during sternal reentry has been reported to be 5% to 38% [25] with a perioperative infarction in 40% of patients [26]. Also, there is a higher incidence of ventricular arrhythmias and the need for prolonged ventilatory support [27]. The utility of preoperative MDCT in RCS patients has not been extensively examined. In a small study by Aviram and colleagues [16], the utility of MDCTA was suggested in 6 of 15 RCS patients. Similarly, Gasparovic and associates [15] noted that three-dimensional MDCTA altered surgical strategies in 7 of 33 patients.

During RCS, a major challenge is sternal reentry and dissection of mediastinal structures owing to the formation of dense adhesions. Additionally, critically important patent bypass grafts may be easily injured if their relative location and course are not fully appreciated. Knowledge gained from preoperative imaging is necessary to plan the potential use of preventive surgical strategies, such as timing and approach to cannulation and cardiopulmonary bypass (with or without hypothermic circulatory arrest) [1]. Alternatively, in patients requiring limited revascularization, risk of sternal reentry can be avoided by using different incisions, including anterior thoracotomy, lateral thoracotomy or an epigastric approach [28].

Strengths and Limitations
This is the largest study evaluating the role of MDCTA in RCS patients, and it was accomplished in a single center quaternary referral center with vast surgical experience where consistent preoperative and postoperative care protocols were employed. For analysis, well-defined variables on both CT and on operative reports were used to quantify the association between MDCTA and use of preventive surgical strategies. The study is necessarily limited as a result of its retrospective design. Consequently, we were dependent upon the availability and quality of documentation in patient charts; fortunately, the availability of electronic medical records limits potential data loss. Although the perioperative mortality rates in this small group were noted to be very low and approach those of first-time surgery patients, this study was not designed or powered to study long-term mortality; therefore, further study of the impact of preoperative MDCTA in RCS patients on long-term mortality is warranted. Finally, acquisition of a contrast-enhanced MDCTA imposes additional cost and radiation burden, and the potential for nephrotoxicity. Some of these concerns are lessened as a result of our intensive use of radiation dose-modulation techniques for spiral acquisitions and emerging use of prospective axial scanning, both of which minimize radiation exposure, while the use of low-osmolar contrast agents significantly reduces risk of nephrotoxicity. Nonetheless, close evaluation of MDCTA’s cost effectiveness in RCS patients would be advantageous in establishing its overall appropriateness. This observational study is also limited in that it has defined an association, but not causality. A prospective study in patients undergoing RCS with and without preoperative MDCTA, if ethically reasonable, would potentially answer that question.

In conclusion, RCS patients with prior CABG in our institution, despite presenting with a steadily increasing rate of complexity and higher preoperative risk scores, have a lower than expected perioperative mortality rate. Routine use of preoperative cardiothoracic MDCTA to detect high-risk findings has a strong association with the adoption of preventive surgical strategies in these patients. The MDCTA-directed adoption of preventive surgical strategies potentially plays a significant role in the improved surgical outcomes in RCS patients; whether it is a causal factor remains to be prospectively validated.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
References
 
The authors would like to thank Stacie Kuzmiak, RT (CT), and Stacey Winners, RT (CT), for their expert technical assistance with the study. The Cleveland Clinic receives modest research support from Siemens Medical Solutions and Phillips Medical Systems.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 Acknowledgments
 References
 

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B. F. Buxton and P. Skillington
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Ann. Thorac. Surg., April 1, 2008; 85(4): 1245 - 1246.
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