Redo cardiac surgery

Transcription

1 Results of redo cardiac surgery in the current era Bakir M. Bakir, M.D. Associate professor, Consultant Cardiac Surgery King Fahd Cardiac Center King Khalid University Hospital King Saud University Redo cardiac surgery Reoperations are an integral part of the cardiac surgeons daily practice. Reoperations continue to present adult cardiac surgeons with their most difficult challenges due to: 1. technical pitfalls 2. significant co-morbidities. 1

2 Redo cardiac surgery Therefore, it is not surprising that morbidity and mortality of cardiac reoperations are higher than a first time procedure. Redo coronary artery bypass surgery Yau et al in 2000 analyzed the changing pattern of 1230 consecutive reoperations at Toronto General Hospital: there was a rise in the prevalence pattern of redo CABG from early 1980s to a peak high in 1994, however, this was followed by a progressive decline over the following years. 2

3 Yau et al. The changing pattern of re-operative coronary surgery: trends in 1230 consecutive re-operations. Ann Thorac Surg 2001; 92:40. Relative and absolute prevalence of re-operative surgery in 20,614 patients undergoing coronary bypass from Redo Coronary Artery Bypass Surgery Spiliotopoulos (2011): found that re-operative CABG decreased from 7.2% 2.2% of the over-all CABG volume from at the Toronto General Hospital. Incidence: : 7.2% : 2.2% 3

4 Prevalence of redo coronary artery bypass grafting (CABG) over time. Konstantinos Spiliotopoulos, Manjula Maganti, Stephanie Brister, Vivek Rao Changing Pattern of Re-operative Coronary Artery Bypass Grafting: A 20-Year Study The Annals of Thoracic Surgery, Volume 92, Issue 1, 2011, Redo Coronary Artery Bypass Surgery Sabik et al (2005): Re-operative CABG volume decreased by 50% at the Cleveland Clinic Foundation from , 568 CABG procedures were performed, of which, 4,518 (21%) were reoperations. Sabik et al. Is reoperations still a risk factor in coronary artery bypass surgery. Ann Thorac surg 2005: 80:

5 Number of isolated primary and re-operative coronary artery bypass graft operations by year Sabik et al. Is re-operation still a risk factor in coronary artery bypass surgery? Ann Thorac Surg 2005; 80: Redo Coronary Surgery Ghanta et al 2013: Analyzed the patient characteristics and postoperative outcomes for 1.5 million isolated CABG operations (72,322 re-operations) at the STS adult cardiac surgery database. Study period:

6 Incidence of re-operative coronary artery bypass grafting (CABG) during study period. Evolving trends of reoperative coronary artery bypass grafting: An analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database The Journal of Thoracic and Cardiovascular Surgery, Volume 145, Issue 2, 2013, Redo Coronary Artery Bypass Surgery Causes: 1. Improved medical management 2. Expanded use of PCI for native and saphenous vein graft disease 3. Increased use of arterial grafting at initial CABG 6

7 Morbidity & Mortality Hospital mortality after re-operative CABG is higher than after primary CABG. The higher risk has been attributable to: 1. Increased technical difficulty of re-operative CABG 2. The higher risk profile of re-operative CABG patients. Yau et al. The changing pattern of reoperative coronary surgery: trends in 1230 consecutive re-operations. J Thorac Cardiovasc Surg 2000; 120;156. The increasing risk profile of patients undergoing a re-operative coronary procedure over 3-time periods. Patient age, symptom class, extent of coronary artery disease, urgent or emergency operation all increased significantly. Ventricular dysfunction and left main disease were also significantly greater in later years. 7

8 Redo Coronary Artery Bypass Surgery Ghanta et al (2013): medical co-morbidities as: Diabetes (42.5% vs 31.7%) Hypercholesterlemia (93% vs 71.8%0 Renal failure (2.2% vs 0.7%) Cerebrovascular accidents (12.4% vs 8.5%) were all more prevalent in 2009 than in Redo Coronary Artery Bypass Surgery In addition, in 2009, the patients presented more with : Congestive heart failure (18.4% vs 14.2%) Left main disease (35.1% vs 25.7%) Myocardial infarction (60.9% vs 55.9%) Urgent procedure (51.6% vs 39%) More pre-operative ACE, statins & B-blockers. 8

9 Redo Coronary Artery Bypass Surgery At Cleveland clinic Foundation: different earlier studies published in 1987, 1990, 1994 showed that the in-hospital mortality rate of a first re-operation to range between 3-4% from and the rate was 3.7% for the period (Lytle et al 1987, Loop et al 1990, Lytle et al 1994). Redo Coronary Artery Bypass Surgery Edwards et al (1994): A study from STS database reported an inhospital mortality of 6.95% for the years Previous operation was identified as a risk factor that increased the mortality rate. Edwards et al. Coronary artery bypass grafting: Experience. Ann Thorac Surg 1994; 57:12. The Society of Thoracic Surgeons National Database 9

10 yau et al. The changing pattern of re-operative coronary surgery: trends in 1230 consecutive re-operations. J Thorac Cardiovasc Surg 2000; 120:156. Trends in hospital outcomes, including hospital mortality, perioperative MI, postoperative LCOS, over 3-time periods. Over the 16-year period, hospital mortality, peri-op MI, and postoperative LCOS decreased significantly in patients undergoing first time CABG. In contrast, patients undergoing reoperations had lesser and nonstatistically significant improvements in survival and MI and no definite reduction in the prevalence of low output syndrome. Redo Coronary Artery Bypass Surgery Sabik et al (2005): hospital mortality was 4.3% for the first reoperation 5.1% for the second reoperation 6.4% for the third or more. Compared with 1.5% for primary operations. Risk of both primary & re-operative CABG decreased with experience (p>0.0002). 10

11 Hospital mortality after primary and re-operative coronary artery bypas s grafting according to year of operation Sabik et al. Is reoperation still a risk factor in coronary artery bypass surgery? Ann Thorac Surg 2005; 80: Redo Coronary Surgery Conclusion: 1. Although the risk of re-operative CABG has been consistently greater than that of primary CABG, the difference has narrowed considerably. 2. Multivariate analysis demonstrated that reoperation was associated with increased risk of death before 1997 but not after. 3. By the end of 2002, poor L.V was no longer associated with hospital death for either. 11

12 Redo Coronary Artery Bypass Surgery Ghanta et al 2013: 1. The postoperative observed mortality decreased from 6.1% in 2000 to 4.6% in During the study period there was a 23.7% reduction in the relative risk of mortality after re-operative CABG. Redo Coronary Artery Bypass Surgery 3. Stroke rate decreased from 1.9% to 1.6% with a 16.5% relative risk reduction. 4. Other complications, such as renal failure (5.5% vs 4.7%) and deep sternal wound infection (0.5 vs 0.3%) also decreased. 5. No change occurred in the incidence of reoperation for bleeding, atrial fibrillation, prolonged ventilation or prolonged length of stay. 12

13 Mortality rate during study period for patients undergoing re-operative coronary artery bypass grafting (CABG). Ravi K. Ghanta, Tsuyoshi Kaneko, James S. Gammie, Shubin Sheng, Sary F. Aranki Evolving trends of reoperative coronary artery bypass grafting: An analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database The Journal of Thoracic and Cardiovascular Surgery, Volume 145, Issue 2, 2013, Fig 3 Operative mortality (OM) and low cardiac output syndrome (LCOS) during the last two decades by (A) unmatched data and (B) matched data. Konstantinos Spiliotopoulos, Manjula Maganti, Stephanie Brister, Vivek Rao Changing Pattern of Reoperative Coronary Artery Bypass Grafting: A 20-Year Study The Annals of Thoracic Surgery, Volume 92, Issue 1, 2011,

14 Redo Coronary Artery Bypass Surgery Prevalence of re-operative CABG has significantly decreased during the last 20 years. Re-operative patients have generally developed a worse profile for both their coronary artery disease risk factors and their co-morbidities. Redo Coronary Artery Bypass Surgery Despite this, hospital outcomes have either remained stable or even improved during the last 10 years. Emergency operation, pre-operative shock, congestive heart failure are the main predictors of operative mortality. 14

15 Redo valve surgery Improvements in surgical techniques and improved life expectancy have increased the frequency of redo heart valve surgery. The incidence of redo mitral valve surgical procedures is increasing and currently accounts for more than 10% of all mitral valve surgeries in the U.S. ( Gammie et al. Trends in mitral valve surgery: results from the society of thoracic surgery adult cardiac surgery database. Ann Thorac Surg 2009; 87:1431). Percentage of primary and repeat sternotomy mitral valve operations. Mehrdad Ghoreishi, Murtaza Dawood, Gerald Hobbs, Chetan Pasrija, Peter Riley, Lia Petrose, Bartley P. Griff... Repeat Sternotomy: No Longer a Risk Factor in Mitral Valve Surgical Procedures The Annals of Thoracic Surgery, Volume 96, Issue 4, 2013,

16 Redo valve surgery The surgical indications for redo valve surgery has been well-defined: 1. failed repair/new native valve disease 2. prosthetic valve dysfunction 3. prosthetic valve leaks 4. valve thrombosis. 5. prosthetic valve endocarditis. Risk factors for redo valve surgery: 1. Impaired EF, C.H.F, or advanced pre-operative functional class (NYHA), emergent operation. 2. Advanced age 3. Pre-operative shock 4. Concomitant CABG or presence of previous grafts. 16

17 5. Prosthetic valve endocarditis 6. Renal dysfunction 7. Pulmonary Hypertension. 8. Early year of operation. The outcome of redo valve surgery was analyzed in several reports starting from the 70s and till the current era. There is a marked heterogeneity of patients in need for redo valve surgery with respect to indications, surgical history, and comorbidities, a point that renders the investigations in this field a challenge. 17

18 In early studies, redo valve surgery carried a higher risk than primary valve procedures. (Antunes et al. Isolated replacement of a prosthesis or a bioprosthesis in the mitral valve position. Amer J Cardiol) 1987; 59: 346) During the 70s, the operative mortality rate in redo valve surgery was as high as 41%. This study included analysis of 549 patients during a 26-year period. (Bortolotti et al. Early and late outcome after re-operation for prosthetic valve dysfunction: analysis of 549 patients during a 26-year period. Journal of heart valve disease. 1994; 3: 81). The first results concerning large series of redo valve surgery were reported in the early 1980s with an operative mortality rate of 14%. (Cohn et al. The in-hospital risk of re-replacement of dysfunctional mitral and aortic valves. Circ 1982; 66(suppl 1): 153). These results were confirmed by Terada et al in late 80s with an overall mortality of 15.7%. (Terada et al. report of 108 patients with valvular heart disease who underwent re-operations through repeated median sternotomy incision. Kyobu Geka 1989; 42: 426.) 18

19 However, throughout the years, the mortality associated with redo valve surgery has dropped significantly. During the 90s, a significant reduction in the overall hospital mortality down to 10% was observed. (Pansini et al. Re-operations on heart valve prostheses: an analysis of operative risks and late results. Ann Thorac Surg 1990; 50: 590.) In another series, a decrease in mortality from 14% in early 80s to 8% in early 90s was observed. (Cohn et al. Decrease in operative risk of re-operative valve surgery. Ann Thorac Surg 1993; 56: 15). 19

20 Redo Mitral Valve Kumar et al 2003: Redo mitral valve surgery is safe and can be performed with an acceptable morbidity and mortality of 4.2%-5.6% ,908 operations 744 reoperations. (Kumar et al. Redo mitral valve surgery. A long-term experience. J Card Surg 2004; 19: 303) 2004 Potter et al (2004) compared 106 patients undergoing repeat MVR to 562 control patients undergoing primary MVR between 1993 & Mortality: 4.1% control group vs 4.7% in the repeat group (p= NS). (Potter et al. Risk of repeat mitral valve replacement for failed mitral valve prostheses. Ann Thorac Surg 2004; 78: An old report from the same institution (Mayo Clinic) reported an operative mortality of 19.6% for primary MVR. (Husebye et al. Re-operations on prosthetic heart valves. J Thorac Cardiovasc Surg 1983; 86: 543). 20

21 Primary AVR ± CABG vs. Redo AVR ± CABG Study period: patients vs. 162 patients (Potter et al. Operative risk of re-operative aortic valve replacement. J Thorac Cardiovasc Surg 2005; 129: 94.) Early mortality: 3% vs. 5% Endocarditis was more common in the reoperative group. When endocarditis was excluded, early mortality was 3% in both groups. 21

22 Lapar et al: 2010 Studied a total of 1603 patients who underwent elective AVR. 191 patients: previous sternotomies. Lapar et al. Outcomes of re-operative aortic valve replacement after previous sternotomy. J Thorac Cardiovasc Surg 2010; 139: 263. Era A ( ) Era B ( ) Era C ( ) Major complications 25.6% 17% 6.1% Mortality 15.4% 15.1% 2% 22

23 Operative mortality decreased over time reaching 2% in the most recent era vs. 3.5% in the primary AVR. Postoperative outcomes were similar among these re-operative groups despite differences in the initial cardiac operation. Isolated reop AVR by era: decreased rate of major complications and operative mortality reaching 0% in era C. 23

24 Luciani et al (2006): studied 316 patients operated within a 6 year period between1997 & In-hospital mortality was 3.8% and the overall mortality at the end of 30-months period was 9.3%. (Luciani et al. Repeat valvular operations: bench optimization of conventional surgery. Ann Thorac Surg 2006; 81: 1279.) Onorati et al: 2015 Studied 711 redo AVR from 7 European institutions. Hospital mortality: 5.1% MRCVCs: 4.9% Low C.O.P syndrome: 15.3% Onarati et al. Mid-term results of aortic valve surgery in redo scenarios in the current practice: results from the multi-centre European RECORD initiative. Eur J Cardiothorac Surg 2015; 47:

25 Elderly patients > 75 years had similar mortality and major morbidity. Urgent/emergent indications resulted in higher hospital deaths, LCOS, prolonged ventilation. Preoperative functional class IV correlated with higher LCOS, IABP, CRRT, and MRCVCs. Endocarditis was associated with higher hospital mortality. Ghoreishi et al (2013): 1. Repeat sternotomy can be performed with low peri-operative mortality (4.6%) and low re-entry injury rate (1.5%). 2. Repeat sternotomy is not an independent risk factor for operative mortality or morbidity. 3. Use of C.T. scanning is essential for careful planning of the operation. 25

26 analysis of survival for patients undergoing first-time sternotomy mitral valve operation (n = 926) (continuous line) compared with those who underwent repeat operation (n = 130). Ghoreishi et al. Repeat Sternotomy: No Longer a Risk Factor in Mitral Valve Surgical Procedures. Ann Thorac Surg 2013; 96: Redo valve surgery in the elderly Maganti et al (2009) at Toronto General Hospital retrospectively studied 112 patients aged 75 years or older who underwent redo valve surgery between 1990 & 2004 with an operative mortality of 10.7%. ( Maganti et al. Redo valvular surgery in elderly patients. Ann Thorac Surg 2009; 87: 521.) 26

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28 Redo valve surgery in the elderly Balsam et al (2010): reported a hospital mortality of 13.8% in patients aged 75 years or more who underwent isolated redo valve surgery. (Ann Thorac Surg 2010; 90: 1195). In contrast, Kirsch (2004) reported a poor outcome with a hospital mortality of 32% in octagenerians. (J Heart Valve Disease 2004; 13: 991). Author Year Result Bortolotti 1994 (26-year period) Cohn % Terada % Lytle % Pansini % Cohn % 41% in early 70s Kumar 2003 ( ) % Potter Potter 2004 (primary vs redo MVR) 2005 (primary vs. redo AVR) 4.1% vs 4.7% 3% vs 5% Lapar % 2% Luciani % Onrati 2015 (redo AVR) 5.1% 28

29 The experience acquired during the last 3 decades in heart valve re-operations is considerable. The most frequently quoted risk factor associated with death in redo valve surgery is the NYHA functional class with mortality up to 30% in those with stage IV compared to less than 10% in stage II and III. Degree of urgency: with low mortality rates between 5&11% in elective cases up to 38&61% for emergency procedures. This highlights the need for early identification and intervention in patients with prosthetic dysfunction to avoid the lasting effects of damage to the myocardium. (Cohn et al. Evolution of redo cardiac surgery: review of personal experience. J Card Surg 2004; 19: 320). With careful planning, the outcomes for redo valve surgeries are favorable and identical to those of primary surgeries. 29

30 Redo Cardiac Surgery The major advances in re-operative cardiac surgery are: 1. Early referral of the patients 2. Improved medical management 3. Better pre-operative planning (C.T. scan) 4. Alternative incisional approaches 5. Alternative perfusion sites Redo Cardiac surgery 6. Improved myocardial protection. 7. No-Touch technique in re-operative CABG surgery. 8. Improved post-operative management. 9. Improved ICU management & dedicated Cardiac Intensivists. 30

31 Thank you 31