Redo Cardiac Surgery in Adults

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Arrives by Friday, Sep Free pickup Fri, Sep Ships to San Leandro, Davis St. Product Highlights Redo or re-operative heart surgery is becoming much more common as patients live longer as a result of an initial heart surgery. Redo heart surgery is recommended to improve your quality of life by helping the heart to function more efficiently. Conditions such as an aneurysm are progressive diseases that usually aggravate over time and require constant management to avoid complications and death.

Apart from this, surgery may be repeated to repair a flaw in the reconstruction method or replace a degenerated or dysfunctional prosthetic valve.

Less invasive procedures are preferred because of the reduced hospital stay, pain and recovery time. A redo operation can provide a longer life, less chest pain, less fatigue and more energy as you age. Interestingly both the patients who had thoroctomy developed phrenic nerve damage and had to be ventilated for a longer time. In another two patient's reintubation was required due to low cardiac output.

Symposium on redo cardiac surgery in adults: introduction.

Two patients developed stroke, both in the posterior circulation. Mean duration of intensive care stay was 7 days 3 days to 42 days. Tracheostomy was done in two patients.

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Table 8. Re-operative procedures have revealed technical obstacles that differentiate them from primary procedures. These problems include 1 difficulties with re-entry 2 potential for cardiac and conduit injury during dissection 3 non availability of conduit in redo CABG 4 management of patent grafts 5 inadequate myocardial protection 6 bleeding and requirement of blood products 7 low body weight and small cannulas particularly femoro-femoral bypass in case of paediatric redo 8 Prosthetic valve dysfunction.

The crude mortality rate in our study was 7. The crude mortality rate for redo CABG is about 7. We had three deaths in our 42 cases; one was redo mitral valve replacement, coming for the third time after two open mitral valvotomy. The cause for the death was low output and sepsis.

The patient died on the third post operative day due to low cardiac output. The last case was a completion Fontan who died due to posterior circulation stroke. Duration from the first surgery did not affect the outcome in our study. Most of our cases are done after five years from the previous surgery. We did not find any literature to substantiate that duration from the first surgery affect the outcome. The re-operative cardiac surgery after previous coronary artery bypass grafting represents a surgical challenge due to the potential for injury to patent coronary grafts, aorta or right ventricle.

Standard preoperative imaging using a coronary angiogram and chest radiograph CXR often results in inaccurate assessment of mediastinal anatomy [ 6 ]. We found that CT Angiography is superior to chest X-ray and conventional angiography in defining the position of patent grafts and vital structures in relation to the midline and posterior sternum.

The 3D CT imaging technique is useful in defining the optimal surgical strategy for re-operative cardiac surgery. Preoperative mapping of patent coronary grafts and the other vital mediastinal structures reduces the morbidity of the re-operation through modification of surgical approaches. Traditionally blood requirement is said to be more in resternostomy. However in our study the blood requirement was not different from the primary surgery.

Redo Cardiac Surgery in Adults

Study by Byrne et al [ 4 ], have shown that thoracotomy have reduced blood requirement. Although we tried thoracotomy in two mitral redo, it ended in phrenic nerve damage requiring longer period of ventilation. Aprotinin was added in all the patients except redo CABG's and in patients in whom it was previously added. We were unable to attach any statistical significance of aprotinin in reducing blood loss.

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Although the blood usage was not different from the regular case, we had a safe practice of reserving adequate units of fresh blood and plasma. Improvements of surgical techniques and prolonged life expectancy in the population have increased the frequency of heart valve surgery; redo procedures still carry specific risk factors for inherent technical problems.

Traditionally operative mortality for heart valve replacements HVR has been reported to be higher in comparison to primary procedures. Furthermore, the patients referred to undergo HVR are noticeably heterogeneous with respect to indications, Special attention to cannulation techniques, perfusion conditions, valve exposure and de-airing maneuvers are all important to ensure good clinical results [ 1 , 2 ].

As a major conclusion of our study, mortality in redo valvular surgery fundamentally shares the same risk factors as primary procedures. However, conventional valvular surgery as described herein has been progressively optimized in the last few years, and in-hospital risk of HVRs is comparable to that for primary interventions if HVR is not delayed until clinical and hemodynamic deterioration occurs. From a technical point of view, even minor improvements in surgical facilities might improve results in these settings [ 1 , 2 ].

Symposium on redo cardiac surgery in adults: introduction.

We had two cases of stroke [4. The Fontan patient died and the redo coronary survived with minor sequale.

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The average ICU stay for redo was about 10 days [ 7 ]. The average stay in our study was seven days which is inclusive of adult and paediatric redo. Repeat median sternotomy in pediatrics though associated with increased perioperative risks, yet the incidence of injury to the underlying structures during sternal re- entry is poorly quantified. With advances in paediatric cardiac surgery, staged procedures and bioprosthetic conduits to repair complex forms of congenital heart disease are not only used more frequently, but also at a young age.

The survival has markedly improved in the last 15 years, therefore an increasing number of patients will require repeat median sternotomy during childhood. Our criteria for femorofemoral bypass were conduits located directly underneath the sternum, lack of retrosternal space, low body weight, difficult access to the femoral vessels and surgeon's decision. We found that a calcified conduit behind the sternum and lack of retrosternal space were the main risk factors. We make every effort to effort to defer cannulating the femoral vessel as it is difficult to obtain proper CPB flow and vessel can be severed more easily.

The most common cause of death was output syndrome secondary to ventricular dysfunction [ 3 ]. The cause of death in our study was posterior circulation stroke. The incidence of cardiac lacerations at repeat sternotomy is9.

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  5. We had four cases of cardiac lacerations three in paediatric group and one in adult group. Among four patients, bleeding was controlled without the institution of any emergent femorofemoral bypass in only one patient. Two were RV-PA conduit tear, one was aortic tear and the other was right ventricle tear. The incidence of injuries during sternal re-entry was significantly lower in those patients where pericardial sac was closed initially.

    Conventional redo coronary artery bypass grafting is associated with significant morbidity. The danger of re-operation is mainly in the reopening the sternum and in the manipulation of the heart and the old grafts. Therefore off pump, redo, CABG, with the patient specific approach in selected cases seems an ideal technique.

    As the over all experience with re-operative CABG has increased alternative strategies have evolved in an attempt to lower the operative risks which exceeds those of initial re-vascuarisation.

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