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Ann Thorac Surg 2009;87:1386-1391. doi:10.1016/j.athoracsur.2009.02.006
© 2009 The Society of Thoracic Surgeons
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Original Articles: Adult Cardiac

Contemporary Results Show Repeat Coronary Artery Bypass Grafting Remains a Risk Factor for Operative Mortality

Cheng-Hon Yap, MBBS, MSa,b,*, Luigi Sposato, MBBSb, Enoch Akowuah, MD, FRCS Ch-Tb, Sanjay Theodore, MChb, Diem T. Dinh, BSc, PhDa, Gilbert C. Shardey, FRACSc, Peter D. Skillington, FRACSb, James Tatoulis, FRACS, MDb, Michael Yii, FRACS, MSd, Julian A. Smith, FRACS, MSc,e, Morteza Mohajeri, FRACSf, Adrian Pick, FRACSg, Siven Seevanayagam, FRACSh, Christopher M. Reid, MSc, PhDa

a Department of Epidemiology and Preventive Medicine, Monash University, Victoria
e Department of Surgery, Monash University, Victoria
b Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Melbourne, Australia
c Monash Medical Centre, Melbourne, Australia
d St. Vincent's Hospital, Melbourne, Australia
f Geelong Hospital, Victoria, Australia
g Alfred Hospital, Victoria, Australia
h Austin Hospital, Victoria, Australia

Accepted for publication February 3, 2009.

* Address correspondence to Dr Yap, Department of Cardiothoracic Surgery, The Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia (Email: cheng-hon.yap{at}mh.org.au).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
Background: Reoperative coronary artery bypass grafting (redo CABG) shows improving outcomes, but with varying degrees of improvement. We assessed contemporary outcomes after redo CABG to determine if redo status is still a risk factor for early postoperative complications and midterm survival.

Methods: Isolated CABG procedures (June 1, 2001 to May 31, 2008) within the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database were included. Redo status as a predictor for early outcomes was assessed with logistic regression analysis. Midterm survival was determined from the National Death Index. Effect of redo status on midterm survival was assessed using a Cox proportional hazards model.

Results: Inclusion criteria were met by 13,436 patients, and 458 (3.4%) underwent redo CABG. Operative mortality was 4.8% for redo CABG and 1.8% for first-time CABG (p < 0.001). After adjustment, redo status remained a predictor for operative mortality (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3 to 3.6), myocardial infarction (OR, 2.8; 95% CI, 1.6 to 6.0), and prolonged ventilation (OR, 1.5; 95% CI, 1.1 to 2.0). Unadjusted survival was lower for the redo CABG group vs the first-time CABG group at up to 6 years (p = 0.01, log-rank test. After adjusting for differences in patient variables, redo status was not a predictor of midterm survival (OR, 1.03; 95% CI, 0.78 to 1.35; p = 0.85).

Conclusions: Early postoperative outcomes of redo CABG are encouraging. Midterm survival is excellent; however, redo remains a significant risk factor for operative mortality in contemporary practice.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 Acknowledgments
 References
 
In recent decades, an increased number of patients have been referred for reoperative coronary artery bypass graft (redo CABG) procedures [1–2]. This is due to an increasing pool of patients who have already had CABG. Moreover, the increasing evidence that elderly patients can have CABG with acceptable mortality and morbidity and enjoy an excellent medium-term and long-term quality of life has led to an increase in the number of patients potentially eligible for redo CABG [3–5].

Traditionally, redo CABG has been regarded as a relatively high-risk undertaking, which is reflected in current risk scoring systems such as the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Parsonnet models. This perception is due to the potential for damage to underlying structures during redo sternotomy, injury to patent coronary artery grafts on which myocardial blood supply may be entirely dependent, distal microemboli from diseased or occluded grafts, difficulties with adequate myocardial protection, and the lack of availability of suitable conduits.

Recent results of redo CABG have shown a decrease in operative death compared with earlier studies [6–16]. The degree of this improvement is variable, however. A single-center study from an institution undertaking large volumes of redo CABG suggested that in the current era, redo CABG might have a similar operative risk as first-time CABG [6]. Other reports, including those from multicenter registry data, suggest that redo CABG is still a significant undertaking, with an average reported mortality rate of 6% to 16% [7–16].

In this article, we present the results of a contemporary multicenter registry study. We assessed outcomes after redo CABG to determine if redo status is still a risk factor for early postoperative complications. We also investigated the role of redo status in midterm survival after CABG.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 Acknowledgments
 References
 
The inclusion criterion for the study was all patients undergoing isolated CABG between June 1, 2001, and May 31, 2008, at hospitals in Australia participating in the Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) Cardiac Surgery Database. The 6 hospitals in the state of Victoria involved in the prospective data collection during the entire study period were the Royal Melbourne Hospital, the Alfred Hospital, Monash Medical Centre, The Geelong Hospital, Austin and Repatriation Medical Centre, and St Vincent's Hospital Melbourne (see Appendix). The data collection was mandatory for these Victorian Hospitals in accordance with the Department of Human Services, Victoria. In addition, 6 cardiac surgical units from the states of South Australia, New South Wales and Queensland voluntarily joined the database in the last 12 months of the study period and contributed 9.5% of the patient numbers. Data collection and external audit methods have been previously described [11, 12]. The Ethics Committee of each participating hospital had previously approved the use of deidentified patient data contained within the database for research and waived the need for individual patient consent. The patients were divided into two groups: those undergoing first-time CABG and those undergoing redo CABG.

Preoperative characteristics, early outcomes, and midterm survival were compared. Six early postoperative outcomes were analyzed:

• operative mortality, defined as death within 30 days from operation or in-hospital death;
• stroke, defined as new transient or permanent focal neurologic deficits;
• postoperative acute myocardial infarction (AMI), defined as at least two of the following: enzyme level elevation, new cardiac wall motion abnormalities, or new Q waves on serial electrocardiograms;
• new renal failure, defined as at least two of the following: serum creatinine increased to more than 200 µmol/L, doubling or greater increase in creatinine vs preoperative value, or new requirement for dialysis or hemofiltration;
• prolonged ventilation (> 24 hours);
• deep sternal infection involving muscle and bone as demonstrated by surgical exploration and one of the following: positive cultures or treatment with antibiotics; and
• return to the operating theater for bleeding.

To assess the role of redo status as a predictor for each early outcome, logistic regression analysis was used to adjust for 16 preoperative patient variables, with the outcome as the dependent variable (summarized in Table 1).


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  		Table 1 Preoperative Characteristics of Patients Undergoing Redo and First-Time Coronary Artery Bypass Grafting
 
Midterm survival status was obtained from the National Death Index. Closing date was June 30, 2008. A Kaplan-Meier estimate of survival was obtained. Differences in midterm survival were assessed by the log-rank test. The role of redo status in midterm survival was assessed by constructing a Cox proportional hazards model using redo status and other preoperative patient characteristics as variables.

Continuous variables are presented as mean ± one standard deviation. The Mann-Whitney U test was used to compare groups of continuous variables. The Fisher exact test or the {chi}2 test was used to compare groups of categoric variables. All calculated values of p were two-sided, and p < 0.05 was considered significant. Statistical analysis was performed using SPSS 17.0 software (SPSS Inc. Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 Acknowledgments
 References
 
Of the 13,426 patients who met the study inclusion criteria, 458 (3.4%) underwent redo CABG. Demographic and preoperative characteristics of patients undergoing first-time vs redo CABG are listed in Table 1. The overall surgical risk profile of patients undergoing redo CABG was significantly worse than patients undergoing first-time CABG (additive EuroSCORE of 8.1 ± 3.5 for redo CABG vs 4.3 ± 3.3 for first-time CABG, p < 0.001). The main reasons for this were an increase in the prevalence of elderly patients, patients with cerebrovascular and peripheral vascular disease, unstable angina, higher New York Heart Association class, greater left ventricular dysfunction, and more patients undergoing an emergency operation.

There were significant differences in intraoperative variables between the two groups. The redo CABG group underwent a fewer mean number of distal anastomoses (2.8 ± 1.0 vs 3.3 ± 1.0, p < 0.001) compared with the first-time CABG group. Also significantly longer in the redo CABG group were the duration of cardiopulmonary bypass support, at 117 ± 50 vs 91 ± 42 minutes (p < 0.001), and aortic cross-clamping, at 79 ± 36 vs 68 ± 35 minutes (p < 0.001). Internal mammary artery graft use was 51.7% in the redo CABG group compared with 96.7% in the first-time CABG group (p = 0.001). The use of off-pump technique was also lower in the redo CABG group (4.9% vs 8.6%; p = 0.006).

Significant differences between the groups were documented in early postoperative outcome (Table 2). Operative mortality was 4.8% in the redo CABG group and 1.8% in the first-time CABG group (p < 0.001). The incidence of postoperative myocardial infarction and prolonged ventilation was higher in the redo CABG group (Table 2). After adjustment for differences in patient variables, redo status remained a predictor for operative death (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.3 to 3.6), myocardial infarction (OR, 2.8; 95% CI, 1.6 to 6.0), and prolonged ventilation (OR, 1.5; 95% CI, 1.1 to 2.0). The logistic regression model predicting early death is shown in Table 3. The model has a c statistic of 0.82 (95% CI, 0.79 to 0.85) and a Hosmer Lemeshow {chi}2 statistic of 4.28 (p = 0.83).


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  		Table 2 Early Postoperative Outcomes After Redo and First-Time Coronary Artery Bypass Grafting
 

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  		Table 3 Predictors of Early Mortality
 
Overall survival for the entire cohort was 96.5%, 93.2%, 88.0%, and 85.1% at 1, 3, 5, and 6 years postoperatively. Unadjusted survival was lower for the redo CABG group compared with the first time CABG group at all time points to 6 years (p = 0.01 by log-rank test). At 1, 3, 5, and 6 years, survival in the redo-CABG group was 93.1%, 90.5%, 85.9%, and 80.5% compared with 96.6%, 93.2%, 88.1%, and 85.3% in the first-time CABG group (Fig 1).


Figure 1
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  		Fig 1. Postoperative survival of patients undergoing redo (solid line) and first-time coronary artery bypass grafting (dashed line).

 
After adjusting for differences in patient variables, redo status was not a predictor of midterm survival (OR, 1.03; 95% CI, 0.78 to 1.35; p = 0.85; Fig 2). The factors that predict nonsurvival in the study cohort are reported in Table 4. They include increasing age, hypercholesterolemia, hypertension, diabetes, peripheral vascular disease, renal failure, respiratory disease, left main stem stenosis, left ventricular function, and emergency status.


Figure 2
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  		Fig 2. Adjusted postoperative survival patients undergoing redo (solid line) and first-time coronary artery bypass grafting (dashed line). There was no difference in survival between groups after accounting for patient characteristics.

 

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  		Table 4 Predictors of Midterm Mortality
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
Acknowledgments
 References
 
Redo CABG is a technically challenging operation with a high operative mortality of 5% to 16.7% [2, 6–16]. Recent results suggest a relative reduction in early postoperative complications, particularly death. This fact, as well as an increase in the number of patients requiring redo CABG, has highlighted the need to better clarify contemporary short-term and long-term results and to better define areas where an effect on improving outcomes can be achieved.

Our large multicenter registry data support the view that mortality and morbidity from redo CABG has diminished significantly in contemporary practice compared with historical data. This is undoubtedly due to advances in surgical technique and increasing surgical experience [13–18]. The fact that there was no increased risk of bleeding in the redo CABG group, a feature of historical reports [19], is a reflection of this. Moreover, midterm survival is excellent and is comparable to first time CABG once adjustments for differences in patient variables are made [20, 21]. Despite these improvements, operative mortality is still considerable, nearly three times greater than for first time CABG. The risk of a perioperative AMI is also nearly three times greater.

Given that the redo CABG patients had an overall higher-risk preoperative profile, we attempted to adjust for patient characteristics to identify if the higher mortality rate was due to redo status or to preoperative patient risk factors. We observed that redo status remained an independent predictor of operative death after adjusting for confounding factors.

The mechanisms by which redo status influences early death are all well described and are mostly technical [22–24]. Cardiopulmonary perfusion times and aortic cross-clamp times in our study were much longer in the redo CABG group, even though this group had fewer distal anastomoses. This reflects the technically challenging nature of the procedure, including issues of difficult surgical exposure, myocardial protection, identification of suitable grafting sites, resternotomy catastrophes, and other factors that are not easily quantified by current risk prediction models. Efforts at decreasing operative death should be aimed at surgical strategies that address these issues directly. Examples of such strategies include preoperative computed tomography scans to define cardiac proximity to the sternum, peripheral cardiopulmonary bypass support to decompress the heart before median sternotomy, increasing use of off-pump techniques, and the use of retrograde cardioplegia, which better protects areas supplied by nonfunctioning grafts and aids flushing of atheromatous debris from diseased grafts [1, 25].

There is a paucity of data regarding long-term outcomes after redo CABG, but our data show that if patients survive the operation, survival out to 6 years is excellent, at 80.5%. Once the groups are risk-adjusted, survival is similar to first time CABG patients. Unlike many factors that are known to negatively affect long-term survival, such as age and poor ventricular function, redo status per se did not have a negative effect on midterm survival in our study.

The strengths of our study are the relatively large number of patients included, the contemporary nature of the data, and that it is multicenter study and is therefore more likely to reflect clinical practice. The main limitation is that it is a retrospective review, and hence, there is a potential for bias, particularly in the selection of patients for redo CABG.

In conclusion, redo-CABG remains a significant surgical challenge. Many technical hazards exist. Future patients undergoing redo CABG are likely to become more complex as the complexity of patients undergoing first time CABG also increases. Specifically, we are likely to see even older patients with worse ventricular function and more diffuse coronary artery disease as well as more complex comorbidities, particularly valvular heart disease. In the current era, early postoperative outcomes of CABG in this challenging group of patients are encouraging. Midterm survival is excellent and not affected by the redo status. However, we conclude that despite an obvious improvement in operative mortality, our data suggest that redo remains a significant risk factor for operative mortality in contemporary practice.


   Appendix
 
The following investigators, data managers, and institutions participated in the ASCTS Registry: Alfred Hospital: Pick A, Duncan J; Austin Hospital: Seevanayagam S, Shaw M; Cabrini Medical Centre: Shardey G; Geelong Hospital: Mohajeri M, Bright C; Flinders Medical Centre: Knight J, Baker R, Helm J; Mater Misericordiae Hospital: Diqer AM, Archer J; Monash Medical Centre: Smith J, Baxter H; Lake McQuarie Hospital: Boyd A, Jacobi M; Liverpool Hospital: French B, Hewitt N; Prince of Wales Hospital: Wolfenden H, Weerasinge D; St George Hospital: Horton D, Redmond C, Shannessy MO; St Vincent's Hospital, VIC: Yii M, Newcomb A, Mack J, Duve K; St Vincent's Hospital, NSW: Spratt P, Hunter T; Royal Melbourne Hospital: Skillington P, Wynne R.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
References
 
The Australasian Society of Cardiac and Thoracic Surgeons (ASCTS) Cardiac Surgery Database is an initiative of the ASCTS and is funded by the Department of Human Services, Victoria and the Greater Metropolitan Clinical Taskforce, NSW.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 Acknowledgments
 References
 

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